Breastfeeding Trends at a Community Breastfeeding Center: An Evaluative Survey Christine A d a m s , RN, BScN, IBCLC, Robin Berger, RN, PHN, IBCLC, Paula Conning , RN, BScN, IBCLC, Linda Cruikshank , RN, BA, BScN, Ka thryn Dorb, MHSc

= Objective: To evaluate the Community Breast- feeding Center’s (CBC) impact on clients’ breast- feeding experiences.

Design: Retrospective survey; participants were mailed a questionnaire.

Setting: A hospital-based drop-in center oper- ated jointly by the Wellington-Dufferin-Guelph Health Unit and Headwaters Health Care Center and offering professional breastfeeding support and peer interaction.

Participants: The 164 mothers of singleton births, both inpatients and community clients, who attended the CBC during a 10-month period in 1996-1 997 and completed a survey.

Main Outcome Measures: A mailed survey with forced-choice and open-ended questions.

Results: Of the respondents, 90.9% rated their overall CBC experience as excellent or good. Seveniy- three percent of respondents breastfed for 4 months or longer. Primiparae and mothers of preterm infants tended to visit the CBC more frequently, while achieving duration rates similar to other sub- groups. Returning to work was the reason most Fre- quently cited for stopping breastfeeding (35%).

Conclusion: The CBC is an effective communi- ty support strategy to lengthen breastfeeding dura- tion and enhance clients’ satisfaction with their breast- feeding experience. JOGNN, 30, 392-400; 2001.

Keywords: Breastfeeding -Clinic - Drop-in center- Evaluation - Survey

Accepted: December 2000

Breastfeeding is influenced by various physical, psychologic, social, and environmental factors (Kearney, 1988). Although many women recog- nize that breastfeeding is the optimal choice and a natural thing to do, like many human behaviors, it is learned (McKilligin, 1994). It has been docu- mented that attending a breastfeeding clinic as well as receiving help from a community/public health nurse (Health Canada, 1995) or lactation consultant (Buckner & Matsubara, 1993) is help- ful to breastfeeding mothers. The purpose of the survey was to evaluate the effectiveness of the Community Breastfeeding Center (CBC) in pro- viding professional and peer support for families in Dufferin County to increase breastfeeding initi- ation and duration rates and greater client satis- faction with breastfeeding.

Background A 1995 survey of breastfeeding practices in the

Wellington-Dufferin-Guelph area provided a base- line of information that was used to determine a need for intervention (Isaacs, 1995). Isaacs found that whereas 83% of mothers initiated breastfeed- ing, 38% stopped before the infant was 4 months old. Furthermore, half of those who stopped did so within the 1st month. The reasons most com- monly cited by mothers for stopping were largely preventable through early intervention, education, and support (i.e., sore breasts and nipples, infant hunger, and perceived lack of breast milk). These

392 lOGNN Volume 30, Number 4

findings also have been supported in other surveys (Health and Welfare Canada, 1993).

Three public health nurses (PHNs) from the Welling- ton-Dufferin-Guelph Health Unit submitted a proposal for the CBC to both the hospital and health unit man- agement. The concept for the CBC emerged from the public health nurses’ awareness of the above findings, together with the following local issues: (a) the need for client contact with community lactation caregivers before leaving the hospital, (b) client reports of inaccu- rate and inconsistent information from hospital and community health professionals, (c) requests from hos- pital obstetric staff for breastfeeding education, (d) the need for improved collaboration between agencies, (e) the challenge of meeting the needs of breastfeeding clients while avoiding additional costs, and (f) the need to decrease rates of infant readmission to the hospital for health problems related to breastfeeding misman- agement (Kemper, 1990).

