Running head: BREASTFEEDING EDUCATION MAR

Implementing Breastfeeding Education into a Perinatal Medication Assisted Recovery Program
Brittany Schulte
Arizona State University

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Abstract
Opioid use disorder (OUD) is a chronic, complex health condition that continues to be a growing
problem in the general population, and this increase is paralleled in pregnant women. Pregnancy
is a time when women with OUD may be ready to begin a journey of recovery. OUD has both
maternal and fetal implications. The safest way to begin recovery during pregnancy is with the
initiation of either buprenorphine or methadone to prevent symptoms of withdrawal which can
increase risk of fetal harm. Both medications have the added benefit of being safe to use during
lactation. There is a minimal amount of either medication that is found in breastmilk.
Breastfeeding during medication assisted recovery (MAR) is linked both to improved maternal
and neonatal outcomes, and improved bonding. Often women who are engaged in MAR are
unaware of the benefits of breastfeeding initiation and exclusivity. Mothers may perceive
breastfeeding as a danger to their baby based on misinformation and bias. Initiation of
individualized and nonjudgmental breastfeeding education to women beginning an inpatient
MAR program can improve maternal understanding of the benefits of exclusive breastfeeding
and increase intention to exclusively breastfeed.
Keywords: medication assisted recovery, opioid misuse disorder, breastfeeding intention,
breastfeeding education.

BREASTFEEDING EDUCATION MAR

Implementing Breastfeeding Education into a Perinatal Medication Assisted Recovery Program
Opioid use disorder (OUD) is a chronic and complex condition that continues to be a
growing problem in Arizona and the United States (Arizona Department of Health Services
[AZDHS], 2019; Centers for Disease Control & Prevention [CDC], 2018). The number of
pregnant women using opioids during their pregnancy across the nation has continued to increase
(American College of Obstetricians & Gynecologists [ACOG], 2017; CDC, 2018; McGlothen,
Cleveland, & Gill, 2018; Smith & Lipari, 2017). Opioid detoxification during pregnancy is not
recommended due to increased risk of fetal harm (ACOG, 2017; Cleveland, 2016, Ecker et al.,
2019; McLafferty et al., 2016). Medication assisted recovery (MAR) with either methadone or
buprenorphine, is the standard recommendation for OUD during pregnancy to decrease fetal
risks and improve both maternal and fetal outcomes. Breastfeeding is recommended for women
engaged in MAR, and has both maternal and infant benefits (ACOG, 2017; Cleveland, 2016;
Ecker et al., 2019; Hicks, Morse, & Wyant, 2018; McLafferty et al., 2016; Reece-Stremtan,
Marinelli, & the Academy of Breastfeeding Medicine [ABM]; 2015; Tsai & Doan, 2016).
Problem Statement
Breastfeeding is recommended for mothers participating in MAR if certain conditions are
met. She should be on stable doses of methadone or buprenorphine, in a treatment program, not
using other substances, and have no other existing contraindications to breastfeeding (ACOG,
2017; Cleveland, 2016; Ecker et al., 2019; Hicks, Morse, & Wyant, 2018; Reece-Stremtan,
Marinelli, & ABM, 2015). Contraindications to breastfeeding include use of other illicit drugs,
including marijuana, and human immunodeficiency virus (HIV) positive status. While there are
many benefits to breastfeeding when engaged in MAR, this population generally has a low rate
of breastfeeding initiation and continuation (Demirci, Bogen, & Klionsky, 2015; Holmes,

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Schmidlen, & Kurzum, 2017; MacVicar, Humphrey, & Forbes-McKay, 2017; McGlothen,
Cleveland, & Gill, 2018; Tsai & Doan, 2016; Wachman et al., 2016; Yonke, Maston, Weitzen, &
Leeman, 2019). Breastfeeding barriers may be personal, societal or systemic. Barriers may
include a history of abuse or trauma, low self-esteem, maternal lack of education and actual or
perceived lack of support (Demirci, Bogen & Klionsky, 2015; Hicks, Morse, & Wyant, 2018;
Holmes, Schmidlin, & Kurzum, 2017; MacVicar, Humphrey, & Forbes-McKay, 2017;
McGlothen, Cleveland, & Gill, 2018; Tsai & Doan, 2016; Wachman et al., 2016). Barriers may
also result from provider prejudice and lack of education, as well as institutional policies and
procedures that are not supportive of breastfeeding or result in extended periods of maternal
infant seperation (Demirci, Bogen & Klionsky, 2015; Hicks, Morse, & Wyant, 2018; Holmes,
Schmidlin, & Kurzum, 2017; MacVicar, Humphrey, & Forbes-McKay, 2017; McGlothen,
Cleveland, & Gill, 2018; Tsai & Doan, 2016; Wachman et al., 2016).
The standard for treatment of OUD in pregnancy is MAR with either methadone or
buprenorphine (ACOG, 2017; Ecker et al., 2019; SAMSHA, 2015, 2016, 2018; WHO, 2014).
Both medications have been shown to decrease the risk of relapse at an appropriate dose. The
goal of treatment is to relieve symptoms of withdrawal and reduce cravings. Stable dosing
decreases serum peaks and throughs that expose the infant to repeated withdrawals. MAR used
in conjunction with comprehensive care for treatment of perinatal OUD has demonstrated
decreased pregnancy complications, increased birth weights, reduction in risky behaviors,
increased compliance with prenatal care and addiction treatment (ACOG, 2017; Ecker et al.,
2019; SAMSHA, 2018). Medications should be offered in conjunction with counseling for best
outcomes (ACOG, 2017; Ecker et al., 2019; McLafferty et al., 2016; SAMSHA, 2018).
Treatment options should be individualized to the patient’s current needs.

