Group Prenatal Care for Breastfeeding Promotion

Prenatal Breastfeeding Workshop: Teaching and Learning Package

All credible health authorities, with even a remote interest in maternal and child health outcomes, spend a great deal of effort promoting the benefits of breastfeeding (AAP n.d.). The official policy statement issued and recently updated by the American Academy of Family Physicians (AAFP 2014) encourages family physicians to incorporate breastfeeding education into preconception, prenatal, and postnatal care visits. The AAFP (2014) also recommended that providers encourage family members, especially the father and maternal grandmother, to participate in supporting the mother’s intention and commitment to breastfeeding. Although an individualized education approach can be beneficial, the American College of Nurse-Midwives (ACNM 2011) recommends a group prenatal care format. The advantages of this model, aside from preserving clinic resources, include better maternal and infant health outcomes. The model mentioned specifically by the ACNM (2011) was the CenteringPregnancy model, which uses a provider- and co-facilitator-led participatory instruction.

I am a nurse who is working in a hospital obstetrics and gynecology ward in my home country, with a strong interest in patient education. Recently, I decided to provide a free prenatal breastfeeding workshop through my department on a voluntary basis and this report presents the details of the proposed teaching and learning package. The objectives will be to expand my role as a patient educator, improve the quality of patient education, expand the services offered by my department, and improve patient awareness about breastfeeding benefits. The chosen model for the prenatal breastfeeding workshop is group prenatal education, which brings women together at approximately the same gestational age to learn and share during the 2-hour workshop. This report will provide justification for the project and discuss the material that should be included in the teaching and learning package.

Overview of the Prenatal Breastfeeding Workshop

During their first prenatal care visit, women under 20-weeks gestation will be invited to attend the prenatal breastfeeding workshop. They will be given a leaflet containing an overview of the information that will be provided in the workshop, a description of how the workshop will be organized, directions, and contact information. The workshop will be in a group format that encourages active participation with facilitators and the other women attending. The topics covered will include the benefits, techniques, and strategies for breastfeeding. The didactic portion of the workshop will begin with a brief video providing a general overview of breastfeeding (Office on Women’s Health 2011). A PowerPoint slide presentation, accompanied by a verbal presentation, will represent the main teaching tools used. Workshop attendees will be asked to complete a breastfeeding knowledge assessment at the end of the workshop, in addition to evaluating the workshop and facilitator performance in written form.

The lesson plan for a 2-hour prenatal breastfeeding workshop will be presented here (Appendix). The rationale for the lesson plan is evidence-based and explained in detail below. The learning modules were adapted from published online information and informed by peer-reviewed research publications. The lesson modules are the following: (1) infant benefits, (2) maternal benefits, (3) how to breastfeed, (4) managing a breastfeeding routine, and (5) breastfeeding in public. What follows is a detailed overview of the information presented in the workshop and a discussion of the relevant learning theories.

Teaching

The information that should be conveyed to pregnant women during prenatal care has been well-established, but the benefits of breastfeeding, while substantial, continue to be elaborated through experimental studies. Current recommendations are for exclusive breastfeeding for the first 6 months of life, followed by at least another year of breastfeeding as the diet is supplemented with liquids and foods (AAP 2012). Beyond that point, continued breastfeeding is optional depending on the wishes of the mother and child. The Office on Women’s Health (2010a) within the U.S. Department of Health and Human Services (HHS) maintains an updated information database on best practice recommendations for breastfeeding, including recommended positions, schedules, duration, exclusivity, diet supplementation, and solutions to any problems that may arise. What follows is an overview of this information, which will form the knowledge base for the breastfeeding prenatal workshop.

Patience and practice are the main requirements for breastfeeding, in addition to a safe and relatively stress- free environment (Office of Women’s Health 2010a). Women attempting to breastfeed for the first time may experience discomfort and frustration, but with persistence comes skill for both mother and infant. The most important things to remember are that milk will be produced in response to suckling behavior and breasts will adapt to consumption rates. Suckling triggers the maternal release of prolactin and oxytocin, in addition to dilation of the milk ducts. Prolactin causes the breast alveoli to make milk, while oxytocin controls postpartum bleeding and induces uterine muscle contraction.

