Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study

doi:10.21203/rs.3.rs-4879620/v1

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Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study

https://doi.org/10.21203/rs.3.rs-4879620/v1

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This study was conducted to evaluate the effectiveness of breastfeeding behavior development training involving the use of videos and simulators with mothers whose babies were in the neonatal intensive care unit and who were staying in mothers’ hotels. The study was conducted in June 2022 and March 2023 in a state hospital with 100 volunteer participating mothers. Study control group (n=33), video training group (n=33), simulator training group (n=34). The study was conducted with a randomized controlled pretest/posttest control group trial model. Data were collected with a sociodemographic information questionnaire, a breastfeeding self-efficacy scale (short form), and a maternal attachment scale. Pretest scores did not significantly differ between groups (p>0.05). The breastfeeding self-efficacy, maternal attachment and retest mean scores significantly increased in the simulator group (p<0.05). This study revealed that breastfeeding training given to women with simulator support was more effective than training given via video methods in terms of breastfeeding success, the perception of breastfeeding self-efficacy, and maternal attachment.

Mother Hotel

Simulator-assisted Education

Video-assisted Education

Simulator-supported breastfeeding training increases mothers' breastfeeding self-efficacy
Simulator-assisted breastfeeding training strengthens mother–infant bonding.
The Mother Hotel helps mothers breastfeed their babies in the NICU until the babies mature.

There are a number of different reasons why newborn babies are admitted to the neonatal intensive care unit (NICU) after birth; thus, skin-to-skin contact between mothers and babies may not be possible in the first hour, and breastfeeding may be delayed until an indefinite time (1). This indefinite period of time can be eliminated when the baby's health condition is stable and when the mother is allowed to hold and breastfeed her baby.

When we look at our country in general, it is known that in some regions of our country, pregnant women who are about to give birth or whose birth has already started have difficulty reaching health institutions because of the winter months and adverse weather conditions. The 'Guest Mother Application' of the Turkish Republic Ministry of Health has established mother hotels on behalf of all hospitals containing NICUs. This enforcement ensures that mothers and newborns are settled comfortably and receive better treatment in hospitals. It has been scientifically proven that breast milk is the best nutritional quality for newborns and that it enhances the immınity of newborns (2). Owing to the use of breast milk, the respiratory, gastrointestinal, and immune systems of newborn babies are strengthened. Thus, the rates of infant and child mortality and morbidity are reduced (3). The mother needs to breastfeed her baby within the first hour after birth, provide skin-to-skin contact, and provide colostrum milk, which strengthens the baby's immunity within the first five days (4). Considering that mothers and babies should immediately have to come together following birth to establish a strong bond and stimulate an increase in the amount of breast milk, it is understandable that mothers should not be apart from their babies after birth. Since contamination is not allowed in the NICU, babies are relatively deprived of skin-to-skin contact and breast milk. Mothers of NICU babies must visit the hospital every two hours to feed their babies. These mothers must cope with breastfeeding under difficult conditions along with physical and psychological trauma after giving birth (2).

In the literature, factors that negatively affect breastfeeding include weak bonding between mothers and infants, feeding the infant with a bottle or pacifier, giving formula in the early period, and allowing the infant to stay in the NICU for a long period of time (5). The separation of infants who have to spend the first days of their lives in the NICU due to health problems from their mothers will lead to an inability to initiate and interrupt interaction, and the attachment process will be negatively affected (6).

Mothers’ Hotels help mothers breastfeed their NICU babies until the babies become mature. In this study, we hypothesized that educating mothers of NICU babies would increase their awareness of the importance of breastfeeding among mothers. We also aimed to relieve mothers' anxiety, make them feel better, encourage breastfeeding, establish a bond between mothers and babies, and continue breastfeeding after discharge. Therefore, we designed an education method with video and simulator methods based on the information-motivation-behavioral skills (IMB) model (7). The aim of the present study will significantly contribute to the field and has unique value.

Study Design

The study was established with a randomized controlled pretest/posttest control group trial model method to evaluate the effectiveness of video and breastfeeding simulator education for enhancing breastfeeding behavior in mothers of hotel-residing mothers whose babies need intensive care after birth.

The research was performed between June 2022 and March 2023 at the Mother’s Hotel of Bitlis State Hospital with the approval of Bitlis Provincial Health Directorate (Turkey).

Hypotheses

H1: Video-assisted breastfeeding education enhances the breastfeeding self-efficacy of mothers.

H2: Simulator-assisted breastfeeding education enhances the breastfeeding self-efficacy of mothers.

H3: Video-assisted breastfeeding education is more effective than simulator-supported breastfeeding education in enhancing breastfeeding self-efficacy.

