One-on-one instruction (Caulfield et al., 1998; Hartley & O’Connor, 1996; Humphreys et al., 1998). 46 Breastfeeding Best Practice Guidelines for Nurses Discussion of Evidence Fairbank et al. (2000), in their systematic review, identified 19 studies examining the effect of stand-alone health education interventions on initiation rates. Although finding several cautious interpretations of results, it can be concluded that information in the form of breastfeeding literature alone will not lead to behaviour change. Fairbank et al. (2000) also reported on one randomized controlled trial (RCT) by Kistin et al. (1990) in their systematic review that lends support for both one-to-one health education and group health education. They found differences in breastfeeding practices: those receiving group health education increased initiation rates of those who planned to breastfeed; while one-to-one health education affected initiation rates of those who planned to bottle feed. Although limited in evidence, practice settings ought to consider the design of their breastfeeding education session following an assessment of their target population. Three other RCTs by Rossiter (1994), Wiles (1984) and Thorley et al. (1997) all supported using group education. Peer counsellors can provide effective education and support beginning at the antenatal period, as evidenced by initiation rates increasing by 15 to 25 percent among low-income urban and rural populations (Caulfield et al., 1998; Kistin et al., 1994; Lang, Lawrence & Orme, 1994; Morrow et al., 1999), and duration rates increasing by 40 to 60 percent (Morrow et al., 1999). There is also a positive relationship between prenatal class attendance and breastfeeding initiation (Kistin et al., 1990). Encouraging a mother to breastfeed even during one prenatal visit may have a positive effect on initiating breastfeeding (Balcazar et al., 1995; Duffy et al., 1997). A study by Pugin et al. (1996) assessed the effect of a hospital breastfeeding promotion program, with or without specific prenatal education. It was concluded that prenatal breastfeeding education is a significant and important component of breastfeeding support, especially among women who have no previous breastfeeding experience. Intervention may have played an important role with group discussion about common myths, problems and support. 47 Nursing Best Practice Guideline Recommendation • 5.1 Evaluation of education programs should be conducted in order to evaluate the effectiveness of prenatal breastfeeding classes. (Level of Evidence II-2) Discussion of Evidence AWHONN (2000) suggests that education plans should be evaluated for the following factors: culturally and age-appropriate, community specific information, and accurate information that includes the benefits of breastfeeding. Recommendation • 6 Nurses will perform a comprehensive breastfeeding assessment of mother/baby prior to hospital discharge. (Level of Evidence III) Appendix K provides examples of discharge assessment tools that can be used to facilitate the transition from hospital to home. Recommendation • 6.1 If mother and baby are discharged within 48 hours of birth, there must be a face-to-face follow up assessment conducted within 48 hours of discharge by a qualified health care professional, such as a Public Health Nurse or Community Nurse specializing in maternal/ newborn care. (Level of Evidence III) Discussion of Evidence In the absence of strong research evidence, the panel endorses guidelines made by the Canadian Paediatric Society (2000). Refer to Appendix L for a summary of these guidelines. Specifically, the panel would like to highlight that if mother and baby are discharged within 48 hours of delivery, there must be an in-person follow up assessment conducted within 48 hours of discharge. This assessment must be provided by a qualified health care professional such as a Public Health Nurse or community-based nurse specializing in maternal/newborn care. However, it is the consensus of the development panel that there are some mothers who would benefit from a home visit and breastfeeding assessment as early as 24 hours following discharge. Mothers identified at risk may be in more need of closer follow-up, early post discharge. 48 Breastfeeding Best Practice Guidelines for Nurses Recommendation • 6.2 Discharge of mother and baby after 48 hours should be followed by a telephone call within 48 hours of discharge. (Level of Evidence III) Discussion of Evidence The Ontario Ministry of Health and Long-Term Care, through the Healthy Babies, Healthy Children Program, has mandated that all new mothers are contacted by a health care professional within 48 hours of hospital discharge, and consenting mothers receive a home visit (Ontario Ministry of Health, 1997). This telephone contact should include an assessment of the mother, which needs to address her physical health, nutritional status, breast care, parenting, support systems, emotional health, medical supervision and other determinants of health. The telephone assessment of the infant should focus on the infant’s feeding and nutrition, general health status, including output, infant care and medical supervision. In addition, the health and well being of other family members and adjustment to the new baby should be reviewed. Information on community resources that