The CBC has been open since May 1, 1996. It was designed to use existing staff, facilities, and resources to provide hands-on professional support for breastfeeding families, including teenage parents and low-birth-weight and preterm infants. The main goal, based on the World Health Organization’s and United Nations Internation- al Children’s Fund’s Innocenti Declaration and the Ontario Ministry of Health’s Mandatory Health Pro- grams and Services Guidelines, is to encourage mothers to breastfeed their infants exclusively or primarily up to 6 months of age and, optimally, to continue breastfeed- ing with complementary foods to 2 years and beyond (Ministry of Health Ontario, 1997; World Health Organization and United Nations International Chil- dren’s Fund, 1990).

Specific objectives of the CBC are to (a) increase breastfeeding rates, both initially and at 6 months; (b) improve clients’ satisfaction with consistency and accuracy of information given by health professionals; (c) decrease the number of mothers and infants experi- encing problems arising from breastfeeding mismanage- ment (i.e., hyperbilirubinemia, inadequate hydration, and traumatized nipples); and (d) have CBC clients express positive comments about their overall CBC experience.

The CBC is located in Orangeville, population 21,505 (Statistics Canada, 1996), a t Headwaters Health Care Center, a Level I1 facility averaging 650 deliveries a year. Orangeville is the largest urban center in Dufferin County, which has a population of 45,000 and lies approximately 100 km northwest of Toronto, Ontario.

The CBC is located near the obstetric unit, in a four- bed ward room reserved for this purpose. It is open Mondays, Wednesdays, and Fridays from 1:00 p.m. to 3:30 p.m. and is staffed by one or two PHNs and an

obstetric staff nurse. Three of the five PHNs who staff the center on a rotating basis are International Board Certified Lactation Consultants (IBCLCs), and one of them is always present. The cost to both agencies has been minimal because on-duty staff as well as hospital space, furnishings, and supplies are used. CBC services include assessment of the breastfeeding dyad, identifi- cation of potential or existing challenges, anticipatory guidance regarding breastfeeding and parenting issues, teaching and reinforcing principles of lactation, provi- sion of hands-on care and individual infant feeding plans as needed, and collaboration with relevant community partners. Care is taken to demedicalize breastfeeding. No appointments are made. Inpatients and community clients, both antepartum and postpartum, are encour- aged to drop in. Mothers can receive professional help, watch a lactation video, or take part in discussions with peers as they feed their infants. Fathers, siblings, and other support persons are welcome to attend the CBC if the mother wishes. Inpatients routinely attend as part of their usual 36- to 48-hour hospital stay.

Method

Study Design Breastfeeding inpatients and community clients, self-

selected to attend the CBC as often as desired to meet their needs for breastfeeding teaching and support, pro- vided retrospective answers to a written questionnaire. Results were compared with those from a previous study of local breastfeeding women. Data included duration and lactation experiences (Isaacs, 1995).

Sample The 229 mothers of singleton births who attended

the CBC during a 10-month period in 1996-1997 were invited to participate in the study and agreed verbally to participate. Care was taken to ensure that the infants would be at least 6 months of age at the time of the sur- vey (the mean age of the infants at time of survey was 11.7 months). Of those mothers who returned the sur- vey questionnaire, 74.5% were between the ages of 19 and 34 years, and 25% were 35 years or older. Only 0.6% of mothers were under age 19; 53% were primi- parae, and 47% were multiparae. All participants were able to read and understand English. The study was approved by the health unit’s epidemiologist and the nursing management of both participating agencies. Consent to be contacted for a follow-up survey had been obtained during each client’s first visit to the CBC.

Instrument The survey instrument included 25 open-ended and

closed-ended questions divided into three sections to elic-

JulylAugust 2 00 1 JOG“ 393

it demographic data, information regarding the client’s past and present breastfeeding experience, and infor- mation regarding the client’s visits to the CBC. Content validity of the survey instrument was established through review by one IBCLC and one PHN. The questions were then tested for clarity by asking 10 similar CBC clients who were not in the study to complete the survey.

Part 1 of the survey provided background informa- tion, including the mothers’ age range at delivery, coun- ty of residence, whether primiparous or multiparous, method of delivery, and the infant’s length of gestation and birth weight.

