Rev. Latino-Am.

Enfermagem
2019;27:e3140
DOI: 10.1590/1518-8345.2777-3140
www.eerp.usp.br/rlae

Original Article

Telephone intervention in the promotion of self-efficacy, duration and

exclusivity of breastfeeding: randomized controlled trial*

Anne Fayma Lopes Chaves1

http://orcid.org/0000-0002-7331-1673

Lorena Barbosa Ximenes2

http://orcid.org/0000-0002-8006-7517

Dafne Paiva Rodrigues3 Objective: to evaluate the effect of a telephone intervention

http://orcid.org/0000-0001-8686-3496
on the self-efficacy of puerperal women in the duration and
Camila Teixeira Moreira Vasconcelos2 exclusivity of breastfeeding. Method: randomized controlled
http://orcid.org/0000-0003-4578-4657
trial composed of 85 breastfeeding mothers at 2 months
Juliana Cristina dos Santos Monteiro4
http://orcid.org/0000-0001-6470-673X and 77 at 4 months. The sample was randomized into two
Mônica Oliveira Batista Oriá2 groups, control and intervention. The intervention consisted
http://orcid.org/0000-0002-1483-6656
of a telephone follow-up performed at seven, 15 and 30 days
after delivery using the precepts of Motivational Interview
and Self-Efficacy in Breastfeeding. Results: self-efficacy in
breastfeeding at 2 months was similar in both groups (p
= 0.773). However, at 4 months, the intervention group
presented higher self-efficacy than the control group (p =
0.011). There was a difference between groups in the duration
* Paper extracted from doctoral dissertation “Efeitos de of breastfeeding at 2 months (p = 0.035). At 4 months, the
uma intervenção educativa por telefone na autoeficácia,
duração e exclusividade do aleitamento materno:
intervention group remained in breastfeeding when compared
ensaio clínico randomizado controlado”, presented to to the control group (p = 0.109). Both groups did not show
Universidade Federal do Ceará, Fortaleza, CE, Brazil.
1
Centro Universitário Estácio do Ceará, Fortaleza, CE, differences in exclusive breastfeeding at two (p = 0.983)
Brazil.
and four months (p = 0.573). Conclusion: the telephone
2
Universidade Federal do Ceará, Faculdade de Farmácia,
Odontologia e Enfermagem, Fortaleza, CE, Brazil. educational intervention was effective in improving self-
3
Universidade Estadual do Ceará, Departamento de
Enfermagem, Fortaleza, CE, Brazil.
efficacy and duration of breastfeeding, but not exclusivity.
4
Universidade de São Paulo, Escola de Enfermagem de (ReBEC: UTN: U1111-1180-5341).
Ribeirão Preto, PAHO/WHO Collaborating Centre for
Nursing Research Development, Ribeirão Preto, SP, Brazil.
Descriptors: Self Efficacy; Breast Feeding; Nursing; Health
Promotion; Evidence-Based Nursing; Communications Media.

How to cite this article

Chaves AFL, Ximenes LB, Rodrigues DP, Vasconcelos CTM, Monteiro JCS, Oriá MOB. Telephone intervention
in the promotion of self-efficacy, duration and exclusivity of breastfeeding: randomized controlled
trial. Rev. Latino-Am. Enfermagem. 2019;27:e3140. [Access ___ __ ____]; Available in: ___________________ .
DOI: http://dx.doi.org/10.1590/1518-8345.2777-3140. month day year URL
2 Rev. Latino-Am. Enfermagem 2019;27:e3140.

Introduction aspects, difficulties and psychological support.

However, no research has specifically addressed
Despite the support of national and international self-efficacy in breastfeeding. Our hypothesis is
health agencies for breastfeeding, early weaning that interventions aimed at this construct may
is still an evident aspect among Brazilian nursing generate significant repercussions for the success
mothers, being a challenge to be overcome (1). of breastfeeding. In this context, the relevance
Evidence indicates the increase in breastfeeding of the present research is based on the fact that
(BF) and exclusive breastfeeding (EBF) until 2006, its findings will subsidize a possibility that can be
but with relative stabilization until 2013. This added to those already used in primary health care
demonstrates the importance of strengthening as a way to facilitate access, guidance, support and
implemented actions and expanding new strategies follow-up of the mothers and their children with
to promote breastfeeding(2). regard to infant feeding. Thus, the objective was
To modify this scenario, health experts aim to evaluate the effect of telephone educational
to propose interventions based on modifiable intervention on maternal self-efficacy, duration and
factors, such as a proposal capable of improving exclusivity of BF.
women’s behavior in relation to breastfeeding. In
this context, women’s self-efficacy in breastfeeding Method
is analyzed, which can be conceptualized as the
mother’s confidence in breastfeeding her child This is a controlled Randomized Clinical