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Methadone and buprenorphine are found in minimal amounts in breastmilk (ACOG,
2017; Cleveland, 2016; Ecker et al., 2019; Hicks, Morse, & Wyant, 2018; Ito, 2018; ReeceStremtan, Marinelli, & ABM, 2015; Wachman et al., 2016; Wu & Carre, 2018). Babies with
neonatal abstinence syndrome (NAS) who breastfeed experience fewer and milder symptoms of
opiate withdrawal, feed better, and are ready for discharge from the hospital sooner (Tsai &
Doan, 2016; Wachman et al., 2016; Yonke, et al., 2019). Maternal breastfeeding benefits include
promotion of maternal infant bonding, decreased frustration, and improved participation in
recovery (Tsai & Doan, 2016; Wachman et al., 2016).
Purpose and Rationale
Increased breastfeeding education is recommended for women in MAR both during
pregnancy and postpartum to improve rates of breastfeeding initiation (Demirci, Bogen &
Klionsky, 2015; Graves, Turner, Nader, & Sinha, 2016; Hicks, Morse, & Wyant, 2018; Holmes,
Schmidlen, & Kurzum, 2017; Ito, 2018; Reece-Stremtan, Marinelli, & ABM, 2015; MacVicar,
Humphrey, & Forbes-McKay, 2017; Wu & Carre, 2018; Yonke et al., 2019). Breastfeeding
education is associated with increased breastfeeding exclusivity at discharge (Yonke et al, 2019).
Education should be tailored to include both maternal and infant benefits of breastfeeding
specific to this population. Yonke, et al. (2019) found that the maternal decision to breastfeed
was impacted by explanation of benefits of breastfeeding especially by the potential to improve
bonding, support of infant immune system, and promotion of infant growth and development.
The need to terminate breastfeeding should the mother begin using illicit substances again must
be made clear (Holmes, Schmidle, & Kurzum, 2017; Ito, 2018). Risks of using additional
substances, including marijuana, should be explained. The mother should be educated that the
rationale for not using substances is not a legal issue but how the substance is transferred to the

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baby through the breastmilk (McLafferty et al., 2016). Additional education should focus on
continued use of methadone or buprenorphine during the postpartum period, and explanation that
breastfeeding is safe due to the minimal amount of either medication that is transferred through
the breastmilk (Ito, 2018; Jansson et al., 2016).
Background/Significance
A Healthy People 2020 goal is to increase the overall proportion of infants who have ever
breastfed to 81.9% (U.S. Department of Health & Human Services [HHS], 2019). Breastfeeding
is recommended to improve maternal and neonatal outcomes (ACOG, 2017; Cleveland, 2016;
Hicks, Morse, & Wyant, 2018; McLafferty et al., 2016; Reece-Stremtan, Marinelli, & ABM,
2015; Tsai & Doan, 2016). Women participating in MAR benefit from increased breastfeeding
education that is tailored to their individual circumstance during pregnancy and during the
postpartum period to improve rates of breastfeeding.
The CDC has a call to action for breastfeeding encouragement that promotes education
regarding the importance of breastfeeding for women and their infants and teaching them how to
breastfeed (HHS, 2011). The CDC also recommends that lactation consultants are available to
patients and staff, and for nursing staff to be educated regarding the importance of breastfeeding
and breastfeeding support. Lactation consultants and staff providing breastfeeding education
should be encouraged to address any potential barriers to breastfeeding promptly to prevent
interference with successful breastfeeding (McGlothen, Cleveland, & Gill, 2018).
Mothers in MAR are considered a special population and require education tailored to
their specific needs (Hicks, Morse, & Wyant, 2018; Tsai & Doan, 2016). Family members and
support people should be included in education regarding benefits of breastfeeding and MAR
(Yonke et al., 2019). Neither methadone nor buprenorphine are present in significant amounts in

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breastmilk (Ito, 2018; Wachman et al., 2016; Wu & Carre, 2018). Currently no breastfeeding
education is being given at an inpatient perinatal MAR program. Evidence supports providing
education to support maternal understanding and support maternal decisions to breastfeed in the
future.
Internal Evidence
A large system-based hospital within the Phoenix Metropolitan area. The Agency
currently has a program for initiation of MAR for OUD in pregnant patients of any gestational
age. Patients check in through the hospital emergency room or Obstetrics (OB) Triage and ask
for help. They are then admitted to the Antepartum Department (APU) in the hospital under the
care of a maternal fetal medicine provider who initiates either methadone or buprenorphine.
Routine prenatal labs appropriate for the trimester are collected. A complete OB ultrasound, and
a maternal electrocardiogram (EKG) are also completed. During their stay the patients are
provided with outpatient resources that will allow them to continue treatment throughout their
pregnancy. They follow up with the maternal fetal medicine providers in the outpatient setting
for prenatal care. Currently no breastfeeding education is offered to these women during their
hospital stay.
In 2018 the Agency had a breastfeeding exclusivity rate of 51.4%, which is well below
the recommended rate of 81.9%. Currently the data includes all mothers who breastfeed
exclusively without considering other factors. Lactation consultants are available within the
hospital seven days a week. There is no protocol for lactation consultants to meet with pregnant
patients in the MAR program in the APU. Breastfeeding education in the Agency begins at birth
for this population. There is a system-wide policy that does not allow for breastfeeding education

