Ab Initio International | Effectiveness of the NBO with Japanese Parents with Breastfeeding Difficulties

by Eiko Kashiwabara, RM, RN, MNSc, PhD

Lecturer, Japanese Red Cross College of Nursing

I. Introduction

For most infants and mothers, breastfeeding not only provides optimal health benefits for infants and their mothers, it also promotes the development of a close relationship between mothers and their infants. Most Japanese pregnant women want to initiate breastfeeding for their baby, and 99.2% of Japanese postpartum mothers start to breastfeed their babies after birth (1). Thus, many Japanese childbearing women consider breastfeeding an integral component of “good mothering”. Studies have shown repeated disharmonic interaction between problematic breastfeeders and mothers, with significantly high comorbid postpartum depression (2,3,4). If a newborn baby is unable to latch on, sleeps without sucking and continues crying for several weeks to a few months, the mother may suffer from a sense of guilt and doubt her own ability as a mother.

In other countries, early interventions with the Newborn Behavioral Observations (NBO) system have been conducted with neonates and their families to help parents recognize and understand the individual behaviors of their infant5.. Such interventions can promote stable interaction between parent and child and increase parental confidence (6, 7,8, 9). Based on the assumption that the NBO could provide the same benefits for Japanese first-time breastfeeding mothers who were experiencing breastfeeding problems, the author developed a unique nursing home visiting intervention program that included fathers and mothers in the NBO program.

In Japan, it is customary that a mother return to her parents' house for the first month after delivery., and is, therefore, rare to see fathers providing support during this period. The presence of fathers (or other important significant others), however, is important to the development of a healthy maternal-infant relationship. For mothers with prolonged breastfeeding difficulties, it was hypothesized that fathers could play an important supportive role. This intervention targeted both the mother-infant and the father-infant relationship, and is the first NBO study to focus on the father-infant relationship in addition to the mother-infant relationship.

II. Objective

To analyze the effectiveness of an NBO-based nursing intervention for problematic breastfeeders and their parents.

III. Methodology

This was a mixed methods study using quantitative and qualitative analyses. This paper, however, will report on the quantitative analyses only.

Participants were limited to mothers who had initiated breastfeeding for their babies but who, after discahrge, were concerned about breastfeeding and childcare because their babies did not suck well. The mothers had experienced either normal spontaneous or vacuum extraction delivery. Their neonates adapted normally after birth and remained healthy. Each participant provided informed consent prior to the study.

Of the 16 pairs of infants and parents who were approached, 11 pairs agreed to participate; however, several fathers could not attend the NBO sessions because they were busy. Consequently, the participants consisted of 5 groups of infants with both parents and 6 pairs of infants and mothers only

Table 1 summarizes the demographic data for participants. The mean ages of the Japanese mothers and fathers were 32.0 and 34.4 years, respectively. There were 10 primiparous mothers and 1 multiparous mother. Of the total, 10 had a normal spontaneous delivery, and 1 had a vacuum extraction delivery. All couples were married. Four mothers had a high school education, and 7 mothers were at least junior college graduates. All fathers were employed. Four fathers had attended the parenting class with their wives, and all fathers had wanted to be with their wives for the birth. The neonates were 6 males and 5 females with a mean birthweight of 3006.7g. They were all almost full-term and remained healthy. (Table 1).

The investigator completed training, was certified in the administration of the NBO, and obtained permission for its use from the developer. Participants were recruited for this intervention study from a large university hospital and an OB clinic in an urban area in eastern Japan, from January to May 2011. The nursing managers identified potential participants and provided them information about the investigator and an outline of the study. The investigator visited the mothers, who were interested in participating, and explained the methods of the intervention in detail.
After informed consent was obtained, demographic data were collected, and the investigator visited participants in their home 5 times: at 3–7 days, 2 weeks, 1 month, 2 months and 3 months after birth. The NBO session was conducted twice by the investigator with each mother and infant dyad and each mother, father and infant triad, at 3–7 days then again at 2 weeks to 1 month or 2 months after birth. After the NBO session, a 30–40 minute semi-structured interview was conducted regarding the responses and behaviors of the baby, as well as the parents’ thoughts and feelings during the NBO session and in daily life.

Quantitative data were collected using the Newborn Behavioral Observations Parent Questionnaire developed by the Brazelton Institute. This questionnaire has a 4-point ordered rating response format. After the NBO session, the investigator handed out the questionnaire with a stamped return envelope. Some parents completed the questionnaire immediately and handed it back to the investigator.

Data analysis
Scored data were analyzed with the Statistical Package for the Social Sciences, SPSS 15.0 for Windows. Descriptive statistics were used to summarize the data. Qualitative data were analyzed using a qualitative induction method, but will not be reported here.

Ethical considerations
The Internal Review Board of the School of Nursing at Chiba University, Japan, approved the research protocol. It was clearly stated that agreement to participate indicated consent. Participants were free to decline to participate without consequence. The investigator permitted parents who felt uncomfortable or whose baby displayed stress signs to stop the NBO session. The data were handled confidentially by all the researchers and were used only for this study.


1. Effectiveness of the NBO program in helping parents understand their baby’s behavior
The Brazelton Institute Parent Questionnaire was used to measure the effectiveness of the NBO in helping parents better understand the meaning of their baby’s behavior. This was completed by the mothers and fathers, who participated in the study. Descriptive statistics were used to analyze the data.

Parents were asked to rate their level of understanding using four ordered response levels: a lot (very well), some (somewhat well), a little (not so well) and nothing (not well at all) on five items. Results are presented in Figures 1-5.

Results from these five figures show that as a result of their participation in the NBO, mothers seemed to understand their infants' capabilities and communication cues very well,. Most of them also stated that they have some understanding of how to respond to their infants' behaviors and reactions, and how to calm them when they cry.

All of the fathers in the study stated that they learned a lot about their infants' capabilities through the NBO. They also maintained that they understand a lot about their baby’s communication cues, about how to respond to their behaviors and reactions, as well as how to interact with their infants.

2. Usefulness of the NBO in terms of parenting behavior and confidence

To access the usefulness of the NBO, participants were asked to evaluate the NBO program on four items, using four ordered response levels: a lot (very well), some (somewhat well), a little (not so well) and nothing (not well at all). Results are presented in Figures 6-9.


Overall, participation in the NBO provided an opportunity for parents to establish closer ties with their infants, boosted their confidence as parents, and provided an opportunity to learn more about their infants. It also enhanced their relationship and confidence in the NBO clinician.

3. NBO as a learning experience for parents

The participants were asked to evaluate the quality of the NBO program as a learning experience using four ordered scales: a lot, (excellent), quite a bit (good), some (fair) and nothing (poor) (see Figure 10).

These results show that the majority of parents in the sample (All the fathers and 10 of the 11 mothers) rated the NBO program as an excellent learning experience.

4. Changes in parent’s understanding of infant behavior before and after the NBO session

Finally, the author administered a questionnaire to the parents, before and after their participation in the NBO, to see if there was any change in their level of understanding of infant behavior, using a 1 to 10 point rating scale, ranging from "Very little" to "A lot".

Findings on the difference between “before-” and “after-participation” scores show that all of fathers and mothers, except for one respondent, indicated an increase in their level of understanding. Subtracting the value of “after participation” from the value of “before participation”, the range of scores was 0 to 9 points for mothers and 3 to 5 points for fathers. The average increase in scores, following participation in the NBO, was 3.9 points for mothers and 4 points for fathers.