Abstract
Purpose:
To determine whether participants in the Baby Talk prenatal education program were more likely to initiate breastfeeding than nonparticipants.
Design:
Retrospective cohort study comparing women with a singleton pregnancy who were enrolled in Baby Talk with matched controls based on zip code, maternal age, race, language spoken, and payer source.
Setting:
Urban Midwest county.
Sample:
Baby Talk participants enrolled between November 2015 and December 2016 (n = 299) and matched controls identified through vital statistics records who were not enrolled (n = 1190).
Intervention:
A 12-hour prenatal education curriculum with 2.5 hours of breastfeeding content.
Measures:
The primary outcome was breastfeeding at hospital discharge as reported in vital statistics.
Analysis:
Likelihood-ratio χ2 and Fisher exact test were used to test the significant association between categorical variables.
Results:
Baby Talk participants were significantly more likely to initiate breastfeeding (93.65%) than matched nonparticipants (87.48%; P = .003). Non-Hispanic white and black Baby Talk participants were more likely to initiate breastfeeding than controls (96.15% vs 89.83%; 91.03% vs 77.02%, respectively; P < .05).
Conclusions:
Prenatal education has the potential to increase breastfeeding initiation among low-income women, especially non-Hispanic white and black. This study is limited as participants were from a single community, though Baby Talk was offered at 5 separate locations, and potentially from information bias as it was reliant on the accuracy of vital statistics data.
Purpose
Increasing the proportion of infants who are breastfed is a Healthy People 2020 objective, 1 and prenatal classes can promote breastfeeding health advantages, processes, techniques, and resources. 2 Although breastfeeding rates have improved, rates among low-income and non-Hispanic black women lag behind non-Hispanic white and Hispanic women. 3 In Kansas, non-Hispanic black breastfeeding initiation rates are lower than non-Hispanic white (71.5% vs 82.9%). 4 Disparities may be due to inadequate breastfeeding education from providers and lack of access to professional breastfeeding support for non-Hispanic black women. 3,4
Formal breastfeeding education beyond standard antenatal care provides additional information to inform feeding decisions. 5 Such prenatal education increases intentions of non-Hispanic black women to breastfeed; 6 however, there is little evidence on specific educational recommendations 7 or on whether community-based breastfeeding groups impact behaviors. 8 -10
The purpose of this study was to determine whether group prenatal education impacted breastfeeding initiation among low-income participants.
Methods
Design
Retrospective cohort study comparing Baby Talk prenatal education program participants with matched controls.
Sample
Baby Talk participants with a singleton pregnancy (November 2015 to December 2016) were identified by Kansas Department of Health and Environment (KDHE) Vital Statistics staff in a linked birth–death data set of 2016 to 2018 Kansas births. To reduce confounding effects of covariates, propensity score matching identified women with a singleton pregnancy who gave birth in Sedgwick County but were not enrolled in Baby Talk. Greedy nearest neighbor matching matched each Baby Talk participant sequentially with the 4 nearest controls based on zip code, maternal age, race, language spoken, and payer source. In addition, birth weight, gestational age, breastfeeding initiation, and mortality were abstracted.
Measures
The primary outcome was breastfeeding at hospital discharge based on birth certificate reporting.
Intervention
The Baby Talk prenatal education program consists of six 2-hour sessions taught by nurses at clinics serving women at high risk for adverse fetal/infant outcomes. 9 The majority of Baby Talk participants are low income. The curriculum, based on the March of Dimes Becoming a Mom (C), covers healthy pregnancy, labor and delivery, infant feeding and care, and postpartum health. The March of Dimes (Kansas Chapter) and the KDHE contracted local expert organizations to build enhanced curricula around key fetal/infant health priorities 11 and topics desired by parents. 12 Versions of this curriculum have been implemented statewide since 2014.
The Kansas Breastfeeding Coalition developed an enhanced 2-hour breastfeeding session including didactics, videos, demonstrations, and hands-on activities to help women understand the benefits and management of breastfeeding. 11 About 30 minutes of breastfeeding information was added across other sessions, for 2.5 hours of total content. Based on this curriculum, Baby Talk participants showed significant knowledge increases; however behavioral outcomes were not assessed. 9
Analysis
Matching procedures, likelihood-ratio χ2, and Fisher exact test were carried out using SAS version 9.4 (2019, SAS Institute Inc). The University of Kansas School of Medicine-Wichita institutional review board approved this study.
