Validity and Reliability of the Infant Breastfeeding Assessment Tool,the Mother Baby Assessment Tool,and the LATCH Scoring System

Abstract

Aim:

We aimed to evaluate the validity and reliability of the Infant Breastfeeding Assessment Tool (IBFAT), the Mother Baby Assessment (MBA) Tool, and the LATCH scoring system.

Subjects and Methods:

Mothers who delivered healthy, full-term infants in the Obstetrics & Gynecology Service of Gazi University, Ankara, Turkey, between December 2013 and January 2014 and their infants were included in the study. Forty-six randomly selected breastfeeding sessions were monitored and scored simultaneously by three researchers (Raters 1, 2, and 3) using LATCH, IBFAT, and the MBA Tool. Researchers put the score sheets in an envelope in order to hide them from each other. The compatibility of the scores given by three researchers was assessed by statistical methods.

Results:

We found positive and significant correlation coefficients between 0.81 to 0.88 for the total MBA score, between 0.90 to 0.95 for the total IBFAT score, and between 0.85 to 0.91 for the total LATCH score. Correlation coefficients testing these three tools ranged from 0.71 to 0.88, with the minimum value being noted for the correlation between LATCH and IBFAT scores and the maximum value being noted for the correlation between LATCH and MBA scores.

Conclusions:

We found positive and significant correlations between researchers' scores for 46 observations using the three assessment tools. This study showed that these above-mentioned tools were compatible for the assessment of the efficiency of breastfeeding.

Introduction

Although there have been efforts to increase breastfeeding initiation, duration, and exclusivity throughout the world, breastfeeding rates are still not at the desired levels. Even in countries with high levels of breastfeeding initiation, exclusively breastfeeding cannot be sustained for various reasons.^1–4 Although breastfeeding initiation rate was 74%, the exclusive breastfeeding rate in the first 6 months was found to be 23.6% in Turkey according to 2008 data.⁵ Studies have established several risk factors for suboptimal breastfeeding and early weaning.^6–10 Hospitals have great responsibility for assessment of breastfeeding and determination of mother–infant pairs at risk for early weaning. Pairs of mother and baby should be closely monitored after birth and pairs at risk for breastfeeding failure should be further supported. However, healthcare professionals have limited time to assess breastfeeding and identify those who are at risk for breastfeeding problems considering short hospital stays.

Over the years, several tools have been developed to assess the breastfeeding behavior and predict breastfeeding problems. These include the Infant Breastfeeding Assessment Tool (IBFAT), the Mother Baby Assessment (MBA) Tool, and the LATCH scoring system.^11–13 These tools quantify the breastfeeding behavior and the measure the efficacy of breastfeeding. The validity and reliability of the tools have been addressed in a few studies. The aim of the study was to evaluate the validity and reliability of the LATCH, IBFAT, and MBA for the assessment of breastfeeding.

Subjects and Methods

Mothers who delivered healthy and full-term infants in the Obstetrics & Gynecology Service of Gazi University, Ankara, Turkey, between December 2013 and January 2014 and their infants were included in the study. Infants requiring intensive care and with congenital abnormalities were excluded from the study. The study was approved by the local ethics committee. Written informed consent was obtained from each mother following a detailed explanation of the study. Three voluntary researchers were chosen according to their experience for breastfeeding assessment (Raters 1, 2, and 3).

Forty-six breastfeeding sessions randomly selected were monitored simultaneously by these three researchers and scored for LATCH, IBFAT, and the MBA Tool. Researchers put the scores in an envelope in order to hide them from each other. Data entry and statistics were done by a statistician other than these three researchers. The compatibility of the scores given by three researchers was assessed by statistical methods.

Instruments

The LATCH breastfeeding assessment tool was developed by Jensen et al.¹³ in 1994 to assist healthcare professionals in evaluating the breastfeeding techniques of mother–infant dyads. The tool provides a systematic documentation and standardization. Each letter in the acronym describes a different area of assessment: L describes the ability of the infant to latch onto the breast, A describes audible swallowing noted at the breast, T describes the type of the nipples, C describes the comfort level of the mother regarding her breasts, and H measures the amount of help the mother requires to position her baby at the breast. A numerical score (0, 1, or 2) is assigned to each measure for a possible total score of 10.

The IBFAT was developed to measure rooting, fixing, and suckling behavior of the infant during a feeding.¹¹ The first item of the tools assesses whether the infant is quite alert, drowsy, crying, or sleeping at the start of the feed. Items 2–5 measure the infant's readiness to feed and rooting, fixing, and suckling behaviors. Item 6 assesses the satisfaction of the mother with the breastfeeding experience. In this study, we did not score the last item and assess the satisfaction of the mother with the feeding experience. The range of scores for each component is 0–3. A total score can range from 0 to 15.

