This quasi-experimental study with a nonequivalent control group design was conducted to examine the effect of a UL-NCEP on the exclusive breastfeeding rate and maternal role confidence level of first-time mothers. This study report followed the TREND (Transparent Reporting of Evaluations with Non-randomized Designs) reporting guidelines [17].

This study included first-time mothers from the Obstetrics and Gynecology Department of Hue University of Medicine and Pharmacy’s Hospital in Vietnam between June and July 2018. The inclusion criteria of the study were as follows: (1) first-time Vietnamese mothers who were inpatient for 3 days after vaginal birth or 5 days after cesarean section; (2) at least 18 years of age; (3) who delivered a healthy newborn (full-term, Apgar score of ≥7, and no birth defects); (4) had no history of obstetric, medical, and psychological problems; (5) did not receive an education program related to newborn care; and (6) understood the study’s purpose and agreed to participate in this study. The exclusion criteria were as follows; (1) mothers and newborn who had any postpartum health problems and (2) those who did not agree to participate.

The sample size of this study was calculated using the G*Power 3.0.10 program. With a power of 0.80, an alpha set at 0.05, and an effect size of 0.5, the minimum sample size required 52 participants. Considering that the dropout rate in Vietnam may be higher than in Korea [13], 35 mothers were included in each group. This research started with 70 mothers, but a total of 52 mothers completed the study (27 in the experimental group and 25 in the control group). A convenience sampling method was used to assign mothers to the experimental and control groups. The participant flow diagram is shown in Figure 1.

The following instruments were used in this study; general characteristics, exclusive breastfeeding rate, and maternal role confidence level questionnaires.

All mothers in the study were informed of the purpose of the research before data collection. To prevent the spread of UL-NCEP, data collection on the control group was performed first. Data were collected using the aforementioned questionnaires about general characteristics, breastfeeding, and maternal role confidence. The pretest data were collected in the hospital within 24 to 72 hours after the mothers gave birth.

After the pretest was administered, the control group received routine care during hospitalization from midwives in the Obstetrics and Gynecology Department. Routine care included newborn care such as baby bathing, umbilical cord care, hepatitis B vaccination for high-risk babies, and maternal care, such as incision care, medication, and neonatal screening consultants. The routine care did not provide systematic knowledge of newborn care at home to mothers. However, about 20% of mothers from this hospital choose paid home care service. The mothers in this study consisted of those who did not choose home care services.

The experimental group received the NCEP in addition to routine care. The NCEP was developed based on the WHO “Essential Newborn Care Course” guidelines [6], a reference manual for “Care of the Newborn” [20], an extensive review of the literature, and a newborn care program developed in a previous study [13,14]. The newborn care education content consisted of five topics for essential newborn care as follows: (1) breastfeeding, (2) sleep and activities, (3) environment and safety, (4) hygiene, and (5) managing newborn health. The NCEP is presented in detail in Table 1. The contents of the program were evaluated by two experts in infant care and were modified according to their advice. The content of the NCEP was designed using text, 18 pictures, and four simulation videos that helped mothers understand the material easily. Mothers were encouraged to self-study how to care appropriately for their babies. A ubiquitous learning method using tablet personal computers (PCs) was used to provide an NCEP to mothers. After they completed the pretest, the NCEP was provided face-to-face from the mother’s bed through tablets PCs provided by research team. The NCEP was implemented when mothers felt comfortable and before they were discharged. While educating, questions and answers were encouraged to increase the interaction between one researcher (author A) and mother. Before discharge, PDF materials of NCEP were downloaded to them by their smartphone so that they could use NCEP even when they went home. A researcher checked mothers whether the newborn was cared for by studying the smartphone data every week through she got the mothers’ text messages.

At 4 weeks postpartum, the posttest data were collected in the homes of mothers for both groups using the same instruments for the pretest by the researcher visiting their home.

Descriptive statistics, the independent t-test, chi-square test, and Fisher’s exact test were used to identify the homogeneity of participants’ characteristics and compare outcome baseline variables between the two groups. The chi-square test was used to evaluate the difference of the exclusive breastfeeding rate at posttest between the two groups to assess the effect of the NCEP on maternal role confidence, the paired sample t-test was used to compare the difference between pretest and posttest responses in each group, and an independent sample t-test was used to compare the difference of pretest and posttest responses between the experimental and control groups. A p-value of <.05 was considered statistically significant, and the confidence interval was 95%. The reliability of the research instruments was verified using Cronbach’s α values. All collected data were analyzed using IBM SPSS for Windows, ver. 20.0 (IBM Corp., Armonk, NY, USA).

The general characteristics of mothers in the experimental (n=27) and control (n=25) groups are shown in Table 2.

In the experimental group, 92.6% of mothers were younger than 30 years of age, 48.1% had more than college level education, 66.7% had full-time jobs, 70.4% were living with extended family, 59.3% were living in urban areas, 55.6% had cesarean section, and 66.7% had male babies. In the control group, 96.0% of mothers were younger than 30 years of age, 40.0% had more than college level education, 60.0% had full-time jobs, 72.0% were living with extended family, 60.0% were living in urban areas, 40.0% had cesarean section, and 60.0% had male babies. However, there were no significant differences in age, education level, occupation, family status, average income, region of residence, delivery method, and sex of the baby between the two groups.

At the pretest, the outcome variables showed no significant differences between the groups. As Table 2 shows, the exclusive breastfeeding rates of the experimental and control groups were only 14.8% and 12.0%, respectively. Maternal role confidences were at midpoint levels in both groups, 106.00±24.07 in the experimental and 103.06±20.64 in the control group.

The exclusive breastfeeding rate of the experimental group at 4 weeks postpartum was 74.1%, which was higher than that of the control group (44.0%). The difference between the two groups was statistically significant (χ²=4.88, p=.027) (Table 3).

The reasons for stopping exclusive breastfeeding in both groups are listed in Table 4. Mother’s perception of insufficient milk (85.7%), baby’s refusal (9.5%), and maternal sickness (the common cold) (4.8%) were the main reasons given. In the experimental group, the reason for stopping exclusive breastfeeding was mother’s perception of insufficient milk (33.3%). However, in the control group, the reasons for stopping exclusive breastfeeding were mother’s perception of insufficient milk (52.3%), baby’s refusal of the breast (9.5%), and maternal sickness (the common cold) (4.8%).

Comparing posttest differences in the mean maternal role confidence level between the two groups, the experimental group (138.37±18.26) was statistically higher than that in the control group (111.60±22.74), and the difference between the two groups was statistically significant (t=-4.70, p<.001) (Table 5).