Simple Antenatal Preparation to Improve
A Randomized Controlled Trial
Citra Nurfarah Mattar, MMed (O&G), MRANZCOG, Yap-Seng Chong, MRACOG, MD,
Yah-Shih Chan, BHSc (Nursing), Annabel Chew, MBBS, Petrina Tan, MBBS, Yiong-Huak Chan, PhD,
and Mary How-Jing Rauff, FRCOG
OBJECTIVE: To address the impact of simple antenatal
educational interventions on breastfeeding practice.
METHODS: A randomized controlled trial was carried
out in a tertiary referral center from May 2002 to Decem-
ber 2004. A random sample of eligible low-risk antenatal
patients was recruited from clinics in the National Uni-
versity Hospital, Singapore. Group A received breast-
feeding educational material and individual coaching
from a lactation counselor. Group B received breastfeed-
ing educational material with no counseling. Group C
received routine antenatal care only.
RESULTS: A total of 401 women were recruited. Mothers
receiving individual counseling and educational material
practiced exclusive and predominant breastfeeding more
often than mothers receiving routine care alone at 3
months (odds ratio [OR] 2.6, 95% confidence interval [CI]
1.2–5.4) and 6 months (OR 2.4, 95% CI 1.0–5.7) postpar-
tum. More mothers practiced exclusive and predominant
breastfeeding at 6 months among women receiving indi-
vidual counseling compared with women exposed to
educational material alone (OR 2.5, 95% CI 1.0–6.3).
CONCLUSION: Where breastfeeding practices are sub-
optimal, simple one-encounter antenatal education and
counseling significantly improve breastfeeding practice
up to 3 months after delivery. Provision of printed or
audiovisual educational material is not enough. Health
care workers should make every effort to have one
face-to-face encounter to discuss breastfeeding with
expectant mothers before they deliver.
(Obstet Gynecol 2007;109:73–80)
LEVEL OF EVIDENCE: I
practice recommended by the World Health Organi-
zation and the American Academy of Pediatrics. Both
recommend exclusive breastfeeding for the first 6
months, followed by the introduction of suitable
complementary foods and continued breastfeeding
up to 2 years of age.1,2Despite increasing awareness of
the many advantages of breastfeeding,3–14the chal-
lenge remains to implement programs that can effec-
tively improve short- and long-term breastfeeding
rates, especially of exclusive and predominant breast-
feeding. In the United States a campaign is under-
way15aimed at improving breastfeeding practice to
meet the goals of Healthy People 2010, in which 75%
of mothers initiate breastfeeding and 50% still breast-
feed at 6 months postpartum.16Although the U.S.
breastfeeding initiation rate has improved from 53.6%
in 199417to 65.1% in 2001,18continued breastfeeding
in the 2001 survey was 27.0% at 6 months, with
exclusive breastfeeding rates at only 7.9%,18falling
short of the Healthy People 2010 goals.
Singapore sees a similar trend. The National
Breastfeeding Survey 2001 demonstrated an encour-
xclusive and predominant breastfeeding rates in
many developed countries often fall short of the
From the Department of Obstetrics and Gynaecology, National University
Hospital, Singapore; Department of Obstetrics and Gynaecology and Biostatis-
tics Unit, Yong Loo Lin School of Medicine, National University of Singapore.
This study was supported by a grant from the National Healthcare Group,
Drs. Mattar and Chong contributed equally to this manuscript.
This study was presented at the 5th Singapore Obstetrics and Gynaecology
Congress, October 7–11, 2005, and the Combined Scientific Meeting, November
4–6, 2005, Singapore.
Corresponding author: Dr. Yap-Seng Chong, Department of Obstetrics and
Gynaecology, Yong Loo Lin School of Medicine, National University of
Singapore, National University Hospital, 5 Lower Kent Ridge Road, Singapore
119074; e-mail: email@example.com.
