DOI: https://doi.org/10.21203/rs.3.rs-70850/v1
Studies revealed that promoting the breastfeeding knowledge level help to improve breastfeeding behaviors. Promoting breastfeeding knowledge was a simple and economical way to increase breastfeeding rates. However, there were no studies focus on the level of breastfeeding knowledge and its influencing factors in GDM women. Thus, the objective of this study was to investigate the breastfeeding knowledge level of GDM pregnant women and explore its influence factors.
Cross-sectional survey and convenience sampling was conducted in this study. The sociodemographic characteristics, caregivers in pregnancy, knowledge source, breastfeeding status and breast status information of participants were collected. Breastfeeding Knowledge Scale was used to assess the breastfeeding knowledge level of pregnant women with GDM. Multiple linear regression was used to analyze the influence factors of breastfeeding knowledge level in this study.
A total of 226 questionnaires were issued and finally 212 valid questionnaires were collected. Some misconceptions still existed (e.g. ’breastfeeding cannot prevent your baby from being overweight’ and ‘it is advisable to breastfeed 3–4 times per day within 2–3 days after delivery’), although women with GDM had a good score of breastfeeding knowledge (mean score: 103.5 ± 10.4). Multiple linear regression analysis found that gestational age, family per capita monthly income, educational level, knowledge source were the independent protective factors for breastfeeding knowledge and minority nationality was the independent risk factor. The educational level had the greatest influence on the breastfeeding knowledge level of GDM pregnant women (β = 0.210, t = 2.978, P = 0.003).
GDM pregnant women with insufficient gestational age, low educational level, low family per capita monthly income and single access to knowledge should be included in the focus of health education on breastfeeding. In-depth and systematic health education should be conducted for pregnant women with GDM to improve their breastfeeding rate.
Breastfeeding is one of the measures proposed by the World Health Organization (WHO) and United Nation Children’s Fund (UNICEF) to protect the health of pregnant women and their children[1, 2]. Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy[3]. GDM has adverse effects on the maternal and neonatal outcomes. A large number of studies have confirmed the short-term and long-term benefits of breastfeeding for pregnant women with GDM and their offspring[4]. Breastfeeding can help GDM patients regulate their weight and blood glucose levels and prevent the recurrence of GDM and type 2 diabetes after delivery. For the offspring of GDM women, breastfeeding can help to reduce the risks of developing obesity and type 2 diabetes in adulthood[5, 6]. Therefore, breastfeeding is especially recommended and encouraged for women who have GDM.
Women with GDM should insist on breastfeeding. However, studies showed that GDM women have less willingness to breastfeed and have lower breastfeeding rate than those of normal women at the same stage. Moreover, the breastfeeding rate of GDM women are falling faster[7–10]. Several studies report that women with GDM have lower rates of breastfeeding and earlier interruption of breastfeeding in the first 6 months[11, 12]. Lack of knowledge is one of the main barriers of breastfeeding[13]. On the contrary, higher breastfeeding knowledge level is significantly associated with greater breastfeeding intention[14], and stronger breastfeeding confidence[15]. Improving pregnant women's breastfeeding knowledge level can effectively promote the occurrence of breastfeeding behavior and extend actual lactation duration[15–18].
However, current studies have shown that the breastfeeding knowledge level among pregnant women is not very ideal. some misconceptions still existed, in spite of considerable awareness of the advantages of breastfeeding[19, 20]. The breastfeeding knowledge level was influenced many factors such as educational level and cultural beliefs[19]. A comprehensive understanding of the factors affecting the breastfeeding knowledge level is conducive to the development of targeted education to improve the knowledge level. However, there are few studies on the breastfeeding knowledge level and it influencing factors in pregnant women with GDM. Therefore, the objective of this study was to investigate the breastfeeding knowledge level of pregnant women with GDM, and then explore the influencing factors on the knowledge level of breastfeeding.