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or support if a mother has used illicit or nonprescribed medications in the two months prior to
delivery.
PICOT Question
This inquiry has led to the clinically relevant PICOT question, “In pregnant women
initiating medication assisted recovery, either methadone or buprenorphine, in a hospital setting
(P), can breastfeeding education (I) compared to the current practice of no education (C),
improve maternal understanding of the benefits of breastfeeding and increase intention to
breastfeed (O), during their hospital stay (T)?
Search Strategy
Three databases (CINAHL, PubMed, Cochrane) were searched in March 2019.
Keywords for the search were combined with Boolean OR and each set of search terms was
combined with Boolean AND to search across title, abstract, and keywords. Search terms
included: breastfeeding, methadone, buprenorphine, opioid agonist therapy, opioid use disorder,
perinatal, education, support, lactation, breastmilk, skin to skin, and benefits. The reference lists
of existing reviews and eligible studies were reviewed after an exhaustive search of databases to
ensure capture of all relevant studies. Limits were English articles from 2014 through 2019. The
initial search yielded 6,420 articles. Articles met criteria for inclusion if they were of moderate to
high quality, qualitative or quantitative, or brought additional support to the PICOT question.
Twenty-six articles were selected for inclusion. (Appendix A).
Critical Appraisal and Analysis
Ten studies were retained for this review (Appendix B). Studies were retained if the study
population included pregnant or breastfeeding women participating in MAR, included a
discussion of at least one breastfeeding outcome, or breastfeeding education. Reviewed studies

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included one cohort study, one cross sectional analysis, one randomized controlled trial, two
meta-analyses, two reviews, and three retrospective cohort studies. Quality and strength of the
evidence was determined by Fineout-Overholt and Melnyk’s (2015) rapid critical appraisal
process. Most studies included women with OUD, women in MAR, safety and efficacy of
breastfeeding with MAR, breastfeeding initiation, or breastfeeding education. The exceptions
were the study by Peisch et al. (2018) which focused on parents with OUD. There was limited
bias in the included articles. Demographic data included in the studies was moderately described.
All studies included primarily female who were pregnant or postpartum, and their infants. The
exceptions were the study by Peisch et al. (2018) that included parents but did not specify age
ranges. The majority of studies were conducted in the United States.
Measurement tools varied depending on the type of study. Measurement tools included
review of literature, review of databases, review of patient electronic health records (EHR),
telephone interviews, and measurement via mass spectrometry. Primary outcomes of interest
focused on impact of OUD on systems, breastfeeding in women participating in MAR, barriers
to breastfeeding, safety and efficacy of breastfeeding in women participating in MAR,
breastfeeding education, and maternal perceptions of breastfeeding during MAR. Most studies
reported confidence intervals, means, standard deviations, effect sizes, and level of significance.
Synthesis of Evidence
The evidence suggests that initiation of breastfeeding education can positively impact
breastfeeding intention for women in MAR. This population has a low rate of breastfeeding
intention, initiation and exclusivity when compared to the general population. Barriers to
breastfeeding are suggested to be the result of maternal, infant, societal, or socioeconomic
factors. There is often a lack of education related to the safety and benefit of breastfeeding while

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participating in MAR. Healthcare providers are positioned to provide individualized and
nonjudgmental breastfeeding education to women participating in MAR. However, provider
prejudice and lack of support can negatively impact breastfeeding intention. Institutional policies
that increase maternal infant separation have been negatively correlated to breastfeeding success.
Rubin (1976) identified the second trimester as a time when the pregnancy has now
become real. During this trimester there is an increase in receptiveness to education and ideas
promoting a safe environment for the pregnancy and the baby. Women in the second trimester
have begun to feel the baby move, and this develops an increased awareness of the baby as a life
growing within her. This awareness helps to develop bonding, encourage maternal learning and
tasks. During this time women begin to look for acceptance of their pregnancy from their family
and peer group.
Education should clearly outline the benefits of breastfeeding to the mother and the
infant. A simple explanation supporting continued participation of MAR, and reassurance that
breastmilk contains a minimal amount of the medication in comparison to maternal dose should
be included. The topic of termination of breastfeeding if she continues or resumes use of illicit
substances should be discussed. In an in-patient healthcare setting, initiation of breastfeeding
education as pregnant women initiate MAR could help to improve understanding of maternal and
neonatal benefits of breastfeeding initiation and exclusivity which can lead to improved intention
to exclusively breastfeed.
Theory Application/Conceptual Framework
The Quality Health Outcomes Model (QHOM) was selected as the conceptual framework
for this project due to its ease of application to system level interventions (Mitchell, Ferketich, &
Jennings, 1998). (Appendix C). The QHOM uses a broad linear approach to evaluate

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relationships between structural and process variables to outcomes. Characteristics of the system
and clients impact intervention outcomes. The QHOM has been used to evaluate system and
participant characteristics at the site of interventions and to examine the impact of multiple
variables on the intervention outcome. Multiple variables were identified that impacted project
initiation and outcomes.
EBP Model/Quality Improvement Model
The Knowledge to Action (KTA) Framework was chosen as the quality improvement
model for this project. (Appendix D). The purpose of the KTA is to guide identification of gaps
between research (knowledge) and practice and to guide application of knowledge to improve
health outcomes (Graham et al., 2006). KTA was applied to this project because the project goal
was to apply knowledge of breastfeeding benefits during MAR to influence a practice change.
The desired practice change is the inclusion of a lactation consultation into the MAR program.
KTA was indirectly applied when appraising studies relevant to the intervention. KTA helped to
guide development of clear, concise education on recommendations to staff impacted by the
intervention. Identification of barriers that may impact application of knowledge is helpful when
examining whether the intervention will result in a sustainable change in practice.
Methods/Results
The project was presented to department leaders when the need was identified. Once
department leadership agreed with the project it could move forward in the Agency approval
process. The initial project was presented in August of 2019 to the Agency Professional Practice
Committee. It included a lactation consult for all pregnant women beginning MAR utilizing
either methadone or buprenorphine. Following several revisions, the final plan for the project
focused on a lactation consult for women in their 2nd trimester.