© 2006 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
VOL. 109, NO. 1, JANUARY 2007OBSTETRICS & GYNECOLOGY
aging breastfeeding initiation rate of 94.5%. However,
only 21.1% of mothers continued to breastfeed at 6
months, with fewer than 5% breastfeeding exclusive-
ly.19In comparison, 46% of Australian mothers con-
tinue to breastfeed at 6 months, with 18.6% practicing
exclusive breastfeeding.20Importantly, among the
many factors21–23influencing the decision not to
breastfeed was a lack of support from health profes-
sionals (reported by over 10% of Singapore mothers)
and a lack of knowledge about breastfeeding.19These
factors are not unique to Singapore, and both can be
addressed by appropriate interventions by health care
Programs aimed at promoting breastfeeding
through patient education and caregiver encourage-
ment have delivered mixed results.24–27Systematic
reviews conclude that educational programs are more
effective at improving breastfeeding initiation and its
short-term duration28,29than literature alone.30This
trial studies the impact of single-encounter antenatal
education, combining educational material with indi-
vidual instruction, on breastfeeding initiation, exclu-
sivity, and duration compared with routine antenatal
care and educational material used alone in a tertiary
MATERIALS AND METHODS
Recruitment for this randomized controlled trial was
performed between May 2002 and December 2003 at
the National University Hospital. The trial was aimed
at women with low-risk pregnancies who would have
term deliveries, and one research assistant recruited
participants from the antenatal population at the
outpatient obstetric clinic.
Inclusion criteria were singleton pregnancy, ges-
tation of at least 36 weeks at recruitment, no uterine
scar, and the absence of any obstetric complication
that would contraindicate vaginal delivery. The
women who agreed to participate were required to
give written informed consent. The study was ap-
proved by the institutional ethics review board. Each
participant was followed up for 1 year. Final data
were collected by December 2004.
Groups A and B were the designated intervention
groups. Group C was the control group. Women ran-
domized to group A received an information booklet
describing the techniques and benefits of breastfeeding,
which was written and published by the hospital’s
breastfeeding support group.31It contains practical ad-
vice on feeding techniques, expressing breast milk, and
management of common breastfeeding problems. Pa-
tients also watched a 16-minute educational video enti-
tled “14 Steps to Better Breastfeeding” (InJoy Videos,
Boulder, CO), in which the benefits of breastfeeding
were introduced, correct positioning, latch-on, and
breast care were demonstrated, and common concerns
(such as nipple pain) discussed. In addition, each
woman had one 15-minute session with a lactation
counselor who examined the woman’s nipples to assess
adequacy for breastfeeding and answered questions on
breastfeeding. Women randomized into group B re-
ceived the same booklet and watched the same video
but did not have an individual session with the lactation
counselor. Women in group C did not receive the
breastfeeding booklet, did not watch the video, and did
not have counseling (Fig. 1). No attempt was made to
prevent the women in any group from seeking addi-
tional information or assistance in breastfeeding from
the regular clinic and hospital resources. All groups
received standard care in all aspects of pregnancy and
delivery, including access to postnatal breastfeeding
The primary outcomes were rates of exclusive
and predominant breastfeeding at 2 weeks, 6 weeks, 3
months, and 6 months after delivery. Secondary
outcomes were the overall breastfeeding rates at each
of these intervals.
A computer-generated list was used to randomize
the women into the three groups. This list was kept by
the research assistant based in the antenatal clinic.
Each woman was allocated to the intervention group
next on the list after written informed consent had
been obtained. Data were collected at 6 weeks post-
partum with self-administered questionnaires and
through telephone interviews conducted by a second
research assistant. The questionnaires were developed
by the research team for this trial and had hitherto not
been assessed for reliability or validity. The second
assistant was blinded to the intervention received by
the women and trained to ask the questions in a
neutral noninfluential manner.
The allocated group was concealed from the
woman at the point of recruitment and from the
second research assistant collecting postnatal data,
who was also blinded to the intervention. The inves-
tigators analyzing the data were not blinded. The
women received the predetermined interventions
(groups A and B) or routine antenatal care (group C).
They were not allowed to change their groups, but
there was no attempt to prevent mothers in the
control group from exchanging information with
mothers in the intervention groups.
Participants recruited during the antenatal visit
had to complete one questionnaire covering the so-
cioeconomic background, medical and obstetric his-
tory, and pre-existing experience of breastfeeding.
Mattar et al Antenatal Preparation for BreastfeedingOBSTETRICS & GYNECOLOGY
Fig. 1. Participant recruitment, randomization, and interventions.
