|Year : 2020 | Volume
| Issue : 2 | Page : 143-149
Effectiveness of simulation-based teaching on manual expression of breast milk among mothers of babies admitted in the neonatal unit, South India
Jane Emily Beatrice1, Ebenezer Ellen Benjamin2, Jenny Rajesh2, Reeta Vijayaselvi3
1 Jr.Lecturer, College of Nursing, CMC, Vellore, India
2 Professor, College of Nursing, CMC, Vellore, India
3 Professor, Department of Obstetrics and Gynaecology, CMC, Vellore, India
|Date of Submission||20-May-2019|
|Date of Decision||11-May-2020|
|Date of Acceptance||01-Sep-2020|
|Date of Web Publication||19-Feb-2021|
Mrs. Jane Emily Beatrice
College of Nursing, CMC, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Feeding sick new born with breast milk is challenging. Mothers of sick infants must express breast milk until their infants are able to feed directly from the breast. Therefore, it is very important to teach the mothers whose babies are admitted in the Neonatal unit about the correct method of manual expression of breast milk. Marmet Hand Expression Technique requires practice, skill and co-ordination. Hence, appropriate teaching method and content is much needed to educate and train the postnatal mothers. The study aims to determine the effectiveness of simulation-based teaching on the manual expression of breast milk. A quasi-experimental research design was undertaken for 6 weeks. Seventy mothers were selected using simple random sampling technique. A knowledge questionnaire and an observational checklist were used to collect data on knowledge and practice from mothers on the Marmet technique of milk expression. Data were collected for the control group with routine teaching in the nursery for the first 3 weeks and the next 3 weeks for the experimental group with simulation-based teaching. Pre-test assessment was made for both groups. Post-test assessment for knowledge was made after 72 h of the teaching. Post-test assessment for practice was made at 24, 48, and 72 h of teaching. The study revealed that there was a statistically significant increase in the knowledge and practice of mothers on the manual expression of breast milk (P < 0.001) in the experimental group. This study identified that simulation-based teaching was an effective teaching tool. Knowledge gained through this research will be used to implement the simulation-based teaching for educating the postnatal mothers on manual expression of breast milk in the Neonatal unit.
Keywords: Breast milk, manual expression, marmet hand expression technique, mothers, simulation-based teaching
|How to cite this article:|
Beatrice JE, Benjamin EE, Rajesh J, Vijayaselvi R. Effectiveness of simulation-based teaching on manual expression of breast milk among mothers of babies admitted in the neonatal unit, South India. Indian J Cont Nsg Edn 2020;21:143-9
|How to cite this URL:|
Beatrice JE, Benjamin EE, Rajesh J, Vijayaselvi R. Effectiveness of simulation-based teaching on manual expression of breast milk among mothers of babies admitted in the neonatal unit, South India. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Jul 26];21:143-9. Available from: https://www.ijcne.org/text.asp?2020/21/2/143/309851
| Introduction|| |
Breastfeeding is an incredible gift from God which can meet the needs of the pre-term as well as term babies and the needs of the growing infant. Breastfeeding has shown improvement in infant and maternal health outcomes in both the developed and developing countries. Breast milk is widely recognised as the optimal feeding not only for the term babies but also for pre-term infants, even if the newborn is in the neonatal intensive care unit (NICU). Breastfeeding, benefits the newborn beyond the period of breastfeeding itself. Hence, it is important to support the mother to breastfeed her child, to improve the quality of life for mother as well as newborn. Breastfeeding has a major impact in providing essential immunity to the child and helps to protect them from various diseases and therefore, all health-care professionals should promote and support breastfeeding. The World Health Organisation and the American Academy of Paediatrics recommend exclusive breastfeeding for the first 6 months of life including sick newborns and pre-term infants and advises on supplemented breastfeeding up to 2 years or more to reduce the death of under-five children. According to United Nations Report nearly one lakh children die every year in India due to diseases that can be prevented through breastfeeding. The report also notes that mortality related to inadequate breastfeeding accounts to the cost of 14 billion dollars per year for our country. In developing countries such as India, China, Nigeria, Mexico and Indonesia poor breastfeeding is responsible for >236,000 child deaths every year among children under 5 years of age.
