Running head: CRITIQUE ON COUNSELING MOTHERS ABOUT BREASTFEEDING

Individual Critique on Counseling Mothers About Breastfeeding

Kendall Lillie

University of Saint Mary

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Introduction

The function of this paper is to critique a research article that examines the relationship

between counseling on maternal health benefits and intentions to breastfeed. The article was

published in 2016 by Springer Science + Business Media.

Title

The title of this article is “Counseling About the Maternal Health Benefits of

Breastfeeding and Mother’s Intentions to Breastfeed.” I believe this identifies the general idea of

the study and what they will be examining. Although it does not include the setting of the study,

I do not think that is totally necessary. This is a very clear title and relates well to the purpose of

the article.

The credentials of the authors are not listed in the article or after their names. There is a

section in the bottom left corner (p. 234) that gives a background to each contributor. However,

it still does not clarify their qualifications. It does state where they work and/or where they went

to school. I had to search their names to find more information and even then I am not sure if

they are the same people. It also does not seem like they have any specialties in obstetrics so I

question if they are really qualified to research this topic.

Abstract

The abstract consists of 272 words and 1,803 characters. According to Burns and Grove

(2011, p.51), abstracts should range from 100-250 words. This would indicate that this particular

section of the article is too long. The results portion is the longest because they stated all of the

demographics (age, race, education, previous births, and history of breastfeeding) of the

participants. I do not think this is totally necessary and without this added information they

would have been a lot closer to the word limit. The abstract also includes the objectives,
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methods, and conclusions for practice. It describes the setting under methods and the purpose

statement under objectives. However, it does not include a background or a problem statement.

These are located in a different section labeled “Significance” right after the abstract.

Problem/Purpose

The problem statement was fairly difficult to identify, and I felt that it did not really

encompass the entire purpose of the article. “As mothers’ breastfeeding intentions have been

found to strongly predict actual infant feeding practices, this approach to lactation counseling

deserves attention and further investigation” (p. 235). I do not believe it is very narrow in scope

because breastfeeding intentions can be affected by a multitude of factors. I think they should

have included something about counseling on maternal health benefits. This would have

enhanced the problem statement and tied it back to the title and the purpose statement of the

article. The problem is significant to practice because they have clearly identified that the

intentions to breastfeed greatly influence the actual process of breastfeeding.

The purpose statement is labeled as the objective for the article which is “to evaluate the

impact of counseling regarding the maternal health effects of lactation on pregnant women’s

intentions to breastfeed” (p. 234). I believe this is a great purpose statement and really embodies

the whole article. The project is significant because breastfeeding has many benefits to both the

child and the mother. It is often preferred in regard to other methods such as formula feeding.

There is also a lack of research on how counseling pregnant women on these benefits can impact

their intentions to breastfeed. The project is feasible in the sense that the counseling does not cost

a lot of money and can be easily replicated. It is researchable due to the methods used to get their

results and the ability to compare them.

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Literature Review

All of the articles seem to be pertinent and represent the main issues of the study. The

majority of the sources listed in the literature review are from the last five years. Almost all of

them are within the last ten years excluding two. It is important to have current sources in order

to have new information that is still relevant to the practice today. They cited a source from 1997

which examined the theory they used in this article. The other older article is from 1947 and

emphasizes the fact that the link of breastfeeding and breast cancer was made over 60 years ago.

The rest of the sources give a background to the study including common barriers women face

and the maternal benefits of breastfeeding.

Twenty-two of the twenty-nine total references were listed in the introduction and

seventeen of those were primary sources. Primary sources are often considered superior to

secondary sources when it comes to research. This is due to fact that secondary sources can be

misinterpreted and often include bias. They should only be utilized when primary sources are not

available or if it contains valid information not located in a primary source (Burns and Grove,

2011, p.167). Overall, the length of the literature is sufficient. It gives a good background to the

study and uses quality sources.

Theoretical Framework

The authors did a great job including a theoretical framework. They used the Theory of

Planned Behavior. They also explained the theory in detail so the reader would not have to do

their own research. The article states that the main principle of the theory is, “a performed

behavior’s immediate antecedent is the intention to perform that behavior” (p.236). The three

concepts of the theory include subjective norms (external pressure), attitudes (internal feelings),

and perceived behavior control (empowerment to make own decisions). Two sources cited in the
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text (Bai et al. 2010; Wambach 1997) concluded that the intentions to breastfeed increase the

behavior of breastfeeding.

