Unpublished Evaluation of RSB Implementation at UNC – 2013
At the time of this evaluation, RSB was offered at North Carolina Women’s Hospital as a voluntary educational session intended to help expectant mothers get ready for their baby. Pregnant mothers are eligible to receive a free RSB educational session immediately after their first ultrasound confirming a viable pregnancy. Obstetric clinics verbally educate patients about RSB at check-out and subsequently make appointments with interested mothers to receive their RSB when they return for their next clinic appointment. RSB appointments are generally scheduled to take place after the patient’s appointment with their physician. Patients are instructed that the location of their RSB session will be in the Women’s Health Information Center, located in the main lobby of the hospital, directly downstairs from the obstetric clinics.
RSB sessions typically last 20 minutes, and patients are welcomed to bring family with them to the session. Staff and volunteers at the Women’s Health Information Center welcome patients with and without scheduled appointments, providing on-the-spot one-on-one sessions that are tailored to the patient’s interest level. Occasionally, RSB sessions are offered to more than one mother at a time.
Methods – Two separate groups of women were interviewed for this evaluation in 2013. In Part I of the evaluation, women were surveyed prenatally and directly after their RSB session. In Part II, a separate group of women were interviewed postpartum on their day-of-hospital discharge. Part II interviewees were patients who received their prenatal care through the Obstetrics Clinics at UNC, and therefore potential participants in RSB.
Part I of the evaluation assessed patient response to the Ready, Set, BABY sessions. Overall, the sessions were very well received from the patient perspective. Patients who responded to the survey are satisfied with their sessions, regardless of the length (from 5 to 55 minutes), and have few suggestions for improvements. For the vast majority of respondents, the sessions improve their self-perceived knowledge on the topics covered. Most respondents also felt better informed about what to expect during their hospital stay, felt more confident about how to care for their baby directly after birth, felt more prepared for their feeding decisions and felt more confident about breastfeeding. In addition, almost three quarters of respondents agreed that the session would influence how they will care for their infants at home. We also found that non-white women were more likely to be satisfied with the session and that women with advanced degrees and full employment were more likely to report being neutral or unsatisfied. These are all positive results as we are trying to reduce disparities and increase equity. In addition, these materials serve to improve patient knowledge on several important maternity care practices that are an integral part of the Baby Friendly Hospital Initiative, which has been demonstrated to be associated with improved breastfeeding outcomes.
Part II attempted to identify whether those who had received the RSB session had different rates of breastfeeding initiation when compared to those who had not. No significant differences were found. This was likely due to small sample size necessitated by the timeline of the evaluation. However, a majority of the women who had participated in RSB agreed that the program helped them feel more prepared for what they had experienced in the hospital regarding the maternity care practices of skin-to-skin, rooming in and feeding on demand. This positive finding echoes the results of the prenatal survey, where a majority of respondents felt more prepared with what to expect during their hospital stay after participating in RSB. In sum, both parts of the evaluation indicate that RSB is a program benefiting patients in measurable ways.
- Non-white women were significantly more likely to respond that they were satisfied with the session compared to other mothers (p=0.006). Considering that minority populations have much lower breastfeeding rates than non-minority populations, this is an important finding. Women were more likely to be neutral or dissatisfied if they held an advanced degree (p=0.04) and were employed full-time (p=0.000). Some of these women who were either neutral or unsatisfied also shared comments requesting more in-depth information.
- The majority of women responded that RSB improved their knowledge on the topics covered, however, the extent to which they agreed varied by topic. The data show that the knowledge improvement was greatest for the first three topics discussed in RSB (above 85.8% for skin-to-skin, rooming-in and feeding cues), and then dropped slightly to below the 80th percentile for the remaining topics (breastfeeding recommendations and practices, benefits for baby, benefits for mom). The importance of skin-to-skin, rooming-in and learning feeding cues to feed on demand highlight important changes in maternity care practices of a facility implementing the Ten Steps to Successful Breastfeeding, as required by Baby-Friendly® USA. Special attention was given in the development of the RSB materials to educate women on the importance of these maternity care practices. This data supports success toward that goal.