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The final plan for the project aligned with evidence that the 2nd trimester is the time when
learning related to the maternal role is most accepted (Rubin, 1976). Additionally, this aligns
with Agency policies regarding breastfeeding support. Following approval in October 2019 by
the Agency Professional Practice Committee, approval as an exempt project was obtained from
the ASU IRB in November 2019. Following notification to the Agency of the ASU IRB
approval, notification that a second level of approval was needed from the Agency Research
Determination Committee which is in place to ensure that research done at the Agency facilities
does not violate Health Insurance Portability and Accountability Act (HIPPA) regulations for
patients. This final level of approval was obtained in early December of 2019.
The project was implemented on December 17, 2019. Implementation began with education
of Antepartum staff and lactation consultants on background and significance, current evidence
supporting breastfeeding and breastfeeding education during MAR, and the process of
evaluation. During the time that the process was evaluated, there were 4 patients in the second
trimester admitted to the APU department for MAR. Three did not meet criteria for inclusion,
resulting in one patient receiving the lactation consult. Given the small N of one for the project,
evaluation of outcomes resulted in a change of focus to an evaluation of the process of
implementation of a change in practice within a department.
Discussion
The available evidence regarding the topic of women in recovery for OUD links
breastfeeding to maternal and neonatal benefits. Breastfeeding education should be initiated early
and continued throughout the pregnancy and postpartum period. Education should be nonjudgmental and specific to the patient’s situation. Inclusion of breastfeeding education for

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pregnant women beginning MAR can help them to focus on their recovery and increase their
intention to breastfeed exclusively.
There were significant barriers to the implementation of this project. During the approval
process there was a change in leadership both within the department and within the system.
Multiple rewrites of the initial project proposal added a significant amount of time to prepare the
project and gain approval from the ASU IRB. The layered approval required at the facility was
not a dynamic, well communicated process and further delayed project initiation. There was a
lack of support from department leadership once the project was implemented to facilitate
participant identification and implementation of the lactation consult.
Project limitations included time constraints and a low participation rate. It is unknown
whether more time would have resulted in increased participation. The bedside nurses in the
APU and the lactation consultants were all receptive to the education. Following project
implementation, the key drivers of the project were the APU nurses. They facilitated
identification of potential participants, communicated regarding any issues or questions, and
ordered the lactation consult appropriately. The single participant verbalized the importance of
the lactation consult to the MAR program. While the inclusion of a lactation consult during the
initiation of MAR is important to long term outcomes, it is unknown whether it will continue
following project termination.
Recommendations for system policy changes that will support breastfeeding in mothers
in MAR include continued lactation education during the antenatal period when patients enrolled
in MAR are identified, regardless of reason for admission. Mothers involved in MAR should be
offered the same support as all breastfeeding mothers including skin to skin, and early initiation
of breastfeeding. System policy that routinely separates mothers and babies being evaluated for

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NAS should be updated to decrease instances of separation of mother baby units and make this
the exception. Staff education regarding benefits of breastfeeding support to mothers in MAR
and their babies should continue to support best outcomes.
Recommendations for future projects include additional evaluation of the impact of
antenatal breastfeeding education on intention or initiation of breastfeeding, and qualitative
studies of attitudes towards breastfeeding during MAR. Evaluation of rooming in for
breastfeeding mothers in MAR will support system changes.

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20

Appendix A:
Evaluation Table

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

ClemansCope, et al.
(2019).
Pregnant
women with
opioid use
disorder &
their infants in
three state
Medicaid
programs in
2013-2016

NS
(Transitional Care
Model)

Design:
Retrospective
Cohort

N= 37,782
(2014)
N= 34,304
(2015)

Purpose: To
“analyze maternal
& infant Medicaid
claims data and
infant birth records
in three states for
the year before and
after a birth, in
2014 or 2015,
examining health,
health care use,
treatment &
neonatal
outcomes.”

Demographics:
Women,
gave birth in
2014 or 2015,
Medicaidenrolled,

Country:
U.S.
Funding:
Center for
Medicare &
Medicaid
Innovation
Bias:
Selection bias
(3 states,
Medicaid
enrolled)

Setting: NS,
included mix of
urban & rural
counties, 1
northwestern
state, 1
southwestern
state, 1
southern state
Inclusion:
mother-infant
dyads, full
benefit
Medicaid for 1
mo. Before

Major
variables
studied and
Their
Definitions
IV1: OUD
IV2: other
SUD
IV3: no SUD
DV: Medicaid
enrolled
delivered live
infant

Time Frame
of the
Intervention:
2013-2016,
depending on
date of del.