The release of milk triggered by suckling is called the let-down reflex

(Office on Women’s Health 2010a). The length of time that it takes from the start of suckling to milk release can vary from a few seconds to a few minutes, therefore patience may be required. The sensation that accompanies the let-down reflex can vary from no sensation, to tingling, to mild discomfort. The let-down reflex can also be triggered several times during a feeding. Other triggers include hearing your baby cry or thinking about your baby, which may be helpful when expressing breast milk for later feedings.

Mother and infant should be brought together immediately after birth, health permitting, to provide every opportunity for breastfeeding to occur (Office on Women’s Health 2010a). How fast the baby will latch onto the mother’s nipple will vary, from immediate to several minutes. Typical searching behavior is the infant rolling the head back and forth and searching for a nipple with the mouth and lips. The steps for helping the baby latch onto the nipple are the following: (1) hold baby upright and against the chest just below the chin, (2) support the neck with one hand and the hips with the other, (3) tilt the baby’s head back slightly to naturally open the mouth and depress the tongue, (4) lower the baby until the breast naturally rests on the baby’s cheek, which will probably cause the infant to search and find the nipple, and (5) support the upper back and shoulders of the infant with one hand and pull the baby in close.

The baby’s head should never be held during suckling, since this may interfere breathing (Office on Women’s Health 2010a). If the proper position is attained, the infant’s nostrils are flared, mouth filled with breast, tongue and chin under breast, areola mostly covered, head straight, chest against torso, swallowing evident, and ears wiggling. This position should be comfortable for both infant and mother. Other useful positions include the following: (1) along the mother’s same-side forearm in a cradle hold, (2) on the opposite-side forearm in a cross-cradle hold, (3) with both forearms in a ‘football’ hold, or (4) while the mother and infant are laying on their sides. Breast pain can be caused by the infant latching onto the nipple and not the breast, which in turn may prevent the release of sufficient milk. The solution is to simply break suction by wedging a clean finger between the breast and the infant’s lips and then trying again.

Shortly after birth the number of feedings per day can range from 8 to 12, with each breast being suckled about 15 to 20 minutes (Office on Women’s Health 2010a). The best approach is to allow a healthy baby to set the feeding schedule and avoid the use of pacifiers and infant formulas unless it is medically necessary. Sharing the sleeping space with the baby increases the convenience of feeding and reduces the risk of sudden infant death syndrome. Initially, the baby may lose a little weight within the first few days after birth, but this trend should reverse after the first week of life if well-fed. The presence of a sufficient volume of pale urine, adequate bowel movements, post-feeding contentment, post-feeding softer breasts, and a healthy wake/sleep cycle are all indicators of a healthy breastfeeding routine.

Breastfeeding women can encounter many problems, including sore nipples, inappropriate milk volume, plugged ducts, infections, or an atypical nipple (Office on Women’s Health 2010b). The primary cause of sore nipples is an improper latch. The only solution to this problem is breaking the suction and repositioning the infant on the breast. A less frequent cause of pain is irritation caused by the development of an abrasion, but if this does not resolve on its own the mother should seek medical care. Getting professional advice is also recommended before the mother attempts to use creams, ointments, nipple shields, and nursing pads.

The primary cause of low milk supply is a lack of experience and knowledge (Office on Women’s Health 2010b). With experience the feeding time may shorten to as much as 5 minutes due to increased infant skill. If the baby is content after feeding and otherwise healthy, the length of feeding time is irrelevant. Adaptation to growth spurts will probably require longer and more frequent feedings, until the breasts can adapt by producing more milk. In order to promote adequate milk production, pacifiers and supplementary liquids should be avoided for the first six months. An oversupply of milk can make feedings difficult for the mother and infant, and this should be remedied promptly. Offering only one breast per feeding and lengthening the feeding time can help, as can reducing milk volume before feedings by hand expressing. Breast engorgement can occur within the first few days after birth and must be handled properly to prevent plugged ducts and mastitis (infection). Other problems that can occur include a fungal infection (thrush), infant refusing to breast feed (nursing strike), and unhealthy infants. Medical help should be sought if these problems do not resolve quickly.

