Effect of continuous supportive telephone counselling on improving breastfeeding self-efficacy in mothers with late preterm infants four months after discharge: A randomized, controlled study

The development of any society depends on the health of its people, especially the health of infants and children who are the future makers of a country. Unfortunately, despite all efforts to prevent premature births and the birth of infants with low birth weights, the global birth rate of such infants is still high [1]. In Iran, the prevalence of premature births varies in different cities. According to the findings of the review article, the overall prevalence of premature birth in Iran is 9.2%. Tehran, with 30.4%, has the highest percentage, and Kermanshah, with 2%, has the lowest percentage [1]. Preterm infants are at risk for hypoglycemia, jaundice, nutritional problems, and respiratory distress due to reduced general growth and insufficient maturity [2]. Due to their physiological characteristics, these infants need special care to achieve normal development and survival [3].

Due to the importance of breast milk in the development of preterm infants, it is necessary to focus on promoting exclusive breastfeeding in these infants [4]. For this purpose, in most preterm infants, milk feeding is performed several times a day by gavage. As the baby grows, direct breastfeeding gradually replaces gavage. The transition period from feeding by gavage to the breast or bottle is variable for each infant, with no fixed protocol [5]. Despite regional and global measures to increase breastfeeding choices and extend the duration of exclusive breastfeeding, many mothers still report problems in the postpartum period that lead them to abandon exclusive breastfeeding [6]. This increases the risk of weight loss and stunted growth in early infancy [7]. Behavioural intention and choice of breastfeeding are influenced by some socioeconomic and demographic factors. Also, self-efficacy has been mentioned as one of the effective factors affecting the continuation of breastfeeding in the first six months after discharge [8].

The term self-efficacy, introduced by Bandura, means the belief and confidence in one’s ability to perform healthy behaviour [9]. In this regard, Nichols believes that the higher the breastfeeding self-efficacy of mothers, the longer the duration of exclusive breastfeeding [10]. Implementing interventions that emphasize breastfeeding training can help improve self-efficacy and other consequences of breastfeeding in preterm infants. In most of these studies, the training has been done face-to-face and to a limited extent by telephone [11,12]. There is an information gap on the effectiveness of continuous supportive telephone counselling on postoperative breastfeeding self-efficacy in women with preterm infants. Midwives are in a great position to provide maternal and child health services, so they can play a key role in supporting these mothers as counsellors. Considering the importance of breastfeeding in preterm infants, the role of self-efficacy in continuing breastfeeding in the post-discharge period, and the unavailability of a similar study, the present study aimed to determine the effect of continuous supportive telephone counselling on breastfeeding self-efficacy in mothers with late preterm infants.

Data were analysed using SPSS software version 16. The normality of the data was assessed using the Kolmogorov-Smirnov test. The data had a normal distribution. Chi-square test and Fisher’s Exact Test were used to compare qualitative variables between the two groups, and independent t-test and paired t-test were used to compare quantitative variables. The repeated measurement ANOVA test was used to evaluate the effect of time and group. The significance level was 0.05.

The results independent t-test showed that the mean score of breastfeeding self-efficacy before intervention was 33.18 ± 4.63 in the intervention group and 31.71 ± 4.28 in the control group. The comparison of the two groups’ mean scores of breastfeeding self-efficacy in the pre-intervention stage was not statistically significant (P =0.479). The mean score of breastfeeding self-efficacy in the control group increased at the first month of the follow-up period (32.59 ± 7.36), but it decreased from the second to the fourth month of the follow-up period compared to the period before the intervention. In the intervention group in the same time period, the mean breastfeeding self-efficacy increased from 33.18 to 53.48. The observed differences between the two groups were statistically significant (p = 0.001). The result of paired t-test showed that the comparison of the pre-test mean difference of breastfeeding self-efficacy between four point of post-test were statistically significant in the intervention group but not in the control group (Table 3).