We conducted a cross-sectional survey in West China Second University Hospital, Sichuan University, which is a women and children’s medical center in West China serving > 5 provinces. The objective of this study was to investigate the breastfeeding knowledge level of pregnant women with GDM, and then explore the influencing factors on the knowledge level of breastfeeding. Convenience sampling was used in this study. We selected pregnant women who were waiting to birth from July to October 2017 in the Department of Obstetrics. Pregnant women of 18 years older and had a diagnosis of GDM were included in this survey. Pregnant women were excluded if they: had a history of GDM and history any other type of diabetes; cannot read and write in Chinese; did not sign the informed consent.
Pregnant women with 2hours 75-g Oral Glucose Tolerance Test (OGTT) values exceeding established thresholds (fasting 5.1 mmol/L, 1hour 10.0 mmol/L, 2hours 8.5 mmol/L) was diagnosed as GDM.
We used self-designed questionnaire to collect sociodemographic information such as age, educational level, marital status, the number of childbirths, occupation, family per capita monthly income, nationality, and caregivers in pregnancy, breast status information such as history of breast surgery, breastfeeding status information such as breastfeeding experiences (see Additional file 1).
Breastfeeding Knowledge Scale[21] was used to assess pregnant women’s perception of breastfeeding. This scales was originally designed by Zhao, M.[22] and later revised by Zhu, Y. and Wan, H.[21]. Breastfeeding Knowledge Scale included 4 parts: benefits of exclusive breastfeeding, breastfeeding skills, breastfeeding storage methods and breastfeeding conditions. This scale was a Chinese 5-point Likert scale and with a total of 25 items. Responses range from “Very much agree” to “Very much disagree”. Breastfeeding knowledge scores range from 25 to 125, with higher scores indicating the higher breastfeeding knowledge level. Cronbach's a coefficient is 0.820.
The mean and standard deviation (M ± SD) was used to describe the quantitative data with normal distribution and approximately normal distribution. T-test and variance analysis was used for univariate analysis. Multiple linear stepwise regression analysis was used for multi-factor analysis (a = 0.05). Durbin Watson was used to test the independence of the independent variables. Collinearity diagnosis was considered in this study. SPSS23.0 (SPSS Inc, Chicago, IL) was used for statistical analysis.
2.1 Setting and participants
We conducted a cross-sectional survey in West China Second University Hospital, Sichuan University, which is a women and children’s medical center in West China serving >5 provinces. The objective of this study was to investigate the breastfeeding knowledge level of pregnant women with GDM, and then explore the influencing factors on the knowledge level of breastfeeding. Convenience sampling was used in this study. We selected pregnant women who were waiting to birth from July to October 2017 in the Department of Obstetrics. Pregnant women of 18 years older and had a diagnosis of GDM were included in this survey. Pregnant women were excluded if they: had a history of GDM and history any other type of diabetes; cannot read and write in Chinese; did not sign the informed consent.
Pregnant women with 2hours 75-g Oral Glucose Tolerance Test (OGTT) values exceeding established thresholds (fasting 5.1mmol/L, 1hour 10.0mmol/L, 2hours 8.5mmol/L) was diagnosed as GDM.
2.2 Data collection
We used self-designed questionnaire to collect sociodemographic information such as age, educational level, marital status, the number of childbirths, occupation, family per capita monthly income, nationality, and caregivers in pregnancy, breast status information such as history of breast surgery, breastfeeding status information such as breastfeeding experiences (see Additional file 1).
Breastfeeding Knowledge Scale[21] was used to assess pregnant women’s perception of breastfeeding. This scales was originally designed by Zhao, M.[22] and later revised by Zhu, Y. and Wan, H.[21]. Breastfeeding Knowledge Scale included 4 parts: benefits of exclusive breastfeeding, breastfeeding skills, breastfeeding storage methods and breastfeeding conditions. This scale was a Chinese 5-point Likert scale and with a total of 25 items. Responses range from “Very much agree” to “Very much disagree”. Breastfeeding knowledge scores range from 25 to 125, with higher scores indicating the higher breastfeeding knowledge level. Cronbach's a coefficient is 0.820.