successfully, which involves knowledge and skill. Trial (CRT) conducted in the period from May to
This factor has been shown to have a positive effect November, 2015, in a District Hospital in the city of
on the duration and exclusivity of BF, promoting in Fortaleza, Ceará. The inclusion criteria were being
the woman the feeling that she is able to modify in the immediate puerperium, single full-term
her behaviors aiming at better health conditions for gestation with newborns hospitalized in rooming-
both her and her child(3). in (RI), being practicing BF and having at least
Several technologies have been used to one telephone number for contact. We excluded
improve maternal self-efficacy in breastfeeding women whose children presented deficiencies that
and the prevalence of BF and EBF (workshops, prevented breastfeeding, presented some type of
educational booklets, album, telephone). Among contraindication for breastfeeding and impaired
these, telephone use has been increasingly used, hearing. The criteria for discontinuation were
being seen as a useful tool capable of promoting BF, maternal or newborn death during the course
proving to be effective when the interventions are of the study, interruption of the BF before the
performed in the long term during the puerperium intervention was completed, and failure to answer
and by health experts with mastery and experience telephone calls after three attempts at different
in breastfeeding(4). days and times.
A US study of 298 women that used a For the sample calculation, we used a
telephone contact intervention developed by formula for comparative group studies, adopting
prenatal breastfeeding consultants up to six months the following values: Z5% = 1.96, z20% = 0.84,
after delivery found that women in the intervention p1 = proportion of the outcome in the control of
group (IG) had longer duration of BF and were 30%, p2 = proportion of the outcome in the 55%
more likely to continue the EBF . A randomized
(5) experiment, n = sample size, confidence coefficient
experimental study involving 461 Nigerian women, = 95%, test power = 80%. Thus, by replacing the
in which counseling on BF was implemented through values, 57 puerperal women would be required
meetings with songs and dramatizations, telephone for each group. However, a safety percentage of
follow-up and text messages, found that women 15% was added based on the losses of a study that
from the IG were more likely to practice EBF with addressed self-efficacy in breastfeeding using the
one month (Odds Ratio: 1.6, p = 0.10), 3 months telephone(7) for possible telephone losses, making
(OR: 1.8, p <0.05) and 6 months (OR: 2.4, p up a total of 66 puerperal women per group, totaling
<0.01)(6). 132 postpartum women. Participants were allocated
Several aspects have already been addressed randomly in two groups:
during the telephone interventions, such as - Intervention Group (GI): Telephone educational
breastfeeding benefits and techniques, cultural intervention. In addition to the assistance and

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 Chaves AFL, Ximenes LB, Rodrigues DP, Vasconcelos CTM, Monteiro JCS, Oriá MOB. 3

