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Fathers’ Perceptions Regarding Breastfeeding and Breast Milk Expression of Extremely Premature Infants

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Title:
Fathers’ Perceptions Regarding Breastfeeding and Breast Milk Expression of Extremely Premature Infants
Creator:
Magalhães, Marina N. ( Magalhaes, Marina N. )
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English

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Breast milk ( jstor )
Breastfeeding ( jstor )
Fathers ( jstor )
Infants ( jstor )
Lactation ( jstor )
Milk ( jstor )
Mothers ( jstor )
Neonatal intensive care units ( jstor )
Nutrition ( jstor )
Parental leave ( jstor )
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Undergraduate Honors Thesis

Notes

Abstract:
Fathers’ education and involvement in the nutrition of their infants has been shown to improve the incidence and duration of lactation. However, little is known about the experiences of fathers of extremely premature infants regarding breastfeeding and breast milk expression in the NICU. The purpose of this study is to better understand the perceptions of fathers of infants born at less than 27 weeks gestation on the lactation process from birth until six weeks post-discharge. Data for this qualitative study was collected through comprehensive phone interviews, and a thematic analysis was performed on transcribed results. Major findings include the perception of fathers as secondary decision makers in the nutrition of their infants, and the reception of information secondarily from the mothers. ( en )
General Note:
Awarded Bachelor of Science in Nursing, magna cum laude, on May 2, 2017. Major(s): Nursing
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College or School: College of Nursing
General Note:
Advisor: Fathers’ Perceptions Regarding Breastfeeding and Breast Milk Expression of Extremely Premature Infants. Advisor Deptarment or School: Biobehavioral Nursing Science

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University of Florida
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University of Florida
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Copyright Marina N. Magalhães. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Running Head: UNDERGRADUATE HONORS THESIS Undergraduate Honors Thesis: Fathers' Perceptions Regarding Breastfeeding and Breast Milk Expression of Extremely Premature Infants Marina Magalh‹es University of Florida College of Nursing Author Note First and foremost I would like to thank Dr. Leslie Parker for all of her guidance and mentorship throughout my undergraduate research studies I could not wish for a better advisor in teaching me about the entailments of the research process, as well as introducing me to t he unique specialty that is neonatology I am also endlessly thankful for the contributions and friendship gained alongside my co researcher Lauren Leonard Lastly, I would like to thank Clara Engelmann for her knowledge, expertise, and input throughout this study.

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UNDERGRADUATE HONORS THESIS # Abstract Fathers' education and involvement in the nutrition of their infants has been shown to improve the incidence and duration of lactation However, little is known about the experiences of fathers of extremely premature infants regarding breastfeeding and breast milk expression in the NICU. The purpose of this study is to better understand the perceptions of fathers of infants born at less than 27 weeks gestation on the lactation process from birth until six weeks post discharge Data for this qualitative study was collected through comprehensive phone interviews, and a thematic analysis was performed on transcribed results. Major findings include the perception of fathers as secondary decision makers in the nutrition of their infants, and the reception of information secondarily from the mothers. Keywords: fathers premature, breastfeeding, breast milk, perceptions, experiences

