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1. JOGNN zyx
PRINCIPLES & PRACTICE
A Home VisitProgram for Breastfeeding
Education and Support
Teresa S. Johnson, RN, PhD, Rita Allen Brennan, RNC, MS, CLE,
Catherine Davis Flynn-Tymkow, RNC, MS zyxw
=A home visit program for breastfeeding edu-
cation and intervention was developed to provide
support for mothers and infants at risk for breast-
feeding failure. This program was developed to
supplement the Early Discharge Program for moth-
ers and newborns who were discharged within 24
hours of delivery. A breastfeeding assessment tool
was developed for use in the hospital and during
the early discharge home visit. Home visits are pro-
vided by a registered nurse with mother-infant
assessmentskills and competence to provide breast-
feeding education, problem management, emotion-
al support, and referrals to lactation consultantsor
physicians as needed. The response from patients
and physicians has been positive. As the demand
for services grew, the program was modified to
include other mothers and infants (e.g., those deliv-
ering via cesarean and high-risk,preterm, and bor-
derline preterm infants in need of breastfeeding
support). The readmission rate for breastfeeding
infants who receive a home visit is lower than for
infantswho do not receive a home visit. Patientsat-
isfaction surveys have been positive. zyxwvuts
JOGNN, 28,
480-485; 1999.
Accepted: March 1999 zyxwvuts
In the late 1980s and 1990s, escalating health
care costs stimulated insurance companies to nego-
tiate with hospitals and physicians for shorter hos-
pital stays and set fees for vaginal and cesarean
births. In response, hospitals began to shorten the
length of stay of mothers and newborns. Although
some health maintenance organizations (HMOs)
had programs to educate and support mothers dis-
charged within 24 hours (Grubbs, 1990; Izsak,
1990),other third-party payers did not. Nurses who
provided care for mothers discharged within 24
hours became concerned because many women
lacked the skill, confidence, andor family support
to care for themselves and their newborns so soon
after giving birth. It also became apparent to nurses
that new mothers needed to hear self-care and
infant care instructions repeatedly before they could
perform these tasks for themselves and their new-
borns with confidence.
In 1994, the unit director and maternity
nurses of Silver Cross Hospital started an early
discharge program. The main purpose of this pro-
gram was to facilitate family-centered maternity
care despite shortened hospital stays by providing
postpartum education and support to mothers in
their homes. Because the PKU T, test was done
during the home visit, the program enabled moth-
ers to leave without having to return to the hospi-
tal or physician’s office the next day.
Soon after the early discharge program began,
one nurse perceived that mothers often had ques-
tions about or needed help with breastfeeding. To
verify her perceptions, she began callingmost of the
breastfeeding mothers the day after their early dis-
charge visit. She found that although the mothers
took their newborns to see their pediatricianswithin
1 to zyxwv
3 days for examinations and weight checks,
many mothers remained insecure about their ability
to breastfeed. Several worried that their newborns
were not getting enough milk. They reported that
pediatriciansfrequently did not have the time, staff,
or expertiseto help motherswork through their inse-
curity with breastfeeding. Generally, the mothers
reported that their spouseswere supportive,but sev-
eral had no friends, mothers, or other relatives who
had had positive experienceswith breastfeeding. zy
480 JOGNN Volume28, Number 5

2. M o t h e r s frequently voice insecurities about
breastfeeding, and some are so frustrated they
may stop prematurely. Knowing that a nurse is
coming to visit the next day provides the
impetus to continue breastfeeding. zyxwvu
Literature Review zyxwvuts
To justify the need for a home visit program to
support breastfeeding mothers, several issues were iden-
tified from the literature. The initiative cited in zyxwvut
Healthy
People 2000 (U. S. Department of Health and Human
Services, 1991) to increase the number of women who
leave the hospital breastfeeding at discharge to 75%
and at 6 months to 50% is supported by the fact that
breast milk provides a specifically tailored combination
of proteins, carbohydrates, and fats for the newborn
(Blackburn & Loper, 1992). Breastfeeding also facili-
tates early mother-infant attachments (Klaus & Kennell,
1982). In addition, breast milk provides immunologic
protection against infection and may decrease the fre-
quency of chronic illnesses developed later in life (Cun-
ningham, Jelliffe, & Jelliffe, 1991).