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Search of Medicaid
claims, eligibility
records, & birth
certificates

SAS 9.3 &
STATA 15,
regression
analysis &
linear
combination

p value – 0.05
IV1: 2.2% of
total
52.1% psych
22.7%
treatment rate,
del.- $22.485
- $34, 885
IV2: 5.9% of
total
46.2% psych
7.9%
treatment rate,
Del.-$16,171
IV3: 91.9% of
total
9.6% psych
Del.- $11,196

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: III
Strengths: Large
sample size, 3-year
time frame
Weaknesses:
Limited to
Medicaid patients
with full benefits,
limited to 3 states,
data limited by
documentation in
record
Conclusions:
Higher costs of
delivery & health
care noted with
SUD, especially
OUD; low
numbers of
treatment during
pregnancy and PP
Feasibility: High,
retrospective
review lack of

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

21
delivery &/or
11 months PP,
with valid BW
& GA

attrition, data
limited to included
claims and
documentation.

Exclusion: Not
on full
Medicaid
benefits during
specified time
frame, no listed
BW or GA.

Citation

Hatzis et al.,
(2017).
Quality of
caregiving in
mothers with
illicit
substance use:
A systematic
review &
meta-analysis
Country:
Australia
Funding:
Griffith
University
Postgraduate
Research
Scholarship

Theory/Conceptual
Framework

Design/
Method/
Purpose

NS (Maternal Role
Attainment Theory)

Design:
Meta-Analysis &
Comprehensive
Systematic review

Attrition: N/A
Sample/Setting

N=3433
mother-infant
dyads
n= 24
Demographics:

Purpose: To
“assess the extent
to which mothers
with substance
misuse have
compromised
caregiving.”

Setting:
Inclusion:
English
language,
range 19952015; Mothers
of children aged
birth – 3 yrs, w/
current SUD
&/or on opioid
replacement
therapy d/t hx
of OUD, &/or

Major
variables
studied and
Their
Definitions
IV1: Mothers
using illicit
substances or
in treatment
IV2: Mothers
not using
illicit
substances or
in treatment
DV1: maternal
sensitivity
DV2: child
responsiveness
Timeframe of
the
Intervention:
N/A

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Database search for
articles based on
search terms

Random
effects
model

DV1:
Population
effect size:
0.46
CI: 0.31-0.61
Z= 5.99
p<.00001
(higher in
non-substance
abusing)
DV2:
Population
effect size
0.32 (95% CI:
0.06-0.59, Z=
2.37p=.02)
(higher in
non-substance
using
mothers)

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: I
Strengths: Large
sample from
included studies
Weaknesses: high
heterogeneity
(DV1: 69%,
DV2: 77%)
Possibly d/t
SE status,
Education, design,
study inclusion.
Conclusions:
Synthesis of
literature including
mothers with SUD
& quality of
caregiving

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

22
in residential
treatment d/t
SUD,
comparison of
non-SUD
mothers
included, w/
observed
interactions

Bias:
Selection bias

demonstrated
higher quality in
mother’s w/o
SUD.
Feasibility: High,
retrospective
review of studies
lack of attrition,
limited by
available studies
meeting inclusion
criteria.

Exclusion:
non-English
language,
outside range of
dates, duplicate
studies, primary
focus not
caregiving,
ineligible
population, no
matched
comparison
group, maternal
sensitivity or
child
responsiveness
not measured

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Jansson, et al.
(2016).
Maternal
Buprenorphine
Maintenance
& Lactation.

NS
(Pender’s Health
Promotion Model)

Design:
Cohort Study
Purpose: To
determine
concentrations of

Attrition: N/A
Sample/Setting

N=10
buprenorphinemaintained
females,
&
N=9

Major
variables
studied and
Their
Definitions
IV: Breastmilk
& plasma
samples at
DV: Amount
of

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Analysis of
breastmilk &
plasma by liquid
chromatography
tandem mass
spectrometry

Spearman
correlation

Day 2 0.85
(.002)
Day 30 0.76
(.030)
(maternal
dose/plasma)

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: IV
Strengths:
consistent
sample

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

Country: U.S.
Funding:
NIH/NIDA
supplement
Bias:
Selection bias
.

buprenorphine and
its active
metabolites in
human milk,
maternal plasma,
infant plasma in
buprenorphinemaintained women
& their infants.”

23
infants
Demographics:
(maternal)
M age- 26.1 yrs
M ed. level12.2 yrs
M GA to begin
treatment- 17.3
Setting: Large
medical center
in Baltimore,
MD
Inclusion:
opioid
dependent,
buprenorphinemaintained
women wanting
to breastfeed w/
no restrictions
Exclusion:
preterm
delivery,
medical
complications,
positive urine
toxicology
indicating
recent use of
illicit
substances

buprenorphine
& active
metabolites
Timeframe of
the
Intervention:
Day 2, 3, 4, 14
& 30 post
birth.

Day 2 0.86
(.002)
Day 30 0.76
(.049)
(maternal
dose &
breastmilk
concentration)

Weaknesses:
small sample size,
attrition rate 20%
by day 30 (N=2)
Conclusions:
Supports
recommendations
for breastfeeding
in this population.
Further studies are
needed in
exclusively
breastfeeding
mothers with
larger sample size.
Feasibility:
Moderate, requires
resources for lab
analysis, increased
chances of attrition
d/t length of study
timeframe.

Attrition:
(Maternal) Day
2 & 3- 0%, Day
4 & 14- 10%,
Day 30 – 20%,
BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

24
(Infants) Day
14 – 0%
Sample/Setting

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Krans, et al.
(2018).
The
Pregnancy
Recovery
Center: A
womencentered
treatment
program for
pregnant &
postpartum
women with
opioid use
disorder.

NS
(Pender’s Health
Promotion Model)

Design:
Retrospective
cohort

N= 248
IG: 71
CG: 177

Purpose: “To
evaluate the impact
of women-centered
substance abuse
treatment
programming on
outcomes among
pregnant women
with OUD.”