H4: Simulator-supported breastfeeding education is more effective than video-assisted breastfeeding education in enhancing breastfeeding self-efficacy.

H5: Video-assisted breastfeeding education strengthens mother–baby attachment.

H6: Simulator-supported breastfeeding education strengthens mother–baby attachment.

H7: Compared with the control group, video-assisted training increases mothers' breastfeeding self-efficacy and maternal attachment levels.

H8: Compared with control training, simulator-assisted training increases mothers' breastfeeding self-efficacy and maternal attachment levels.

Sample

The participants consisted of volunteer mothers whose babies were hospitalized in the neonatal unit of Bitlis State Hospital and who resided in the Mother Hotel.

The sample size of the study was 0.6 for 80% power, within the 95% confidence interval, and it was calculated that at least 90 individuals in total should be included in the study. Since the study was conducted with 2 interventions and 1 control group, 30 people were included in each group (n = 30). The study was completed with a total of 100 mothers: n = 33 in the control group, n = 33 in the video-educated group, and n = 34 in the simulator-trained group. To ensure homogeneity between groups and to eliminate selection bias in the research, 'block' was used as a fixed probability randomization method. In accordance with block randomization, mothers who met the inclusion criteria were homogeneously allocated to each group according to the time they spent in the mother's hotel (according to their planned discharge day).

Instrumentation

Data were collected with a sociodemographic information questionnaire, a breastfeeding self-efficacy scale (short form), and a maternal attachment scale.

Sociodemographic Data Survey

The content was prepared on the basis of the recommendations of academics specializing in midwifery, obstetrics, and women's health nursing and a detailed literature review (5, 8, 9)

Breastfeeding Self-Efficacy Scale (short form)

It is a 33-item scale developed by Dennis in 1999 to assess mothers' breastfeeding self-efficacy. In 2003, a 14-item short scale was developed. Aluş Tokat et al. (2010) conducted a study of the validity and reliability of the scale in Turkey and reported that the Cronbach's alpha value was 0.86 (9). In our study, the Cronbach's alpha value of the scale was 0.83 in the pretest, 0.85 in the posttest, and 0.88 in the retest.

Maternal Attachment Scale

Scale is a unidimensional scale developed by Muller in 1994. The scale is a 4-point Likert-type scale and consists of 26 items. In our country, Kavlak et al. (2009) conducted a validity and reliability study of the scale, and Cronbach's alpha values were determined to be 0.77 for mothers with a 1-month-old baby and 0.82 for mothers with a 4-month-old baby (8). In our study, the Cronbach's alpha value of the scale was 0.86 in the pretest, 0.86 in the posttest, and 0.94 in the retest.

Ethical and Legal Aspects of Research

The study was initiated with the permission of Hasan Kalyoncu University Health Sciences Non-Interventional Ethics Committee in June 2022 (Decision no: 2022/043). Written permission was obtained from the Bitlis Provincial Health Directorate for the hospital where the study was conducted (Number: E-916-54458-040-99). All participants were asked for verbal and written consent before data collection by the Declaration of Helsinki, and all information was kept confidential.

Inclusion and exclusion criteria

Age 18 and over,
Mothers whose babies were admitted to the neonatal unit after birth and who stayed in the mother's hotel,
Mothers of babies who are not breastfed within the first 30–60 minutes after birth, who have not had skin-to-skin contact, and who are immediately admitted to the neonatal unit.

Exclusion criteria

Mothers who did not meet the inclusion criteria;
Mothers with incomplete and inconsistent data
Mothers who wish to leave the study at any stage of the study were excluded from the study.

Application of the Research

Education was performed individually to prevent the influence of one another. The data collection and implementation stages of the research were carried out as shown in Fig. 1. Our study was registered with the International Clinical Trials Registry Platform under number NCT05735821 (2022/043). Informed consent forms were obtained from the mothers. A pretest was applied to mothers who volunteered to participate in the study and who stayed in mothers’ hotels after birth. Mothers are unable to see and breastfeed their babies after birth, so they express milk and leave it in the intensive care unit. Some babies were fed with formula only, some with breast milk + plus formula, and some with breast milk only. Trainings were given during this period. Volunteered mothers were randomly divided into three groups: the control group (n = 37), the video group (n = 37), and the simulator group (n = 37), as represented below.

Control Group (n = 37)

A pretest was administered to volunteer mothers who stayed at their mother's hotel after birth. Mothers in the control group (n = 37) did not receive any training, only the standard training in the hospital protocol (in the hospital protocol, the training nurse verbally provided information about the duration and time of breastfeeding), and the posttest was applied 4 weeks after the pretest (mothers and babies were discharged when the last test was applied, so they were contacted, and the last test was applied n = 33; 4 participants refused to participate in the posttest and were excluded from the study).