Some women may feel uncomfortable breastfeeding in public, but government and medical organizations urge women to overcome this difficulty on behalf of the infant’s and mother’s health (Office on Women’s Health 2010c). Purchasing loose tops, using slings or breastfeeding blankets, discovering private spaces, and practicing at home can help. Breastfeeding at work poses its own challenges, but many of the potential difficulties can be effectively addressed (Office on Women’s Health 2010d). Practicing expressing milk at home by hand or with a pump, storing milk in the refrigerator or freezer, and bottle feeding the infant will prepare the mother and infant for her return to work. During a typical work day the milk will need to be expressed two to three times and refrigerated under sanitary conditions for the next day. A photo of the baby can help trigger let-down and expressing the milk will take about 15 minutes. Since work was cited as the primary reason for women who stopped breastfeeding, overcoming these barriers are important to infant health (Keister, Roberts, and Werner 2008).

Breastfeeding outcomes have been studied extensively, but the research quality is almost uniformly low due to ethical concerns about randomizing women to different treatment groups (Ip et al. 2007). Despite these significant limitations, systematic reviews and meta-analyses have revealed several significant maternal and infant health benefits associated with breastfeeding.

Breastfeeding confers short-term protection against respiratory infections regardless of maternal age and socioeconomic status (Horta and Victora 2013a). In addition, both hospitalization and mortality due to respiratory infections were reduced 57 and 70%, respectively. Middle ear infections (otitis media) were reduced by 23% when comparing ‘any breastfeeding’ to no breastfeeding and 50% when comparing no breastfeeding to exclusive breastfeeding, but only if exclusive breastfeeding lasted 3 to 6 months (Ip et al. 2007). Infant diarrhea was reduced by 30% when mothers had been exposed to breastfeeding promotion, but infants younger than 6 months of age obtained the greatest benefit (Horta and Victora 2013a). At 6 months, gastrointestinal infections were reduced by almost 40% when comparing ‘any’ to ‘exclusive’ breastfeeding (Ip et al. 2007). Breastfeeding was also protective against necrotizing enterocolitis in preterm infants by a small, but clinically-significant margin (5%).

To date, no conclusive evidence has been obtained that shows a significant benefit of breastfeeding for child cognitive performance (Horta and Victora 2013b); however, a recent large study (N = 11,134)

examined the association of breastfeeding with developmental milestones and found ‘ever’ breastfeeding significantly improved gross motor, fine motor, problem-solving, and personal-social by 32, 60, 20, and 38%, respectively, during the first postnatal week only (McCrory and Murray 2013). Breastfeeding has also been consistently associated with a modest 3.5 point increase in child intelligence (IQ) scores and a 24% reduction in overweight/obesity risk (Horta and Victora 2013b).

The five main reasons why women choose to breastfeed their infants are (1) infant health, (2) natural lifestyle, (3) maternal-infant bonding, (4) convenience, and (5) maternal health, in that order (Hahn-Holbrook, Schetter, and Haselton 2013). The main reasons for choosing to not to breastfeed or discontinue breastfeeding are (1) paternal opposition, (2) infant nutrition worries, (3) career obligations, (4) physically uncomfortable, and (5) concerns about physical appearance. If the published maternal risks associated with suboptimal breastfeeding practices are examined, however, there would have been an excess of 5,000 cases of breast cancer, 28.7 cases of premenopausal ovarian cancer, 4,500 cases of type 2 diabetes, 53,847 cases of hypertension, 14,000 myocardial infarctions, and 4,400 deaths before the age of 70 in 2005, at a cost of $10.5 to $44.5 billion dollars in direct and indirect health care costs (Bartick 2013). From a mental health perspective, increasing the hours of skin-to-skin contact between mother and infant provided significant protection against depression, anxiety, and elevated salivary cortisol levels (Bigelow et al. 2012).