Significance and need for the study
Breastfeeding sick infant is a unique challenge. It includes establishing and maintaining milk supply in the mother as well as changing the baby from gavage feeding to breastfeeding. Mothers of sick newborns must express their breast milk for weeks or months until their infant is able to feed directly from their breast. The major challenge for mothers in establishing breastfeeding is insufficient production of breast milk. Therefore, the health-care team needs to emphasise the importance of establishing and maintaining lactation through expression of breast milk. Mothers who cannot start direct breastfeed immediately but had continue to supply breast milk for their premature or ill infants should be encouraged to start expressing their breast milk as early as possible and 8–10 times in every 24 h to establish and maintain a good lactation.
In November 2016, the United Nations Human Rights Commission issued a joint statement on protection, promotion and support of breastfeeding. Therefore, the pivotal role of health care providers is to bridge the gap between knowledge and practice of breast milk expression among feeding mothers. Especially for the mothers of sick newborn, there is increased stress due to separation from newborns which can interfere with the establishment of breastfeeding and thereby increases the risk of developing complications.
Eglash and Malloy voiced that hand expression is an important skill for every breastfeeding mother. The Baby-Friendly Hospital Initiative recommends that all mothers must be taught about the effective manual expression of breast milk before discharge. Morton has quoted that hand expression of milk has been an under-utilised skill among breastfeeding women and highlights the benefits of knowing how to express breast milk without the use of expensive or cumbersome pumps. The manual expression of breast milk (Marmet technique) requires systematic skill, practice and coordination. In India and abroad there are very few studies done in this regard. Hence, the researcher felt the need to identify the effectiveness of manual expression of breast milk using the Marmet technique. Marmet technique is the most widely referenced, simple and efficient method specially designed to use for long-term expression of breast milk. The mothers can achieve the best results with this technique when practised accurately.
Most of the mothers whose newborns are admitted in NICU need to express breast milk for their babies. The mothers with inadequate knowledge on milk expression have higher chances of decreased lactation and are prone to develop complications related to inadequate breast emptying. Infants of mothers who are unable to establish good lactation often are initiated on supplemental feeds too early and may later present with gastrointestinal infections and feed intolerance. Hence, it is very important to teach the correct method of breast milk expression to the mothers with sick child in the neonatal unit to ensure continuation of lactation.
- To compare the knowledge and practice of mothers on manual expression of breast milk before and after the standard teaching method in the control group and the simulation-based teaching method in the experimental group
- To determine the effectiveness of simulation-based teaching on knowledge and practice of mothers on the manual expression of breast milk
- To compare the breast milk amount in the control group and experimental group at pretest and post-test.
| Methodology|| |
A quasi-experimental research design was chosen for the study as control and experimental groups were chosen separately without random allocation. The population consisted of all the postnatal mothers whose babies were admitted in NICU who fulfilled the inclusion criteria. Mothers whose newborn were admitted in the NICU requiring the expression of breast milk who can comprehend specific languages were included in the study using simple random sampling method. Totally 70 mothers were included in the study with 35 mothers in each arm.
The sample size was calculated using the following formula:
The instrument consisted of three sections:
- Section A: The demographic and clinical variables assessed in the study were age, education and occupation, type of family, residence, previous knowledge, parity, mode of delivery and amount of milk expressed per expression
- Section B: A self-administered investigator prepared knowledge questionnaire was used to assess the knowledge of mothers on the manual expression of breast milk. The questionnaire had 20 single choice questions and was available in Tamil, English and Telugu and the mothers were allowed to choose according to the preferred language. Each correct answer carried one mark. The score was interpreted as inadequate knowledge (0%–50.9%), moderately adequate knowledge (51%–75.9%) and adequate knowledge (76%–100%)
- Section C: Observational practice checklist was used to assess the skill on manual expression of breast milk. This section had 10 steps from 'Marmet Technique'regarding the practice of manual expression of breast milk.
The content validity of each item was calculated and the content validity index was 0.8 for both knowledge and practice tool. The reliability of the instruments (knowledge and practice) was assessed by checking the internal consistency using Cronbach's alpha and was found to be 0.72. The pilot study and the main study were conducted after obtaining approval from the College of Nursing Research Committee. Informed written consent from the participants was obtained before participating in the study. Privacy and confidentiality of subject-related information were ensured.