In Part 2, clients were asked about their previous lac- tation experience, their breastfeeding intentions and outcomes with the present infant, use of formula or other supplements, and whether they experienced any problems arising from breastfeeding mismanagement (i.e., sore, cracked nipples). The survey identified both the clients’ duration of exclusive breastfeeding (no extra water, juice, solids, or formula) and total duration of breastfeeding regardless of complementary foods. Clients also were asked their opinion regarding the value of formula compared with breast milk.

In Part 3 of the survey, clients were asked to evaluate their experience at the CBC, including number of visits, perceived helpfulness, specific benefits, preference of either home visits by a PHN or visits to the CBC for lac- tation support, and any other comments.

Procedure A survey form, a letter of invitation to participate,

and a stamped return envelope were mailed to each par- ticipant. Of the 242 surveys sent, 19 were returned from the post office as undeliverable, leaving a total of 223. Despite a postal worker strike, 154 surveys were returned. A follow-up telephone call made by a PHN/IBCLC who had been on maternity leave during the survey time and had not met the clients resulted in a further mail in of 22 surveys, for a total response rate

Twelve surveys were excluded from the data: Six clients did not physically attend the CBC (i.e., they were seen in their hospital rooms), two clients had twins, two surveys were completed using data from an infant less than 6 months of age, one survey was returned blank, and one client had an anxiety attack and left the center before using any services. Evaluative findings are based on the remaining 164 surveys (a response rate of 78%).

All data were entered into an electronic database using Epi Info version 6.0. Univariate frequencies for all relevant research variables were examined, and any inconsistencies were addressed and corrected. Multi- way contingency tables were used to examine associa- tions, and chi-square statistics were used to determine statistical significance.

of 79% ( n = 176).

Results Demographic and delivery characteristics of the sur-

vey respondents and nonrespondents are shown in Table 1. Similarities can be noted in the numbers of mothers for all age groupings except for those mothers over age 35. Nearly 70% of respondents were ages 25 to 34 years, with 25% (41) being 35 years or older. Most lived in Dufferin County, and the numbers of multi- parous and primiparous mothers were almost equal.

Characteristics of mothers’ previous and present breastfeeding experiences are summarized in Table 2. Of the 77 multiparae, 71 had breastfed previously. Forty-six percent of mothers with previous breastfeed- ing experience had stopped earlier than planned with children in the past. The most common reasons given were perceived inadequate milk supply and dissatisfac- tion with their breastfeeding experience.

The median intended breastfeeding duration among respondents was 6.0 months ( n = 44). Twenty-seven percent (43/15 8 ) of respondents breastfed their present infant for less than 4 months, 73% (115/158) breastfed longer than 4 months, and 56% ( S S l l S S ) breastfed for longer than 6 months. Twenty-eight respondents were

TABLE 1 Demographic and Delivery Characteristics of Nonrespondents and Respondents

Variable Age of mother (years)

15-18 19-24 25-34 35 +

Residence Dufferin County Other

Primiparous Multiparous Gestation

> 38 weeks < 38 weeksa

Infant’s birth weight Type of delivery

Vaginal Cesarean

Nonrespondents (n = 46)

n (%)

1 (2.4) 8 (19.5)

31 (75.6) 1 (2.4)

37 (80.4) 9 (19.6)

21 (45.7) 25 (54.3)

34 (81.0) 8 (19.0)

M = 3,462 g

36 (87.8) 5 (12.2)

Respondents (n = 164)

n (%)

1 (0.6) 8 (4.9)

114 (69.5) 41 (25.0)

137 (83.5) 27 (16.5) 87 (53.0) 77 (47.0)

141 (86.5) 22 (13.5.)

M = 3,235 g

132 (80.5) 32 (19.5)

aMean gestation of infants of respondents born at less than 38 weeks = 35.2 weeks.