The MBA Tool was developed to assess the process of learning to breastfeed.¹² The Tool divides the learning process into the following five steps: signaling, positioning, fixing, milk transfer, and ending. Considering that breastfeeding is a mutual effort, both the mother's and the infant's behaviors are assessed in each step. Ten is the highest possible score (5 for maternal behaviors and 5 for infant behaviors in each of the steps) and indicates a highly effective feeding.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences software (version 20.0; SPSS Inc., Chicago, IL) and Microsoft^® (Redmond, WA) Excel^® 2010. Normality distribution was tested using the Kolmogorov–Smirnov/Shapiro–Wilk test. As the data met normal distribution assumption, the Spearman correlation coefficients were calculated to determine the correlation among the three rates. A p value of <0.05 was considered statistically significant.

Results

Estimated inter-rater reliability obtained using Spearman correlation coefficients between raters' scores ranged from 0.45 to 0.57 for maternal signaling behavior. Although the correlation was positive and strong between the scores of Rater 1 and Rater 2 as well as the scores of Rater 1 and Rater 3 (r=0.57 and r=0.51, respectively; p<0.001 for both comparisons), there was a positive but moderate correlation between the scores of Rater 2 and Rater 3 (r=0.45, p=0.001).

Regarding signaling behavior of the infant, there was a positive strong correlation between the scores of Rater 1 and Rater 2 and between the scores of Rater 2 and Rater 3 (r=0.55 and r=0.58, respectively; p<0.001 for both comparisons); however, the correlation was positive and moderate between the scores of Rater 1 and Rater 3 (r=0.46, p=0.001).

The Spearman correlation coefficient among raters' scores ranged from 0.49 to 0.58 for positioning behavior of the mother. The correlation between the scores of Rater 1 and Rater 2 was positive but moderate (r=0.49, p=0.001). On the other hand, the correlations between the scores of Rater 1 and Rater 3 and between the scores of Rater 2 and Rater 3 were positive and strong (r=0.58 and r=0.51, respectively; p<0.001 for both comparisons). The Spearman correlation coefficients for positioning behavior of the infant ranged between 0.42 and 0.67, with the highest correlation coefficient being noted between the scores of Rater 2 and Rater 3 (r=0.67, p<0.001).

For the fixing behavior of the mother, the correlation coefficients between raters' scores ranged from 0.49 to 0.58, with the highest coefficient noted for the positive and strong correlation between the scores of Rater 1 and Rater 3 (r=0.58, p<0.001). The correlation was also strong and positive between the scores of Rater 2 and Rater 3 (r=0.51, p<0.001); however, the correlation was positive but moderate between the scores of Rater 1 and Rater 2 (r=0.49, p<0.001).

The correlation for the fixing behavior of the infant was positive and strong between the scores of Rater 1 and Rater 2 as well as between the scores of Rater 2 and Rater 3 (r=0.52 and r=0.67, respectively; p<0.001 for both comparisons). On the other hand, a positive moderate correlation was noted between the scores of Rater 1 and Rater 3 (r=0.42, p<0.001).

The correlations among raters' scores were all positive and strong for the milk transfer behavior of both mother and infant (p<0.001 for all comparisons). Similarly, there were positive strong correlations among scores regarding the ending behavior of both mother and infant (p<0.001 for all comparisons).

The Spearman correlation coefficients between rater's scores ranged from 0.81 to 0.88 for total MBA score. The correlations between raters' scores were all positive and strong for total score (p<0.001 for all comparisons). The correlation coefficients for these comparisons are given in Table 1.

Table 1.

Spearman Correlation Coefficients for Mother Baby Assessment Tool Scores

	Rater 2	Rater 3
Signaling
Mother
Rater 1	0.57	0.51
Rater 2	—	0.45
Infant
Rater 1	0.55	0.46
Rater 2	—	0.58
Positioning
Mother
Rater 1	0.49	0.58
Rater 2	—	0.51
Infant
Rater 1	0.52	0.42
Rater 2	—	0.67
Fixing
Mother
Rater 1	0.49	0.58
Rater 2	—	0.51
Infant
Rater 1	0.52	0.42
Rater 2	—	0.67
Milk transfer
Mother
Rater 1	0.65	0.61
Rater 2	—	0.71
Infant
Rater 1	0.82	0.52
Rater 2	—	0.70
Ending
Mother
Rater 1	0.75	0.56
Rater 2	—	0.66
Infant
Rater 1	0.62	0.62
Rater 2	—	0.81
Total score
Rater 1	0.88	0.81
Rater 2	—	0.82

There was a positive strong correlation among raters' scores for individual items and total IBFAT score. The lowest correlation coefficients were noted for the first item of the tool, ranging from 0.70 to 0.78 (p<0.001 for all comparisons; Table 2).

Table 2.

Spearman Correlation Coefficients for Items 1–5 of the Infant Breastfeeding Assessment Tool

	Rater 2	Rater 3
Infant's alert state
Rater 1	0.70	0.78
Rater 2	—	0.77
Readiness to feed
Rater 1	0.92	0.88
Rater 2	—	0.86
Rooting
Rater 1	0.90	0.80
Rater 2	—	0.80
Fixing
Rater 1	0.92	0.84
Rater 2	—	0.83
Suckling
Rater 1	0.87	0.86
Rater 2	—	0.87
Total score
Rater 1	0.95	0.92
Rater 2	—	0.90

The correlations between raters' scores were strong and positive for each item and total LATCH score. The Spearman correlation coefficients ranged from 0.65 to 0.91 (p<0.001 for all comparisons; Table 3).