Data collection procedure
First 3 weeks (control group)
The investigator-assessed the knowledge of the 35 mothers using self-administered questionnaire. After administering the knowledge questionnaire, the researcher observed the mother's practice on manual breast milk expression using the 'Marmets technique' observational checklist. The amount of milk expressed per expression was also measured and documented. After 72 h, the investigator visited the mothers and assessed the knowledge using the same questionnaire and observed the practice of the mothers on breast milk expression using the same checklist. The regular health teaching on breastfeeding and instructions on manual expression was continued by the nursing staff in the unit.
Next 3 weeks (experimental group)
The investigator assessed the knowledge of another 35 mothers using self-administered questionnaire. After administering the knowledge questionnaire, the researcher observed the mother's practice on manual breast milk expression using the 'Marmets technique' observational checklist. The amount of milk expressed per expression was also measured and documented. After assessing the knowledge and practice, the investigator provided simulation-based teaching on Manual expression of breast milk. After the teaching, the investigator assessed the practice of the mothers on the manual expression of breast milk using Marmet technique observational check list, once immediately after the teaching, and then at 24 and 72 h. Post-intervention knowledge was assessed at 72 h.
All the categorical variables were summarised using frequencies and percentages. Quantitative variables were summarised using mean and standard deviation for normally distributed variables. Two sample t-test was used to compare the knowledge and practice among mothers on the manual expression of breast milk between the experimental and control group. The Chi-square test was used to find an association between the categorical demographic variables and clinical variables on knowledge and practice of mothers regarding manual expression of breast milk and two-sample t-tests was used to compare means of the continuous demographic variables and clinical variables. For all the analyses, 5% level of significance was considered to be significant.
| Results|| |
With regard to demography [Table 1], about half the proportion (51.4%) of mothers in the control group were in the age group of 21–25 years and the same proportion were between 26 and 30 years in the experimental group. With regard to the educational qualification, 48.6% and 31.4% of the mothers were graduates in the control group and experimental group, respectively. In both groups, the majority of the mothers were homemakers and belonged to the joint family. About half (51.4% and 57.1%) of the mothers were from urban setting in the control and experimental groups.
|Table 1: Distribution of mothers according to demographic and clinical variables in both control and experimental group (n=70)|
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Findings also showed that 54.3% had not received any information about the manual expression of breast milk in the control group compared to 80% who did not have any information in the experimental group. Similarly, the proportion of primi mothers were higher in the experimental group (82.9%) compared to 65.7% in the control group.
At pre-test, the majority of the mothers in both control and experimental groups (88.58%, 85.72%) demonstrated inadequate knowledge as well as inadequate practice (100%, 91.43%), respectively [Figure 1].
|Figure 1: Distribution of mothers according to levels of knowledge and practice in control and experimental groups at pre-test|
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In the post–test, a larger proportion of mothers demonstrated adequate knowledge (65.72%) and adequate practice (97.2%) in the experimental group compared to the control group where none demonstrated adequate knowledge or adequate practice [Figure 2].
|Figure 2: Distribution of mothers according to levels of knowledge and practice in control and experimental groups at post-test|
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In the experimental group, in the post-test, 88.58% demonstrated adequate practice immediately after simulation teaching and 97.2% continued to exhibit adequate practice even after 72 h [Figure 3].
|Figure 3: Distribution and comparison of post-test practice of mothers in the experimental group|
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The increase in the mean difference in knowledge and practice of the mothers between control and experimental was statistically significant with the P < 0.001 [Table 2].
|Table 2: Comparison of mean knowledge and practice scores of mothers in control and experimental group|
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[Table 3] shows an increase in the amount of breast milk per expression between pre- and post-assessment in both control and experimental groups. However, the mean increase in breast milk amount was significantly higher (P < 0.002) in the experimental group.
|Table 3: Comparison of difference in breast milk and the amount per expression in the control and experimental group|
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| Discussion|| |
The demographic and clinical variables assessed in the study were age, education, and occupation, type of family, residence, previous knowledge, parity mode of delivery and amount of milk expressed per expression. The investigator found that among the subjects, more than half of them belonged to the age group of 21–25 years (51.4%) in the control group and 26–30 years (51.4%) in the experimental group, respectively. This result was in congruence with the results of a study done at Ethiopia among lactating mothers. The study revealed that the majority (68.5%) of the subjects belonged to the age group of 20–30 years.