Results
Of 302 Baby Talk participants, KDHE matched infant records for 299 (99%) based on mother’s name, mother’s date of birth, infant sex, and infant date of birth. The pool of potential controls included 20,400 women. The 299 Baby Talk participants were matched with 1190 controls. Demographics are reported in Table 1. Participant age averaged 26 years (standard deviation = 6).
Characteristics From Linked Birth/Death Certificates Stratified by Baby Talk Participants and Matched Nonparticipants.
a Statistically significant (P < .05).
In terms of outcomes, neither birth weight nor gestational age differed between groups (all P > .05). However, Baby Talk participants were significantly more likely to initiate breastfeeding (93.65%) than nonparticipants (87.48%; χ2(1) = 9.077, P = .003). Breastfeeding initiation by race and ethnicity showed non-Hispanic white (96.15% vs 89.83%; χ2(1) = 5.182, P = .023) and black (91.03% vs 77.02%; χ2(1) = 7.381, P = .007) Baby Talk participants were significantly more likely to breastfeed than controls. No infants of Baby Talk participants or controls died before one year of age; Sedgwick County infant mortality rate during this time was 7.3 deaths per 1000 live births.
Discussion
Summary
The association between breastfeeding and maternal–infant health is well established. Breastfed infants have lower risks of illness, such as respiratory infection, gastrointestinal disease, and a reduced risk of sudden infant death syndrome (SIDS). Women who breastfeed are at lower risk of diseases, such as type 2 diabetes, cardiovascular disease, and certain forms of cancer. The cost savings related to medical, nonmedical, and death cannot be overstated. 13 The Healthy People 2020 objective for breastfeeding initiation is 81.9%. 1 Although both Baby Talk and control participants exceeded this (93.65% and 87.40%, respectively), infants born to Baby Talk participants were significantly more likely to be breastfed at hospital discharge. Further, a significant increase in breastfeeding initiation was observed for non-Hispanic black participants, a group that has been identified to have significantly lower initiation rates at the state 4 and national level. 14 This difference may be attributed to multiple factors including: access to the Baby Talk program at 5 locations across the community, enhanced breastfeeding-specific curricula including multiple information delivery methods for different learning styles, provision of the education by nurses, incentives provided to participants who completed all sessions, or the group format which allowed partner/family attendance, discussion, and opportunity to form supportive relationships with other participants.
Limitations
This study is limited as Baby Talk participants were from a single community. It was reliant on the accuracy of data reported on birth certificates. Of the 2 delivering hospitals, 1 was designated Baby-Friendly (R) in June 2015, which may have influenced breastfeeding rates. However, only 45% of Baby Talk participants delivered there, while two-thirds of the county’s babies delivered there. The second hospital, where 55% of Baby Talk participants delivered, launched Baby-Friendly (R) processes in August 2015. The higher initiation rate for the control group (87.4%) may have been influenced by the changes in hospital maternity care practices, despite not participating in the Baby Talk program.
Significance
In conclusion, group prenatal education settings have the potential to increase breastfeeding initiation among low-income women. Additionally, our findings show a significant improvement in vulnerable populations who typically breastfeed at lower rates. Future studies should examine the impact of prenatal education on breastfeeding duration and exclusivity.
So What?
What is already known on this topic?
Breastfeeding improves health outcomes for infants and mothers, and breastfeeding education during pregnancy increases knowledge.
What does this article add?
Group breastfeeding education during pregnancy increases initiation among low-income women, especially non-Hispanic white and black.
What are the implications for health promotion practice or research?
Breastfeeding education during pregnancy should be considered in tandem to high-quality clinical care in order to increase breastfeeding initiation among groups with lower initiation rates.
Footnotes
Authors’ Note
This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U. S. Government.
Acknowledgments
The authors would like to thank Ashley Hervey, MEd, Molly Brown, MPH, and Matthew Engel, MPH for their work on this project.
Declaration of Conflicting Interests
The author(s) declare that there is no clinic of interest. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded in part by the Kansas Department of Health and Environment’s Bureau of Family Health Maternal and Child Health Services Block Grant #B04MC30614 funded by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS).
