Lactation Outcomes Among Dyads Following Participation in a Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

Abstract

Introduction:

MamaCare is an adaptation of the CenteringPregnancy group prenatal care model designed to support women when the pregnancy has been complicated by the presence of known congenital anomalies. The lactation-related outcomes of participants were unknown.

Materials and Methods:

This is a retrospective descriptive cohort study describing the lactation-related outcomes of participants of MamaCare over 43 months. Data collection included abstraction of maternal demographic data, maternal group prenatal care session participation data, maternal pregnancy and delivery data, as well as documented lactation and breastfeeding data.

Results:

The total cohort consisted of 92 dyads. Of the 81 women who received an individualized prenatal nutrition consultation, 65 (80.2%) voiced a prenatal feeding goal of human milk and breastfeeding only, while the remaining 16 (19.8%) expressed goals of combination feeding (human milk and infant formula). For the surviving 85 infants, 91.8% of the mothers initiated lactation on the delivery day and the remaining 7 women initiated lactation on postpartum day 1. Also at the time of discharge from the initial intensive care unit stay, 87.1% of infants were receiving maternal human milk.

Discussion:

Introduction

Patients with prenatally diagnosed fetal anomalies face unique challenges in regard to their prenatal care and lactation support.^1–10 The challenges associated with caring for patients within an international prenatal referral center are a condensed visit schedule, complex social needs, including housing and psychosocial support, as well as an increased need for antenatal surveillance and relatively frequent preterm delivery.^11–13

In December of 2013, the Center for Fetal Diagnosis and Treatment (CFDT) at Children's Hospital of Philadelphia (CHOP) began offering group prenatal care, based on the CenteringPregnancy Model of group prenatal care, to women whose pregnancies had been complicated by a prenatal diagnosis of a fetal anomaly.¹⁴ Research has demonstrated favorable outcomes associated with CenteringPregnancy, including a reduction preterm birth, increased satisfaction with care, and higher rates of breastfeeding.^15–20

CenteringPregnancy models of prenatal care have shown positive impacts on rates of breastfeeding initiation and duration.^19–25 Among 307 women enrolled in a hospital-based midwifery practice in south central Connecticut, women in their CenteringPregnancy program had 2.44 times the odds of breastfeeding initiation compared with those women in the practice's traditional prenatal care program.²⁰ Focusing specifically on the probability of breastfeeding initiation, Robinson and colleagues' systematic review found that participation in CenteringPregnancy significantly impacts the likelihood of breastfeeding initiation by 53% (95% confidence interval = 29–81%, n = 8,047).¹⁹ Also at the time of discharge in a hospital in Tennessee, women in CenteringPregnancy had significantly higher odds of breastfeeding (odds ratio [OR] 2.08, p < 0.001).²⁵

Jafari and colleagues²³ compared breastfeeding outcomes of CenteringPregnancy participants at 2 months postpartum and rates of breastfeeding were higher among the women who were in the CenteringPregnancy model. Similar findings are supported with CenteringPregnancy participants at a residency-based family medicine outpatient office 2.9 times more likely to still be breastfeeding in the postpartum period (p = 0.001).²² Also in regard to rates of exclusive breastfeeding, Brumley and colleagues²⁴ found significantly higher rates of exclusive breastfeeding at 6 weeks postpartum (OR 4.07, p < 0.001) among women choosing the CenteringPregnancy group prenatal care model over traditional models of care.

The CHOP group prenatal care model, named MamaCare, incorporates significant adaptations to accommodate the care of patients with fetal anomalies who typically began care at the CFDT in the late second or early third trimester.¹⁴ To specifically address the lactation care and support needs of MamaCare participants, a doctorally prepared nurse scientist in the field of human milk and breastfeeding facilitates an hour-long presentation focused on the science of human milk as it relates to infants with known congenital anomalies.