The result of the repeated measurement ANOVA test showed that the change of the mean scores in four time periods between the two groups was also significant (Fig. 2).

Figure 2

The results showed that continuous supportive telephone counselling could effectively improve breastfeeding self-efficacy in the intervention group. The mean breastfeeding self-efficacy in the intervention group increased from 33.18 to 53.48, whereas in the control group, it decreased from 31.17 to 28.56. Sibel Küçükoğlu et al. (2014) showed that performing five days of face-to-face breastfeeding counselling in the hospital and a phone call to mothers with preterm infants one week after discharge could increase breastfeeding self-efficacy up to six months after delivery. This study showed that mothers with higher self-efficacy had fewer breastfeeding problems [4], which is consistent with the results of the present study. It also shows that telephone follow-up after discharge can be effective in improving and maintaining breastfeeding self-efficacy. Brockway (2018) suggested that family-centred counselling could improve breastfeeding self-efficacy in mothers with preterm infants [15], which is consistent with the results of the present study. The current results also showed that telephone counselling, as a cost-effective method, can be as effective as direct counselling in improving breastfeeding self-efficacy in mothers of preterm infants. However, the effectiveness of telephone counselling other than for self-efficacy of breastfeeding in initiating or continuing breastfeeding in these infants has been emphasized in some studies, including the study of Ericson et al. (2018) and Lavender et al. (2013) [11,16]. Also in the study of Akbarian et al. (2017), telephone counselling was associated with a decrease in readmission of preterm infants after discharge [17]. In another study in 2020, Jang et al. reported similar results, showing that conducting three face-to-face training sessions during hospitalization and continuing telephone support counselling every 15 days until 6 months postpartum improved parenting confidence but not the exclusive breastfeeding rate in mothers with preterm infants [18]. It seems that breastfeeding difficulties in late-preterm infants can decrease mothers’ confidence. Bostanabad et al. reported similar results in 2019 [19]. The results of the above studies emphasized the importance of telephone counselling in the post-discharge period in improving neonatal-related outcomes that can be considered by health planners and policymakers. In a contradictory study, Chan Man et al. (2016) showed that having a face-to-face breastfeeding training session in the third trimester of pregnancy and a telephone counselling session in the first week after delivery had short-term effects on improving breastfeeding self-efficacy. The first week after delivery had a significant increase but was not effective in self-efficacy improvement after four weeks of delivery [12]. The results of the above study are not consistent with the results of the present study, probably due to the difference in the type of intervention method. In the present study, continuous supportive counselling was performed in the first two weeks after discharge. Breastfeeding self-efficacy means a person’s belief and confidence in her ability to perform healthy and breastfeeding behaviours [13], which is influenced by some individual and social factors. Breastfeeding self-efficacy in mothers with preterm infants and low birth weight is lower than that of other mothers [8,13]. Expanding the maternal support system, especially after discharge, can be considered one effective solution in this field. The important point about breastfeeding these infants is the presence of a caregiver who can encourage mothers to continue breastfeeding and be responsible for the mothers’ educational needs before and after the birth of the infant and can follow up after discharge [20]. According to the evidence, these mothers are often unable to attend face-to-face counselling classes after discharge due to their baby’s condition. Because software, messengers, and telephone calls are convenient, available, interactive, and reliable, they can be considered in the post-discharge service package for preterm infants [21]. However, due to the variety of protocols and possible costs for purchasing or installing software and using social networks, it is suggested that the effectiveness and cost-effectiveness of using online methods with a continuous consultation approach be compared with periodic consulting in future studies. According to the findings of the present study, it can be concluded that supportive telephone counselling was effective in improving breastfeeding self-efficacy in mothers with preterm infants. It seems that the present approach is an acceptable basis for designing intervention programs in this field, especially for mothers with middle to lower socioeconomic status.

All authors declare that our organizational affiliations are not dependent on any organizations sanctioned by the United States. The research centre is not dependent on sanctioned organizations.