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Still Feeding That Baby

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Still Feeding That Baby Still feeding that baby A cluster randomised controlled trial, with training of general practice nurses, to examine motivational support for ongoing breastfeeding. Megan Elizabeth Elliott-Rudder MBBS DRANZCOG GradDipRuralGP FRACGP CertIVBreastfeedEd(Comm,Couns) Submitted for the degree of Doctor of Philosophy Rural Clinical School, Faculty of Medicine The University of New South Wales Australia 30 March 2012 ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation, and linguistic expression is acknowledged.’ Signed …………………………………………….............. Megan Elliott-Rudder Date ……………………………………………............. THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Elliott-Rudder First name: Megan Other name/s: Elizabeth Abbreviation for degree as given in the University calendar: PhD School: Rural Clinical School Faculty: Medicine Title: Still feeding that baby: A cluster randomised controlled trial, with training of general practice nurses, to provide motivational support for ongoing breastfeeding. Abstract 350 words maximum: AIM: To increase exclusive breastfeeding and any breastfeeding of infants aged four months and six months compared to controls and to evaluate trial processes. INTRODUCTION: Despite its known importance, continuation of breastfeeding in Australia is lower than recommended. Cross-disciplinary research identifies the dilemma that mothers face: they are questioned regarding when, where, how and why they are breastfeeding. Protection and promotion of breastfeeding are inadequate. This complex interpersonal behaviour needs more support. Systematic literature review suggests that training in breastfeeding management and counselling skills, within a theoretical framework, are needed for effective health professional support. METHOD: Using a motivational interviewing framework The Conversation Tool flowchart was developed. Ten hours of training prepared the intervention practice nurses to use the Tool during infant immunisation appointments, in a cluster randomised controlled trial. Independent mail recruitment and telephone data collection for breastfeeding outcomes were conducted with mothers. Statistical analysis was conducted in STATA, adjusted for clustering. Periodic telephone contact was maintained with practice nurses. RESULTS: The trial involved 15 general practices, 19 intervention practice nurses, and 330 mothers. Training improved practice nurse breastfeeding knowledge (t 7.27(14), p=.000 2-tailed) and attitudes (t 6.25(14), p=.000 2-tailed). Full breastfeeding OR 1.95 (95%CI 1.03-3.69) p=0.041 and exclusive breastfeeding OR 1.88 (95%CI 1.01-3.50) p=0.047 were increased at four months (24 hour recall) compared to control, adjusted for return to work/study plans. Duration of breastfeeding was not significant compared to controls. Mixed methods process evaluation included analysis of 43 telephone interviews with practice nurses. Despite community resistance, workplace restrictions, and their own learning curves, support for ongoing breastfeeding was satisfying for practice nurses and mostly non-threatening. DISCUSSION AND RECOMMENDATIONS: This successful clinical translational research demonstrates a rural preventive health intervention and improved breastfeeding outcomes. The motivational interviewing framework and this training model are appropriate. Policy commitment to address structural barriers is needed. Future research is awaited on support for ongoing breastfeeding with women from disadvantaged groups and on improved maternal access to support. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). ……………………………………………… …………………………..…………… ………………. Signature Witness a Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. FOR OFFICE USE ONLY Date of completion of requirements for Award: THIS SHEET IS TO BE GLUED TO THE INSIDE FRONT COVER OF THE THESIS 3 [this page is blank] ACKNOWLEDGEMENTS This thesis is dedicated to my mother Trixie Rudder (1937-2008). She loved learning, and encouraged each of her children to continue their education. Research I thank my supervisors, Professor Louis Pilotto and Associate Professor Ellen McIntyre, for mentoring me with such skill and warmth. I have benefitted enormously from their expertise, generosity, and unfailing faith in my ability to complete this doctorate. I thank my PhD colleagues, Dr Ginny Sargent and (soon to be Dr) Jane Anderson-Wurf for their academic support in our isolated rural campus. I cherish their friendship. I thank those who guided and supported my research, by sharing ideas, insights, and wise advice, and those who contributed time and effort so that recruitment, meetings, and writing could be achieved. Dr Lisa Amir, Dr Nina Berry, Dr Wendy Brodribb, Dr Karleen Gribble, Joel Porter, Dr Julie Smith and other researchers and experts have responded kindly to my questions over the past five years. My work stands on the shoulders of so many others. I thank friends and medical colleagues for their interest in my path of research capacity building. I thank Jen Byrne and Australasian Lactation Courses for providing the kit used in practice nurse training, Breastfeeding Management in a Baby Friendly Health Service: An 8 hour structured course for health professionals working with mothers and babies in maternity settings 5th Ed. I thank each of the intervention practice nurses; the outcomes of this study are due to their work. I am grateful for their enthusiasm, their interest in learning, and their care for each patient who walks through the door. The valuable role of practice nursing deserves respect and support from the rest of the team. I thank all the women who participated. Without the generous gift of their time and interest, this study could not have been conducted. I wish them long and fulfilling relationships with their children. 5 Personal I thank past and current fellow volunteers in the Australian Breastfeeding Association (formerly Nursing Mothers') for their enthusiastic, irreverent, and talented support for breastfeeding and parenting. I am grateful for our shared stories of mothering and mother-to-mother support. From the tears and embraces of my early motherhood to the typing of my thesis, their welcome continues to motivate me. Finally, I thank my husband, four children, and my husband's parents for their tolerance and interest over the past five years of my research. I will always be grateful for my husband Glenn's commitment to fathering, his enjoyment of our family, and his constant support in my own journey of mothering (and breastfeeding) our children. Grants 2009 UNSW Postgraduate Student Support Scheme for conference presentation 2007 to 2009 Department of Health and Ageing PhD scholarship 6 DISSEMINATION Peer-reviewed publications Elliott-Rudder M. Researcher networking drives change: an autoenthnographic narrative analysis from medical graduate to primary health researcher. Australian Journal of Primary Health 2010;16:108–115 (Two citations) Smith J, Dunstone M, Elliott-Rudder M. Health professional knowledge of breastfeeding: Are the health risks of infant formula feeding accurately conveyed by the titles and abstracts of journal articles? Journal of Human Lactation 2009;25(3): 350-58. (Seven citations) Smith JP, Dunstone MD, Elliott-Rudder ME. ‘Voldemort’ and health professional knowledge of breastfeeding – do journal titles and abstracts accurately convey findings on differential health outcomes for formula fed infants? Canberra: Australian Centre for Economic Research on Health, Working Paper No. 4 2008; December. (Six citations) Other publications Elliott-Rudder M. Why don’t more women breastfeed? In: Zest for Life. Wagga Wagga: Riverina Division of General Practice and Primary Health, Winter 2008 Elliott-Rudder M. Support for ongoing breastfeeding: A randomised clinical trial endorsed by the APNA Policy & Research Committee. Primary Times 2008;1:16-17 Invited workshops 19 and 26 February 2012: ACT
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