routine individual service activities provided by the the admission to the obstetric ward, the puerperal
child-friendly hospital professionals, the women women were approached about their consent
received an educational intervention by telephone. to participate in the research, after receiving
The intervention consisted of a telephone call explanation on the objectives and benefits thereof.
lasting seven minutes, on average, made by an Subsequently, the participants answered a form
experienced nurse and lactation educator, in which containing sociodemographic, obstetrical and
she initially introduced herself and recalled the breastfeeding data and the BSES-SF, which assessed
approach in the rooming-in, in order to establish the participants’ maternal self-efficacy. At the end
a bond with the infant. Subsequently, using a form of the study, the following primary outcomes were
that followed the principles of the Motivational assessed: self-efficacy of women in breastfeeding,
Interview (MI), the evoking-informing-evoking duration and exclusivity of breastfeeding.
technique was used, which is recommended to The BSES-SF was validated in Brazil, with
change patients’ behaviors in a collaborative way, Cronbach’s alpha of 0.74, showing to be a
based on their motivation . At each call, guidance
(8)
reliable instrument(11). It is composed of 14 items
was given on two items on the scale to which women randomly distributed in two domains (technique
showed lower self-efficacy in the rooming-in; these and intrapersonal thoughts) related to maternal
guidelines were based on the instrument created confidence in breastfeeding, which has a Likert
by the researcher, based on the Breastfeeding Self- type scale ranging from 1 to 5 points. Mothers are
Efficacy Scale - Short Form (BSES-SF) (9)
and in the classified as follows: Low efficacy: 14 to 32 points;
Serial Album “I can breastfeed my child”(10), which Average efficacy: 33 to 51 points; High efficacy: 52
addressed issues on technique and interpersonal to 70 points. This instrument is self-applied when
thinking on breastfeeding. The doubts of the women the participant has the ability to read and answer to
were solved and, when necessary, they were guided the questions. In view of the public involved in this
to seek the institution’s milk bank. research, the application was through an interview
- Control Group (CG): Women received only the conducted by the researchers.
routine guidelines of the child-friendly hospital, that In the second phase, the intervention was
is, individual routine service activities. made to the IG women through three telephone
After the initial approach to the women in the contacts within one month, in the days previously
rooming-in, the randomization was performed in established with the patients, being at 7 days, 15
“blocks”, 13 blocks of 10 puerperal women and days and 30 days after childbirth. In the third phase,
one block of two puerperal women. This type of also by telephone, the evaluation of the primary
randomization was important for equitable initial outcomes was performed based on BSES-SF and on
distribution between groups to facilitate logistics a specific form developed by the authors, applied to
in collecting data from subsequent phases. both groups.
Randomization occurred by a computerized Of the 132 participants evaluated for eligibility,
algorithm performed by a first statistician. Thus, only 77 composed the final sample due to the
each puerperal woman was allocated to participate discontinuity criteria, in which there was 40.9% of
in a group based on chance, that is, with the loss, as detailed in Figure 1.
same chance of being distributed in one of the The data obtained were compiled in the
comparison groups. Statistical Package for the Social Sciences (SPSS)
This research involved a team, encompassing program, version 20.0. Continuous variables were
nurses and nursing academics, previously trained expressed as medians with a 95% confidence
to evaluate outcomes. These people were blinded interval, and categorical variables in absolute and
as well as the statistician responsible for the relative frequencies. For the comparisons between
analysis. However, the researcher responsible for the groups, we used the chi-square, Fisher, Pearson
the intervention and the research participants were and Mann-Whitney U tests.
not blinded. The study was approved by the Ethics and
The research was divided into three phases. Research Committee of the Federal University of
The first phase took place on a day-to-day basis in Ceará (Opinion 1,026,156) and registered in the
the recruitment of puerperal women for a period Brazilian Registry of Clinical Trials (ReBEC) (UTN:
of three months in the rooming-in unit. During U1111-1180-5341).

www.eerp.usp.br/rlae
4 Rev. Latino-Am. Enfermagem 2019;27:e3140.

Calculated sample
114 participants

Addition of 15% due

Patients involved

to possible losses

132 participants
(100% of the foreseen
sample)

Randomization
Allocation of

66 participants
patients

66 participants
Intervention Group
Control Group

7-day
Educational
Session
56 (84.%) participants
Losses: 10 (15.2%)
- Did not answer/phone off (9)
- Stopped breastfeeding (1)

15-day
Educational
Session
Follow-up

49 (74.2%) participants
Losses: 7 (10.6%)
- Did not answer/phone off (6)
- Stopped breastfeeding (1)

30-day
Educational
Session

43 (65.1%) participants
Losses: 6 (9.1%)
- Did not answer/phone off (6)
- Stopped breastfeeding (0)

41 (62.1%) participants 44 (66.6%) participants

Losses: 2 (3%) Losses: 22
Evaluation of the - Did not answer (17)
- Did not answer (2)
outcomes after 2 Result
Result
months - Stopped breastfeeding (5)
- Stopped breastfeeding (0)
Final evaluations

Evaluation of the 39 (59.1%) participants 38 (57.5%) participants

outcomes after 4 Lossess: 2 (3%) Losses: 6 (9.1%)
months - Did not answer (1) - Did not answer (1)
Result Result
- Stopped breastfeeding (1) - Stopped breastfeeding (5)

Figure 1 - Flowchart of the phases and follow-up of participants

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 Chaves AFL, Ximenes LB, Rodrigues DP, Vasconcelos CTM, Monteiro JCS, Oriá MOB. 5

Results significant difference between groups (Table 1). The

mothers of the CG had a lower median age (CG: 22; IG:
Comparisons of sociodemographic and obstetric 24.5), but with similar median of years of schooling (CG:
variables indicate that there was no statistically 11; IG: 11.5).