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UNDERGRADUATE HONORS THESIS $ Undergraduate Honors Thesis : Fathers' Perceptions Regarding Breastfeeding and Breast Milk Expression of Extremely Premature Infants In 2016, the Center for Disease Control's report Birthweight and Gestation demonstrated that the 14 out of 1000 newbor ns in the United States are very low birth weight (VLBW), b orn at less than 1500g S pecifically in Florida and the southeast United States, the prevalence of infants born under 1500g has been steadily in creasing since the early 1990s (CDC National Vital Statistics System) The World Health Organization highlighted the scale of this growing problem with the 2012 report, Born Too Soon: The Global Action Report on Preterm Birth, which includes the U.S., Brazil, India, and Nigeria within the top 10 countries with the hi ghest number s of preterm births. Also included in the report are recommendations for priority evidence based interventions which consistently include skin to skin kangaroo care and breastfeeding support. E arly and exclusive breastfeeding are additionally listed as "essential care for all babies and recommendations for preterm infants include extra support for breastfeeding such as milk expression pumps and supplementation s (WHO, 2012). Very low birth weight infants frequently suffer from complications such as hypothermia, hypoglycemia, respiratory anomalies, fluid and electrolyte imbalances, anemia, imbalanced nutrition, infections, and neurological complications among others. However, breast milk has a multitude of benefits for both moth er and baby, which include reduced risk for respiratory infections, decreased risk for necrotizing enterocolitis (NEC) improved neurodevelopmental outcomes, reduced risk for sudden infant death syndrome, reduced risk for type I and type II diabetes mellit us, decreased risk for childhood cancers, and higher IQs (American Academy of Pediatrics, 2012) In extremely preterm infants, the benefits of human milk are even more pronounced (Underwood, 2012) One Norwegian study found that the number of days without

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UNDERGRADUATE HONORS THESIS % full enteral feedings of human milk was the highest predictor of late onset septicemia in extremely premature infants (Rnnestad et al. 2005). In a 2013 study, the incidence of NEC in extremely preterm infants in the NICU was found to be 21% for those who received bovine milk based human milk formula compared to 3% for infants who received donor human milk with human milk based human milk fortifier (Cristofal o et al. ). Additionally, a 2014 study found increased rates of morbidity and mortality in extremely preterm infants fed breast milk diets fortified with bovine based fortifiers in comparison to human milk fortifier (Abrams, Schanler, Lee, Rechtman & Prolacta Study Group, 2014). The benefits of human milk are so profound that the American Academy of Pedi atrics considers increasing the use of mother's own milk for infant nutrition to be a public health concern. In 2010, H ealthy People 2020 (HP2020) objectives regarding breastfeeding were determined which include d increasing the proportion of infants who are breastfed, increasing the proportion of employers who have worksite lactation support programs, reducing the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life, and increasing the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies ( CDC, 2016 ). Seven years out, although today's current rate of 81. 1% of infants who were breastfed in Florida is clo se to HP2020's goal of 81.9%, Florida has much progress to make in breastfeeding duration rates While HP2020 goals at 6 months and 12 months are 60.6% and 34.1%, Florida's current rates remain at 47.3 % and 24.6%, respectively. Additionally, only 24.6% and 18.4% of infants in Florida are breastfed exclusively through 3 months and 6 months of life (CDC, 2016). As incidence of prematurity increases, Florida's breastfeeding duration rates are falling behind national averages in almost every measurement ( CDC, 2016 ) For mothers and fathers of extremely preterm infants in the neonatal intensive care

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UNDERGRADUATE HONORS THESIS & unit increased barriers may be impacting the volume of breast milk that these infants receive. Infants this young are unable to simultaneously suck, swallow, and br eathe, and pumped milk must therefore be provided through feeding tubes until infants are able to effectively breastfeed on their own. Early milk pumping may be difficult for mothers of these infants in the NICU, as they may not be exposed to many physiologic mechanisms such as infant's presence, cry, and suck which stimulate lactation Additionally at less than 27 weeks gestational age, mothers are often attempting to pump milk before their bodies are prepared to lactate However, it is crucial f or mothers to initiate early pumping for lactation success (Parker, Sullivan, Krueger, Kelechi & Muller, 2012). For these reasons, p roviding breast milk to extremely preterm infants, who are frequently in the NICU for months at a time, can be emotional and stressful and may generate individual experiences for mothers and fathers. Still the experiences of parents of this population of infants are not well understood It is therefore necessary to identify perceived stress, lack of education, lack of encourag ement, or other barriers that new parents may be facing during this demanding time. Although this study as a whole involve s both mothers and fathers of extremely premature infants who received breast milk in the NICU, this honors project specifically focuses on the perceptions and experiences of fathers. Paternal involvement and encouragement is correlated with increase d breastfeeding incidence and duration (Bich, Hoa & MÂŒlqvist, 2014 ; Witters Green, 2003 ) Additionally, partners with negative attitude s towards breastfeeding have been found to increase stress and encumber breastfeeding for working mothers (Witters Green, 2003). A 2014 study in Vietnam found that 16% of infants of fathers who rec eived breast milk education continued to be breastfed exclusively at 6 months of life, compared to 3.9% of infants whose fathers did not receive breast milk education ( Bich et al. ). Previous research supports the