Evaluation of the Research Methods

Research Design Elements

The authors did not state what design they used for the study but I believe it was a

predictive correlational design. The purpose of the design is to examine the relationship between

one variable and another, also known as the independent and dependent variables (Burns and

Grove, 2011, p. 220). The hypothesis was clearly stated as, “informing pregnant women of the

maternal health effects of lactation would strengthen their intentions to breastfeed” (p.235). The

main variables include “informing pregnant women on maternal health effects” as the

independent and “intentions to breastfeed” as the dependent. I believe this is a quasi-

experimental, directional, simple, research study.

Data collection and instruments

Data collection occurred at an urban clinic in Pittsburgh, Pennsylvania. Women seeking

prenatal care were recruited to complete surveys before and after counseling on maternal health

effects of breastfeeding. The counseling was delivered in a semi-private area of the waiting

room. This could be considered a natural setting for the target population since they are not

taking them somewhere unfamiliar or unrelated. They used a 7-point Likert scale (1 being

extremely unlikely and 7 being extremely likely) for the surveys and compared the pre/post

changes using paired t tests (p. 234). They indicated that this scale was tested with Cronbach’s

alpha (pre-intervention = 0.80; post-intervention = 0.79) and considered reliable (p.236).

However, they did not mention if the scale had acceptable validity.
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I believe the Likert scale was the best way to get information about the participant’s

knowledge. It was quick and easy to compare and contrast the change of opinion in the

participants. Since the focus of the study is increasing intentions there really is no other way to

obtain this information than to ask questions with a survey. I am unsure if the setting really

reflected the real world or at least the rest of the world. Although they did perform the research

in an actual hospital, there was a large gap in demographics of the participants. This could

definitely alter the results of the study.

Protection of Human Subjects

The study was exempt by the University of Pittsburgh Institutional Review Board

(p.235). However, it did not state that they received written or verbal consent from the

participants involved. Although it seemed as if the participants volunteered, it is always smart to

have something to support your case. They also performed the counseling in a semi-private area

of the waiting room so the participants right to privacy could have been infringed. The script was

written at a fifth grade reading level so the participants would more than likely be able to

understand the information. The pamphlet they used was also very simple and easy to

understand. Overall, I believe the authors conducted their research in an ethical manner.

Replication

Some parts of the research procedure would be very easy to replicate while others lacked

information on the authors part. They stated, “The full wording of all study questions is available

in the Appendix 2 of ESM” (p.236). However, I was unable to find this appendix. They provided

a pamphlet titled “Maternal Benefits of Breastfeeding” (p.237) in addition to the counseling.

This would be extremely easy to duplicate and was very beneficial for visual learners. The

evaluation tool would also be simple to produce since most 7-point Likert scales are very similar.
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They stated that all women visiting the clinic were invited to participate so convenience

sampling was used for the study. The authors provided a lot of information on their methods

which would usually allow for easy replication but without the counseling points it would be

difficult to ensure the study was done the same way.

Data Analysis

Descriptive

The authors described the subjects of the study in very clear detail. The sample size

consisted of 65 pregnant women who were willing to partake. The article stated that 72% of

participants were African-American and 58% were not employed. They also listed the

educational level stating only 9% had college degrees but 81% had graduated high school. The

average age was around 24 years old give or take six years. The majority of participants (65%)

were married or seriously committed to someone. Half of the participants had previously given

birth but only 21% had previously breastfed (p.236). The description of the subjects identifies the

characteristics of the sample that they used for the study. It also relates to the study by indicating

how many participants have previously breastfed. The description indicates that the population is

not equally dispersed in demographic variables. This could imply bias from the authors for

choosing that particular hospital. However, it could have just been the most convenient setting. It

also indicates that a large sum of the participants belong to a vulnerable population and may not

have great access to healthcare.

A power analysis was not completed for the study. I believe this is a major flaw on the

authors’ part. The sufficiency and appropriateness of the sample size is appraised using this tool.