Table 1 - Sociodemographic and obstetric data of the participants. Fortaleza, CE, Brazil, 2015
Intervention (n=66) Control (n=66)
Variable p-value‡
Md*±SD †
n(%) Md*±SD† n(%)

Age (years) 24.5 ± 7.4 22.0 ± 6.4 0.484§

1st quartile P25 19.5 19

3rd quartile P75 29 29.0

Range of schooling (years of study) 11.0 ± 3 11.5 ± 2.9 0.237§

1st quartile P25 08 09

3rd quartile P75 13 13

Family income|| 0.712¶

Less than one wage 6 (9.1) 7 (10.6)

From one to three wages 60 (90.9) 59 (89.4)

Marital status 0.018**

Married/Stable union 57 (86.4) 45 (68.2)

Outros 9 (13.6) 21 (31.6)

Occupation 0.738**

Housewife 37 (56) 30 (42.7)

Maid 15 (22.7) 16 (24.2)

Other 14 (21.2) 20 (30.3)

Parity 0.541¶

Primipara 34 (51.5) 40(60.6)

Multipara 32 (48.5) 26(39.4)

Previous breastfeeding practice 0.080**

Yes 31 (96.9) 21 (80.8)

No 1 (3.1) 5 (19.2)
*Median; †Standard deviation; ‡p-value; §Mann-Whitney test; || Minimum wage: R$ 788.00, 2015, Brazil; ¶Chi-square test; **Fisher’s exact test

Mothers of the GI had a higher prevalence of

70
married/stable marital status (CG: 68.2%; IG: 86.4%), p*=0.01
68
as well as of housewife as occupation (CG: 42.7%; IG: p*=0.77
66
56%). These differences were not significant, except
64
for marital status, since women living in married/stable p*=0.21
unions had better levels of self-efficacy in breastfeeding. 62

There was no difference between the groups 60

in relation to the obstetric history, although the CG 58

presented a majority of primiparous women and 56

Baseline 2 months 4 months
the lowest percentage of mothers with previous
Intervention Group Control Group
breastfeeding experience.
Figure 2 shows the median self-efficacy scores in *Mann-Whitney U Test

both groups over time. Figure 2 - Intergroup comparison of median self-efficacy

The analysis showed that the median self-efficacy scores in breastfeeding over time. Fortaleza, CE, Brazil,
scores were the same in the short term (two months). 2015
However, in the long term (four months), it was evidenced
that the IG obtained higher levels of self-efficacy when Figure 3 shows that the educational intervention
compared to the CG. This leads us to conclude that the was effective in maintaining BF in the short term (two
telephone intervention has increased women’s self- months) in the IG to 100% of the women who remained
efficacy in breastfeeding in the medium term. in the study until two months; while the CG presented

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6 Rev. Latino-Am. Enfermagem 2019;27:e3140.

decrease. With regard to the fourth month, most women On the other hand, marital status influenced
in the IG remained in BF when compared to the CG, but maternal self-efficacy in breastfeeding. Women living
it was not statistically significant. with their partner may have increased self-efficacy in
breastfeeding, since partner support may be a protective

102 factor in confidence to breastfeeding, making it critical

p*=not significant p*=0.035 to adherence to breastfeeding(13-15). Thus, the nurse is
100

98
p*=0.109 of utmost importance to guarantee qualified attention

96 to this specific public since prenatal care in order to

94
achieve a positive repercussion in the beginning and
duration of BF.
92
Among the women of the IG, there was a
90
predominance of occupation as housewives; however,
88
this difference between the groups did not significantly
86
influence breastfeeding. Nevertheless, the literature
84
points out that this aspect may favor exclusive
82
Baseline 2 months 4 months breastfeeding, considering that women who work out of
Intervention Group Control Group home feel more distressed with the child’s adaptation to
a new food pattern and offer the bottle prematurely(16).
*Mann-Whitney U Test
Despite the greater predominance of primiparous
Figure 3 - Intergroup comparison of duration of
women in the CG, no difference was identified in the
breastfeeding over time. Fortaleza, CE, Brazil, 2015
groups regarding maternal self-efficacy in breastfeeding.
Primiparity is, in most cases, identified as a risk factor
The intergroup comparison of the exclusivity of BF
for low self-efficacy in breastfeeding, which may have
indicates that both groups (CG/IG) presented minimal
repercussions on adherence to this practice(6,16). Thus,
differences regarding the exclusivity of BF at two and
these mothers need to receive care from the beginning of
four months (Figure 4). Thus, it is evident that the
prenatal care through counseling, educational activities
educational intervention did not influence the exclusivity
and a practical approach aiming at a better performance
of BF.
in their first experience in breastfeeding.
The educational intervention did not influence
120 breastfeeding at two months (p = 0.773). However, it
p*=not significant
100 was effective at four months, increasing the self-efficacy
80 of breastfeeding among mothers of the IG. Similar
p*=0.98
60 results were found in a pilot study conducted in Canada,
p*=0.573
40 which developed an intervention focused on self-efficacy