2.3 Statistic analysis
The mean and standard deviation (M±SD) was used to describe the quantitative data with normal distribution and approximately normal distribution. T-test and variance analysis was used for univariate analysis. Multiple linear stepwise regression analysis was used for multi-factor analysis (a=0.05). Durbin Watson was used to test the independence of the independent variables. Collinearity diagnosis was considered in this study. SPSS23.0 (SPSS Inc, Chicago, IL) was used for statistical analysis.
This study investigated the breastfeeding knowledge level of pregnant women with GDM and explored its influence factors. Pregnant women with GDM had an average level of breastfeeding knowledge. However, some misconceptions of breastfeeding knowledge still existed in GDM population. Multiple linear regression analysis found that gestational age, family per capita monthly income, educational level, knowledge source were the independent protective factors for breastfeeding knowledge level and minority nationality was the independent risk factor for breastfeeding knowledge level. The educational level had the greatest influence on the breastfeeding knowledge level of GDM pregnant women.
This study showed that the 99.1% of GDM pregnant women had breastfeeding intention before delivery, which was higher than 73.2% reported by Dai and 92.17% reported by in Zhang[23, 24]. It revealed that GDM pregnant women had a higher willingness to breastfeed. In Japan, researchers found that 96% of pregnant women expressed an intention to breastfeed. However, the breastfeeding rate was only 46% in 4 weeks postpartum. Although there was a strong desire to breastfeed before delivery, pregnant women may stop breastfeeding when they encounter difficulties or obstacles that are difficult to solve in postpartum. Therefore, it suggested that nurses or midwifery should pay more attention to GDM pregnant women who have breastfeeding intention and strengthen their intention by health education or peer education. Additionally, nurses or midwifery should focus on postnatal breastfeeding status of GDM women and assisted them to solve the difficulties to breastfeeding in a timely manner. Moreover, to form correct breastfeeding cognition and improve breastfeeding rate of women with GDM, scientific and systematic health education should be carried on these population.
This study showed that pregnant women with GDM had an average level of breastfeeding knowledge. However, some misconceptions of breastfeeding knowledge still existed in GDM population. Pregnant women with different sociodemographic characteristics had different understanding degree of breastfeeding knowledge. GDM pregnant women who did not receive health education of breastfeeding had insufficient understanding of breastfeeding conditions, such as ‘breast size affecting milk secretion’. However, GDM pregnant women who received health education on breastfeeding had significantly higher knowledge level, which was consistent with the conclusion of Thomas’s report[25]. GDM pregnant women who had lower educational level, premature birth, and lower family per capita income, and whose husband had lower educational level were not optimistic about the mastery of breastfeeding knowledge about breastfeeding conditions and breastfeeding benefits, which was supported by some researchers’ reports [16, 20, 26]. Research revealed that the higher the knowledge level of breastfeeding, the less likely it is to terminate breastfeeding early[27]. Breastfeeding knowledge education can help avoid the occurrence of early interruption of breastfeeding, suggesting that breastfeeding knowledge education was necessary for GDM pregnant women.
Multivariate regression analysis revealed that gestational age, education level, family per capita monthly income, knowledge source were independent protective factor for breastfeeding knowledge level. This result was similar to Thomas’ study[25]. The study found that breastfeeding counseling, socioeconomic status and educational level had a great impact on breastfeeding cognition of primipara. However, Thomas’s study did not report the impact of gestational age and knowledge source on breastfeeding cognitions. This study showed that the education level has the greatest influence on the knowledge of breastfeeding. Therefore, in nursing work, pregnant women with lower educational level cannot be ignored. These population had weaker ability to understand and grasp the knowledge. Therefore, there was a need for detailed and in-depth health education on breastfeeding for low-educational-level pregnant women. There was a growing concern among pregnant women about the breastfeeding knowledge with the increasing of gestational age. Study had shown that 66.3% of pregnant women were willing to receive knowledge education in the second trimester[16], which was the time for pregnant women to have regular prenatal examination. Therefore, medical staff should make full use of this period to educate pregnant women about breastfeeding. Moreover, studies had found that the medical staff is the main source of breastfeeding knowledge of women and is also the main object for help of any difficulty of women. In some countries and regions, pregnant women get knowledge mainly by means of the media and women's magazines[16, 27]. Therefore, GDM pregnant women should be provided health education on breastfeeding through a variety of ways, which is conducive to improving the knowledge level of breastfeeding. More diversified forms of health education should be carried out, such as breastfeeding salons and WeChat network platforms, and Internet media resources should be fully utilized to carry out health education.
