A randomized controlled trial of knowledge sharing practice with empowerment strategies in pregnant women to improve exclusive breastfeeding during the first six months postpartum.

Abstract

Although there are many benefits to breastfeeding, its prevalence and duration in many countries is still lower than the international recommendation for 6-month exclusive breastfeeding. The objective of the present study was to investigate whether a knowledge sharing practices with empowerment strategies (KSPES) program on antenatal education and postnatal support strategies improves the rates of 6-month exclusive breastfeeding during the first six months postpartum compared with a standard knowledge of breastfeeding techniques.
A randomized controlled trial was conducted. Pregnant women of more than 32 weeks' gestation were randomly assigned to receive a routine standard knowledge of breastfeeding techniques alone (control group) or with KSPES on antenatal education and postnatal support strategies (study group). The primary outcome was the rate of exclusive breastfeeding at 6-month postpartum. The secondary outcomes were rates at 7 days, 14 days, 1, 2, 3, 4, and 5 months postpartum.
Rates of exclusive breastfeeding in the study group were significantly higher when compared with those in the control group at 14 days (82.5% vs. 52.6%, p = 0.005), 1 month (77.5% vs. 52.6%, p = 0.021), 2 months (62.5% vs. 368%, p = 0.023), 4 months (35.0% vs. 7.9%, p = 0.008), 5 months (25.0% vs. 2.6%, p = 0.012), and 6 months postpartum (20.0% vs. 0%, p = 0.005).
KSPES on antenatal education and postnatal support strategies significantly improve rates of exclusive breastfeeding at 6-month postpartum. These strategies also significantly improve rates of exclusive breastfeeding at 14 days, 1, 2, 4, 5, and 6 months postpartum.

Full text

Page 1

J Med Assoc Thai Vol. 93 No. 9 20101009
Correspondence to:
Phupong V, Department of Obstetrics and Gynecology,
Faculty of Medicine, Chulalongkorn University, Rama IV Rd,
Pathumwan, Bangkok 10330, Thailand.
Phone: 0-2256-4241, Fax: 0-2254-9292
E-mail: vorapong.p@chula.ac.th
A Randomized Controlled Trial of Knowledge Sharing
Practice with Empowerment Strategies in Pregnant
Women to Improve Exclusive Breastfeeding during
the First Six Months Postpartum
Jutamart Kupratakul BRN, MEd*, Surasak Taneepanichskul MD**,****,
Nipunporn Voramongkol MD***, Vorapong Phupong MD**,****
* Research for Health Development (Multidisciplinary and International Programs),
Graduate School, Chulalongkorn University, Bangkok, Thailand
** College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
*** Bureau of Health Promotion, Department of Health, Ministry of Public Health, Nonthaburi, Thailand
**** Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Background: Although there are many benefits to breastfeeding, its prevalence and duration in many countries is still lower
than the international recommendation for 6-month exclusive breastfeeding. The objective of the present study was to
investigate whether a knowledge sharing practices with empowerment strategies (KSPES) program on antenatal education
and postnatal support strategies improves the rates of 6-month exclusive breastfeeding during the first six months postpartum
compared with a standard knowledge of breastfeeding techniques.
Material and Method: A randomized controlled trial was conducted. Pregnant women of more than 32 weeks’ gestation were
randomly assigned to receive a routine standard knowledge of breastfeeding techniques alone (control group) or with KSPES
on antenatal education and postnatal support strategies (study group). The primary outcome was the rate of exclusive
breastfeeding at 6-month postpartum. The secondary outcomes were rates at 7 days, 14 days, 1, 2, 3, 4, and 5 months
postpartum.
Results: Rates of exclusive breastfeeding in the study group were significantly higher when compared with those in the control
group at 14 days (82.5% vs. 52.6%, p = 0.005), 1 month (77.5% vs. 52.6%, p = 0.021), 2 months (62.5% vs. 36.8%,
p = 0.023), 4 months (35.0% vs. 7.9%, p = 0.008), 5 months (25.0% vs. 2.6%, p = 0.012), and 6 months postpartum (20.0%
vs. 0%, p = 0.005).
Conclusion: KSPES on antenatal education and postnatal support strategies significantly improve rates of exclusive
breastfeeding at 6-month postpartum. These strategies also significantly improve rates of exclusive breastfeeding at 14 days,
1, 2, 4, 5, and 6 months postpartum.
Keywords: Breastfeeding, Exclusive, Knowledge sharing practices with empowerment strategies, Standard knowledge
For time immemorial, infants have been
nurtured at their mother’s breast. Feeding is necessary
for sustaining health, giving many advantages and for
all the most important things, in every life cycle. It is
generally accepted that human breast milk is the best
type of nutrition for neonates and infants(1). Most health
organizations such as the World Health Organization
(WHO) and the United Nations Children’s Fund
(UNICEF) have updated their recommendation that
exclusive breastfeeding should be given until a baby
is six months old before offering other additional food,
and partial breastfeeding should be continued along
with complementary feeding for at least the first two
years of life(2). Exclusive breastfeeding consists of only
breast milk being given to infants. Medicine, vitamins,
and oral rehydration solution may be given but no
J Med Assoc Thai 2010; 93 (9): 1009-18
Full text. e-Journal: http://www.mat.or.th/journal