20 in breastfeeding from telephone contacts. There was no

0
difference between the groups in the self-efficacy until
Baseline 2 months 4 months the second month; however, the mothers belonging
Intervention Group Control Group to the IG presented higher levels of self-efficacy in
breastfeeding at four and eight weeks after delivery
*Pearson’s Chi-Square
compared to mothers of the CG(17).
Figure 4 - Intergroup comparison of exclusive
Thus, in the short term, mothers tend to maintain
breastfeeding over time. Fortaleza, CE, Brazil, 2015
high self-efficacy in breastfeeding regardless of
intervention. This may be related to pre-existing factors,

Discussion such as guidelines received during prenatal care and

previous breastfeeding experience. In view of this, such
The analysis of the sociodemographic variables strategies are essential to sustain mothers’ confidence
revealed that age did not influence the self-efficacy of for a longer period and, consequently, to maintain BF
breastfeeding, although some research have shown and EBF(18).
that the younger the age, the shorter the length of The educational intervention was able to maintain
breastfeeding. This fact justifies that women be constantly BF at two and four months, showing to be effective
stimulated through group actions directed at pregnant in maintaining BF in both the short and long term.
and puerperal women to enable them and support them Regarding the exclusivity of BF, the intervention
so that they can breastfeed up to six months(12). developed did not influence this aspect, regardless of

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 Chaves AFL, Ximenes LB, Rodrigues DP, Vasconcelos CTM, Monteiro JCS, Oriá MOB. 7

the time. A recent research has pointed out that there telephone support developed by trained nurses, focused
are several factors that contribute to discontinuation of on self-efficacy in breastfeeding and based on the
exclusive breastfeeding (low milk production, difficulty in approach of MI increases the mothers’ self-efficacy in
attachment, breast complications and lack of confidence breastfeeding and increases the duration of BF, but does
in breastfeeding)(13). Thus, in order to overcome this not influence the exclusivity of BF.
complex challenge, health professionals need to expand The most relevant contribution of this research is
their area of intervention so that interventions address to make evident that telephone support consists of a
different problems. viable technology in the promotion of BF, especially if it
In the face of globalization, nursing has been using is used as an educational component, and that can be
Information and Communication Technologies (ICTs) as idealized and applied in the health services with the aim
a way to develop care in the different health settings, and of improving the rates of BF and EBF.
the telephone is an effective tool for communication(19). However, it is important to point out that the
In the present study, the intervention performed by telephone should be considered as a form of support in
telephone was developed during four weeks through the the assistance to mother and child to promote BF, and
guidance of a trained nurse. Comparing the findings of should not replace direct contact, attention and care of
this study with an American study in which a telephone professionals to this binomial.
intervention was carried out by lactation consultants The high sample loss rate (40.9%) is a limitation
certified by the International Board of Lactation of this study, which restricts the generalization of the
Consultant Examiners (IBLCE) for up to 72 hours after
effects. However, this RCT is a pioneering initiative in
delivery, one can identify better BF and EBF rates in the
Brazil that may not only fill this gap in the literature but
Brazilian study. The duration of breastfeeding was 4.3
also increase the knowledge of limitations that can be
weeks shorter in the IG than in the CG (p = 0.08), which
adjusted in future replications.
was also observed at 30 and 90 days (p = 0.10 and p =
0.08, respectively). The duration of EBF was 4.7 weeks Conclusion
shorter in the IG than in the CG(20).
Although the previously presented studies show The results of this study provide positive evidence
significant limitations, such as specific public and small on the effectiveness of professional telephone support
sample size, the findings allow us to understand that for the promotion of BF. This short-term educational
educational interventions carried out for a short period intervention was able to increase self-efficacy and
show gaps in their efficacy . (4)
duration of BF, but did not influence exclusivity. It
The only study found in the literature conducted is believed that this research can contribute to the
for a short period that obtained a satisfactory result in innovation of the care methodology, considering that
the duration and exclusivity of BF had as intervention it is a new possibility of strategy to be added to those
a telephone follow-up aimed at the specific difficulties already used in the health services. However, further
of the mothers, being developed by nurses that were research is needed to explore and identify the reasons for
lactation consultants up to four weeks after delivery. persistently low EBF rates and to test new interventions
Mother of the IG were more likely to maintain BF at either that seek to improve these rates.
one month (OR: 1.63) or at two months (OR: 1.48).
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Received: Apr 11th 2018

Accepted: Jan 5th 2019

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