The goal of the lactation session in MamaCare is to meet the needs of the families and address any and all lactation-specific concerns they have. To start the discussion, the nurse scientist first asks the families about themselves, where they are from, and their babies' diagnoses. The group discusses any exposure to lactation/breastfeeding and what their goals are for infant feeding. In addition, the nurse scientist asks the group to share any specific questions or concerns about lactation. Each lactation session in MamaCare is tailored to the needs of the families; however, four key tenets are consistent in all sessions: (1) the science of human milk and how human milk is a medical intervention for critically ill infants, (2) the physiology of lactation, (3) creation of a sense of urgency about establishing milk supply, and (4) involvement of the mothers' support person(s) in the initiation and maintenance of lactation. In addition to the content provided in the MamaCare group session, families are provided with an individual prenatal consultation with a member of the hospital's lactation program.^6,26,27

During the lactation MamaCare session, the nurse scientist uses a flip chart book to teach MamaCare participants and support persons about the science of human milk and the specific ways in which human milk improves outcomes for vulnerable infants. This tailor-made book also aids in the discussion of specific components of human milk and how the components work to protect infants from disease and illness (e.g., osteopontin, white blood cells, stem cells, human milk oligosaccharides, antioxidants, antibodies, and lactoferrin). Regarding the physiology of lactation, the families are taught that the mother has been making milk since she was in her 16th week of pregnancy. Families are assured that they have the perfect amount of milk and that every drop of colostrum produced at birth will immediately be used for oral care.²⁸ Participants are taught that the first 4 days of pumping are critical and to focus on schedule (not volume) with a goal to pump within the first hour following the birth and then every 2–3 hours, for a goal of eight or more pumping sessions in a 24-hour day.²⁹ The identified support persons are given a job list with 10 tips to best assist the mother with pumping.²⁹ The participants are also provided a hands-on demonstration of use of the Medela Symphony^® hospital-grade double electric breast pump with Initiation Technology™. Most MamaCare participants are unable to directly feed at the breast due to the congenital anomalies of their infants, so it is of paramount importance that MamaCare participants use research-proven technologies to come to full milk volume.³⁰ By teaching families how to use the Medela Symphony pump's Initiation Technology and two pumping patterns, MamaCare participants are better empowered and prepared to pump after the birth of their infant(s). Lastly, the nurse scientist focuses again on the critical importance of family and friends supporting the mothers to meet their personal breastfeeding goals. The MamaCare participants' support persons are asked to focus on pumping early and often, and making sure that the new mothers are able to visit their infants, eat and hydrate, and rest between pumping sessions.

As MamaCare is an adaptation of CenteringPregnancy, to meet the needs of women with prenatally diagnosed fetal anomalies and their identified support person(s), the study team wanted to better understand the lactation-related outcomes of the MamaCare participants.

Materials and Methods

This study was approved by CHOP's Institutional Review Board (IRB). This study is a retrospective descriptive cohort study that aims to describe the lactation-related outcomes of dyad participants of MamaCare via an electronic chart review and abstraction of maternal demographic data, maternal group prenatal care session participation data, maternal pregnancy and delivery data, as well as documented lactation and breastfeeding data (abstracted from the mother's medical record). Inclusion criteria limited the cohort to MamaCare participants between December 1, 2013, and June 30, 2017. The MamaCare team maintains a data set of all participants of MamaCare and this list was utilized as the main source of cases to consider for the study.

Following IRB approval, the research team used this data set to review the electronic medical records of all dyads who meet the prescribed inclusion and exclusion criteria for demographic, clinical, and lactation-related data elements. The lactation-related data elements included documentation of a completed individual prenatal lactation consultation (yes/no), and if a consultation was completed, the mother's prenatal feeding intentions (human milk, infant formula, or combination). In addition, the research team was able to collect data specific to the timing of lactation initiation following the birth of the infant (delivery day or postpartum day 1) and if the infant, at the time of discharge from the initial intensive care unit stay, was receiving maternal human milk (yes/no).