Encouraging the retention of the above information will require the facilitators to be competent teachers. Among the many roles that nurses may encounter in patient education, those most relevant to a group prenatal breastfeeding workshop are: (1) orchestrating the many facets of workshop administration, (2) providing effective feedback, (3) identifying concerns, and (4) assessing patient knowledge, skills, and attitudes (Walsh 2010: 17). While these activities are important for the learning process the method of instructions also matters a great deal (Banning 2005). A strictly didactic means of transmitting information from the teacher to student is fraught with potential problems, including rote learning, boredom, and minimal investment in the transaction by both parties. A better approach, according to Banning (2005), is a facilitatory teaching style where the teacher helps the student to engage in self-directed learning. The teacher attributes that are needed for this teaching style is a high level of competency in the material being taught, compassion, respect, and flexibility in teaching methods. In addition, the quality of the relationship between the teacher and student is important, which is a significant departure from a didactic teaching style where the teacher and student rarely, if ever, have a personal interaction. The facilitatory teaching style is the chosen method for this workshop, because this method is ideally suited for adult learners and shifts the balance from a teacher-centered approach to a student-centered approach.

The essential requirements for facilitatory teaching are a compilation of learning materials and academic support (Banning 2005). The above discussion of breastfeeding benefits and techniques represent the knowledge base upon which the workshop will be constructed, while the academic support will be provided by a number of tools, including a PowerPoint presentation, leaflets, brochures, and practice dolls.

Learning

Learning is the process of change that can alter an individual’s cognitive, affective, and behavioral repertoire in often permanent ways (Braungart, Braungart, and Gramet 2011). The process of learning has been of significant interest to researchers wishing to improve the many forms of education. Accordingly, theories of learning have been developed in an attempt to model the independent and dependent variables involved (Braungart, Braungart, and Gramet 2011). Probably the most basic learning theory conceptually is behaviorism, because it assumes that the environment controls all behavior. Under this model, women attending a prenatal care class are assumed to be passive, reactive participants; therefore, changing the environment will alter prenatal health outcomes. Behaviorism is the least attractive model for a patient-centered approach, because it ignores the patient’s emotional and cognitive contributions to learning.

By comparison, cognitive theory assumes that learning occurs primarily by altering cognition (Braungart, Braungart, and Gramet 2011). Under this model, clients and patients are assumed to be primarily rational beings who are influenced to some extent by personality traits. The model most relevant to group prenatal care is social learning theory, because the students learn by interacting with both teachers and classmates. Under this model, the facilitators of a prenatal care class would act as role models, sources of perceived reinforcement, and as agents of influence acting upon the internal processes of the student. A woman’s lifestyle choices, past experiences, and current mood are the focus of psychodynamic learning theory; however, an instructor is required to evaluate each student in order to understand how these factors influence the learning process (Braungart, Braungart, and Gramet 2011). Accordingly, psychodynamic theory appears to be more appropriate for individual prenatal care encounters (Levy 1999). Under humanistic learning theory the facilitator would be more of a coach than teacher, which is not appropriate for the aim of this workshop

. The most recent learning theory is not so much a theory as a collection of neuropsychology empirical findings. For example, neuroscientists have discovered that emotions are essential to the learning process, in addition to cognition. Empirical findings also support the relevance of past experiences, cognitive load, sensory modalities, instructional pace, practice, motivation, arousal, and attention, to the learning process.

