Good Article Review On Quantitative Article
Type of paper: Article Review
Topic: Breastfeeding, Study, Evidence, Education, Practice, Exercise, Nursing, Health
Improving the quality of health care requires the utilization of evidence-based practice or guidelines, protocols, and interventions strongly supported by research. Doing so ensures that care is effective, efficient, and safe as well as consistent with ethical principles that uphold the rights of patients. Adopting evidence-based practices entails the process of research utilization that facilitates the transformation of knowledge and behaviors towards change. The steps in the process include discovering primary research, summarizing the evidence, translating the evidence into guidelines, integrating the evidence into practice, and evaluating the outcomes (Stevens, 2013). Research utilization applies in promoting exclusive breastfeeding during the first six months of life to achieve better outcomes for both mother and child as demonstrated in this paper.
Rationale for Choosing the Articles
The American Academy of Pediatrics and the World Health Organization recommend that infants be given breast milk only from birth up to 6 months to ensure their optimal growth, health, and development (NICHHD, 2014). The National Institute of Child Health and Human Development (NICHHD) (2014) further estimates that 75% of mothers who have just given birth begin with exclusive breastfeeding but only 13% continue doing until their babies reach 6 months of age. Based on observations, a lot of mothers do indeed breastfeed at delivery but at the 6-week visit, they are either no longer breastfeeding or alternating with formula. The two articles focused on the factors influencing the duration of breastfeeding and the effectiveness of an intervention promoting exclusive breastfeeding, respectively. Hence, they were chosen to better understand the issue and possible solutions.
Comparison of the Methods, Purpose, and Results
The purpose of the systematic review by Castano and Ortiz (2012) was to summarize available evidence on the factors influencing how long new mothers provide exclusive breastfeeding to their babies. On the other hand, the randomized-controlled trial (RCT) by Petrova et al. (2009) aimed to assess the effectiveness of promoting exclusive breastfeeding among participants of the Women, Infant, and Children Supplemental Nutrition Program. Thus, the RCT as a method of conducting primary research generates new knowledge, particularly to determine if a cause-and-effect relationship exists between the intervention and the selected outcomes. The nature of the relationship between the study variables is the basis for conclusions on effectiveness. On the other hand, the systematic review gathers together the evidence from various RCTs and studies using other methodologies that fit the criteria established by the authors pertaining to the research problem, language used, and quality. The output is not new knowledge but a synthesis of evidence that is useful in generating recommendations for practice.
The methods of the systematic review and the RCT also differ. The former began with a search and retrieval of peer-reviewed studies from 4 databases using defined search terms. The second step was to assess each study’s title and abstract against inclusion and exclusion criteria. The third step was to evaluate the quality of the remaining studies. The CASPe critical reading program was used for this purpose. It is a software application that allows researchers to determine the trustworthiness of studies by answering 11 questions pertaining to the detail, results, and applicability of the results of each study.
Answers to the 11 questions correspond to a numeric score where the higher the score, the better the quality. Only those that scored 4 or more on the CASPe were included in the review as these were of moderate to high quality. In the fourth step, the results were compared and contrasted the results to determine the protective factors and barriers to sustained exclusive breastfeeding. Meta-analysis or pooling of the quantitative data was not possible because of heterogeneity in the studies.
Meanwhile, the RCT which was done in a single center involved the recruitment of participants via convenience sampling with the sample size determined using power analysis. The participants were then allocated to the control or intervention group in a randomized process using a computer program. Baseline data were obtained from all participants. The intervention protocol consisting of routine care in addition to pre- and postnatal breastfeeding education and support by a lactation consultant was then implemented to enhance the mothers’ knowledge, skills, and attitudes.
Compliance with the breastfeeding recommendations was monitored. The control group received only routine care. Outcomes, namely the mothers’ knowledge, skills, and attitudes and breastfeeding behaviors, i.e. exclusive breastfeeding, partial breastfeeding, or exclusive bottle feeding, were collected after the intervention. The outcomes were then compared with the baseline and/or between groups using statistical analysis to determine if there were significant differences indicative of the effectiveness of the intervention.
Because the two studies differed in terms of the research problem and methods, there were also differences in the results. In their systematic review, Castano and Ortiz (2012) found that 50% of the studies highlighted the use of a baby bottle or pacifier as a key factor negatively affecting the duration of sole breastfeeding. On the other hand, multiparity, low family income, attaining high levels of education, and participation in a breastfeeding program were found to be promotive factors towards a longer length of time of exclusive breastfeeding.
Petrova et al. (2009) did not find statistically significant differences between the intervention and control groups in terms of outcomes. This means that while there was actual difference between the two groups with the women in the intervention group registering greater breastfeeding knowledge and reporting more positive behaviors, it was not significant enough to attribute the outcomes to the intervention. The lack of significant difference does not automatically mean that the intervention is totally ineffective and must be abandoned, however, because other RCTs have demonstrated effectiveness. Rather, an RCT using a larger sample and with a better research design must be done to validate the findings.