Page 2

1010J Med Assoc Thai Vol. 93 No. 9 2010
formula or water(3). Breast milk promotes sensory and
cognitive development, and protects the infant
against infectious and chronic diseases. Exclusive
breastfeeding reduces infant mortality resulting
from common childhood illnesses such as diarrhea
or pneumonia and aids for a quicker recovery from
illness(4). It could reduce infant mortality by 13%(5)
and decrease the risk of morbidity from infection(6,7).
Moreover, it increases infant immunity through
generous nutrients for growth and development and
provides physiological and social psychological benefit
as well as learning interactions and communication
between parents and their infants(8).
Although there are many benefits to
breastfeeding, its prevalence and duration in many
countries is still lower than the international
recommendation for exclusive breastfeeding for the
first six months of life(4). In the United States, data from
the national survey in 2004 demonstrated that only
30.5% and11.3% of mothers exclusively breastfed at
the three and six months, respectively(4). In Sri Lanka,
the median duration of exclusive breastfeeding was
four months. The rates of exclusive breastfeeding at
four and six months were 61.6% and 15.5%,
respectively(9). In Hong Kong, only 10% and 2% of
mothers exclusively breastfed at three and six months,
respectively(10).
In Thailand, the National Breastfeeding
Project began in 1989. Its major objective was to
promote postpartum mothers to exclusively breastfeed
for the first six months and breastfeed with
supplementary food until the infants are two years old.
The main activities have been the promotion of the
Baby-Friendly Hospital Initiative; legislation on
maternity leave; and the Code of Marketing of
Breast Milk Substitutes and related products. The
development of the Baby-Friendly Hospital Initiative
may in part explain the increase in the prevalence rate
of breastfeeding. However, exclusive breastfeeding
has not shown a favorable increase. The survey in
2005 found exclusive breastfeeding at 6-month was
only 14.5% while the national target of the Ninth
National Health Development Plan (NHDP) had been
set at 30%(11). Recently, the prevalence of exclusive
breastfeeding at 6-month in Bangkok was still low
(11%)(12). There are many factors affecting the success
of breastfeeding promotion.
Although there have been many studies
regarding intervention or instruments to increase the
rates of exclusive breastfeeding for the recommended
duration of six months(3,13-16), the success rates were
still lower than the international recommendation(4).
Therefore, an additional special important strategy
and technique for education and promoting the
exclusive breastfeeding during the first six months
among pregnant women are needed. From the
compilation and review of various Knowledge Sharing
Practices with Empowerment Strategies (KSPES)(17),
this should be the most appropriate method to change
and motivate behavior of exclusive breastfeeding at
6-month postpartum. It is composed of Knowledge
Sharing Practices (KSP) and Empowerment, which
KSP is top management support has been very effective
in the organization under study as indicated by
the existence of KM (Knowledge Management)
technologies. The explicit and tacit knowledge in the
organization is shared through knowledge sharing
practices. Explicit knowledge in an organization is
represented in the form of databases, documents,
best practices, or processes in the organizations.
Tacit knowledge is not structured and more concrete,
in invisible form. In this case, the transmission of
sensations, feelings, or values plays an important
role. Knowledge sharing practices model composed
of communication, demonstration and display, best
practices, and storytelling. Furthermore, empowerment
process of Gibson(17) who revealed that the mothers’
commitment to, bond with, and love for, their
child, which motivated and sustained the process of
empowerment, consists of four steps as discovering
reality, critical reflection, taking charge, and holding
on. KSPES is never applied with promoting exclusive
breastfeeding during the first six months of life. The
objective of the present study was to compare the
effectiveness of KSPES on antenatal education and
postnatal support strategies versus the usual standard
knowledge of breastfeeding technique on the rates of
exclusive breastfeeding during the first six months
postpartum.
Material and Method
Study population
Between January and March 2009, healthy
pregnant women of more than 32 weeks’ gestation who
were attending antenatal care clinics at the Department
of Obstetrics and Gynecology, King Chulalongkorn
Memorial Hospital, Faculty of Medicine, Chulalongkorn
University and Theptarin Hospital, Bangkok, Thailand
were recruited. The eligible pregnant were those with
more than 32 weeks’ gestation, healthy, delivery of full
term healthy infants, no disease or contraindications
to breastfeeding, no nipple abnormalities, and infants