Based on the above analysis, a group prenatal breastfeeding workshop would benefit from cognitive, social, and neuropsychological learning theories. The main assumptions of cognitive learning theory are: (1) distinct sensory channels, (2) limited cognitive capacity, and (3) learning occurs when attending to sensory information, processing it, organizing it into meaningful categories, and integrating it with existing knowledge (Mayer 2010). The critical component, however, is the concept of ‘cognitive load,’ which implies that the information processing capacity of working memory is finite. This concept is critical because sensory memories last for a few seconds at best and unless working memory has the capacity to accept the information it will be lost (Khalil et al. 2005). In addition, information retained in working memory must transition into long-term memory (LTM) to free up capacity for incoming sensory information. This is accomplished by the creation of ‘schema’ within the LTM, which help organize information to facilitate long-term storage. Schema also speed up the transitioning of information from the working memory to LTM, thereby increasing working memory capacity and reducing cognitive load. The other essential elements of cognitive learning are motivation and rehearsal. The importance of motivation is obvious, while rehearsal helps retain information in working memory long enough for it to become encoded into LTM schema(s).

If some of the main elements from cognitive, social, and neuropsychological learning theories are combined, the result would encompass Bandura’s theory of self-efficacy and the theory of adult learning principles (Noel-Weiss et al. 2006). Self-efficacy theory has four components: (1) performance, (2) vicarious learning, (3) persuasion, and (4) emotional/physiological arousal. Adult learning principles assume that students are self-motivated, need a reason to learn, and arrive in class with a rich history of past experiences, therefore adult learners are distinct from child learners (Hand 2006a). For these reasons adult learners benefit the most from patient-centered teaching styles. Noel-Weiss and colleagues (2006) created a 2.5-hour workshop on breastfeeding using these theories and breastfeeding self-efficacy scores increased significantly compared to a control group. Women in the intervention group were also significantly more likely to be breastfeeding exclusively (78 vs. 53%) or ‘any’ breastfeeding (95 vs. 71%) 8 weeks postnatal.

There are a large number of learning theories that have been used for patient education (Bellamy 2004), but based on the above discussion the most relevant theories to a 2-hour group prenatal breastfeeding workshop are cognitive, social, and neuropsychological. The main contributions from cognitive are the importance of motivation, attention, and rehearsal, but with close attention being paid to cognitive load (Mayer 2010). The graphics and text included in the slides should be relevant and barebones, respectively, to minimize the extraneous processing load. To improve essential processing performance the following will be implemented: (1) leaflets presenting the main points of the information conveyed in the workshop will be given to women during the first prenatal care visit, thereby triggering schema formation, (2) the information will be organized into coherent modules to reduce cognitive load, and (3) the text presented in the PowerPoint slides will be also be verbally presented to make use of the distinct visual and auditory information processing pathways.

To minimize the generative processing load the information and teaching materials being presented will be relevant, well-organized, stripped down to the essentials, and presented within a pleasant surrounding and using a positive tone (Mayer 2010). With a nod to social learning theory the facilitators will become role models, provide perceived reinforcement (e.g., infant and maternal health benefits), and act as cognitive and emotional agents of influence (Braungart, Braungart, and Gramet 2011). For example, the use of graphics depicting the correct positions of breastfeeding, well-fed infants, and a mother breastfeeding in public can trigger different emotional responses, from joy to stress. Since neuroscientists have shown that emotions directly influence motivation, the graphics included in the slides will be chosen to influence the emotional climate of the workshop. In addition, the experiential histories of the women will be addressed as needed to facilitate the learning process. Both neuropsychology and cognitive learning theory recognizes that past experiences can determine learning quality. All of these facets will be considered during the design and presentation of the group prenatal breastfeeding workshop.

Assessment

The 2-hour group prenatal breastfeeding workshop will contain the following modules: (1) infant benefits, (2) maternal benefits, (3) how to breastfeed, (4) managing a breastfeeding routine, and (5) and breastfeeding in public. Within each module a number of subtopics will be presented. For example, the module on breastfeeding in public will contain information about clothing choice, private spaces, returning to work, practicing at home, let-down cues, hand-expressing, and breast pumps.

A self-assessment form will be presented to the workshop participants at the end of the workshop. The purpose of this assessment form is to help the participants rehearse key points about breastfeeding, trigger discussions about breastfeeding topics, and help the facilitators monitor how effective their teaching skills and techniques are. This assessment strategy is a commonly used strategy in patient education (Hand 2006). Completion of the self-assessment form will be followed by a quick discussion to help the participants understand how much the workshop helped them to understand breastfeeding and to provide feedback.