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UNDERGRADUATE HONORS THESIS notion that fathers are encouraging of breastfeeding and would like to better support mothers, but they often feel excluded from support programs and feel uneducated on the subject matter (Brown & Davies, 2014) These studies support the conclusion that integrating fathers into support programs and services that aim to promote breastfeeding is an important intervention area to achieve breastfeeding rates that meet the Healthy People 2020 objectives The main objective of this study is to develop a b etter understanding of the experiences that fathers of extremely premature infants face in the NICU in order to shed light into factors that are impeding and/or facilitating the lactation process. By creating new knowledge, we can ident ify areas for improvement that are identified by patie nt family feedback rather than paternalistic ideas This strategy may allow us to better cater to a patient/family centered approach. Personal objectives of this study are to learn abou t the research process and team studies, gain an application based understanding of evidence based initiatives, and better understand the experiences that par ents of extremely premature infants face as I initiat e a career in the neonatal ICU. Project N arrative This study took place at the Neonatal Intensive Care Unit at UF Health Shands Children's Hospital in Gainesville, Florida. The NICU at UF Heal th is a level IV center a facility that has capabilities to treat the highest level of acuity in diverse patient population s throughout the southeastern United States. This study is part of a larger study that explores the experiences of mothers, fathers, and nurses of extremely preterm infants in the NICU Results are to be compared with a similar study in Sweden, whose starkly homogenous population and comprehensive legislation on parental leave may provide insight into the differences these

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UNDERGRADUATE HONORS THESIS ( factors pose in the experiences of parents of this population of infants during the lactation process Parti cipants This study consisted of 11 qualitative phone interviews of mothers and 7 interviews of fathers. Qualifications for inclusion in the study were (a ) parents must have had an infant born at less than 27 weeks gestation, (b ) the infant must have recei ved mother's own milk at some point during hospitalization (c ) infants must have been admitted to the NICU and (d) subjects must be at least 18 years of age S ubje cts were sampled by convenience, and a ll participants were consented prior to the interviews. Stakeholders Stakeholders involved in this study include the NICU NICU patients, patient 's families, and clinicians working in the NICU Our undergraduate research advisor, Dr. Leslie Parker, formally introduced us to the study and has a pro fessional relationship with involved patients as a neonatal nurse practitioner. Dr. Parker continuously monitored our progress and supported and mentored us on the research process, scholarly writing, and conference presentations. Clara Engelmann, a master of health administration candidate at UF, had prior experience with the study and therefore mentored and educated us about our roles and responsibilities throughout the study. Stakeholders additionally include my colleague, Lauren Leonard and myself. Toge ther, we worked to compile information about eligible subjects, contact and consent parents, organize and conduct interviews, and analyze data. Additionally, we presented our study at the Southern Nursing Research Society conference in Dallas, Texas as well as the UF College of Nursing Research and Scholarship Day & Malasanos Lectureship in Gainesville, Florida. Procedure