Page 3

J Med Assoc Thai Vol. 93 No. 9 2010 1011
who had no sucking problems. They also had to be
able to communicate with others, and had to have a
telephone line. The authors excluded pregnant women
with high-risk and multifetal pregnancies.
After the present study was approved by the
Ethical Review Committee for Research Involving
Human Research Subjects, the Health Science Group,
the Ethics Committee of Faculty of Medicine,
Chulalongkorn University, Thailand and the Ethics
Committee on Researches Involving Human Subjects
of Theptarin Hospital, eligible women who signed an
informed consent were randomized into two groups,
the study and control groups. A randomization scheme
was generated using a random number table. The
co-investigator generated the allocation sequence,
and principal investigator enrolled participants and
assigned participants to their groups. When a woman
met the present study inclusion criteria, the principal
investigator picked up a sequentially numbered opaque
envelope that contained a ticket identifying the group.
The woman was then assigned to either the study or
the control group according to the ticket. Neither the
provider nor the woman was blind to the treatment
regimens.
A first self-administered anonymous written
questionnaire that consisted of general information,
knowledge about breastfeeding, attitudes towards
breastfeeding and self-efficacy for self-management
toward breastfeeding was completed. Then, the women
in the control group received only routine standard
knowledge of breastfeeding techniques, while the
women in the study group received routine standard
knowledge of breastfeeding techniques with knowledge
sharing practices with an empowerment strategies
(KSPES) program on antenatal education and postnatal
support strategies. The KSPES program on antenatal
education took about three hours by only the principal
investigator. A second self-administered written
questionnaire was completed after receiving the
knowledge. They subsequently received routine
intrapartum and postpartum obstetric care. All women
in the present study group were followed-up with
regard to exclusive breastfeeding by telephone
interviews at 7 and 14 days, 1, 2, 3, 4, 5, and 6 months
after delivery and by home visits in cases that had
problems with exclusive breastfeeding. Pregnant
women in the control group receive a routine breast-
feeding education at least two times. At the first time
antenatal check-up, their breasts and nipples were
checked, and any abnormality corrected such as by
using Hoffman’s maneuver or using breast cups to
cover the nipples. At the second and subsequent
antenatal check-ups, pregnant women received
advice on breastfeeding education such as benefits of
breastfeeding, significance of exclusive breastfeeding,
techniques in successful of exclusive breastfeeding,
importance of breastfeeding immediately, disadvantages
of formula milk and water, and ways to make sure for
breastfeed when mothers have to return to work outside
the house. In addition, document on breastfeeding
was provided, that affects breastfeeding behavior of
postpartum mothers. All the women in the control
group were followed up with regard to exclusive
breastfeeding by routine visit at 1, 2, 4, and 6 months
postpartum at Pediatrics clinic. The KSPES program
in antenatal education class was explored for the
purpose of formalization, sharing discussion of
their knowledge by storytelling, experience by best
practices, demonstrating and displaying the thoughts
of the pregnant women, which are the steps of the
Knowledge Sharing Practice (KSP) and applying them
with empowerment based on Gibson’s theory(17).
Gibson’s theory consists of four steps, discovering
reality, critical reflection, taking charge, and holding on
(Fig. 1). In this way, it is the processional concept in
leading to intrinsic and extrinsic development of the
individuals to gain potential in accepting the situation
and successful experience of exclusive breastfeeding.
They could discover their own success in managing
themselves to breastfeeding and learn about the
others’ experiences. The former strategies were the
most appropriate methods in changing and motivating
behavior in the pregnant women for improving
exclusive breastfeeding during the first six months.
The demographic data and delivery outcomes were
recorded.
The primary outcome was the rate of exclusive
breastfeeding at 6-month postpartum in study and
control groups. The secondary outcomes were rates of
exclusive breastfeeding at seventh and fourteen days,
one, two, three, four, and five months postpartum.
Exclusive breastfeeding was defined as only mothers’
breast milk was the infants’ food source, without the
other oral rehydration solution including water.
Predominant breastfeeding was defined as the infants
were fed with the mothers’ breast milk and water,
sweetened water and juices without formula. Partial
breastfeeding was defined as the infants who were fed
with the mothers’ breast milk and complementary food
such as formula milk, gruel, semisolids, or solids. No
breastfeeding meant the infants were fed only with
formula milk and other liquids or food.