Evaluation

A number of research groups have studied the outcomes of prenatal breastfeeding classes for several decades, but group prenatal care is a relatively new phenomenon (Thielen 2012). An example would be the CenteringPregnancy prenatal care program first developed by nurse-midwife Sharon Schindler Rising in 1998 (Thielen 2012). This particular program has been adopted on a national level in the United States, thereby motivating a number of research groups to investigate the relative impact of group prenatal care on infant and maternal outcomes, including breastfeeding practices (Thielen 2012). The evaluation criteria utilized by several research groups will be discussed here as justification for use in an outcome evaluation for the group prenatal breastfeeding workshop proposed here (Thielen 2012).

The evaluation approach utilized for the prenatal breastfeeding workshop described here will focus on participant perspectives of the workshop and its facilitators; therefore, only a few brief questions will be required to provide a general sense of how well the workshop was received by the women who participated. The questions included in the evaluation will be informed by a prenatal satisfaction questionnaire published previously (Raube, Handler, and Rosenberg, 1998). A one-page evaluation form will be used at the end of the workshop and participants will be expected to complete the form before leaving. A long-term evaluation will be conducted by phone six weeks postnatal and the same questions will be asked of participants verbally.

References

AAFP

. (2014) Breastfeeding, Family Physicians Supporting (Position Paper) [online] available from [29 March 2014].

AAP. (2012) ‘Policy Statement: Breastfeeding and the Use of Human Milk’. Pediatrics 129, e827-41.

AAP. (n.d.) Breastfeeding Initiatives: Health Professional Resource Guide [online] available from [29 March 2014].

ACNM. (2011) Position Statement: Models of Group Prenatal Care [online] available from [29 March 2014].

Artieta-Pinedo, I., Paz-Pascual, C., Grandes, G., Bacigalupe, a., Payo, J., and Montoya, I. (2013) ‘Antenatal Education and Breastfeeding in a Cohort of Primiparas’. Journal of Advanced Nursing, 69(7), 1607-17.

Banning, M. (2005) ‘Approaches to Teaching: Current Opinions and Related Research’. Nurse Education 25, 502-8.

Bartick, M.C., Stuebe, a.M., Schwarz, E.B., Luongo, C., Reinhold, a.G., and Foster, E.M. (2013) ‘Cost Analysis of Maternal Disease Associated with Suboptimal Breastfeeding’. Obstetrics and Gynecology 122 (1), 111-9.

Bigelow, a., Power, M., MacLellan-Peters, J., Alex, M., and Mcdonald, C. (2012) ‘Effect of Mother/Infant Skin-to-Skin Contact on Postpartum Depressive Symptoms and Maternal Physiological Stress’. Journal of Obstetric, Gynecologic and Neonatal Nursing 41 (3), 369-82.

Bellamy, R. (2004) ‘An Introduction to Patient Education: Theory and Practice’. Medical Teacher 26(4), 359-65.

Braungart, M.M., Braungart, R.,G., and Gramet, P. (2011) ‘Applying Learning Theories to Healthcare Practice’. In Health Professional as Educator. ed. By Bastabel, S., Gramet, P., Jacobs, K., and Sopczyk, D.L. Sudbury, MA: Jones & Bartlett Learning, 51-89.

Hahn-Holbrook, J., Schetter, C.D., and Haselton, M. (2013) ‘Breastfeeding and Maternal Mental and Physical Health’. In Women’s Health Psychology. ed. By Spiers, M.V., Geller, P.A., and Kloss, J.D. Hoboken, NJ: Wiley, 414-39.

Hand, H. (2006a) ‘Promoting Effective Teaching and Learning in the Clinical Setting’. Nursing Standard 20(39), 55-63.

Hand, H. (2006b) ‘Assessment of Learning in Clinical Practice’. Nursing Standard 21(4), 48-56.