Factors that might affect the success of the breast-
feeding mother-infant dyad also were studied. Bottorff
and Morse (1990) reported that although mothers will
verbalize the importance of breastfeeding their infants for
the first 6 months of life, many mothers perceive breast-
feeding as being less important after 3 months, as long as
their infants are healthy. Several authors found that one
variable that contributed to successful breastfeeding was
the presence of professional support and education during
pregnancy and once the mother and infant were at home
(Chapman, Macey, Keegan, Borum, & Bennett, 1985;
Hawthorne, 1994; Rogers, Morris, & Taper, 1987).
Hewat and Ellis (1986)compared women who breastfed
for short and long durations. Similarities between the
groups of women included (a) a desire to breastfeed, (b)
ambivalent feelings about breastfeeding, (c) prenatal
preparation for breastfeeding, and (d) physical discom-
forts related to breastfeeding.Differences noted in women
who breastfed for a longer duration were (a) more fre-
quent early feeding, (b)less concern about infant weight,
(c)a positive interpretation of infant’s behavior, and (d)
emotional and psychologic support from their partners.
A factor that negatively influenced breastfeeding
duration was formula supplementation (Walker, 1993;
Winikoff, Laukaran, Myers, & Stone, 1986).Conversely,
Coreil and Murphy (1988)reported that lack of support
from familyand friends may be a factor contributingto for-
mula supplementation. Other factors reported to influence
the length of breastfeedingwere inadequacyof milk supply,
poor infant weight gain, sleepingpatterns, sorenipples, and
maternal fatigue (Chapmanet al., 1985;Graef et al., 1988).
Other reasons cited for interrupting or discontinuing
breastfeeding included parental concerns related to the
infants behavior and color changes (jaundice) (Pascale,
Brittian, Lenfestey, & Jarrett-Pulliam, 1996).
Initial Objectives of the Program
The objectives of the program were to (a)promote
successful breastfeeding among a population at risk for
breastfeeding failure, (b)increase the number of moth-
er-infant dyads who continued to breastfeed 3 months
after hospital discharge, and (c)provide in-home breast-
feeding teaching and intervention to mothers and
infants who were discharged within 24 hours after
delivery. The mothers and newborns specifically target-
ed by the program were those who lack resources for
obtaining outside breastfeeding support. However, the
program does not exclude any mother or infant in need
of breastfeeding support.
Target Population
When the program began, the maternity unit pro-
vided services to a heterogeneous population comprised
of approximately 40% white, 35% black, and 25%
Hispanic women. Approximately 40% of this popula-
tion received or was eligible for Medicaid. Most women
who receive Medicaid also receive services from WIC
(Supplemental Food Program for Women, Infants, and
Children) before and/or after giving birth. Although
WIC provides informational material supporting
breastfeeding and nutritional supplements after delivery
for breastfeeding mothers, when the program was initi-
ated no local programs provided in-home breastfeeding
support for the targeted group of mothers and infants.
After the program began, the population served at
the hospital changed. The percentage of clients covered
by Medicaid decreased and the number of clients cov-
ered by HMO or preferred provider organization (PPO)
agreements increased. It was found that the clients cov-
ered by HMO and PPO insurance also met obstacles in
obtaining coverage for breastfeeding support services.
Most clients were discharged from the hospital within
24 hours after delivery. Like their Medicaid counter-
parts, these women encountered breastfeeding difficul-
ties. They, too, felt insecure about their breastfeeding
competence and support networks. With the nurses’
help during the home visits, mothers were able to work
through their problems and continue breastfeeding.
SeptemberlOctober zyxwvutsrq
1999 zyxwvutsr
JOGNN 481

3. Identifying Mothers at Risk for Breastfeeding
Failure zyxwvutsr
Before the Breastfeeding Education and Interven-
tion Home Visit Program began, several breastfeeding
tools were evaluated for use with the program. The
Infant Breast Feeding Assessment Tool (IBFAT)
(Matthews, 1988) evaluated only infant behaviors;
LATCH (Jensen, Wallace, zyxwvutsr
& Kelsay, 1994) and the
Mother-Baby Assessment tool (MBA) (Mulford, 1992)
evaluated mother and infant behaviors. According to reli-
ability and validity studies, most of these tools are in their
beginning stages of development. Because the tools are
lengthy, the current authors were concerned about adher-
ence by staff nurses. Furthermore, the authors of the
tools disagree on what components constitute successful
breastfeeding.These concerns were later substantiated by
the Riordan and Koehn (1997)study that evaluated the
reliability and validity for each of the breastfeeding
assessment tools that were reviewed. Riordan and Koehn
(1997)report that none of these tools are sufficientlyreli-
able and valid to predict breastfeeding success.