Video Group (n = 37)

A pretest was applied to the mothers in the Video group. Following the determination of the average time babies were held in the NICU, a video education process was planned. Mothers in this group were exposed to a video prepared by the researcher on the basis of the IMB model (benefits of breast milk for mothers and babies, enhancement of breastfeeding behavior, right breastfeeding positions, time to start breastfeeding, maintenance, frequency, duration of breastfeeding, milking, storing and skin-to-skin contact). The training period continued from approximately 45 minutes to 1 hour. Individual and group counseling education was provided, and mothers were allowed to ask questions about issues they did not understand 15 minutes after training. After training, a posttest was given to the mothers (n = 33, 4 mothers refused to participate in the posttest and were excluded from the study). Four weeks after the last test, a retesting was performed (n = 33; when retesting was performed, mothers and babies had been discharged, contacted, and retested).

Simulator Group (N = 37)

Women in the simulator group were trained with a breastfeeding simulator following the pretest application. The training duration and content were the same as those of the video group. The breastfeeding simulator is a wearable technique. Mothers wore simulators and trained for approximately 45 minutes − 1 hour. After training, a posttest was given to the mothers (n = 34; 3 mothers refused to participate in the posttest and were excluded from the study). Four weeks after the last test, a retesting was conducted (n = 34; when retesting was performed, mothers and babies had been discharged, contacted, and retested).

Breastfeeding simulator features

It is a simulator that simulates the breasts of a woman's upper body with realistic soft breasts, resulting in a realistic feeling of soft contact with the skin. The demonstration and management of breastfeeding are more vivid. It is a practical and wearable breastfeeding model that educators can use for interactive education. It can be worn over the shoulders, placed on the chest, and secured with a seat belt from behind. During training, there is a newborn baby model with flexible joints and soft legs. This allows mothers to practice skin-to-skin contact during breastfeeding training.

Application Scheme of the Research

Statistical analysis of data

Data analysis was performed with SPSS 21.0. Normality was ensured according to skewness and kurtosis scores between + 3 and − 3, and parametric tests were used. Independent groups t tests were used for two groups, and variables with three or more groups were analyzed by ANOVA. The relationships between categorical variables were analyzed and reported via the chi-square test. The significance level is presented as α = 0.05.

Results obtained from data collected between June 2022 and March 2023;

Table 1. Comparison of the Sociodemographic Information Distribution of Mothers and Babies

Group

Video

Simulator

Control

Total

Chi-square

Current gestational age of the mother

25 years and under

26-30 years old

31 years and over

48,5

21,2

30,3

23,5

29,4

47,1

51,5

24,2

41,0

25,0

34,0

7,096

,131

Education status

Did not finish school

Primary school

Middle school

High school and above

12,1

36,4

30,3

21,2

35,3

29,4

20,6

14,7

12,1

36,4

33,3

18,2

20,0

34,0

28,0

18,0

7,803

,253

Length of stay at mother hotel (days)

1,0

2,0

3,0

69,7

21,2

9,1

70,6

26,5

2,9

69,7

21,2

9,1

70,0

23,0

7,0

1,485

,829

Age of Baby (Weeks-days)

1,0

2,0

3,0

69,7

21,2

9,1

67,6

29,4

2,9

69,0

25,0

6,0

1,531

,821

Baby's Gender

Girl

Male

54,5

45,5

38,2

61,8

27,3

72,7

40,0

60,0

5,093

,087

Nutritional status of baby

Breast milk

Just Formula

Breast Milk + Formula

39,4

9,1

51,5

26,5

23,5

50,0

39,4

6,1

54,5

35,0

13,0

52,0

5,111

,279

Clinical picture of a baby in intensive care

Followed by CPAP

Oxygen support in an incubator

Followed in incubator

6,1

3,0

90,9

14,7

6,1

12,1

81,8

9,0

10,0

81,0

5,094

,266

Our sociodemographic information questionnaire results are presented in Table 1. These results indicated that the distribution of the sociodemographic results of the groups was homogenous. According to the results, there was no statistically significant difference in the sociodemographic information of the groups, indicating homogeneity (p>0.05; Table 1).

Additionally, babies' birth week (38.06±2.41) and birth weight (3,051.21±1.119 g) did not significantly differ according to group (p>0,05).