394 JOG” Volume 30, Number 4

TABLE 2 Characteristics of Mothers' Previous and Present Breastfeeding Experience

V~z'Jri'iDle

Did you stop breastfeeding earlier than planned with previous children? (n = 69)

Yes No

If yes, why? Thirty-three respon- dents cited 46 reasons for stopping breastfeeding earlier than planned with previous children. Perceived inadequate milk supply Dissatisfied with breastfeeding experience Problems with latch or suck Special needs infant Returned to work Too tied down Maternal health problems

Breastfeeding at time of survey All respondents (n = 163) Primiparae (n = 86) Multiparae ( n = 77) Full-term birth (pi = 141) c 38 weeks gestation ( M = 22)

Duration of breastfeeding

n

32 37

12

9 7 7 5 3 3

28 13 1s 25

2

Result

'%

46.4 53.6

26.1

19.6 15.2 15.2 10.9 6.5 6.5

17.2 15.1 19.5 17.9 9.1

All respondents (n = 130)

Primiparae (n = 87) Multiparae (pi = 77) Full-term birth ( t i = 141) c 38 weeks gestation (n = 22)

Mean = 5.7 months Median = 5.0 months

Mean = 5.4 months Mean = 6.1 months Mean = 5.6 months Mean = 6.3 months

(continrtedj

breastfeeding a t the time of the survey. The mean dura- tion of breastfeeding of the 130 respondents who had stopped a t the time of the survey was 5.7 months. The mean duration of breastfeeding by mothers of preterm infants (n = 22) was 6.3 months. The duration of exclu- sive breastfeeding (i.e., n o other water, juice, solids, or formula) was most frequently given a s 3 to 4 months (30.7%) and 4 to 5 months (23.5%). Respondents were asked to identify any breastfeeding problems they had experienced. The most frequently cited problem was sore, cracked, bleeding nipples (56.4%).

Almost 82% of respondents identified that in their opinion formula is not as good for infants as breast milk.

TABLE 2 Continued

Vmiahle

Exclusive breastfeeding (n = 1.53) 0-1 month 1-2 months 2-3 months 3-4 months 4-5 months 6-9 months

Did you experience any of the following problems during breast- feeding? (n = 163) Sore, cracked, bleeding nipples Other breastfeeding problems Infant requiring extra fluids Very sleepy infant Jaundice related to not enough

breast milk Other breastfeeding problems, please specify (n = 38)

Breast infection/fullness Suck/latch problems Perceived lack of milk/

poor weight gain Yeast/thrush Hospitalization jaundice

n

24 14 16 47 36 16

92 39 38 3s

18

15 13

5 2 2 I

Result

'%

15.7 9.2

10.5 30.7 23.5 10.5

56.4 24.4 23.3 21.5

11.0

9.2 7.8

3.1 I .2 1.2 0.6

Table 3 summarizes the reasons for stopping brenst- feeding for all respondents and subpopulations. The most frequent reasons overall were returning to work ( 3 5 % ) and infant not interested (32%). The reasons given for stopping did not differ significantly among multiparae and primiparae, with two exceptions. Mul- tiparae were more likely to have reached their goal compared with primiparae, and primiparae were more likely to have stopped because of sore breasts and nip- ples than were multiparae. Reasons for stopping did not differ significantly between mothers of full-term and preterm infants.

The third section of the survey was an evaluation of the CBC. Almost 50% (8 1/163) of the respondents had visited the CBC a t least three times. Similar percentages, 36.8% (32/87) of primiparae and 36.4% (8/22) of mothers of preterm infants visited more than five times, compared with only 13.2% (10/76) of multiparae. As one mother responded, the CBC was "excellent in help- indencouraging me to continue pumping and breast-

July/August 200 I JOGNN ,395

TABLE 3 Reasons for Stopping Breasqeeding

Reason for Stopping

Returned to work Infant not interested Infant still hungry Lack of breast milk Reached my goal Maternal health reasons Sore breasts or nipples Convenience Too tied down Infant gaining weight