Demographics:
Female

Country: U.S.
Funding:
Partially
supported by
NIDA
Bias:
Selection bias

IG
M age- 28.9
BF during del.
hospitalization:
39
BF at
discharge: 34
CG
M age- 28.7
BF during del.
hospitalization:
96
BF at
discharge: 70
Setting:
Delivery
occurred at
University
Associated
Medical Center
between July
2014- July
2016.

Major
variables
studied and
Their
Definitions
IV1: in PRC
IV2: not at
PRC
DV1: pregnant
women
DV2: on
buprenorphine
Timeframe of
the
Intervention:
July 2014 –
July 2016

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

EMR review

Chi-square
& t test
conducted
with
STATA 15.

buprenorphine
doseIG: 16.0mg
CG: 14.1 mg
(p=0.02)
Attendance to
PP visit
IG: 67.9%
CG: 52.6%
(p=0.05)
Rate of BF
decrease
IG: -14.7%
CG: - 37.1%

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: III
Strengths: Large
sample size,
comparison
samples
homogenous.
Weaknesses: IG &
CG sample size
not balanced,
performed at single
center in large
metropolitan
center, primarily
Caucasian (95.796.5%)
Conclusions:
Findings indicate
improved
outcomes and
compliance to care
with a womencentered treatment
facility. Supports
need for BF
education to
improve BF rates.
Feasibility:
Moderate, would
require a women’s

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

25
centered treatment
facility to be
compared to nonwomen’s centered
treatment facility
for comparison of
results for
application to
practice.

Inclusion:
Pregnant
female, OUD,
participants in
PRC or nonPRC treatment
services,
buprenorphine
maintained,
Exclusion:
missing
prenatal &
delivery
information,
methadone
maintained

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Peisch, et al.
(2018).
Parental
opioid abuse:
A review of
outcomes,
parenting, &
parenting
interventions.

NS
(Modeling & Role
Modeling Theory)

Design: MetaAnalysis of RCTs

Country: U.S.
Funding:
University of

Purpose: “review
rigorously
conducted studies
examining the
association of
opioid abuse with
parenting & child
outcomes & to
review parenting
intervention

Attrition: N/A
Retrospective
review
Sample/Setting

n=21
Demographics:
Parents with
SUD, primarily
OUD

Major
variables
studied and
Their
Definitions
IV1: child
outcomes
IV2: Parenting
behaviors
DV: Parents
w/ OUD

Setting: varied
Inclusion:
English
language
studies with
comparison

Timeframe of
the
Intervention:

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Review of available
studies from
databases with
associated terms

Inferential
statistical
analysis

IV1:
decreased
social support
may impact
decreased
social,
academic
functioning
IV2: studies
reviewed did
not favor
positive or
negative

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: I
Strengths: Studies
were across large
timeframe,
Weaknesses:
Limited sample
size of studies that
met inclusion
criteria, studies did
not all match in
demographic or
intervention data.

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR
Vermont
REACH
Grant, the
College of
Arts &
Sciences, the
College of
Education &
Social
Sciences.

programs with
these caregivers.”

26
group,
quantitative
data w/
inferential
statistical
analyses.

Studies from
1986-2015
reviewed

behaviors in
parents with
OUD

Exclusion:
Non-English
language
studies, at least
49% of parents
in study did not
have OUD.

Bias:
Selection bias.

Feasibility: High,
retrospective
review of studies
can be repeated to
be applied to
practice.

Attrition: N/A

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

Tsai & Doan.
(2016).
Breastfeeding
among
mothers on
opioid
maintenance
treatment: A
literature
review.

NS
(Maternal Role
Attainment Theory)

Design: Review of
case-control studies

n=9

Country: U.S.
Funding:
None stated

Purpose: “Review
of
experimental/quasiexperimental
studies over last 10
years that examine
interventions aimed
at increasing rates
of breastfeeding
initiation and
duration in mothers
receiving OMT.

Demographics:
Female,
pregnant or PP,
receiving OMT.
Setting: varied,
primarily
inpatient
Inclusion:
English
language,
human studies,
from January

Conclusions:
Indicates need for
further study on
the topic.
Suggestive of need
to support
parenting skills in
parents with OUD.

Major
variables
studied and
Their
Definitions
IV1: BF
initiation
IV2: BF
duration
DV: Mothers
on OMT
Timeframe of
the
Intervention:
varied

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Review of studies
meeting inclusion
criteria

NS

IV1 highest in
rooming in
(62.5%)
Intervention
groups had
higher rates of
IV1 & IV2,
than no
intervention

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: III
Strengths:
Cohesive
population
Weaknesses:
Limited number of
studies,
Conclusions:
Indicates need for
additional BF
support to improve
BF rates in this
population.

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

27
2005- October
2015,
preference to
experimental &
quasiexperimental
studies.

Bias:
Selection bias.

Feasibility: High,
Supports need for
patient education
& support to
improve BF rates,
applicable to
practice.

Exclusion:
Non-English
language,
studies w/o
original data

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Whiteman, et
al. (2014).
Maternal
opioid drug
use during
pregnancy &
its impact on
perinatal
morbidity,
mortality, &
the costs of
medical care
in the U.S.

NS
(Transitional Care
Model)

Design: Cross
Sectional Analysis
Purpose: “To
identify factors
associated with
opioid use during
pregnancy & to
compare perinatal
morbidity,
mortality &
healthcare costs
between opioid
users & non-users.”