There are contradictions in the results of the two studies – the systematic review mostly based on descriptive studies linking participation in a breastfeeding program with longer durations of exclusive breastfeeding while the RCT found the breastfeeding program they investigated did not result in a similar finding. Also, the systematic review found that multiparity was a promotive factor, but this was not found to be so in the RCT. In addition, the RCT did not find significant association between the duration of exclusive breastfeeding and the mode of delivery, rooming in, prior breastfeeding experiences, and return to work.
Level of Evidence
Using the recommendations employed by the National Guidelines Clearinghouse, the systematic review is Level IIA evidence. This is because only 2 out of the 18 studies included in the review were clinical trials. The rest were of descriptive methodologies - cross-sectional, cohort, and case and control studies. However, the trials were not randomized. In terms of grade, the systematic review is Grade B because the factors found to negatively or positively affect breastfeeding duration are based directly on the results of the review which is Level II evidence. As such, it can be used in practice.
The grade of the evidence is different when considering the recommendation that breastfeeding programs must be designed and implemented targeting those who are found to have a greater tendency to not breastfeed exclusively for the first 6 months. In the systematic review, this included first-time mothers, those from higher income families, and those who are better education. As this is an extrapolated recommendation from Level II evidence, it is Grade C. For this reason, support from other systematic reviews and other studies with a direct focus on this recommendation should be considered before its adoption in practice.
The RCT which does not provide support for the effectiveness of the breastfeeding promotion program that was implemented is Level IB evidence and corresponds to Grade A. Again, the grade changes when the recommendation that other factors such as culture which could impact patient learning, intent, and enactment of recommended breastfeeding behaviors should be considered when developing the content and method of delivery of breastfeeding education and lactation support. In this case, the evidence is Grade B as it is extrapolated from Level I evidence.
Applicability of Findings
The systematic review included five studies conducted in developed countries – one in the US, two in Australia, one in the Netherlands, and one in Japan. The others were conducted in third world settings such as Turkey, Brazil, and Colombia. However, there was congruence in the findings that whether in developed or developing settings, the use of feeding bottles and pacifiers hastened the transition to partial or exclusive bottle feeding within the first six months of an infant’s life. Hence, these factors must be considered in the practice of promoting exclusive breastfeeding among new mothers. With respect to other factors, the differences in social and cultural aspects as well as health care delivery systems warrant that the findings of studies done in the United States or at least in developed Western countries should shape practice.
Consideration of the negative and positive factors affecting the duration of breastfeeding identified in the literature, the specific patient population, and the individual patient adheres to the ethical principle of beneficence and distributive justice. The benefits of breastfeeding for the mothers and their infants regardless of their economic status, ethnicity, and other demographic characteristics are not optimized in the facility because of the absence of the lack of knowledge among the staff of the factors influencing the issue and the absence of EBP guidelines on how to improve exclusive breastfeeding rates. The benefits in infants include lower rates of infection, adequate nutrition, improved survival during the first 12 months of life, lower risk of allergic diseases and type 1 diabetes, and better bonding with the mother (NICHHD, 2014).
In regards to the RCT, the lack of statistically significant findings means that the findings of other studies, especially systematic reviews, should be explored in order to determine best practices in the design and implementation of breastfeeding promotion that can be applied in practice. Otherwise, practice recommendations cannot be made based only on the RCT used in this paper. Nevertheless, the study demonstrated how a breastfeeding promotion program can be designed and evaluated for effectiveness. The facility can consider this information in conjunction with the findings of other studies as well as patient culture, values, and preferences thus employing a patient-centered approach that upholds beneficence and distributive justice.
Impact of Findings on Policy
The evidence can prompt assessments of patient-specific factors hindering or promoting exclusive breastfeeding for the first 6 months after delivery. It also underscores the need for staff education and training on the importance of increasing exclusive breastfeeding rates, what works in terms of promoting this behavior, and the skills needed to teach or support new mothers in this aspect. For example, the use of pacifiers and feeding bottles should not be encouraged. There must also be surveillance of outcomes to determine of practice changes improve infant and maternal outcomes. The above elements can be integrated into a program in the maternity unit in coordination with homecare nurses conducting home visits. Further, technology can be used to increase awareness and compliance of the new policies. For instance, screensavers and prompts serve as reminders to assess patients while clinical support systems can provide readily available information that nurses can use in their decision making in regards to promoting exclusive breastfeeding.
Castano, J.H.O., & Ortiz, B.E.B. (2012). Factors associated to the duration of exclusive breastfeeding. Investigacion Y Educacion En Enfermeria, 30(3), 390-397. Retrieved from http://aprendeenlinea.udea.edu.co/revistas/index.php/iee/article/view/7953/12896
National Institute of Child Health and Human Development (2014). What are the benefits of breastfeeding? Retrieved from http://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/benefits.as px
National Institute of Child Health and Human Development (2014). What are the recommendations for breastfeeding? Retrieved from http://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/recommen dations.aspx
Petrova, A., Ayers, C., Stechna, S., Gerling, J., & Mehta, R. (2009). Effectiveness of exclusive breastfeeding promotion in low-income mothers: A randomized controlled study. Breastfeeding Medicine, 4(2), 63-69. doi: 10.1089/bfm.2008.0126.
Stevens, K.R. (2013). The impact of evidence-based practice in nursing and the next big thing. Online Journal of Issues in Nursing, 18(2). Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJI N/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based- Practice.html