This study had 2 limitation. First, only one hospital was included in this study, which is the one of the best hospitals of west China. Our participants almost are well educated and have high household income. So, this may reduce the representativeness of the sample in this study. Second, Multiple linear regression analysis showed that the influencing factors studied in this study could only explain 20.7% of the variation in breastfeeding knowledge score, revealing that there are other factors that did not be found and need to be studied.
A cross-sectional survey was conducted in West China. This study showed that GDM pregnant women had a strong willingness to breastfeed before delivery, and an average level of breastfeeding knowledge. However, some misconceptions of breastfeeding knowledge still existed in these GDM population. GDM pregnant women who had lower educational level, insufficient gestational age, poor socioeconomic status and single knowledge source had significantly lower level of breastfeeding knowledge. Therefore, special attention should be paid to these population. Systematic and in-depth breastfeeding health education should be carried on these women. Medical staff were still the main source of breastfeeding knowledge for pregnant women. Thus, medical staff especially nurse and midwifery should play a major role in breastfeeding health education. At the same time, more diversified forms of health education, such as breastfeeding salons, WeChat network platforms, and Internet media resources should be fully utilized to carry out health education for pregnant women with GDM.
GDM: gestational diabetes mellitus; WHO:World Health Organization; UNICEF:United Nation Children’s Fund; M ± SD:Mean ± Standard Deviation; OGTT:oral glucose tolerance test
Ethics approval and consent to participate
The protocol for this investigation was approved by the Ethics Committee of the West China Second University Hospital, Sichuan University. The research assistants obtained the written informed consent from study participants prior to the study.
Consent to publication
Not applicable.
Availability of data and materials
The dataset supporting the conclusions of this article is included within the article’s additional file (see Additional file 2).
Competing interests
The authors declare that they have no competing interests.
Funding
Not applicable.
Authors’ contributions
LBR contributed to study design and manuscript revision. WY and YHX contributed to collect, analyze and interpret data and write this manuscript. All authors have read and approved the manuscript.
Acknowledgement
Not applicable.
Table 1 The characteristic of pregnant women.
|
variable |
Frequency（n=212） |
Percent（%） |
|
Age (year) ≤29 30-34 35-39 ≥40 Gestational age (week) ≤36+6 ≥37 Multipara Educational level Junior High and below Senior High Junior college Bachelor or above Occupation Professional Administrative Clerk Farmer Freelance Unemployed Nationality Han Minority Marital status Never married Married Divorced Family per capita monthly income (yuan) <3000 3001-5000 5001-10000 >10000 Caregivers Pregnant women Husband Mother Mother-in-law Nanny Relatives Husband’s educational level Junior High and below Senior High Junior college Bachelor or above Knowledge source Book Newspaper/magazine Internet Television programs Family member or friends Medical staff Number of knowledge source 1 ≥2 Breastfeeding experience Yes No Breastfeeding intention Yes No Health education on breastfeeding Yes No |
33 85 67 27
42 170 111
14 15 45 138
36 62 55 2 29 28
203 9
0 210 2
15 51 91 55
41 121 89 35 4 7
11 12 46 143
95 26 94 23 117
87 125
99 113
210 2
124 88 |
15.6 30.1 31.6 12.7
19.8 80.2 52.2
6.6 7.1 21.2 65.1
17.0 29.2 25.9 0.9 13.7 13.2
95.8 4.2
0 99.0 1.0
7.1 24.1 42.9 25.9
19.3 57.1 42.0 16.5 1.9 3.3
5.2 5.7 21.7 67.5
44.8 12.3 44.3 10.8 55.2
41.0 59.0
46.2 53.8
99.1 0.9
58.5 41.5 |
Table 2 The breastfeeding knowledge scores of pregnant women with GDM (n=212).