Therefore, a breastfeeding assessment tool was
developed for use in the hospital and home settings to
assess which mothers and newborns needed in-home
breastfeeding support. This breastfeeding assessment tool
(see the Appendix) was developed to include the major
points identified in the more lengthy assessment tools.
The tool also served as a guide for determining eligibility
for home visits.
The mothers and newborns targeted for a visit are
identified in the hospital or by the registered nurse who
provides the home visit for the Early Discharge Pro-
gram. Mothers with a score of 5-6 on the breastfeeding
assessment tool are called within 24 hours after dis-
charge. If they report problems and have questions that
cannot be handled over the phone, a breastfeeding edu-
cation and intervention visit is arranged. If no further
contact is required, the case is closed. A visit is arranged
for a score of 4 or below. Although the breastfeeding
assessment tool was initially used as a guide for defin-
ing eligibility for the breastfeeding support visits, this
use was short-lived. Soon after the program began,
some physicians began ordering breastfeeding support
visits for all their patients because of the positive feed-
back they received from the mothers.
Professional support and education for
mothers and infants at home contribute to
successful breastfeeding.
Program Components
The breastfeeding education and intervention visit
is individualized for each mother and infant. Basic con-
tent includes
1. correct positioning of the newborn at the breast.
2. assessment of the infant's suck and swallow.
3. assessment of the infant's milk intake,
4. assessment of the infant's urine and stool output. z
5. instruction on hand expression of milk.
6. identification of resource people available for
breastfeeding questions.
7. identification of specific nutritional and fluid
needs of the breastfeeding mother and infant.
8. identification of methods for continuing breast-
feeding support of the mother returning to work.
9. infant weight and measurements.
The forms completed at the home visit include an
infant assessment and a maternal breastfeeding knowl-
edge assessment tool. This tool highlights the informa-
tion needed by the mother to improve her breastfeeding
skill and confidence.
Because weight change is an important component
of evaluating infant feeding, accurate measurements are
critical for assessment. The accuracy of the Baby Weigh
scale (Medela, Inc., McHenry, IL) for use with preterm
and high-risk infants has been documented (Meier et al.,
1994).Before the scale was purchased, a trial scale was
used to compare weights against the Model 20 Smart
scale (Olympia Medical, Seattle, WA) on 36 full-term
and 14 preterm infants. The greatest difference between
the two weights obtained from the two scales was 4 g
(unpublished data). Funding for a scale was requested
and secured through a charitable fund.
Program Changes
Soon after the breastfeeding support visits were
initiated, it became clear that other patients, not just
those discharged within 24 hours of delivery, would
benefit from these visits. To meet this need, the pro-
gram was expanded to include mothers who had
cesarean births and infants who were high-risk. High-
risk infants were defined as those who experienced
extended hospitalization for phototherapy, antibiotic
therapy, or prematurity. Because of their neonatal
problems, many of these infants are not able to initiate
successful lactation until just before or after discharge.
One or two home visits often enable those moth-
ers and infants to breastfeed exclusively. As the pro-
gram gained credibility, the nurses and physicians
began collaborating to identify and document medical
diagnoses, such as dehydration, hyperbilirubinemia,
and decreased oral intake, that would qualify mothers z
482 zyxwvutsrqp
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4. and infants for regular home health services. As a result,
the program became a feeder to the home health ser-
vices, ensuring that those infants requiring medical fol-
low-up did not fall through the cracks. This extended
care and support through home health enabled mothers
of preterm infants to breastfeed successfully. Most of
the mothers of high-risk and preterm infants reported
that they would have discontinued breastfeeding with-
out this additional support.
Although the initial program was developed to pro-
vide in-home breastfeeding support for mothers and
infants with identified risk factors, the program provided
additional benefits. Many nurses noted that parents were
unable to absorb all the information provided while the
mother and infant were in the hospital. The home visit
program provided parents with support and education in
a comfortable place, at a time when they were ready to
hear and retain the information. Thus, many physicians
ordered the breastfeeding visits without a specific identi-
fied need or prompting from the nursing staff. While
some critics saw this as an unnecessary, unreimbursed
expense, the vice presidents of nursing and marketing
saw dividends in maintaining the program. Since its
inception, the program has become not only good mar-
keting for the hospital, but a patient and physician satis-
fier. The number of unnecessary phone calls and other
visits to the physician decreased, and patients feel satis-
fied with the quality of information they receive and the
time the nurse spends with them. zyxwvuts
Evaluation
The program began in May 1995, and 134 breast-
feeding support visits were made that year. Since the pro-
gram began, more infants who had no breastfeeding sup-
port visit have been readmitted to the hospital than those
who had a home visit (see Table 1).The most common
reasons for readmission are hyperbilirubinemia and dehy-
dration. This difference in readmission may be due in part
to pediatricians being more comfortable with letting
infants stay home with mild feeding problems or hyper-
bilirubinemia when they know that the infant will be seen
at home by the nursing staff and they will be notified of
urgent problems requiring their attention.