- A vast majority (90.5%) of respondents agreed they felt better informed about what to expect during their hospital stay after participating in RSB. The session, therefore, does a great job explaining to patients about the Baby-Friendly practices they will be receiving upon admission to the hospital.
- More women had their baby placed skin-to-skin immediately after birth who had participated in RSB than who had not participated (80% vs. 63%), and more women reported that they feed their baby based on infant cues who had participated in RSB than those who had not (95% vs. 88.9%). These differences were not significant, despite indicating a possible trend toward better maternity care practices among RSB participants.
- Of the women who had participated in RSB, 86.7% agreed that the program helped them feel more prepared for what they had experienced in the hospital regarding the maternity care practices of skin-to-skin, rooming in and feeding on demand.
- Among women who did not participate in RSB, 69.5% did not recall hearing about it from a receptionist at a prenatal care appointment; and 63.4% of these women said they would have participated in RSB if they had known about it.
- When examining other responses of those women who participated in RSB, it was found that they were similar to the corresponding responses of women who did not participate in RSB. Additionally, responses of women who had self-selected to participate in some other breastfeeding class were also similar to those who did not participate in RSB. No significant associations were identified among women who participated in RSB with regard to their evaluation of the RSB session, satisfaction with their maternity care practices, exclusive breastfeeding rate in the hospital, breastfeeding intention scores, or breastfeeding self-efficacy scores. Similarly, no significant associations were identified among women who participated in another breastfeeding class with regard to those same outcomes of interest.
- Literature shows that participation in prenatal breastfeeding education is associated with improved breastfeeding-related outcomes and lower supplementation. However, the efficacy of RSB participation on breastfeeding-related outcomes is not demonstrated by the results of this evaluation. Neither do these data demonstrate the efficacy of having self-selected to participate in another breastfeeding class during the prenatal period. Considering this point, it is plausible that the lack of association discussed above is due to small sample size, with only 25.6% of the sample population participated in RSB and not due to the lack of efficacy of the breastfeeding education.
Using the Evaluation Data: Adding Anticipatory Guidance
- Common concerns that women have about breastfeeding in the prenatal period line up with those cited as reasons women discontinue breastfeeding. These include ‘insufficient milk’, ‘baby is not satisfied on breast milk alone’, ‘going back to work’, ‘sore or damaged nipples’, and ‘baby had difficulty breastfeeding’. (North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) 2008-2010 Data: State Center for Health Statistics, Raleigh, NC) RSB materials initially addressed these concerns indirectly: the content about latch/positioning and getting off to a good start could help mitigate the concern of potential pain and the baby having difficulties latching. The section on Making and Maintaining Milk could help alleviate anxieties about not producing enough milk. Educating on the type and frequency of hunger cues could offer support for the concern that the baby is not satisfied on breast milk alone. Drawing attention to the last page containing resources for support could also help mothers realize there is help available when she needs it. Educators should help women understand the relationship between the content in RSB and common concerns they may currently have or will have postpartum. To that end, we are using evidence to guide the addition of content targeted at addressing these common concerns and reasons for cessation.
- Nearly three quarters of respondent (68.4%) agreed that the program will influence how they will care for their infant. While doing a great job at better preparing mothers what to expect when they arrive at the hospital, RSB could improve on how well it influences mothers once they get home from the hospital. Information about Day 3 to Week 6 of the postpartum period could be presented in such a way that simply lets the mother know a few basic things and points her to the page in the materials that contains more detailed information to which she can refer when she is ready. We know that the biggest drop in exclusive breastfeeding happens in the first week. Any education to prepare a mother for the realities of the first week at home would therefore be supportive of extending the duration of exclusive breastfeeding.