|
Items |
Scores (M±SD, score) |
|
1. Exclusive breastfeeding is the best option for baby up to 6 months of age. 2. Containing antibody composition in breast milk, can enhance baby immunity and reduce disease occurrence. 3. Early breastfeeding can prevent constipation of infants. 4. Breastfeeding cannot prevent your baby from being overweight. * 5. Breastfeeding can reduce the incidence of allergic diseases in baby. 6. Breastfeeding is conducive to the development of the baby's intelligence. 7. Breastfeeding is beneficial to uterine contraction, and can reduce postpartum hemorrhage. 8. Breastfeeding cannot help the mother form an intimate relationship with the baby. * 9. Breastfeeding does not necessarily reduce a mother's risk of developing breast cancer in the future. * 10. Breastfeeding does not necessarily reduce a mother's risk of developing ovarian cancer in the future. * 11. Early and frequent sucking can promote milk secretion. 12.The baby should be breast-fed within 2 hours after delivery. 13. It is advisable to breastfeed 3-4 times per day within 2-3 days after delivery. * 14.Breast milk can be frozen for 3 months after extrusion. 15. Breast milk can keep fresh for 24-48 hours in cold storage after extrusion. 16. The breast milk can be microwaved before feeding the baby. * 17. Breastfeeding should be given according to the actual needs of the newborn. 18. Although complementary foods are added after 4-6 months of age, breastfeeding can be maintained until the baby is 1-2 years old. 19. Breast size affects milk production. * 20. Mothers with sunken nipples must not breastfeed. * 21. Mothers with cracked nipples must not breastfeed. * 22. After breastfeeding, the remaining milk should not be excreted. * 23. Water should be given to the baby after breastfeeding every time. * 24. Only 5-10ml/ time should be fed to the baby on the first day after birth. * 25. Breastfeeding helps mothers regain their pre-pregnancy weight as quickly as possible. Total score |
4.85±0.49 4.86±0.47
4.42±0.84 3.09±1.25 4.45±0.86 4.49±0.81 4.64±0.66 4.34±1.32 3.96±1.24
3.91±1.18
4.60±0.75 4.38±0.90 3.18±1.37 3.52±1.12 3.56±1.14 4.00±1.14 4.45±0.80 4.32±0.89
4.19±0.97 4.30±0.88 4.09±1.02 4.06±1.14 3.96±1.21 3.49±1.10 4.40±0.90 103.5±10.4 |
Note: GDM: gestational diabetes mellitus; Breastfeeding benefits include item 2,3,4,5,6,7,8,9,10,25; Breastfeeding skills include item 1,11,12,13,17,22,23; Breast milk storage methods include 14,15,16; Breastfeeding conditions include item 18,19,20,21,24. *Item 4, 8, 9, 10, 13, 16, 19, 20, 21, 22, 23, 24 was scored in reverse.
Table 3 Subgroup analysis of breastfeeding knowledge level of pregnant women (M±SD, score).