While comparing the educational status of the subjects a major proportion were graduates, with 48.6% in the control group and 31.4% in the experimental group. This result was in accordance with a study conducted by Shamili et al. among working postnatal mothers which showed that most (65%) of the mothers were graduates. However, in this study, majority of the mothers were homemakers with 82.9% and 88.6% in the control and experimental group, respectively. Although major proportion had a higher level of education, they were not working at the time of study and many of them expressed that they resigned their jobs for safe confinement.
Most of them belonged to joint family with 65.7% in the control group and 71.4% in the experimental group. While comparing the area of residence nearly half of the subjects were from urban area with 51.4% in the control group and 57.1% in the experimental group. This may be because of the still prevailing traditional system of families practiced in India even in urban areas which may reduce the burden of care of newborns as there will be sharing of responsibilities.
Majority of the subjects had no previous knowledge on manual expression of breast milk. This may be attributed to the fact that though the majority of the mothers were graduates they were ignorant about the health-care information related to breastfeeding, specifically about manual expression, as this is not a usual practice for all mothers and occurs in crisis situations for babies. Therefore, nurses should understand that this is a concept which needs to be specifically explained and demonstrated for mothers when this specific need arises. Just instructing a mother to 'express and give' is not a sufficient or appropriate intervention.
The present study revealed that none of the mothers had adequate knowledge in the control and experimental group regarding the manual expression of breast milk in the pre-test proving that this is an area which is hardly addressed in any prenatal teaching. In contrast, Okonya, Nabimba, Richard and Ombeva's study on perceptions of breast milk expression and practices among working mothers, showed that 79.3% of respondents were knowledgeable about breast milk expression but 73.7% have not practiced and 64.5% raised doubts on acceptability, hygiene and safety of the milk. The results of the study highlighted there is a wide gap between knowledge and practice on breast milk expression. The findings, in addition to the current study findings, lay emphasis on the responsibility of health-care professionals to sensitise mothers to practice breast milk expression for exclusive breastfeeding when needed. A study done by Jiang et al. reveals that in late pregnancy and postpartum, most mothers were found to have lack of awareness about breastfeeding recommendations and nutritive values of breast milk. It is concluded that the health benefits of breastfeeding and the recommended duration of breastfeeding should be emphasised in prenatal educational programmes for all mothers irrespective of the condition of their newborns.
In post-test, although none had adequate knowledge in the control group the proportion of mothers with moderate knowledge had increased from 11.42% to 31.42%. This may be due to the effect of regular health education talks delivered by nurses in the neonatal unit. In the simulation group, the increase in the proportion of mothers with adequate knowledge was 66% revealing a good response for this method of teaching. Similar increase in the proportion of mothers with good knowledge after video-assisted teaching on breast massage for breast milk expression was found in another study.
There was a significant increase in the mean knowledge score in the experimental group in post-test which was not found in the control group. In congruence with these findings, a study done by Shinde and Samaj's reveals that the pre-test average knowledge score of mothers on expression and storage of milk was 6.25 and post-test average knowledge score was 17.68 which was significant.
There was also a significant difference in the increase in mean knowledge score between control and experimental groups (P < 0.001) revealing that the simulation-based teaching was effective than the regular health teaching in improving knowledge. Earlier study also reveals that a structured teaching programme instead of a non-structured educational activity may benefit in improving knowledge in mothers.
Manual expression of breast milk is not an easy task for many mothers. It is also not equivalent to the effect of baby's sucking has on the breast in breast milk output. Therefore, the aspect of manual expression, when needed, has to be sensitively taught and mothers need to be assisted with compassion to achieve the adequate quantity of breast milk that is needed for their infant.
In the experimental group, 97% of the mothers were able to demonstrate adequate skill in expressing breast milk after simulation-based teaching whereas none in the control group were able to demonstrate adequate skill in the post-test. The mean score of the practice of the mothers in the control group was 2.91 in pretest and 4.40 in post-test, whereas in the experimental group the mean score of pre-test was 3.54 and post-test was 8.97 at 72 h. The difference in mean scores between the experimental and control groups calculated by two mean t-test was significant (P < 0.001).
This finding highlights the need for demonstration for any skill. It is also seen that the increased proportion of mothers with adequate knowledge in post-test in the control group was not reflected in practice revealing that simulation-based teaching not only improves knowledge but is effective for improving practice. Similar result on improvement in the practice of breast massage was seen in the study that used video-based teaching.