Not enjoying Infant health reasons Advised by doctor Latch problems Colic Planning another child Lack of support Influenced by friends

too slowly

or relatives

All Respondents (n = 137)

n

48 44 37 28 24 19 16 16 14

12 12 9 6 4 3 2 2

1

%

35.0 32.1 27.0 20.4 17.5 13.9 11.7 11.7 10.2

8.8 8.8 6.6 4.4 2.9 2.2 1 .5 1.5

0.7

Primiparae (n = 74)

n

27 26 22 15 8 6

14 8 8

5 4 3 2 3 2 1 1

0

%

36.5 35.1 29.7 20.3 10.8

8.1 18.9 10.8 10.8

6.8 5.4 4. I 2.7 4.1 2.7 1.4 1.4

0.0

Note. Respondents may have noted more than one reason for stopping.

“Statistically significant p < .05 (Yates corrected chi square).

Multiparae (n = 63)

n

20 16 15 13 16 7 2 7 6

7 8 3 3 1 1 1 1

0

YO

31.7 25.4 23.8 20.6 25.4.’ 1 1 . 1 3.2”

1 1 . 1 9.5

1 1 . 1 12.7 4.8 4.8 1.6 1.6 1.6 1.6

0.0

n

42 34 33 21 23 10 14 15 12

9 9 5 3 2 1 1 2

0

YO

25.0 40.0 20.0 35.0 5.0

15.0 10.0 0.0

10.0

15.0 15.0 5.0

10.0 10.0 10.0 5.0 0.0

0.0

Full-Tern Infants (n = 1 1 7)

Infants < 38 Weeks Gestation (n = 20)

% n

35.9 5 29.1 8

8.2 4 17.9 7 19.7 1 8.5 3

12.0 2 12.8 0 10.3 2

7.7 3 7.7 3 4.3 1 2.6 2 1.7 2 0.9 2 0.9 1 1.7 0

0.0 0

feeding my premature infant and getting him to feed so he could come home.”

The researchers also looked a t the association between duration of breastfeeding and frequency of vis- its for all respondents and subpopulations. Of the 42 respondents who visited the CBC more than five times, 69.0% (29/42) breastfed their infants for more than 6 months. Conversely, of the 82 respondents who visited the CBC one to two times, only 39% (32/82) breastfed longer than 6 months. This trend was espe- cially evident among primiparae; 68% (22/32) of the primiparae who visited five or more times breastfed longer than 6 months, whereas only 31.6% (12/38) of the primiparae who visited only one to two times breastfed longer than 6 months. Because only 10 multi- parae visited the CBC more than five times, this trend could not be demonstrated in that subgroup.

Table 4 summarizes respondents’ evaluation of the CBC. Respondents rated their overall CBC experience as excellent (59.8%), good (31.1%), satisfactory (7.9%), or poor (1.2%). More than 94% of respon-

dents (149/155) agreed or strongly agreed that the CBC helped them to “feel more confident about breastfeed- ing” and to “feel more positive about their breastfeeding experience” (146/155). More than 90% of respondents (144/155) agreed or strongly agreed that the center helped them to “know more about breastfeeding” and “prevent or overcome breastfeeding difficulties” (137/152). More than 72% (107/148) reported that the CBC helped them to breastfeed longer and (1 12/144) meet other new mothers. As one mother indicated, “Nurses at the center were extremely supportive at times when I would have stopped breastfeeding due to my lack of experience and support.”

Clients were asked whether they preferred to attend the CBC or to have a PHN from the CBC staff visit their home for lactation support. Fifty-one percent pre- ferred to attend the CBC, 29.6% preferred home visits, and 19.1% checked both options. The reason most commonly given for choosing the CBC was the social aspect. The reason most commonly given for choosing home visits was convenience (related to transportation

396 JOGNN Volume 30, Number 4

TABLE 4 Communiiy Bwm$ding Center (CBC) Evaluation

Result

Variable (N = 264)

How helpful has the CBC been to you? ( n = 160) Very helpful Somewhat helpful Not helpful

Which breastfeeding support would you prefer? (n = 162)

Nurse visiting home CBC Both

138 reasons were cited by 116 respon- dents for preferring either home visits or CBC services.