Mattar. Antenatal Preparation for Breastfeeding. Obstet Gynecol 2007.
VOL. 109, NO. 1, JANUARY 2007Mattar et al Antenatal Preparation for Breastfeeding
Groups A and B were exposed to the allocated
intervention at this time or at the next visit. Routine
antenatal, intrapartum, and postnatal care continued
for all three groups of women subsequently.
Postpartum questionnaires were administered a
day after delivery (before discharge from hospital)
and 6 weeks later, either over the telephone or in
person during a clinic visit. The information gathered
concerned the delivery and feeding practices during
each of the first 6 weeks of the puerperium. Follow-up
questionnaires were administered over the telephone
3 and 6 months after delivery.
Descriptions of different feeding practices were
printed on each questionnaire. Women were in-
formed that exclusive breastfeeding meant no formula or
water in the baby’s diet, predominant breastfeeding
meant no formula (water allowed), and partial breast-
feeding meant feeding formula in addition to breast
milk. Breastfeeding initiation was defined as any breast-
feeding within the first 2 weeks of delivery.
A study in Singapore showed that in 1996 only
15.9% of mothers were still breastfeeding their chil-
dren 4 months after delivery.32We assumed an ? of
0.05 and power of 0.8. Taking the exclusive and
predominant breastfeeding rate at 3 months among
women not receiving any antenatal education as 15%
compared with 30% among mothers who were given
antenatal preparation, the estimated sample size re-
quired was 134 in each group. The planned analysis
was a pairwise comparison between exclusive and
predominant breastfeeding rates in groups A and C.
We did not perform power analysis for any other
Analysis of breastfeeding rates was by intention
to treat. All analyses were performed using SPSS 13.0
(SPSS Inc, Chicago, IL). The association between
intervention groups and feeding practices was deter-
mined using chi-square/Fisher exact tests, with odds
ratios presented where applicable. We performed
pairwise comparisons between exclusive and pre-
dominant breastfeeding and no breastfeeding (com-
paring groups A and B, A and C, B and C). Subse-
quently, multiple comparisons were adjusted for using
the Bonferroni correction. Comparisons of baseline
data among the groups were performed using one-
way analysis of variance.
We planned to recruit 450 women into the study but
by the end of the recruitment period. Of these, 123
women were assigned to Group A, 132 women to
Group B and 146 women to Group C. 17 women were
lost to follow-up after randomization but before deliv-
ery. Data were collected at delivery from 384 patients. A
further 9 women were lost to follow-up before the 6th
week visit and another 9 women dropped out after 6
months postpartum. The reasons for loss to follow-up
were stillbirth, delivery in another country, a change of
address without forwarding new contact information to
the clinic, incorrect contact information, or withdrawal
for personal reasons. Complete data sets from 361
participants were finally analyzed, bringing the dropout
rate to 10%. Figure 1 shows the randomization and
number lost to follow-up at each stage.
Participants were similar in all respects across the
three groups (Tables 1 and 2). A majority of the
women were aged between 20 and 39 years, with
Malays being the highest represented ethnicity in all
groups, followed by Chinese and Indian women.
Most were multiparas, lived in government subsi-
dized public housing, did not have tertiary education,
were housewives and lived within a nuclear family
setting with a household income not exceeding US
$3000 a month. Most women had vaginal deliveries at
term. No differences were found in the distribution of
previous breastfeeding experience among the groups.
Of mothers with no prior breastfeeding experience,
95.8% had planned to breastfeed at the time of
recruitment versus 94.9% of mothers with prior expe-
In each group the number of women practicing
exclusive or predominant breastfeeding was com-
pared with the number who were exclusively feeding
formula (Table 3). When groups A and C were
compared, the proportion of women who exclusively
or predominantly breastfed at each interval was
higher in group A. Before correction, the difference in
rates was significant at 3 and 6 months. At 3 months,
36.0% in group A compared with 17.9% in group C
practiced exclusive or predominant breastfeeding
(P?.01, odds ratio [OR] 2.6, 95% confidence interval
[CI] 1.2–5.4). At 6 months, women in group A were
again more than twice as likely to practice exclusive
or predominant breastfeeding (20.0% versus 9.5%,
P?.047, OR 2.4, 95% CI 1.0–5.7). For every 6
women given antenatal preparation, one additional
woman would practice exclusive or predominant
breastfeeding at 3 months. For every 10 women given
antenatal preparation, one additional woman would
exclusively or predominantly breastfeed at 6 months.