Nurses providing home visits have shared anecdotal
reports of the kinds of support they have offered to the
families served. Fluctuations in staffing and changing
roles for lactation consultants, educators, and case man-
agers, however, have made evaluation of the program
challenging. Although data sheets were developed for
phone follow-up at 3 and 6 months to determine whether
breastfeeding continued or reasons for weaning, data for
the whole program since inception are unavailable.
During 1997, the following data were available:
approximately 50% of all of the mothers left the hospital
breastfeeding. Of the mothers who received home visits
for breastfeeding support and were contacted, zy
50% were
breastfeeding at 3 months, and zyxw
22% were breastfeeding
at 6 months. Data from 1998 show a similar trend.
Evaluating the program’s results via phone has
been problematic because of disconnected services,
clients not home, no answer, or no answering machines.
Anecdotal notes from mothers who quit at 3 months
indicated that some of their reasons for weaning were
return to work, infant was fussy, not enough milk, and
taking antibiotics incompatible with breastfeeding.
A survey was developed to assess the mothers’ sat-
isfaction with the breastfeeding education and interven-
tion visit. In addition to documenting the number of
infants still breastfeeding at designated intervals, a ques-
tionnaire was given to mothers. Most women who had
a home visit were satisfied or very satisfied with the
teaching they received regarding positioning and latch-
ing on, discerning infant readiness cues, assessing for
adequate milk supply, maternal nutritional and fluid
needs, management of sore nipples, and engorgement.
Conclusions and Implications for Practice
This program was initiated with the support of the
hospital administrators and pediatricians. Although
standing orders were used as one way to remind physi- z
TABLE 1
Number of Deliveries, Infants Who Received Breastfeeding Support Visits,
and Readmissions by Year
Year
1995
1996
1997
1998
No. zyxwvutsrqp
of Deliveries
1,630
1,391
1,324
1,268
No. of Infants Who zyxwvu
% of Readniissioris
Received Visits Without Visit
134
350
317
180
5.5
5.5
3.3
6.9
% of Readmissions
With Visit
1.5
1.5
0.7
0.4
SeptemberlOctober 1999 JOGNN 483

5. Reinforcing the teaching that occurred in
the hospital helps the mothers and reduces
their number of phone calls to the nursery and
to their primary health care providers. zyxwvu
cians of the program’s availability, collaboration between
the nurses and physicians was one of the most important
factors in identifying mothers and infants who could ben-
efit from a home visit to provide lactation support. Before
the program began, a breastfeeding assessment tool was
developed to determine who would benefit most from the
program. As the program evolved, communication
between nurses and physicians provided better though
less structured guidance in identifying mothers and
infants who would benefit from a home visit.
A challenge for the program has been the staffing.
The program initially was staffed by nurses from the
maternity unit who were cross-trained to work in the
home health department. Subsequently, the program
was turned over to the maternity unit for administration
and staffing. Over the life of the program, the staffing
has been provided by nurses from the nursery and
mother-baby units, both regular and registry staff. The
ideal system would provide a sufficient number of nurs-
es with expertise in this area to follow their patients
from inpatient care through the home health experi-
ence, but cost containment, fluctuating staff interest,
and turnover have not made this feasible.
As the program developed, some clinicians had a
preconceived notion that multiparae do not need the
breastfeeding visit as much as primiparae. However, nurs-
es who made the home visits found that multiparous
mothers appreciated the visits as much as primiparous
mothers. Other early discharge programs reported similar
responses (Brown &Johnson, 1998).Some of the multi-
parae had not breastfed their other children or had disap-
pointing or unsuccessful previous breastfeeding experi-
ences. For some, the newborn’s behavior varied so much
from their previous infant’sthat the mothers found it reas-
suring for a health care professional to tell them that their
newborn was responding normally.