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UNDERGRADUATE HONORS THESIS ) The recruitment processes for this study consisted of frequent census reviews of admitted patients in order to accurately compile information on eligible subjects All communication and data sharing of protected health information was secure; E lectronic medical records and l ogbooks were systematically recorded on SharePoint, an encrypted document management and storage system. Part icipants were additionally d e identified using allotted personal identification numbers specific to this study. Continuous communication was crucial for success in meeting with parents in person to answer individual questions and obtain consent if interest was expressed All fathers were contacted through communication with the mother or using fathers' contact information listed in the infants' medical records. Following consent, discharge dates of the infants were monitored in order to timely conta ct parents for interviews in six weeks Phone interviews were open ended and discussed parents' individual experiences with breastfeeding and milk expression, parents' roles in supporting the nutrition of their infant, their perceptions of breastfeeding pr e delivery and post discharge, education or advice received about breastfeeding and milk expression, familial history with breastfeeding, and demographical information (see appendix for more information ) Following the collection of all interviews, recordi ngs were l istened to and transcribed for a thematic data analysis. Procedural Barriers T he first challenge encountered was overcoming the steep learning curve associated with the onset of a qualitative study. We learned through trial and error the methods that were most successful and efficient in communicating with and consenting parents. For instance, we learned that it was significantly more effective to meet parents on the unit to obtai n consent rather than to leave consent forms at the bedside to be picked up at a later time. We also learned that it was

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UNDERGRADUATE HONORS THESIS oftentimes more effective to check the unit at various intervals for parents who may be visiting their infants, rather than scheduling a time to meet. We realized through trial and error that it was crucial for consents to be obtained while the infants were still admitted on the unit because distributing forms by mail was seldom successful. Often, interview times were repeatedly reschedul ed if parents had a change in availability, and it was therefore always best to interview as soon as possible. It was equally important to be flexible with personal schedule s despite inconveniences. A second challenge that was discovered was a limited number of eligible subjects du e to the strict inclusion criteria Birth at t wenty seven weeks is very premature and not as routinely encountered as babies closer to term age. All fathers were contacted through the mother or through information listed in the infant's medical records. If there was no previous contact information in medical records, fathers were oftentimes invited to participate in the study if present at the NICU during time of consent of the mother Frequently, the father was not present o r the mother was the sole provider of the infant thus limit ing our ability to consent many fathers in comparison to mothers. Additionally, many young infants had never received mother's own milk because onset of milk production in these mothers is often d elayed. Different factors such as the time demand, the availability of donor milk, discouragement, and noncompliance in pumping may have caused mothers to produce insufficient milk. This disqualified many infants from the study. The limited sample size was a barrier with minimal solutions. An additional significant barrier experienced during our study was the delay from discharge to the time when interviews were permitted to take p lace. According to our protocol, all interviews were to be conducted after the infant has been discharged for six weeks. Infants who were born extremely prematurely were in the ICU for months at a time which prolonged

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UNDERGRADUATE HONORS THESIS !+ data collection and analysis. Many in terviews were conducted of parents who had been consented before thi s study was put on hold. However, if consent s took place many months prior to the onset of this study, parents' previous interest was no longer reliable and those subjects were therefore not contacted for interviews. On the other hand, many of our consented families during this study period are still on the uni t or have not yet been interviewed due to the six week protocol. In order to best manage this, patient records are routinely monitored for discharge status so that parents can be interviewed quickly and methodically Resu lts and Discussion Our results highlighted four major themes: F a thers were not decision makers E ducation was pr imarily received by the mother. F athers had knowledge of the benefits of breast milk. F athers pl ayed more of a supportive role. These themes were cho sen because of their prevalence throughout interviews. I. Decision m aking In general, fathers displayed interest in parti cipating in discussions about their infant' s nutrition. However, they were not co decision makers about whether their children would receive breast milk or formula or when other forms of nutrition would be introduced as their infants grew In accordance with this theme, o ne father simply stated : . it was more of my wife's decision When questioned about input provided on his child's nutrition, another father shared: . no, she did all that [providing input]