Table 3.

Spearman Correlation Coefficients for LATCH Scores

	Rater 2	Rater 3
Latch on
Rater 1	0.68	0.72
Rater 2	—	0.85
Audible swallowing
Rater 1	0.89	0.79
Rater 2	—	0.83
Type of nipple
Rater 1	0.90	0.78
Rater 2	—	0.90
Comfort level of the mother
Rater 1	0.80	0.79
Rater 2	—	0.65
Help required for positioning
Rater 1	0.81	0.76
Rater 2	—	0.80
Total score
Rater 1	0.90	0.85
Rater 2	—	0.91

Each letter in the acronym LATCH describes a different area of assessment: L describes the ability of the infant to latch onto the breast, A describes audible swallowing noted at the breast, T describes the type of the nipples, C describes the comfort level of the mother regarding her breasts, and H measures the amount of help the mother requires to position her baby at the breast.

Spearman correlation coefficients among the three tools ranged from 0.71 to 0.88, with the minimum value being noted for the correlation between LATCH and IBFAT scores and the maximum value being noted for the correlation between LATCH and MBA scores (Table 4).

Table 4.

Correlations Between Pairs of the Three Breastfeeding Assessment Tools

Instrument	R
LATCH and IBFAT	0.71
MBA and IBFAT	0.86
LATCH and MBA	0.88

IBFAT, Infant Breastfeeding Assessment Tool; MBA, Mother Baby Assessment. Each letter in the acronym LATCH describes a different area of assessment: L describes the ability of the infant to latch onto the breast, A describes audible swallowing noted at the breast, T describes the type of the nipples, C describes the comfort level of the mother regarding her breasts, and H measures the amount of help the mother requires to position her baby at the breast.

Discussion

There is an ongoing controversy in the literature regarding the validity and reliability of the tools. Adams and Hewell¹⁴ reported that the LATCH was reliable for the assessment of breastfeeding based on high percentages of agreement among raters in their study in which they used direct observations rather than videotapes. On the contrary, in their study on the reliability and validity of LATCH, IBFAT, and MBA, Riordan and Koehn¹⁵ rated 23 breastfeeding observations and reported estimates of inter-rater reliability ranging between 0.27 and 0.69 for the IBFAT, between 0.11 and 0.46 for the LATCH, and between 0.33 and 0.66 for the MBA. The highest correlation was noted between MBA and IBFAT scores, and the lowest was noted between LATCH and MBA scores (r=0.78 and r=0.68, respectively). Percentages of agreement among raters were highly variable, with the minimum agreement noted in milk transfer in the MBA and the maximum agreement noted in nipple type in the LATCH.¹⁴ Based on these findings, the authors suggested that these tools were not reliable and thus could not be used in clinical practice in their current form; they attributed these findings to the fact that the tools was developed recently and not yet revised based on findings of a reliability and validity testing. A more recent study by Riordan et al.,¹⁶ however, reported a significant correlation between mothers' and nurses' assessment scores (r=0.58, p<0.05) that were both positively correlated with the duration of breastfeeding (r=0.22 and r=0.26, respectively; p<0.05 for both comparisons). The authors concluded that these findings supported the validity of the LATCH tool and were consistent with the previous research of Adams and Hewell¹⁴ and Matthews,¹¹ who reported 91% inter-rater reliability between mothers' and raters' scores.

Similarly, in their study investigating the correlation of IBFAT and LATCH scores with maternal satisfaction and breastfeeding problems, Schlomer et al.¹⁷ reported that despite the lack of statistical significance, maternal satisfaction scores tended to increase and breastfeeding problem scores tended to decrease with increasing LATCH and IBFAT scores.

In the current study, we found positive and significant correlations between raters' scores for 46 observations scored using the three assessment tools. Although correlations between raters' scores for some of the individual items fell below the cutoff point, they were >0.80 when considering total scores. We reported correlation coefficients ranged between 0.81 and 0.88 for the total MBA score, between 0.90 and 0.95 for the total IBFAT score, and between 0.85 and 0.91 for the total LATCH score. These values were higher than those reported by Riordan and Koehn.¹⁵ Moreover, the correlations were >0.80 between MBA and IBFAT scores as well as between LATCH and MBA scores (r=0.86 and r=0.88, respectively). However, correlation between LATCH and IBFAT scores fell below the cutoff (r=0.71).

We found that the three breastfeeding assessment tools were both compatible and reliable. These tools were not very time consuming according to our observations. It is also important to note that we used well-trained researchers to assess these tools, which may have increased the correlation rates. We propose that the staff members who give these tests should be trained accordingly. However, these tests have several shortcomings. For example, we observed that it was not possible to evaluate awake, irritable babies with IBFAT. We believe that the mother's emotional state and breast volume are important for breastfeeding success. In the light of these considerations, we propose that new tests that include the emotional status of the mother should be developed.

In conclusion, this study showed that these three tools are both reliable and compatible to assess breastfeeding.

Footnotes

Disclosure Statement

No competing financial interests exist.

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