Convenience of home visit Privacy of home visit I : 1 setting more personal/helpful/

Social aspect of CBC Convenience of CBC Advantages of CBC (economic,

equipment, and professional availability)

Supportive environment of CBC Prefer both CBC and home visit

154 comments were written by 97 respondents in response to an open- ended question asking for further comments.

fathers included

CBC valuable service Support expanding the CBC Disagreed with advice Other recommendations suggested Disappointed with CBC Problems coping with breastfeeding

not related to CBC

n

126 30 4

48 83 31

32 10

10 40 10

3 3

30

128 13 4 4 3

2

%

78.8 18.8 2.5

29.6 51.2 19.1

23.2 7.2

7.2 29.0

7.2

2.2 2.2

21.7

83.1 8.4 2.6 2.6 1.9

1.3

difficulties or timing after birth). As one primiparae said, “I need to get out and socialize and talk to other first-time moms.”

Ninety-seven mothers wrote 154 responses in answer to an open-ended question inviting general comments about the CBC. Almost 92% (141/154) of these com- ments identified the CBC as a valuable service and/or recommended its expansion. As one multipara wrote, “Keep up the good work. Lack of support and infor- mation is probably the real reason mothers stop (or never start) breastfeeding.”

Discussion This survey found that the professional and peer sup-

port available at the CBC helped families breastfeed more successfully. A higher percentage of survey respondents were breastfeeding their infants at 4 and 6 months of age (at 4 months, more were exclusively breastfeeding) than researchers found in neighboring urbadrural regions (Hayman & Valters, 1996; Isaacs, 1995; Valaitis, 1995; Valaitis & Shea, 1993). Clients of the CBC were less likely to stop breastfeeding because of problems arising from breastfeeding mismanagement (i.e., sore nipples) than mothers in other studies (Hill & Humenick, 1993; Kearney, Cronenwett, & Barrett, 1990; Ziemer, Paone, Schupay, & Cole, 1990). Primiparae and mothers of preterm infants achieved a mean dura- tion of breastfeeding similar to the overall mean dura- tion, yet they tended to visit the CBC more frequently.

C l i e n t s of the center were less likely to stop

breastfeeding because of problems arising

from breastfeeding mismanagement.

One limitation of the CBC survey is that the clients who attend the CBC are self-selected, thus adding a pos- sible bias to the survey, It has been documented by Ellis, Livingstone, and Hewat (1993) and Pastore and Nelson (1997) that mothers who attend breastfeeding centers may breastfeed longer than mothers who do not attend. Further research into whether this effect is due to inher- ent differences in women who access such support or to the effects of the centers themselves is warranted.

Clients of the CBC were less likely to stop breast- feeding because of problems arising from breastfeeding mismanagement than clients in other surveys. Researchers report as many as 96% of breastfeeding women experience nipple soreness, leading as many as 27% of those mothers to discontinue breastfeeding ear- lier than planned (Biancuzzo, 1999; Buchko et al., 1993; Hill & Humenick, 1993; Kearney et al., 1990; Mohrbacher & Stock, 1997; Riordan & Auerbach, 1999; Ziemer & Pigeon, 1993). In this survey, only 56.4% of respondents complained of nipple soreness, and only 11.7% stated that this was one of their rea- sons for stopping. As in other studies (Buchko et al., 1993), a significantly larger percentage of primiparae (1 8.9’70) than multiparae (3.2%) stopped breastfeeding in part because of this lactation challenge.

Unlike a local survey in 1995, in which Isaacs found 74.5 YO of respondents who discontinued breastfeeding

JulylAugust 2001 JOGNN 397

cited “lack of breast milkhfant hunger” as reasons for stopping (Isaacs, 1995), the current researchers found that only 47.4% of the respondents cited these reasons. This suggests the CBC has a positive influence on reduc- ing the incidence of problems arising from breastfeed- ing mismanagement.