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UNDERGRADUATE HONORS THESIS !! Although it is ultimately the woman's decision whether or not to breastfeed her infant, these quotes suggest that fathers do not feel than can provide input into their in fant' s nutriti on. Rather, it is viewed as the mother's domain II. Education Fathers expressed that most information about breast milk and breastfeeding was received secondarily. For instance, when questioned about education received about breast milk or pumping, one father stated: "I guess from my wife or the NICU . whatever the things she [his wife] said." Unlike mothers, fathers did not discuss techniques or tips learned, nor did they discuss education received about the benefits of breast milk Another father expressed similar experiences: . a couple of her friends are lactation consultants so she [his wife] gave me a lot of information." Overall, information was primarily directed towards the mother of the infant and fathers received information from the mother. Th e direction of education towards mothers rather than both parents highlights a need for healthcare providers to recognize the importance of the father's role. III. Knowledge Most fathers were aware that breast milk i s more nutritious than formula. One father commented that he recognized it was better for his child's immune system. Another simply stated, . I heard it was healthier to breastfeed This theme is notable in demonstrating that fathers have general knowledge about breast milk. Yet, they did not contribute to decision making despite basic knowledge about its importance.

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UNDERGRADUATE HONORS THESIS !# IV. Role Fathers stated that they played more of a supportive role rather than being an active participant with mothers and healthcare providers. Attitudes conveyed feelings of helplessness in what they could contribute. They nonetheless expressed eager ness in describing their contributions. One father shared: ". . I would clean pump parts. If she couldn't go to the NICU I would bottle feed." Washing bottle parts and being physically present to encourage their partners were common forms of support that fathers used to describe their roles. Limitations This study has several lim itations to be addressed. This was a single site study in North Central Florida. Additionally, c ontact with all fathers was made through mothers as medical records seldom included fathers' contact information. The inclusion of only fathers involved with the mother limited our data on perceptions of uninvolved fathers o n breast milk and the nutrition of their infant. Additionally, representation of all fathers may be limited as this study included only fathers wh o consented to interview about their infants' nutrition. Summary The purpose of this study is to explore the perceptions of fathers of extremely premature infants (< 27 weeks gestational age) during their partner 's lactation process. Literature supports that the father's involvement is correlated with increased duration of breastfeeding (Maycock et al., 2013). The objective of the study was to gain a greater understanding of facilitating factors and barriers that fa thers experience during the many months that their infants are hospitalized in the neonatal intensive care unit. Seven qualitative interviews were conducted of fathers who previously had an extremely premature infant in the NICU. Our results support curren t literature

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UNDERGRADUATE HONORS THESIS !$ that although fathers are interested in bec oming more involved, education by healthcare providers o n breast milk is catered towards mother s Findings suggest that father s feel they hold a secondary role rather than being a co decision maker. Conclusion The NICU is a unique unit where care for the patient's family is equally as necessary as that of th e patient. Findings that fathers feel uneducated and secondary to mothers are consistent with results found in current literature ( Bich et al., 2014; Brown & Davies, 2014; Denoual et al., 2016 ). Fathers consistently shared that pumping milk and breastfeeding were stressful and very taxing for their partners, and some communicated feelings of helplessness Fathers indicated interest in bet ter supporting their partners and receiving more educat ion on the subject. This finding provides a unique intervention area for education and teaching in nursing practice. Improving paternal inclusion in plans of care is a wellness promotion and illness prevention intervention that may decrease stress for pumping mothers of very low birth weight infants and improve breastfeeding duration rates (Maycock et al., 2013) A 2011 study in Western Australia e valuated a perinatal program for new fathers designed to promote father s relationship s with their infants and discuss breastfeeding support. This study found that 77% of mothers whose partners participated in the program enjoyed breastfeeding. In comparis on, only 69% of mothers in the control group reported enjoy ment (Tohot o a et al.). While it is necessary to emphasize that breastfeeding decisions are ultimately made by the mother, it is likely that improved education and support from the father will help counteract stress and social factors that impede mothers from choosing to exclusively breastfeed ( Maycock et al., 2013) Fathers' perceptions and roles are social constructs that should be addressed by healt hcare providers to improve lactation for mothers and infants. Nurses, physicians, nurse