It allows you to discover the differences and associations in the population that actually exist

(p.266). The possibility of a sampling error could occur without the proper sample size for the
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study. I do not believe the sample size was adequate because it was fairly small and could have

skewed the results.

Study Results

Most of the results were statistically significant including the participant’s viewpoint that

lactation can lower the risk of breast and ovarian cancer as well as hypertension and rheumatoid

arthritis. The authors did not state a set p value to base the significance of the study. However,

they did list which results were significant and which were not. This led me to assume that they

used the common parameter of a p value less than 0.05. Counseling on the positive effects of

lactations resulted in a majority p value of <0.0001. Most of the negative effects of breastfeeding

did not have statistically significant p values (greater than 0.05). The likelihood that the

participants will try to breastfeed had a p value of <0.001 (p.239). The p is abbreviated for

probability and the significance is usually set at <0.05. A result that meets this criteria is

considered statistically significant (Burns and Grove, 2011, p. 348).

Understanding

The statistics are reported pretty clear and are understandable. They used narrative and a

table format to present their findings. Some of the tables can be slightly confusing especially

with no experience reading research results. They did section the tables in a clear and concise

manner. They also mentioned their methods under the results to get a visual idea of what they

were doing. While statistical significance is often determined by p values and data, clinical

significance is described as what is relevant to practice. I believe this study is both statistically

and clinically significant. It has been proven that breastfeeding is beneficial for both the mother

and the baby so if counseling pregnant women on the effects increases their intentions than more

babies will be breastfed.

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Discussion and Conclusions

Discussion of Findings

I believe the findings were presented without any bias. The authors were not employees

of the clinic where the study was conducted or part of any groups that particularly advertise

breastfeeding. They did use a hospital that was highly populated with lower socioeconomic

patients; however, it is unclear whether this was with purpose or due to a lack of other options.

The authors cited previous studies on the importance of breastfeeding, when counseling should

be initiated, and how counseling techniques can influence patients. The authors also related the

evidence they found back to the theoretical framework that intentions to breastfeed often result in

the management of breastfeeding.

Conclusions

The results are logically related to the hypotheses that breastfeeding intentions would

improve after counseling. I do not strongly believe that the findings will generalize to the target

population of pregnant women seeking prenatal care. Since they used a small sample size, their

results could easily be inaccurate. Prior studies have also found that breastfeeding is important

and that intentions strongly predict performance. However, the authors did not cite any studies

with results from counseling pregnant women so I assume these findings would be considered

new.

Limitations

The authors did identify their limitation of using a small population size and that it may

not generalize to other settings (p. 240). However, they failed to mention some of their other

mistakes. They did not state anything about doing a power analysis in the article. This would
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have avoided the limitation of a small sample size. Their problem and purpose statement did not

correlate well and they would have benefited from a different problem statement altogether.

They also did not state any of their credentials which makes it difficult to clarify their credibility.

They neglected to include a design for the study, although it was fairly easy to figure out. They

also left out the appendix with study questions for the counseling which makes it almost

impossible to replicate. Lastly, they did not test their tool for validity or state their set p value of

significance. Their suggestions for further study included the importance of confirming the

participant’s short-term knowledge from the counseling to their long-term knowledge on the

information.

Confidence

I am not extremely confident that the results are valid and useable mainly because of the

effect that a small sample size can have on a study. I believe their results could have been

skewed and in order to verify those results a replication study should have been completed. I do

believe the implications are logical and realistic for practice. I think healthcare professionals

would support implementing counseling on the maternal health benefits of lactation. It would not

be very expensive and it could be included in their regular checkups. I believe the study was

adequate and that the idea was wonderful. I think the next step would be to try to replicate the

study with a larger population size and evaluate the results.

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References

Burns, N. & Grove, S. K. (2011). Understanding nursing research: Building an evidence-based

practice. (6th ed.). Maryland Heights, MO: Elsevier Saunders.

Ross-Cowdery, M., Lewis, C., Papic, M., Corbelli, J., Schwarz, E. (2017). Counseling about

the maternal health benefits of breastfeeding and mothers’ intentions to breastfeed.

Maternal & Child Health Journal, 21, 234-241. https://doi.org/10.1007/s10995-016-

2130-x