Returning to work was the reason most frequently cited for stopping breastfeeding by CBC attendees (35%). Maternity leaves in Canada averaged 27 weeks at the time of this survey. Many women think of wean- ing at this time, rather than developing strategies to continue breastfeeding as they rejoin the work force. Many mothers (32.1%) also cited infant disinterest as a reason for terminating breastfeeding. Further work is needed to explore with mothers the underlying factors that lead them to this perception of infant disinterest. This study validates the need to support mothers during the early weeks of breastfeeding to prevent problems and during lactation crises when they may contemplate stopping.

The survey results show the majority of respondents affirmed the usefulness of CBC services in supporting and enhancing their breastfeeding outcomes. As research continues into how the breastfeeding mother perceives and uses support systems, the need for consis- tent, accurate advice and personal support provided by a knowledgeable professional is clear (Izatt, 1997; Rajan, 1993). In addition, the trend for shorter post- partum hospital stays puts more responsibility on health care providers to give information, nonconflict- ing advice, and hands-on help to assess and overcome early lactation challenges (Canadian Paediatric Society and Society of Obstetricians and Gynaecologists of Canada, 1996; Lawrence, 1995; Page-Goetz, 1989; Rajan, 1993). Lactation consultants were found to be helpful in answering questions regarding milk supply and encouraging maternal confidence (Buckner & Mat- subara, 1993). The findings of the current study vali- date research conducted by Buckner and Matsubara (1993) and Pastore and Nelson (1997).

Primiparae used the services of the CBC more fre- quently, achieving breastfeeding durations similar to multiparae. The CBC was a positive source of support for first-time mothers. Perhaps, as other researchers found, these clients were able to continue breastfeeding longer because they perceived that their health care providers supported breastfeeding (Buckner & Matsub- ara, 1993; Izatt, 1997; Rajan, 1993). As well, first-time mothers may not have fully developed their own infor- mal network of family, neighborhood, and peer sup- ports to assist them in coping with the crises and chal- lenges of new motherhood. A significant difference was found between multiparae and primiparae who cited “reached my goal” as one of their reasons for stopping breastfeeding. Whereas 25.4% of multiparae cited this

reason, only 10.8% of primiparae did so. This differ- ence may reflect how new mothers’ uncertainty or lack of confidence can affect their breastfeeding outcomes.

Cronenwett and Reinhardt (1987) and Page-Goetz (1989) investigated the role of social support in the ini- tiation and duration of breastfeeding and found that programs to promote breastfeeding should focus on determining sources of support, strengthening existing support systems, and providing new opportunities for mothers to develop additional supportive relationships. More than 90% of respondents agreed or strongly agreed that time spent at the CBC helped them feel more confident and positive about their breastfeeding experience. The informal atmosphere of the CBC fos- ters an environment in which new mothers can meet and share experiences. Increasing a woman’s informa- tion and social support network has been shown to be influential in positive lactation outcomes (McNatt & Freston, 1992; Muhlenkamp & Sayles, 1986).

The needs of mothers of preterm infants are well documented (Biancuzzo, 1999; Diamond, 1999; Hill, Hanson, & Mefford, 1994; Kavanaugh, Mead, Meier, & Mangurten, 1995; Kavanaugh, Meier, Zimmerman, & Mead, 1997; Mohrbacher & Stock, 1997). They tend to worry more about their milk supply and whether their infant is feeding effectively and gaining weight appropriately. In contrast to mothers of full- term infants, mothers of preterm infants may be unable to use infant cues to reassure themselves that their infants are doing well and beginning to self-regulate (Hill et al., 1994). Other researchers have suggested that these mothers need a consistent, individualized approach to infant feeding after hospital discharge to meet the challenges of parenting and breastfeeding a preterm infant (Hill et al., 1994; Kavanaugh et al., 1995).

Rirniparae used the services of the center

more frequently, achieving breastfeeding

durations similar to other subgroups.