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UNDERGRADUATE HONORS THESIS !% practitioners, and lactation consultants may not be sufficiently including fathers in education about the nutrition of their infants. It is possible that preconceived n otions about the father's role need to be reevaluated by the healthcare team in order to better care for patients. By better educating healthcare providers and fathers, other themes such as perceived ideas about fatherhood and lack of participation in disc ussion s about their infants' nutrition may improve as well. Future research may evaluate the effectiveness of support programs for fathers in improving perceived stress and increasing breastfeeding incidence and prevalence rates for mothers of extremely pr eterm infants in the NICU. The importance of fathers' support is even greater for working mothers. A literature review found that strong social support system s and workplace s were significantly influential in working women s ability to breastfeed (Johnston & Esposito, 2007). I n general, insufficient time an unsupportive work environment, embarrassment and feeling bothersome when pumping at work are frequently cited as a reason s that mothers initiate formula feeding sooner. In Sweden, both mothers and fathers are guaranteed 480 days of paid family leave per child. The United States is the only industrialized nation in the world that does not guarantee paid parental leave ( Burtle & Bezruchka 2016 ) Child parental leave policies in the U.S. do not recognize fathers and offer mothers only 12 weeks of unpaid leave. Comprehensive parental leave laws allow parents more time to breastfeed, bond, and care for their infants (Baker & Milligan, 2008; Huang & Yang, 2015) Extensive research has additionally discovered the strong correlation between paid parental leave and decreased infant mortality (Burtle & Bezruchka 2016; Nandi et al., 2016 ) Because extended parental leave is associated with prolonged breastfeeding duration, mothers and fathers of low socioeconomic status are most likely to benefit from job protected paid parental leave. This study at large may offer some insight into the experiences of Swedish

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UNDERGRADUATE HONORS THESIS !& parents in comparison to American parents in breastfeeding extremely premature infants Due to the diversity of the United States' population in comparison to that of Sweden, exploration of experiences of these two starkly different populations may be helpful in highlighting the need for improved legislation in the United States as well as the experiences and roles mothers and fathers in breastfeeding and infant care.

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UNDERGRADUATE HONORS THESIS !' References Abrams, S. A., Schanler, R. J., Lee, M. L., Rechtman, D. J., and the Prolacta Study Group. (2014). Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeeding Medicine 9(6), 281 285. doi:10.1089/bfm.2014.0024. Bich, T. H., Hoa, D. T. P., & MÂŒlqvist, M. (2014). Et for improved exclusive breastfeeding in Viet Nam. Maternal and child health journal 18 (6), 1444 1453. Brown, A., & Davies, R. (2014). Fathers' experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Maternal & child nutrition 10 (4), 510 526. Burtle, A., & Bezruchka, S. (2016). Population Health and Paid Parental Leave: What the United States Can Learn from Two Decades of Research. Healthcare, 4(2), 30. http://doi.org/10 3390/healthcare4020030 Centers for Disease Control. Birthweight and Gestation. (2016, July 06). Retrieved February 14, 2017, from http://www.cdc.gov/nchs/fastats/birthweight.htm Centers for Disease Control. (2016) Breastfeeding report card. Retrieved from https://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdf Cristofalo EA, Schanler RJ, Blanco CL, Sullivan S, Trawoeger R, et al. (2013). Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr 163(6): 1592 1595. Denoual H, Dargentas M, Roudaut S et al Father's role in supporting breastfeeding of preterm infants in the neonatal intensive care unit: a qualitative study. BMJ Open 2016; 6: e010470. doi: 10.1136/bmjopen 2015 010470