When groups A and B were compared, the only
significant difference was noted at 6 months postpar-
tum, with 20% of women from group A breastfeeding
exclusively or predominantly compared with 9.0%
from Group B (P?.041, OR 2.5, 95% CI 1.0–6.3).
Mattar et alAntenatal Preparation for Breastfeeding OBSTETRICS & GYNECOLOGY
However, after correction for multiple compari-
sons, the difference in exclusive and predominant
breastfeeding rates between groups A and C re-
mained statistically significant only at 3 months
(P?.03). Comparing groups B and C, we found no
difference in breastfeeding rates at any interval.
At 2 weeks postpartum, 341 of the 370 women
(92.2%) breastfed. Exclusive or predominant breast-
Table 1. Baseline Comparison of Intervention and Control Groups
Less than 29 y
Prior breastfeeding experience
Household monthly income
Less than SGD 5,000
62 (50.4)74 (56.1) 80 (54.8).64
76 (61.8)81 (61.4) 95 (65.1).78
63 (56.3) 79 (67.5)76 (58.0).17
31 (25.2)22 (16.7) 33 (22.6).24
46 (37.4) 51 (38.6)60 (41.1).804
120 (97.6)129 (97.7) 141 (96.6).81
116 (94.3)129 (97.7) 134 (91.8).09
SGD, Singapore dollars.
Data are expressed as n (%).
Table 2. Comparison of Delivery and Birth Weight
Mode of delivery: vaginal [n (%)]
Gestational age at birth (wk, mean?SD)
Birth weight (g, mean?SD)
SD, standard deviation.
Table 3. Distribution of Exclusive and Predominant Breastfeeding by Groups
P [OR (95% CI)]
A and BA and C B and C
.176 [2.0 (0.7–5.8)]
.457 [1.3 (0.7–2.5)]
.294 [1.4 (0.7–2.9)]
Month 6 16/80 (20.0) 8/89 (9.0) 9/95 (9.5).041 [2.5 (1.0–6.3)]a
OR, odds ratio; CI, confidence interval.
Chi-square tests performed: a) OR 2.5, 95% CI 1.02–6.3; b) OR 2.6, 95% CI 1.2–5.4; c) OR 2.4, 95% CI 1.01–5.7.
* Total ? number (exclusive and predominant breastfeeding) ? number (exclusive formula feeding).
†Adjusted for multiple comparisons.
VOL. 109, NO. 1, JANUARY 2007Mattar et alAntenatal Preparation for Breastfeeding
feeding was practiced by 190 women (51.4%), and
151 (40.8%) mixed breastfeeding and formula. By 6
weeks postpartum, the number of breastfeeding
women had dropped to 253 from the original 370
(68.4%), with 109 women (29.5%) exclusively or
predominantly breastfeeding compared with 117
(31.6%) who fed formula. At 3 months postpartum, 63
of the 362 women (17.4%) were breastfeeding exclu-
sively or predominantly while 172 women (47.5%)
were now only feeding formula. By 6 months, only 33
of the 361 women (9.1%) were still exclusively or
predominantly breastfeeding compared with 232
(64.3%) who were no longer breastfeeding. There
were no intergroup differences in the type of contin-
ued breastfeeding up to 6 months.
The mean age at which infants started being
weaned onto solids was 17.24 weeks. Weaning of
group A infants started at 17.04?3.6 weeks, group B
infants started solids at 17.75?4.6 weeks, and infants
in group C started solids at 16.95?3.1 weeks. The
difference was not statistically significant (P?.313).
No adverse events were reported in this trial.