|
Subgroup |
Breastfeeding benefits |
Breastfeeding skills |
Breast milk storage methods |
Breastfeeding conditions |
Total score |
|
|
Age (year) ≤29 30-34 35-39 ≥40 F P value Educational level Junior High and below Senior High Junior college Bachelor or above F P value Nationality Han Minority t P value Family per capita monthly income (yuan) <3000 3001-5000 5001-10000 >10000 F P value Husband’s education level Junior High and below Senior High Junior college Bachelor or above F P value Gestational age (week) ≤36+6 ≥37 t P value Breastfeeding health education Yes No t P value Number of knowledge source 1 ≥2 t P value |
42.3±6.3 41.8±6.5 42.4±5.0 43.8±5.1 0.740 0.529
37.6±4.4 38.5±11.4 41.9±5.8 43.4±4.6 7.463 <0.001
42.5±5.8 39.7±5.2 1.417 0.158
39.5±6.4 41.0±7.8 42.3±4.6 44.3±4.6 4.298 0.006
36.5±13.1 41.8±5.5 42.0±5.5 43.1±4.7 4.612 0.014
40.3±5.6 42.8±5.8 -2.571 0.011
43.0±6.4 41.4±5.0 -2.100 0.037
40.7±7.0 43.5±4.5 -3.562 <0.001 |
30.0±3.9 29.5±4.7 28.5±3.3 29.9±3.3 1.500 0.216
27.1±3.8 25.8±8.8 28.9±3.6 30.1±3.2 7.825 <0.001
29.4±4.0 26.9±4.3 1.877 0.062
27.4±4.4 28.3±5.5 29.8±3.3 30.1±3.1 3.312 0.021
25.7±9.2 30.3±3.7 28.8±4.1 29.3±3.3 4.029 0.008
28.4±4.1 29.6±4.0 -1.732 0.085
29.8±4.3 28.7±3.7 -1.524 0.129
28.4±4.8 30.0±3.3 -2.803 0.006 |
11.5±2.2 11.2±2.3 10.9±2.1 9.9±1.6 3.234 0.023
10.0±1.6 10.1±3.0 10.7±2.3 11.3±2.0 3.394 0.019
11.0±22.2 10.6±1.7 0.665 0.507
10.3±2.2 10.6±2.2 11.2±2.0 11.8±2.2 3.870 0.010
9.1±3.3 11.1±1.9 10.9±2.1 11.2±2.2 3.350 0.020
10.5±2.0 11.2±2.2 -1.765 0.079
11.3±2.4 10.8±1.9 -1.574 0.117
10.5±2.3 11.4±2.0 -3.243 0.001 |
20.2±3.4 20.6±3.9 19.6±2.9 21.1±2.6 1.838 0.141
17.9±2.8 18.0±5.8 19.8±3.1 21.0±2.9 7.528 <0.001
20.4±3.3 17.6±3.9 2.529 0.012
18.6±3.2 19.5±4.0 20.3±3.1 21.6±2.8 5.393 0.001
16.4±5.9 19.9±2.9 19.9±2.8 20.8±3.4 6.640 <0.001
19.3±3.0 20.5±3.5 -2.201 0.029
20.7±3.4 19.8±3.5 -1.853 0.065
19.3±3.8 21.0±2.9 -3.768 <0.001 |
104.0±13.4 104.5±9.9 101.4±10.2 104.7±8.1 1.361 0.256
92.6±11.1 98.9±9.7 101.3±12.1 105.8±8.8 10.075 <0.001
103.9±10. 94.7±12.3 2.640 0.009
95.8±14.3 101.3±10.7 103.5±9.8 107.8±8.0 7.103 <0.001
96.4±11.6 103.2±11.4 101.6±12.2 104.7±9.5 2.683 0.048
98.5±12.0 104.8±9.7 -3.598 <0.001
105.7±9.8 100.7±10.7 -3.335 0.001
100.0±11.5 105.9±8.9 -4.206 <0.001 |
|
Table 4 Multiple linear regression analysis of breastfeeding knowledge level.
|
Variables |
β |
Standardized β |
t |
P |
|
Constant Gestational age (1= gestational age<36+6 week) Nationality (1=Han) Educational level (1=Junior High and below) Family per capita monthly income (1= income <3000 yuan) Knowledge source (1= 1 source) |
85.465 3.970 -7.942 2.471 1.784
1.407 |
- 0.151 -0.155 0.210 0.151
0.172 |
15.297 2.389 -2.478 2.978 2.196
2.661 |
0.000 0.018 0.014 0.003 0.029
0.008 |
Note：R2=0.226; Adjust R2=0.207; F=4.948, P=0.027. Durbin Watson=2.043. Tolerance in the model were as follows: gestational age 0.947, educational level 0.764, family per capita monthly income 0.808, and knowledge sources 0.908, nationality 0.976. “-” no value.