The breastfeeding education and intervention home
visit program was developed to provide in-home support
for mothers and infants who were thought to be at high-
risk for breastfeeding failure. As the program evolved, the
nurses and physicians who provided care for these moth-
ers and infants determined that other mothers and infants
could benefit from the program, such as preterm infants,
infants hospitalized for jaundice, and borderline preterm
infants. Ultimately, it was communication between the
nurses and physicians providing care for the mothers and
infants and an awareness of the individual needs that pro-
moted the home visits. A breastfeeding assessment tool
was developed to provide a framework for establishing eli-
gibility for visits. This tool also served as a guide for
breastfeeding evaluation, particularly for novice nurses.
The breastfeeding home visit program depends on open
communication between physician, patient, and nurses to
ensure that breastfeeding is initiated and maintained. The
home visit program has provided parents with timely
breastfeeding education and support that has helped them
through those vulnerable first weeks after childbirth.
Acknowledgment
This program was funded in part by a grant from
the March of Dimes. This work won an Honorable Men-
tion Award for Innovative Programs at the AWHONN
National Convention, Washington, DC, June 1997. zy
REFERENCES
Blackburn, S. T., & Loper, D. L. (1992). zyx
Maternal, fetal, and
neonatal physiology. Philadelphia: W. B. Saunders Co.
Bottorff,J. L. & Morse, J. M. (1990).Mothers’ perceptions of
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charge with home follow-up: zyxw
A pilot project. Journal zy
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Obstetric, Gynecologic, and Neonatal Nursing, 27,
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for HMOs. HMO Practice, 4, 94-99.
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Hewat, R. J., & Ellis, D. J. (1986).Similarities and differences
between women who breastfeed for short and long
duration. Midwifery, 2, 37-43.
Izsak, J. (1990). Early neonatal discharge and home care.
HMO Practice, 4, 100-101.
Jensen, D., Wallace, S., & Kelsay, P. (1994). LATCH: A
breastfeeding charting system and documentation tool.
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ing, 23, 27-32.
33-38. zyxw
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6. Klaus, M. H. zyxwvutsrqp
& Kennell, J. H. (1982). zyxwvutsrq
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risk infants. Journalof Human Lactation, 10, 163-168.
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Teresa S. Johnson is an assistant professor in the School z
of
Nursing, University of Wisconsin-Milwaukeeand was a staff
nurse at Silver CrossHospital,Joliet, lL, when the home visit
program was implemented.
Rita Allen Brennan is outcomes manager for pediatrics at
Central Dupage Hospital, Winfield,IL, and was a case man-
ager/lactation consultant, Silver Cross Hospital, Joliet, IL.
Catherine Davis Flynn-Tymkow is a research nurse at North-
western Memorial Hospital, lecturer at Governors State Uni-
versity, University Park, lL, and is pursuing a doctorate at
Rush University, Chicago, IL. She was director of Perinatal
Nursing at Silver Cross Hospital when the home visit pro-
gram was implemented.
Address for correspondence: T. S. Johnson, RN, PhD, School
of Nursing, University of Wisconsin-Milwaukee, zy
l? 0. Box
413, Milwaukee, w7 53201. zyxw
Appendix
Mother-Infant Breastfeeding Assessment Tool
Mother’s name: Address: Mother’s Hospital Record #:
Baby’s name: Phone #: Baby’s Hospital Record #:
1
Yes
-
-
-
-
-
-
-
-
-
-
1. Mother is able to get the infant latched onto the breast.
2. Infant latches onto the breast without difficulty.
3. Infant nurses with a strong suck.
4. Mother does not have flat or inverted nipples.
5. Mother has nursed infant 3-4 times while in the hospital or
6. Infant has had 2 2 wet diapers in 24 hours prior to discharge or
7. Mother has had a previous successful breastfeeding experience.
8. Mother has a supportive partner or has identified a support person for breastfeeding.
Mother has nursed infant 5-6 times since discharge or in a 12-hour period.
Infant has has 2 6 wet diapers in 24 hours by 2 days after discharge.
TOTAL -
0
No
Scoring system
7-8 At low risk for breastfeeding failure. (Thesemothers will be offered a follow-up phone call.)
5-6 At risk for breastfeeding problems. (These mothers will receive a follow-up phone call and a visit will be arranged if
1 4 At risk for breastfeeding failure. (A home visit will be arranged.)
problems are identified upon phone contact.)
SeptemberlOctober 1999 JOGNN 485