Regarding the amount of milk expressed per expression, there is a significant difference in the amount of breast milk expression between pre- and post-assessment of the mothers among the control and experimental group. There is a significant increase in the amount of milk expressed by the mothers after simulation-based teaching in the experimental group (P < 0.002). The increase in breast milk amount in the control group also is noteworthy. Although improved knowledge and skill in manual expression has shown an effect on breast milk amount per expression, the increase amount in the control group reveals that the increase in milk can be physiological based on number of days of post-partum and also any effort that is constantly applied, such as that of expression efforts that were continued in the control group also, may have an effect on breast milk amount. Preference for manual expression over breast pumps was noticed in another study where a cross over design was used and these mothers came forward to demonstrate the manual technique that worked for them. Another study findings revealed that mothers who had practiced manual expression were more likely to continue breastfeeding till 2 months compared to those in the breast pump group, although the amount of milk expressed by breast pump was slightly higher than the amount by manual expression. Hand expression in the early post-partum period appeared to improve eventual breastfeeding rates at 2 months after birth compared with mothers who used breast pump. The findings from this study as well as other studies project a well-established evidence for manual expression and its effect on breast milk amount and breast feeding.
| Conclusion|| |
Baby-friendly hospital initiative (WHO and UNICEF) has recommended ten steps for successful breastfeeding. Among which the fifth step highlights about educating mothers on 'how to breastfeed, and how to maintain lactation even if they should be separated from their infants'. This study focused on accomplishing this step, to have successful breastfeeding for the sick newborns in the neonatal unit who are unable breastfeed after birth. The findings of the study highlight the importance of educating the mothers on manual expression of breast milk and the use of simulation-based teaching on improving the mothers' knowledge and practice. This scientific study has identified with the mounting evidence that there is increase in the knowledge and practice of mothers after simulation-based teaching. The findings revealed that the simulation-based teaching is effective and enables the mothers to recall the information provided and the procedure on the manual expression of breast milk and further shows that manual expression of breast milk based on the Marmet technique is effective.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827-41.
Daniels L, Heath AL, Williams SM, Cameron SL, Fleming EA, Taylor BJ, et al
. Baby-led introduction to solids (BLISS) study: A randomised controlled trial of a baby-led approach to complementary feeding. BMC Pediatr 2015;15:179.
Eglash A, Malloy ML. Breastmilk expression and breast pump technology. Clin Obstet Gynecol 2015;58:855-67.
Tadele N, Habta F, Akmel D, Deges E. Knowledge, attitude and practice towards exclusive breastfeeding among lactating mothers in Mizan Aman town, Southwestern Ethiopia: Descriptive cross-sectional study. Int Breastfeed J 2016;11:3.
Shamili GS. Effectiveness of information booklet on knowledge and practices of expressed breast milk among working postnatal mothers in selected maternity hospitals at Nellore. IOSR J Eng 2016;2016:17-9.
Okonya JN, Nabimba R, Richard M, Ombeva EA. Perceptions of breast milk expression practices among working mothers. Afr J Midwifery Women's Health 2017;11:169-75.
Jiang H, Li M, Yang D, Wen LM, Hunter C, He G, et al.
Awareness, intention, and needs regarding breastfeeding: Findings from first-time mothers in Shanghai, China. Breastfeed Med 2012;7:526-34.
Thakur V. Effectiveness of video assisted teaching module on knowledge and practice regarding breast massage for breast milk expression and volume among Primiparous mothers. Int J Adv Educ Res 2017;2:18-21.
Shinde E, Samaj's MV. Self-instruction module is effective in improving knowledge of mothers regarding expression and storage of breast milk. Innovational J Nurs Healthcare 2015;1:193-202.
Elaiyamudha G. Effectiveness of structured teaching programme on knowledge and attitude regarding expression and storage of breast milk among employed postnatal mothers in Sothupakkam, Kanchipuram district (masters). Melmaruvathur: Adhiparasakthi College of Nursing; 2012. Available from: http://repository-tnmgrmu.ac.in/3859/
. [Last accessed on 2017 Apr 24]
Jones E, Dimmock PW, Spencer SA. A randomised controlled trial to compare methods of milk expression after preterm delivery. Arch Dis Child Fetal Neonatal Ed 2001;85:F91-5.
Flaherman VJ, Gay B, Scott C, Avins A, Lee KA, Newman TB. Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly. Arch Dis Child Fetal Neonatal Ed 2012;97:F18-23.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]