Horta, B.L. And Victora, C.G. (2013a) Short-Term Effects of Breastfeeding: A Systematic Review on the Benefits of Breastfeeding on Diarrhoea and pneumonia mortality. Geneva: WHO Press. available from [29 March 2014].

Horta, B.L. And Victora, C.G. (2013b). Long-Term Effects of Breastfeeding: A Systematic Review. Geneva: WHO Press. available from [29 March 2014].

Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., Trikalinos, T., and Lau, J. (2007) Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-Based Practice Center, under Contract No. 290-02-0022). AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality.

Keister, D., Roberts, K.T., and Werner, S.L. (2008) ‘Strategies for Breastfeeding Success’. American Family Physician 78 (2), 225-32.

Khalil, M.K., Paas, F., Johnson, T.E., and Payer, a.F. (2005) ‘Interactive and Dynamic Visualizations in Teaching and learning of Anatomy: A Cognitive Load’. Anatomical Record, Part B: New Anatomy 286B, 8-14.

Levy, V. (1999) ‘Protective Steering: A Grounded Theory Study of the Processes by which Midwives Facilitate Informed Choices during Pregnancy’. Journal of Advanced Nursing, 29, 104-12.

Mayer, R.E. (2010). ‘Applying the Science of Learning to Medical Education’. Medical Education 44, 543-9.

McCrory, C. And Murray, a. (2013) ‘The Effect of Breastfeeding on Neuro-Development in Infancy’. Maternal & Child Health Journal 17, 1680-8.

Noel-Weiss, J., Rupp, a., Cragg, B., Bassett, V., and Woodend, a.K. (2006) ‘Randomized Controlled Trial to Determine Effects of Prenatal Breastfeeding Workshop on Maternal Breastfeeding Self-Efficacy and Breastfeeding Duration’. Journal of Obstetric, Gynecologic and Neonatal Nursing 35, 616-24.

Office on Women’s Health. (2010a). Breastfeeding: Learning to Breastfeed [online] available from [29 March 2014].

Office on Women’s Health. (2010b). Breastfeeding: Common Breastfeeding Challenges [online] available from [29 March 2014].

Office on Women’s Health. (2010c). Breastfeeding: Breastfeeding in Public [online] available from [29 March 2014].

Office on Women’s Health. (2010d). Breastfeeding: Going Back to Work [online] available from [29 March 2014].

Office on Women’s Health. (2011). Breastfeeding: Breastfeeding Advice Videos. Join the Conversation on Breastfeeding! [online] available from and [29 March 2014].

Raube, K., Handler, a., and Rosenberg, D. (1998) ‘Measuring Satisfaction Among Low-Income Women: A Prenatal Care Questionnaire’. Maternal and Child Health Journal 2(1), 25-33.

Thielen, K. (2012) ‘Exploring the Group Prenatal Care Model: A Critical Review of the Literature’. Journal of Perinatal Education 21(4), 209-18.

Walsh, D. (2010) the Nurse Mentor’s Handbook: Supporting Students in Clinical Practice. Berkshire, UK: Open University Press.

Appendix

LESSON PLAN

Facilitator/Teacher: Dr. Mary Anne Donaldson, Janet a. Franks, RN, CNM

Date: 04/10/2014

Patients: Pregnant women, 20-weeks gestation

Subject: Breastfeeding

Length of Training: 2 hours

Purpose

Actions

Materials/Resources

Assessment/Evaluations

Get Professional Assignment Help Cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Why Choose Our Academic Writing Service?

Plagiarism free papers
Timely delivery
Any deadline
Skilled, Experienced Native English Writers
Subject-relevant academic writer
Adherence to paper instructions
Ability to tackle bulk assignments
Reasonable prices
24/7 Customer Support
Get superb grades consistently

Online Academic Help With Different Subjects

Literature

Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.

Finance

Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!

Psychology

While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.

Engineering

Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.

Nursing

In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.

Sociology

Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.

Business

We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!

Statistics

We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.

Law

Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
We will have a different writer write the paper from scratch.
Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment Help Service Works

1. Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2. Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3. Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4. Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!