All data were electronically stored and managed using a secure REDCap database of which only study team members had access. All fields containing personal health information were marked as such to protect the confidentiality of study participants during data collection and data analysis. Following completion of the chart abstractions, all study data were checked and cleaned by the second author. Demographic, clinical, and lactation-related characteristics were then analyzed by standard descriptive summaries: means and standard deviations for continuous variables and percentages for categorical variables.

Results

The total cohort consisted of 92 dyads: 92 mothers and 93 infants (1 set of twins) (Table 1). Forty-eight (52.7%) of the women relocated to Philadelphia, Pennsylvania, for their prenatal care. The majority of the cohort (n = 71, 77.2%) had private medical insurance. The average age of the maternal participants was 29.5 years with a range of 18 to 45 years. In addition, 88.9% of the maternal participants (n = 80) had a support person attend the MamaCare sessions with them: husband (n = 50), partner (n = 6), father of infant (n = 6), participant's mother (n = 19), participant's aunt (n = 3), participant's father (n = 2), participant's grandmother (n = 2), participant's grandfather (n = 2), participant's cousin (n = 2), participant's mother in law (n = 2), participant's sister (n = 1), participant's friend (n = 1), and doula (n = 1). MamaCare consists of a total of four sessions and the majority of MamaCare participants (n = 59, 64.1%) were able to attend all four. Due to the nature of the population and the potential for early deliveries, 20 dyads (22.2%) participated in MamaCare postpartum. Other documented reasons for missed sessions included schedule confusion, transportation, changes in fetal status, and one participant lost interest in participation.

Table 1.

Demographics

n = 92 dyads (92 mothers, 93 infants [1 set of twins])	Frequency (%)	Mean (mdn; range)
Relocated for prenatal care and delivery	48 (52.7)
Home state, PA	47 (51.1)
Insurance
Private	71 (77.2)
Public	20 (21.7)
None	1 (1.1)
Maternal age (years)		29.5 (mdn 29; range 18–45)
Gravida		2 (mdn 2; range 1–7)
Para		0 (mdn 0; range 0–3)
Fetal diagnoses
Cardiac	32 (34.8)
Neurologic	19 (20.7)
Congenital diaphragmatic hernia	14 (15.2)
Gastroschisis	12 (13)
Lymphangioma	3 (3.3)
Sacrococcygeal teratoma	3 (3.3)
Omphalocele	3 (3.3)
Multiple congenital anomalies	3 (3.3)
Other	3 (3.3)
Palliative care consult	1 (1.1)
Support person participated in MamaCare	80 (88.9)
Number of MamaCare sessions completed
4	59 (64.1)
3	20 (21.7)
2	7 (7.6)
1	6 (6.5)
Attended MamaCare sessions postpartum	20 (22.2)
Planned route of delivery
Vaginal	59 (64.1)
Cesarean	33 (35.8)
Route of delivery
Vaginal	41 (44.6)
Cesarean	51 (55.4)
Infant's survival	85 (92.4)
Infant's gestational age (weeks)		37.5 (mdn 38; range 28.7 – 40.4)
Infant's birth weight (grams)		2,953.5 (mdn 2,980; range 1,387–4,290)
Infant's length of stay (days)		40 (mdn 20; range 3–313)
Human milk at discharge	74 (87.1)
Prenatal nutrition consultation	81 (88)
Mother's feeding intention
Human milk/breastfeeding	65 (80.2)
Combination	16 (19.8)
Timing of lactation initiation
Delivery day	78 (91.8)
Postpartum day 1	7 (8.2)

mdn, median.

In addition to the 92 MamaCare participants receiving an hour-long presentation related to human milk and breastfeeding during a MamaCare session, 81 (88%) of the mothers (and families) received an individual prenatal nutrition consultation from a member of the hospital's lactation program. Also, of the 81 women, 65 (80.2%) voiced a prenatal feeding goal of human milk and breastfeeding only, while the remaining 16 (19.8%) expressed goals of combination feeding (human milk and infant formula).