Table 2. Normality Test Statistics of Scale Score Averages

	n	Skewness	Kurtosis
Breastfeeding Self-Efficacy Pretest	100	-,577	-,244
Breastfeeding Self-Efficacy Posttest	100	-,824	-,299
Breastfeeding Self-Efficacy Retest	67	-1,143	,061
Maternal Attachment Pretest	100	-,893	1,913
Maternal Attachment Posttest	100	-,513	,818
Maternal Attachment Retest	67	-,330	-,803

The normality test results are presented in Table 2. According to the normality test, the scale scores were between +3 and -3, normality was ensured, and parametric tests were used.

Table 3. Comparison of the Pretest Scale Scores of the Educational Training Methods

	Group						F	P
	Video		Simulator		Control
	Mean	ss	Mean	ss	Mean	ss
Breastfeeding Self-Efficacy Pretest	55,18	9,61	58,24	7,00	55,70	6,39	1,483	,232
Maternal Attachment Pretest	82,55	5,94	86,47	6,66	84,70	7,14	2,968	,056

When the pretest mean scores were analyzed, the pretest mean scores did not significantly differ (Table 3) (p>0.05).

Table 4. Comparison of Post-Test Scale Scores of Educational Training Methods

	Group						F	P	Multiple to compare
	Video		Simulator		Control
	Mean	ss	Mean	ss	Mean	ss
Breastfeeding Self-Efficacy Posttest	57,21	9,24	63,38	5,19	57,09	9,04	6,775	,002*	1<2; 2>3
Maternal Attachment Posttest	84,45	7,82	92,62	4,92	90,36	7,01	13,279	,000*	1<2; 1<3

*p<0.05 ANOVA test, Tukey test; independent groups t test for retesting

Our results revealed that the mean breastfeeding self-efficacy posttest scale scores of the simulator group were significantly higher than those of the video and control groups. The mean breastfeeding self-efficacy scores were 63.38±5.19 for the simulator group, 57.21±9.24 for the video group, and 57.09±9.04 for the control group. The breastfeeding self-efficacy posttest mean scores were significantly different (F: 6.77; p<0.05).

The mean maternal attachment score was 92.62±4.92 in the simulator group, 90.36±7.01 in the control group, and 84.45±7.82 in the video group. Posttest attachment scores significantly differed according to group (F=13.27; p<0.05). When the results were examined, the average of those in the simulator or control group was significantly greater than the average of those in the video group (Table 4).

Table 5. Comparison of the Retest Scale Scores of the Educational Training Methods

Group

Retest

Multiple

to compare

Mean

-2,731

,009*

1<2

Breastfeeding Self-Efficacy

Video

Simulator

62,91

66,44

6,37

3,88

Maternal Attachment

Video

Simulator

91,88

94,88

8,47

6,18

-1,661

,102

1<2

*p<0.05 Repeated ANOVA and dependent groups t test for Repeat; Dependent groups t test for retesting

The breastfeeding self-efficacy test revealed statistically significant differences by group (F: -2,731; p<0,05). The average score of the simulator group was calculated as 66.44±3.88, and the average score of the video group was calculated as 62.91±6.37. Maternal attachment retesting did not significantly differ by group (F: -1,661; p>0,05). However, when the results were examined, the average value of those in the simulator group was significantly greater (Table 5).

This study aimed to investigate the effectiveness of video and simulator education based on the IMB model for improving the breastfeeding behavior of nonbreastfeeding mothers whose babies were in a neonatal intensive care unit and who resided in a mother's hotel. To the best of our knowledge, this study is the first work based on such an educational process to ensure mother and baby attachment by enhancing breastfeeding behavior.

According to our sociodemographic information of the mother participants, the variables of the groups did not significantly differ. These findings suggested that the distribution of the groups was homogeneous. The similarity of the groups at baseline is important for evaluating the effectiveness of training on breastfeeding success, the perception of breastfeeding self-efficacy, and maternal attachment. When the pretest scores were analyzed in terms of groups, there was no statistically significant difference according to group (Table 1, Table 3; p > 0.05). In similar studies in the literature, the distributions among mothers, infants, and groups and the pretest were homogenous (5, 10, 11, 12, 13, 14).

One of the most important factors affecting breastfeeding success is mothers’ sense of self-efficacy. The mother's high level of confidence in her self-efficacy affects her efforts in breastfeeding, as believing that her milk is sufficient and having positive thoughts and feelings about breastfeeding increases breastfeeding success (3). Breastfeeding education is very important in developing breastfeeding skills and increasing breastfeeding success (15, 16). In this context, evidence-based guidelines specifically recommend practical training to support breastfeeding (5, 17). In our study, breastfeeding self-efficacy posttest scores after training significantly differed according to group (F = 6,77; p < 0.05). The results revealed that the breastfeeding training provided with simulator support increased the breastfeeding self-efficacy of the women in the simulator group at a high rate. The breastfeeding self-efficacy test scores of the training groups 4 weeks after the posttest were significantly different according to group (F = 2,731; p < 0.05). When the results were analyzed, the mean of those in the simulator group was found to be significantly greater. The findings of our study are similar to the findings of the literature (5, 18, 19). In this context, learning in a realistic environment with simulation is a more effective training method for developing breastfeeding skills and success.