Page 4

1012 J Med Assoc Thai Vol. 93 No. 9 2010
Statistical analysis
The sample size calculation was based upon
the estimated rates of exclusive breastfeeding at
6-month, 5% in the control group (from pilot survey),
and 30% in the study group. Thus, the authors needed
36 women in each group to detect statistical difference
(α = 0.05, β = 0.2). With adjustments for a withdrawal
rate of 10%, a minimum of 40 women in each group
were required.
SPSS version 13 was used for statistical
analysis (SPSS Inc., Chicago, IL, USA). Test-retest
reliability was used for confirmation of the validity of
the questionnaire. Categorical data was expressed by
percentage and comparison was made by the Chi-square
test or Fisher exact test. Continuous variables were
expressed as mean and standard deviations or median
and compared by student t-test or Mann-Whitney U
test. Intra-group comparison of continuous variables
was carried out using paired t-test and unpaired t-test
for inter-group comparison. A p-value < 0.05 was
considered statistically significant.
Results
Screening, randomization, discontinuation,
and loss to follow-up are summarized in Fig. 2. Eighty
women were enrolled in the present study. The women
were equally randomized into two groups (40 women
were randomized in the study group, and 40 women in
the control group). Sixty pregnant women were from
King Chulalongkorn Memorial Hospital (75%), while
20 (25%) were from Theptarin Hospital. The follow-up
was completed in October 2009. Seven women were
lost to follow-up (3 in the study group and 4 in the
control group). Two women in the control group were
excluded, dead fetus in utero and neonatal death
from heart disease at 1-month of age. Seventy-one
(88.8%) women (37 in the study group and 34 in the
control group) completed six months of follow-up. The
demographic characteristics of the women according
to group are summarized in Table 1. There was no
statistical difference between the groups regarding age,
religion, education, occupation, work place, family
income, parity, family status, family’s characteristics,
intention, and plan to breastfeeding. Both groups were
also similar in mode of delivery and the infants’ birth
weight (Table 2). Since seven women were lost to
follow-up, an intention-to-treat analysis, counting all
lost to follow-up women as non-exclusive breast-
feeding, was performed.
Table 3 shows the score of KSPES before
and after intervention between the study and control
groups. The mean scores of knowledge, attitude, and
Fig. 1 A model for KSPES

Page 5

J Med Assoc Thai Vol. 93 No. 9 20101013
self-efficacy for self-management before intervention
in both groups were similar. The mean scores after
intervention of the study group were significantly
higher (p < 0.001).
Table 4 shows the mean scores of knowledge,
attitude, and self-efficacy for self-management before
and after intervention in the control group were similar.
The mean scores after intervention were significantly
higher than those before in the study group (p < 0.001).
Table 5 shows the rates of exclusive
breastfeeding. Comparing with the control group,
women in the study group had significantly higher
rates of exclusive breastfeeding at 14 days, 1, 2, 4, 5,
and 6 months. Rates of exclusive breastfeeding in the
study group compared with those in the control group
were 82.5% vs. 52.6%, p = 0.005 at 14 days, 77.5% vs.
52.6%, p = 0.021 at 1 month, 62.5% vs. 36.8%, p = 0.023
at 2 months, 35.0% vs. 7.9%, p = 0.008 at 4 months,
25.0% vs. 2.6%, p = 0.012 at 5 months, and 20.0% vs.
0%, p = 0.005 at 6 months. Rates of predominant
breastfeeding were also significantly higher in the
study group than those in the control group at 3, 5, and
6 months. However, the rates of partial breastfeeding
were no difference between groups. Rates of “no
breastfeeding” were significantly higher in the control
group than those in the study group at 2, 3, 4, 5, and
6 months.
Discussion
The present study showed that KSPES
on antenatal education and postnatal support
strategies could significantly improve rates of
Fig. 2Profile of patient recruitment and follow-up following randomization to either study or control group