Sadly, seven infants did not survive, and therefore, lactation initiation data and rates of human milk at discharge were not collected for those seven dyads. For the surviving 85 infants, 91.8% of the mothers initiated lactation on the delivery day and the remaining 7 women, initiated lactation on postpartum day 1. Also, at the time of discharge from the initial intensive care unit stay, 87.1% of infants were receiving maternal human milk.

Discussion

The provision of human milk to hospitalized neonates with complex conditions is a life-saving intervention.³¹ Unfortunately, in many settings, the provision of human milk and ensuring that all families receive research-based lactation care and intervention are not a top priority.³² At the study's setting, human milk and breastfeeding are the predominant cultural norm, but this is a culture that has been established over the past 18 years.^33,34

For families who participate in MamaCare, not only do they form a sense of community and learn about human milk and breastfeeding before delivery, the MamaCare facilitators and presenters also normalize their experience to help MamaCare participants and support persons to understand that even though their start to lactation and breastfeeding may have not been what they initially planned, all of the clinicians and staff will partner with them to ensure that they can meet their personal breastfeeding goals.²⁷

Pregnant mothers whose newborns will be admitted directly to an intensive care unit benefit from prenatal education about the benefits of human milk, lactogenesis, and the care and cleaning of breast pumps and accessories.^27,35 Ample evidence has demonstrated the benefits of peer support for improving breastfeeding outcomes.³⁶ The present article suggests that a group care model may offer valuable support for meeting lactation-related goals among a cohort of mothers whose neonates will be admitted to an intensive care unit.

Clinicians at the study setting are sensitive to the fact that not all infants of MamaCare participants may survive, but that MamaCare and the lactation care and education are meaningful to all families. The participants of MamaCare are invited to attend a yearly reunion. During the reunion, the provision of human milk and breastfeeding are a major topic of conversation. The senior author of this article had an experience with a MamaCare family at a recent reunion, which demonstrates the meaning. The mother and her mother came to the reunion even though her child had not survived. At the reunion, the mother passed around her phone and shared videos of her doing human milk oral care with her child. She talked to the other families about how her child knew her and how she had an attachment with her child by pumping for her child and doing the child's human milk oral care multiple times every day. The mother also shared with the other families that all of the milk that she pumped while her child was alive was going to save the lives of many other infants in the study setting's neonatal intensive care unit. This mother was going to donate an entire freezer of milk she pumped to the setting's milk bank as she shared with the other families that she was in the process of being an approved milk donor. This narrative further supports how the provision of evidence-based human milk and lactation support can transform families' lives, even if it is not the outcome that we all hope for.

Conclusion

Group prenatal care has consistent research-proven improved outcomes. Although the team at the study setting had to modify and adapt the CenteringPregnancy model of group prenatal care, the team has demonstrated improved patient satisfaction and lactation-related health outcomes.¹⁴ The provision of human milk and breastfeeding are an important public health initiative. Unfortunately, in much of the clinical lactation-related research, mothers who have infants with congenital anomalies are excluded in the study populations. This research is the first study that specifically examines the role of group prenatal care, prenatal lactation interventions, and lactation outcomes of women with pregnancies complicated by the presence of known congenital anomalies.

This research is important not only to improve the health outcomes of infants with congenital anomalies but also to improve the experiences of the families and their attachment to their infants. Research demonstrates the importance of human milk oral care for families to bond with their infants.²⁸ This research adds to the body of knowledge of the importance of prenatal preparation and family involvement to ensure that all families can reach their personal breastfeeding goals.

Footnotes

Acknowledgments

We are so thankful for the families that we have been able to partner with through MamaCare. Being able to be with them through this life-changing experience has also changed our lives and gives meaning to the research and clinical care that we provide.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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