When all the studies were examined, it was observed that breastfeeding was important, as recommended by the WHO, and that formula feeding was rarely preferred. In some studies, formula in addition to breastmilk was given because the babies were hospitalized in the neonatal intensive care unit immediately after birth, and the first breastfeeding started late. The findings of our study are similar to the findings in the literature (12, 20, 21). In our study, the rate of receiving breast milk and formula was 52.0%. The reason for this is that the babies were in intensive care, and breastfeeding was started late.

One of the most important conditions for successful breastfeeding is establishing skin-to-skin contact between mothers and babies after birth to start breastfeeding within the first hour and to ensure frequent breastfeeding optionally (22). The WHO recommends ensuring skin-to-skin contact between the baby and the mother within 1 hour after birth, encouraging the mother to breastfeed her baby, and supporting the mother in breastfeeding her baby (23). In our study, maternal attachment posttest scores after training significantly differed according to group (F = 13,279; p < 0.05). When the results were analyzed, the maternal attachment levels of women in the simulator group were found to be greater. The training provided with simulator support increased the maternal attachment levels of women in the simulator group at a high rate. The posttest was administered to the control group 4 weeks after the pretest while their babies were with them. This is thought to be the reason why attachment to the mother was slightly greater in the control group than in the video group at the posttest (Table 4).

There was no statistically significant difference between the maternal attachment test scores applied to the training groups 4 weeks after the posttest (F = 1,661; p > 0.05). However, when the retest rates were examined, the mean maternal attachment scores of the women in the simulator group were higher than the mean scores of the women in the video group. The findings of our research are similar to the findings of the literature (24, 25). Simulation training enables the learning of situations that can be encountered in real life through practice and improves the knowledge, skills, competencies, and behaviors of the learner (5).

Within the scope of the study, it is thought that women in the simulation training group practice breastfeeding in a realistic environment in the postpartum period, seeing situations in which they are deficient or inadequate in breastfeeding and learning what they need to do to overcome them increase women's self-confidence in breastfeeding, reduce their feelings of inadequacy and anxiety about breastfeeding and increase their maternal attachment levels. In this context, women feel competent in breastfeeding, their self-efficacy perceptions increase, and the bond between mothers and babies is strengthened.

Breastfeeding education with a simulator was determined to be the most effective breastfeeding method for enhancing breastfeeding success, perceptions of breastfeeding self-efficacy, and maternal attachment.

In conclusion, simulator-supported education was more effective than video-assisted education in improving breastfeeding behavior and ensuring attachment security between mothers and babies. Additionally, our hypotheses H2, H4, H6, H7 and H8 were confirmed. Thus, in hospitals, training to be given to pregnant women, mothers who have given birth, and mothers whose babies are in intensive care via a breastfeeding simulator will support mothers in starting and continuing breastfeeding.

RELEVANCE FOR CLINICAL PRACTICE

On the basis of the findings of this study, breastfeeding education provided to women with simulator support was the most effective method for increasing breastfeeding success, perceptions of breastfeeding self-efficacy, maternal attachment, attitudes, and knowledge levels toward breastfeeding. In this context, in hospitals, neonatal intensive care units, and pregnancy schools, breastfeeding simulator training can be extended to expectant mothers and mothers whose babies are taken to neonatal intensive care immediately after birth.

Limitations of the study

It was made in a single province.

Generalizability

This study can be applied to all mothers. The results cannot be generalized.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contribution

H.T.M wrote the main manuscript text and H.T.M prepared figures 1-5. F.Y, analysed statistics and tables. H.T.M and FY reviewed the manuscript.

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No competing interests reported.

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Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study

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Abstract

Figures

Key points

INTRODUCTION

MATERIALS AND METHODS

Study Design

Hypotheses

Sample

Instrumentation

Sociodemographic Data Survey

Breastfeeding Self-Efficacy Scale (short form)

Maternal Attachment Scale

Ethical and Legal Aspects of Research

Inclusion and exclusion criteria

Exclusion criteria

Breastfeeding simulator features

Statistical analysis of data

RESULTS

DISCUSSION

CONCLUSION

Declarations

References

Additional Declarations

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