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UNDERGRADUATE HONORS THESIS !( Eidelman, Ai, Rj Schanler, M. Johnston, S. Landers, L. Noble, K. Szucs, L. Viehmann, L. Feldman Winter, R. Lawrence, S. Kim, N. Onyema, Sect Breastfeeding, and Section On Breastfeeding. "Breastfeeding and the Use of Human Milk." Pediatrics 129.3 (2012): E827 841. Web. 19 Oct. 2016. Johnston, M. L. and Esposito, N. (2007), Barriers and Facilitators for Breastfeeding Among Working Women in the United States. Journal of Obstetric Gynecologic, & Neonatal Nursing, 36: 9 20. doi:10.1111/j.1552 6909.2006.00109.x Kuyper, E., & Dewey, K. (2012). Fathers support infant and young child feeding: their contributions to better outcomes. Mar ch of Dimes, PMNCH, Save the Children, WHO. (2012). Born Too Soon: The Global Action Report On Preterm Birth Retrieved from http://www.who.int/pmnch/media/news/2012/ 201204_borntoosoon report.pdf Maycock, B., Binns, C. W., Dhaliwal, S., Tohotoa J., Hauck, Y., Burns, S., & Howat, P. (2013). Education and support for fathers improves breastfeeding rates: A randomized controlled trial. Journal of Human Lactation, 29(4), 484 490. doi:10.1177/0890334413484387 Nandi, A., Hajizadeh, M., Harper, S., Koski, A., Strumpf, E. C., & Heymann, J. (2016). Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low and Middle Income Countries: A Quasi Experimental Study. PLoS Medicine 13 (3), e1001985. http://doi.org/10.1371/journal.pmed.1001 985 Parker, L. A., Sullivan, S., Krueger, C., Kelechi, T., & Mueller, M. (2012). Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: A pilot study. Journal of Perinatology, 32, 205 209.

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UNDERGRADUATE HONORS THESIS !) Rnnestad A, Abrahamsen TG, Medb S, Reigstad H, Lossius K, et al. (2005). Late onset septicemia in a Norwegian national cohort of extremely premature infants receivi ng very early full human milk feeding. Pediatrics 115(3): e269 276. Tohotoa, J., Maycock, B., Hauck, Y., Howat, P., Burns, S., & Binns, C. (2011). Supporting mothers to breastfeed: The development and process evaluation of a father inclusive perinatal e ducation support program in perth, western australia. Health Promotion International, 26(3), 351 361. doi:10.1093/heapro/daq077 Underwood, M. A. (2013). Human milk for the premature infant. Pediatric Clinics of North America 60 (1), 189 207. http://doi.org/10.1016/j.pcl.2012.09.008 Witters Green, R ( 2003 ). Increasing breastfeeding rates in working mothers Families, Systems & Health 21 415 434 World Health Organization. (2016). Preterm birth fact sheet. Retrieved from http://www.who int/mediacentre/factsheets/fs363/en/

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UNDERGRADUATE HONORS THESIS !* Appendix Question areas for mothers: Tell me about your : Thoughts about breastfeeding before delivery Experiences with breastfeeding/milk expression Helping factors? Barriers? Experiences of support in relation to breastfeeding/milk expression Experiences of information in relation to breastfeeding/milk expression Experiences of advice in relation to breastfeeding/milk expression Experiences of participation i n decisions concerning your infants nutrition Thoughts today about breastfeeding/milk expression Who did you turn to, to get advice/help/support around infants' nutrition after discharge? Question areas for fathers: Tell me about your : Thoughts about breas tfeeding before becoming a parent Experiences about the mothers' breastfeeding/milk expression at the NICU and at home. Helping factors? Barriers? Experiences of your role concerning the infants' nutrition Experiences of supporting the mother and the infant in relation to breastfeeding/milk expression Experiences of information in relation to breastfeeding/milk expression Experiences of advice in relation to breastfeeding/milk expression Experiences of participation in decisions concerning your infants nutrition Thoughts today about breastfeeding/milk expression Who did you turn to, to get advice/help/support around infants' nutrition after discharge? Demographic questions for parents Gender of baby Mothers' age Partners' age Time since discharge

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UNDERGRADUATE HONORS THESIS #+ Infant s' age at discharge Infants' age at birth Other children Have yo u breast fed you other children Were you breast fed as child Breastfeed ing at discharge Yes/no /partly Do you/your partner breastfeed your baby now, yes/no /partly? If not when did you/she sto p breastfeeding/pumping?