Our results showed that mothers who received simple
antenatal instruction with a short, single, individual
counseling session combined with educational mate-
rial were twice as likely to practice exclusive or
predominant breastfeeding at 3 and 6 months post-
partum compared with mothers who did not receive
formal antenatal instruction. The observed difference
was no longer statistically significant at 6 months after
correction for multiple comparisons probably due to
an inadequate sample size. Providing printed infor-
mation on breastfeeding alone before delivery was
not as effective as personalized antenatal counseling
at enhancing exclusive or predominant breastfeeding
rates. The introduction of solids did not appear to
influence the outcome because weaning began at
similar ages across the groups.
This trial was limited by a number of factors.
Block randomization would have ensured the same
number of participants in each group. We also did not
recruit enough women to fulfill our power calcula-
tions. Contamination between groups was not strictly
prevented, and women in the control group came to
know about the interventions offered to the other
groups simply by speaking to women in those groups.
They were, however, not given access to the booklet
or the video, which were available only at the clinic.
It is unclear how much contamination there was and
how it affected outcomes.
This study was conducted in a pragmatic fashion
in a tertiary hospital setting. The two antenatal inter-
ventions were given in addition to routine ambulatory
and inpatient hospital care. Other than the interven-
tions, all other aspects of management were similar.
There were no differences between groups. The find-
ings are therefore generalizable to any hospital setting
where pregnancy and delivery are managed. In addi-
tion, the deliberate single-encounter design is easy to
implement in any clinic, and the materials used were
inexpensive to procure.
Antenatal preparation of pregnant women for
breastfeeding raises awareness of the importance of
breastfeeding, empowers them with practical knowl-
edge and skills in breastfeeding techniques, and pre-
pares them for possible difficulties. Meeting with a
lactation counselor antenatally puts them in touch
with someone who can continue to provide postnatal
care and support. Although the decision to initiate
breastfeeding and the eventual decision to stop are
influenced by other factors such as family and work, it
is still worthwhile integrating lactation preparation
into routine pregnancy care. This should be part of a
greater multifaceted program aimed at educating
pregnant women for motherhood.
Many women make infant feeding decisions be-
fore delivery and before any contact with health
professionals.33–35Although health promotion cam-
paigns are influential in educating women about
breastfeeding, they often do not dissuade women
from formula feeding once the decision has been
Although new mothers may be aware of breast-
feeding benefits, they often lack practical knowledge
about the technique and process of initiating and
maintaining breastfeeding, and this may make them
resort to infant formula instead. In a survey of new-
born health care knowledge among Brazilian women,
almost 60% of the women were ill prepared for
breastfeeding, with perceived difficulties leading to a
conscious decision to formula-feed.36
Mothers also vary in their knowledge of breast-
feeding, and standard breastfeeding educational ma-
terial may not answer all their questions. Individual-
ized counseling enables mothers to clarify any
personal doubts they may have about the theoretical
and practical aspects of breastfeeding.
Various forms of breastfeeding education have
been tried with mixed results. Henderson found that
teaching first-time mothers about positioning and
breast attachment in the puerperium did not increase
breastfeeding duration.37In other trials, individual or
small-group teaching, counseling, practical advice,
audio-visual aids, and demonstrations were associated
Mattar et alAntenatal Preparation for BreastfeedingOBSTETRICS & GYNECOLOGY
with improved breastfeeding rate and duration.38–42
Systematic reviews show that postnatal support from
health care professionals and peer counselors leads to
a modest reduction in breastfeeding cessation and a
prolonged duration of exclusive breastfeeding43and
suggest that these trained health care professionals
should give women early practical advice on correct
positioning and attachment to reduce lactation diffi-
culties and increase breastfeeding duration.44
Our results support the current body of evidence
in favor of educational intervention. The outcome of
this trial demonstrates the effectiveness of a simple,
structured, one-encounter form of antenatal interven-
tion leading to a significant increase in exclusive and
predominant breastfeeding at 3 months. There is a
definite trend toward higher exclusive and predomi-
nant breastfeeding rates at 6 months. Provision of
printed or audiovisual educational material is not
enough. The most useful intervention includes dem-
onstration of breastfeeding techniques (educational
video), one-to-one teaching by a trained lactation
counselor, and a breastfeeding information booklet.
There is a trend toward exclusive or predominant
breastfeeding with a greater degree of intervention.
Thus, health care workers should provide at least one
face-to-face encounter to educate and prepare moth-
ers for breastfeeding before they deliver.
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