Attrition: N/A
Sample/Setting

N= 55,781,965
Pregnancy
related
hospitalizations
N=138,224
associated with
opioid use
Demographics:
Pregnancy
related
discharges
between 19982009.

Country: U.S.
Funding: Not
stated,
reviewed by
IRB of

Setting:
Inpatient
Inclusion: NIS
database,

Major
variables
studied and
Their
Definitions
IV1: opioid
use
IV2: no opioid
use
DV1:
pregnancy
DV2: cost of
health care
costs
Timeframe of
the
Intervention:
data between
1998-2008

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Review of
pregnancy related
hospital discharges
from 1998-2009
using NIS.

Two sided
statistical
tests with
level of
significance
at 5%.

Increased
rates of use of
opioids in
pregnancy as
study
progressed.
Primary
payor-Private
#1, Medicaid
#2

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: III
Strengths: large
sample size, length
of study.
Weaknesses:
Opioid use not
identified during
hospital stay was
missed,
deidentified
information did not
allow for
association of
mother-infant
dyads or allow for
identification of
multiple
hospitalization

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR
University of
South Florida
Bias:
Selection bias.

28
pregnancy
related
discharges

during the
specified time
frame.

Exclusion: Not
pregnancy
related

Conclusions:
Study indicated
increased rates of
maternal comorbidities, longer
hospital stays,
increased
mortality, poor
fetal growth &
survival associated
with opioid use in
pregnancy.

Attrition: N/A

Feasibility:
Moderate,
applicable to
practice as
background for
increased costs
associated with
opioid use in
pregnancy.

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

Wong et al.
(2014).
Antenatal
education to
increase
exclusive
breastfeeding:

NS
(Pender’s Health
Promotion Model)

Design: RCT

N= 469
IG-233
CG-236
Demographics:
Pregnant
females

Purpose: “evaluate
the effectiveness of
a professional oneto-one antenatal
breastfeeding

Major
variables
studied and
Their
Definitions
IV: Exclusive
breastfeeding
rates
DV1:
Standard
antenatal care

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Telephone
interviews

KaplanMeier
Survival
curves &
unadjusted
Cox
proportional

Intervention
group no
more likely to
continue
exclusive
breastfeeding,
at 6 weeks

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: I
Strengths:
Adequate sample
size, minimal rate
of attrition

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR
A randomized
controlled
trial.

support and
education
intervention on the
exclusivity
&duration of
breastfeeding.”

Country:
Hong Kong
Funding:
Grant from the
University of
Hong Kong.
Bias:
Selection bias.

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Wu & Carre.
(2018).
The impact of
breastfeeding

NS
(Pender’s Health
Promotion Model)

Design:
Review of
experimental/quasi-

29
Setting: 2
public antenatal
clinics in Hong
Kong
Inclusion: at
least 18 yrs.,
Cantonese
speaking,
primiparous, 35
weeks GA or
greater,
singleton
pregnancy, no
complications,
intends to BF,
plans to stay in
Hong Kong for
at least 6 mo.
PP.
Exclusion: Not
entitled to
health benefits
in Hong Kong
&/or not a
Hong Kong
resident
Attrition:
IG:6.4%
CG: 4.7%
Sample/Setting

n= 7
Demographics:

DV2: 1-1
breastfeeding
support &
education
session

hazards
regression

Timeframe
for the
Intervention:
6 weeks, 3
months, & 6
months PP.

(37.8% vs.
36.4%,
P=.77, 95%
CI), at 3
months
(26.6% vs.
25.9%, P=.85,
95% CI)
93.6% -95.3%
rate of
completion

Weaknesses:
Study population
limited, may not
apply to other
cultures or
geographical areas.
Conclusions: A
single one on one
antenatal education
and support
session did not
significantly
impact BF rates.
Feasibility:
Moderate, further
education is
needed to increase
BF initiation and
duration rates with
consideration to
barriers.
Applicable to
practice as
rationale for
individualized
education.

Major
variables
studied and
Their
Definitions
IV1: breastfed
infants
IV2: formula
fed infants

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Review of studies
from databases with
associated search
terms

NS
(varied)

BF associated
with
decreased
length of

Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: III

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR
on health
outcomes for
infants
diagnosed
with neonatal
abstinence
syndrome: A
review.

experimental
studies
Purpose:
Evaluation of
literature that
suggests
breastfeeding may
have the potential
to reduce symptom
severity & improve
outcomes of infants
with NAS

Country: U.S.
Funding: Not
stated.
Bias:
Selection bias,
& both authors
work for
University of
Central
Florida.

30
Women on
OMT, infants
w/ NAS
Setting: varied
Inclusion:
human studies,
English
language, from
1997-2018,
women with
SUD receiving
OMT, & infants
with NAS

DV1:
Postpartum
women on
MAT
DV2: Infants
diagnosed
with NAS

hospital stay
in infants with
NAS.

Strengths: Studies
supportive of BF
in OMT.

BF associated
w/ decreased
symptoms of
NAS with BF.

Weaknesses:
Small sample of
studies.
Conclusions: BF
improves maternal
& infant outcomes
in women
receiving OMT.
Overall percentage
of this population
BF remains small,
supports need for
additional
information.