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Honors Thesis Submission Form Name: Marina Magalhaes UFID: 19992333 Additional Authors: Email: mmagalhaes95@ufl.edu Major: Nursing Advisor Name: Leslie Parker, Ph D, A RNP Advisor Email: parkela@ufl.edu Advisor Department: Nursing Thesis Title: Undergraduate Honors Thesis: Fathers' Perceptions Regarding Br eastfeeding and Breast Milk Expression of Extremely Premature Infants Abstract (200 words max): Fathers' education and involvement in the nutrition of their infants has been shown to improve the incidence and duration of lactation. However, little is known about the experiences of fathers of extremely premature infants regarding breastfeeding and breast milk expression in the NICU. The purpose of this study is to better understand the perceptions of fathers of infants born at less than 27 weeks gestation on the lactation process fro m birth until six weeks post discharge. Data for this qualitative study was collected through comprehensive phone interviews, and a thematic analysis was performed on transcribed results. Major findings include the perception of fathers as secondary decisi on makers in the nutrition of their infants, and the reception of information secondarily from the mothers. Keywords: fathers, premature, breastfeeding, breast milk, perceptions, experiences Student Signature /Date _________________________________________ Thesis Advisor Sig nature /Date _________________________________________ !"#$%&''()*%+,*%&-./0 % "#$%&'!((((((((((((((((( )*+,-.#/,%.'!(((((((((((( 0 #/,%.!3*&4'!((((((((

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Departmental Honors Coordinator Signature _________________________________________ Please indicate your preference for public access to your thesis by initialing the appropriate statement below: ____ I grant permission to the University of Florida to list the title and abstract of this thesis in a publicly accessible database. _____ I do not grant permission to the University of Florida to list the title and abstract of this th esis publicly. If you wish to make the entire thesis publicly available, you must also complete the Internet Distribution Permissions Form, available at 5//6'771,-,/ #892:8,;92:89*1276&%<*12&*+7<%6=&,-5/70&#./%:>*&4,++,%.+91%< !! If you do not include this form, your thesis will be archived but will not be viewable online.



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Form online: http://digital.uflib.ufl.edu/procedures/c opyright/GrantofPermissions.doc Honors Thesis GRANT OF PERMISSIONS : Internet Distribution Agreement In reference to the following Undergraduate Honors Thesis, including any supplementary file (s): Marina Magalhaes [ Undergraduate Honors Thesis: Fathers' Perceptions Regarding Breastfe eding and Breast Milk Expression of Extremely Premature Infants ]. University Of Florida : Gainesville,FL [ April 28, 2017 ] I, Marina Magalhaes as copyright holder or licensee with the authority to grant copyright permissions for the aforementioned title(s), hereby authorize the University of Florida, acting on behalf of the Board of Trustees of the University of Florida to digitize, distribute and archive the title(s) for nonprofit, educational purposes via the Internet or successive technologies. This is a non exclusive grant of permissions for on line and off line use for an indefinite term. Off line uses shall be c onsistent either, for educational uses, with the terms of U.S. copyright legislation's "fair use" provisions or, by the University of Florida, with the maintenance and preservation of an archival copy. Digitization allows the University of Florida to gener ate image and text based versions as appropriate and to provide and enhance access using search software. This grant of permissions prohibits use of the digitized versions for commercial use or profit. ______________________________________ Signature o f Copyright Holder Marina Magalhaes Printed or Typed Name of Copyright Holder 05/19/17 Date of Signature Attention : IR Manager Digital Production Services ; Smathers Libraries University of Florida P.O. Box 11700 3 Gainesville, FL32611 700 3 P: 352. 273.2831 IRManager@uflib.ufl.edu