Frequent weight and progress checks are important because these mothers feel their premature infants are vulnerable for inadequate intake and slow weight gain. The reasons most frequently cited by the mothers of preterm infants for stopping breastfeeding were similar to those reasons noted by Hill et al. (1994) and Kavanaugh et al. (1995), specifically, “baby not inter- ested,” “lack of breast milk,” or “baby not getting enough breast milk.” However, mothers of preterm infants using the services of the CBC attained a breast-

398 JOG” Volume 30, Number 4

feeding duration rate slightly longer than other popula- tion subsamples in this study. Although the small sam- ple size limits generalization of findings, further research is warranted to determine anticipatory guid- ance strategies to help mothers manage their concerns about their preterm infants, specifically related to milk transfer issues, perceptions of “baby not interested,” and “lack of breast milk.”

Conclusion The CBC is successfully meeting its goal of support-

ing mothers in Dufferin County to breastfeed. Results of the survey indicate that primiparae and mothers of preterm infants, who tended to use the services of the CBC more often than experienced breastfeeding moth- ers, achieved good breastfeeding duration outcomes. Because few teenage mothers attended the CBC, the needs of this group could not be determined.

Although some CBC clients experienced lactation challenges, such as sore nipples and jaundiced, sleepy infants, these were not the most commonly cited rea- sons for stopping breastfeeding. Rather, the dual roles of returning to work and continuing to breastfeed were problematic for many clients. More work is needed in identifying strategies to support mothers both at home and in the workplace to assist them in meeting their breastfeeding goals. In January 2001, maternity leaves in Canada were extended to 12 months, which may affect future breastfeeding initiation and duration rates.

According to the survey results, a large percentage of CBC clients felt satisfied with the support they received. Although the positive informal publicity gen- erated by CBC clients is hard to quantify, a 55% increase in attendance by 1999 seems to indicate con- tinued client satisfaction.

With early discharge, concerns can arise after the mother and newborn have gone home. The services of the CBC, along with a multifaceted approach offered by the Wellington-Dufferin-Guelph Health Unit (telephone assessment within 48 hours of hospital discharge, home visits, a telephone warm line, and parenting classes), have been instrumental in assisting Dufferin families to meet their breastfeeding goals.

REFERENCES

Biancuzzo, M. (1999). Breastfeeding the newborn: Clinical strategies for nurses. St. Louis, MO: Mosby.

Buchko, B. L., Pugh, L. C., Bishop, B. A., Cochran, J. F., Smith, L. R., & Lerew, D. J. (1994). Comfort measures in breastfeeding, primiparous women. Journal of Obstet- ric, Gynecologic, and Neonatal Nursing, 23, 46-52.

Buckner, E., & Matsubara, M. (1993). Support network uti- lization by breastfeeding mothers. /ournu1 of Human Lactation, 9, 23 1-23s.

Canadian Paediatric Society and Society of Obstetricians and Gynaecologists of Canada. (1996). Facilitating dis- charge home following a normal term birth. Paediatric Child Health, I , 165-168.

Cronenwett, L. R., & Reinhardt, R. (1987). Support and breastfeeding: A review. Birth, 13, 109-113.

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732-744.

Christine Adams is a public health nurse/lactation consult- ant in Dufferin County, Orangeville, Ontario.

Robin Berger is a public health nurse/lactation consultant in Dufferin County, Orangeville, Ontario.

Paula Conning is a public health nurse/lactation consultant in Dufferin County, Orangeville, Ontario.

Linda Cruikshank was a public health nurse on the Dufferin Family Health Team, Orangeville, Ontario, at the time of this research.

Kath y n Dore' was the epidemiologist overseeing research projects cam'ed out by the Health Unit, Orangeville, Ontario, in 1997 and 1998.

Address for correspondence: Robin Berger, RN, PHN, IBCLC, Family Health Team (Dufferin), Wellington-Dufferin- Guelph Health Unit, 51 Zina Street, Orangeville, Ontario, Canada L9W IES. E-mail: louberg@ora.auracom.com.

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