Timeframe of
the
Intervention:
Varied, studies
included from
1997-2018

Exclusion:
non-English
language
studies
Attrition: N/A

Citation

Theory/Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

Yonke et al.,
(2019).
Breastfeeding
intention
compared with
breastfeeding
postpartum
among women
receiving
medication-

NS
(Pender’s Health
Promotion Model or
Maternal role
attainment theory)

Design:
Retrospective
cohort study

N= 228
women/infant
dyads

Purpose: “To
determine
difference between
stated intention to
breastfeed
prenatally in

DV1-107
DV2-121
Demographics:
Women,
pregnant,

Major
variables
studied and
Their
Definitions
IV1: Intention
to breastfeed
IV2:
breastfeeding
rates post
delivery
DV1:
methadone use

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

EMR review

Chi-square
tests

84% intended
to breastfeed
DV1: initiated
71%, 21%
exclusive BF
at dc, 12%
exclusive BF
at 2-month PP
visit

Feasibility: High,
rates of success
and improved
outcomes supports
use in practice.
Level of
Evidence/Decision
for
Use/Application
to Practice
LOE: IV
Strengths:
Adequate
sample size,
consistent
sample

BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR
assisted
treatment.
Country: U.S.
Funding: part
of a larger
study, no
financial
support
reported.
Bias: Authors
work with
patients at the
clinic where
study occurred
& selection
bias.

women taking
methadone or
buprenorphine
compared with
breastfeeding at
discharge & 2
months postpartum.
Secondary outcome
to determine if
breastfeeding was
more common in
women taking
buprenorphine.”

31
enrolled in
perinatal
substance abuse
program
affiliated with
university
Setting: a
university
affiliated
prenatal care
program
Inclusion:
Began OMT
with methadone
or
buprenorphine
prior to 36
weeks GA, plan
to BF, delivered
between June
2011 & June
2015 at 36
weeks GA or
greater, at least
3 prenatal visits
with university
prenatal care
program.
Exclusion:
Illicit drug use
at time of del.,
twin gestation,
did not keep 2
month PP visit.

DV2:
buprenorphine
use
Timeframe of
Intervention:
June 2011June 2015

DV2: initiated
82.6%, 31.4%
exclusive BF
at dc, 8.9%
exclusive BF
at 2-month PP
visit

Weaknesses:
unable to
determine
what impacted
decision to
BF
Conclusions:
Results indicated a
low incidence of
breastfeeding
initiation and
duration despite
stated BF
intentions.
Prevalence of BF
was higher in
buprenorphine
group. Study
suggests need for
additional
education
regarding benefits
of BF to this
population.
Feasibility: High,
Follow up can be
performed during
hospitalization for
delivery & during
PP visit.
Applicable to
practice, need for
education
regarding BF
benefit.

Attrition: N/A.
Retrospective
study.
BF- Breastfeeding, BW- Birth weight, CG- control group, CI- Confidence interval, del.- delivery, DV- Dependent variable, ed. -education, EMR- electronic medical record, GA- Gestational age, IG- Intervention group, IV-Independent variable, LOElevel of evidence, M- mean, mo.- month, N- -sample size (population), n- sample size (studies), N/A- Not applicable, NAS- Neonatal Abstinence Syndrome, NIDA- National Institute on Drug Abuse, NIH – National Institute of Health, NIS- National
Inpatient Sample, NS- Not stated, OMT- Opioid maintenance Treatment, OUD- Opioid use disorder, PP- Postpartum, PRC- Pregnancy Recovery Center, Psych- Psychiatric, REACH- Racial and Ethnic Approaches to Community Health, RCTRandomized Controlled Trial, SAS- Statistical software program, SE- Socioeconomic status, STRATA- Statistical software program, SUD- Substance use disorder, U.S.-United States, w/- with, w/o- without, yrs.- years, Z- standard deviation from mean,
& - and

BREASTFEEDING EDUCATION MAR

32
Appendix B:

Outcomes

Evaluations

2016
III
REV
9
X

X
X

X
X

2014
III
CSA
138,224
X
X
X

2014
I
RCT
469

Yonke

2018
I
MA
21
X

Wu

2018
III
RC
248
X

Wong

Tsai

2016
IV
CS
10
X

Whiteman

Peisch

2017
I
MA
3,433
X
X
X

Krans

2019
III
RC
72,086
X
X
X

Jansson

Year
LOE
Design
Participants
M-OUD
M- No OUD
Infants
BUP
MTD
BF Edu
TF
OP
MS
CS
BF in hosp
BF at DC
BF INT
BF rates
FF
NAS
Cost to HCS
Breastmilk

Hatzis

Basics

Studies

ClemonsCope

Synthesis Table

2018
III
REV
7
X

2019
IV
RC
228
X

X
X
X
X

X
X

X
X

X
X
X
X
X

X
X
X

X
X

X

X
X
X
X
X

X
X
X
X

X
X
X
X
X

X
X
X
X
X

X
X
X
X
X

X
X

KEY: BF- breastfeeding, BUP- buprenorphine, CS- study, CSA- cross sectional analysis, CS- child sensitivity,
DC- discharge, Edu- education, FF- formula fed, hosp-hospital, INT- intention, HCS- healthcare system, MAmeta-analysis, MS- maternal sensitivity, M-OUD-maternal opioid use disorder, M-no OUD- maternal no opioid
use disorder, MTD- methadone, NAS- neonatal abstinence syndrome, OP- outpatient treatment, RCretrospective cohort study, RCT- randomized controlled trial, REV- Review of studies, TF- treatment facility

BREASTFEEDING EDUCATION MAR
Appendix C
Quality Health Outcomes Model

(Mitchell, Ferketich, & Jennings, 1998)

33

BREASTFEEDING EDUCATION MAR

Appendix D
Knowledge to Action Framework

(Graham et al., 2006)

34