Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study

Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study Hatice Tetik Metin, Feride Yiğit This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4879620/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 4 You are reading this latest preprint version Abstract This study was conducted to evaluate the effectiveness of breastfeeding behavior development training involving the use of videos and simulators with mothers whose babies were in the neonatal intensive care unit and who were staying in mothers’ hotels. The study was conducted in June 2022 and March 2023 in a state hospital with 100 volunteer participating mothers. Study control group (n=33), video training group (n=33), simulator training group (n=34). The study was conducted with a randomized controlled pretest/posttest control group trial model. Data were collected with a sociodemographic information questionnaire, a breastfeeding self-efficacy scale (short form), and a maternal attachment scale. Pretest scores did not significantly differ between groups (p>0.05). The breastfeeding self-efficacy, maternal attachment and retest mean scores significantly increased in the simulator group (p<0.05). This study revealed that breastfeeding training given to women with simulator support was more effective than training given via video methods in terms of breastfeeding success, the perception of breastfeeding self-efficacy, and maternal attachment. Mother Hotel Simulator-assisted Education Video-assisted Education Figures Figure 1 Key points Simulator-supported breastfeeding training increases mothers' breastfeeding self-efficacy Simulator-assisted breastfeeding training strengthens mother–infant bonding. The Mother Hotel helps mothers breastfeed their babies in the NICU until the babies mature. INTRODUCTION There are a number of different reasons why newborn babies are admitted to the neonatal intensive care unit (NICU) after birth; thus, skin-to-skin contact between mothers and babies may not be possible in the first hour, and breastfeeding may be delayed until an indefinite time ( 1 ). This indefinite period of time can be eliminated when the baby's health condition is stable and when the mother is allowed to hold and breastfeed her baby. When we look at our country in general, it is known that in some regions of our country, pregnant women who are about to give birth or whose birth has already started have difficulty reaching health institutions because of the winter months and adverse weather conditions. The 'Guest Mother Application' of the Turkish Republic Ministry of Health has established mother hotels on behalf of all hospitals containing NICUs. This enforcement ensures that mothers and newborns are settled comfortably and receive better treatment in hospitals. It has been scientifically proven that breast milk is the best nutritional quality for newborns and that it enhances the immınity of newborns ( 2 ). Owing to the use of breast milk, the respiratory, gastrointestinal, and immune systems of newborn babies are strengthened. Thus, the rates of infant and child mortality and morbidity are reduced ( 3 ). The mother needs to breastfeed her baby within the first hour after birth, provide skin-to-skin contact, and provide colostrum milk, which strengthens the baby's immunity within the first five days ( 4 ). Considering that mothers and babies should immediately have to come together following birth to establish a strong bond and stimulate an increase in the amount of breast milk, it is understandable that mothers should not be apart from their babies after birth. Since contamination is not allowed in the NICU, babies are relatively deprived of skin-to-skin contact and breast milk. Mothers of NICU babies must visit the hospital every two hours to feed their babies. These mothers must cope with breastfeeding under difficult conditions along with physical and psychological trauma after giving birth ( 2 ). In the literature, factors that negatively affect breastfeeding include weak bonding between mothers and infants, feeding the infant with a bottle or pacifier, giving formula in the early period, and allowing the infant to stay in the NICU for a long period of time ( 5 ). The separation of infants who have to spend the first days of their lives in the NICU due to health problems from their mothers will lead to an inability to initiate and interrupt interaction, and the attachment process will be negatively affected ( 6 ). Mothers’ Hotels help mothers breastfeed their NICU babies until the babies become mature. In this study, we hypothesized that educating mothers of NICU babies would increase their awareness of the importance of breastfeeding among mothers. We also aimed to relieve mothers' anxiety, make them feel better, encourage breastfeeding, establish a bond between mothers and babies, and continue breastfeeding after discharge. Therefore, we designed an education method with video and simulator methods based on the information-motivation-behavioral skills (IMB) model ( 7 ). The aim of the present study will significantly contribute to the field and has unique value. MATERIALS AND METHODS Study Design The study was established with a randomized controlled pretest/posttest control group trial model method to evaluate the effectiveness of video and breastfeeding simulator education for enhancing breastfeeding behavior in mothers of hotel-residing mothers whose babies need intensive care after birth. The research was performed between June 2022 and March 2023 at the Mother’s Hotel of Bitlis State Hospital with the approval of Bitlis Provincial Health Directorate (Turkey). Hypotheses H1: Video-assisted breastfeeding education enhances the breastfeeding self-efficacy of mothers. H2: Simulator-assisted breastfeeding education enhances the breastfeeding self-efficacy of mothers. H3: Video-assisted breastfeeding education is more effective than simulator-supported breastfeeding education in enhancing breastfeeding self-efficacy. H4: Simulator-supported breastfeeding education is more effective than video-assisted breastfeeding education in enhancing breastfeeding self-efficacy. H5: Video-assisted breastfeeding education strengthens mother–baby attachment. H6: Simulator-supported breastfeeding education strengthens mother–baby attachment. H7: Compared with the control group, video-assisted training increases mothers' breastfeeding self-efficacy and maternal attachment levels. H8: Compared with control training, simulator-assisted training increases mothers' breastfeeding self-efficacy and maternal attachment levels. Sample The participants consisted of volunteer mothers whose babies were hospitalized in the neonatal unit of Bitlis State Hospital and who resided in the Mother Hotel. The sample size of the study was 0.6 for 80% power, within the 95% confidence interval, and it was calculated that at least 90 individuals in total should be included in the study. Since the study was conducted with 2 interventions and 1 control group, 30 people were included in each group (n = 30). The study was completed with a total of 100 mothers: n = 33 in the control group, n = 33 in the video-educated group, and n = 34 in the simulator-trained group. To ensure homogeneity between groups and to eliminate selection bias in the research, 'block' was used as a fixed probability randomization method. In accordance with block randomization, mothers who met the inclusion criteria were homogeneously allocated to each group according to the time they spent in the mother's hotel (according to their planned discharge day). Instrumentation Data were collected with a sociodemographic information questionnaire, a breastfeeding self-efficacy scale (short form), and a maternal attachment scale. Sociodemographic Data Survey The content was prepared on the basis of the recommendations of academics specializing in midwifery, obstetrics, and women's health nursing and a detailed literature review ( 5 , 8 , 9 ) Breastfeeding Self-Efficacy Scale (short form) It is a 33-item scale developed by Dennis in 1999 to assess mothers' breastfeeding self-efficacy. In 2003, a 14-item short scale was developed. Aluş Tokat et al. (2010) conducted a study of the validity and reliability of the scale in Turkey and reported that the Cronbach's alpha value was 0.86 ( 9 ). In our study, the Cronbach's alpha value of the scale was 0.83 in the pretest, 0.85 in the posttest, and 0.88 in the retest. Maternal Attachment Scale Scale is a unidimensional scale developed by Muller in 1994. The scale is a 4-point Likert-type scale and consists of 26 items. In our country, Kavlak et al. (2009) conducted a validity and reliability study of the scale, and Cronbach's alpha values were determined to be 0.77 for mothers with a 1-month-old baby and 0.82 for mothers with a 4-month-old baby ( 8 ). In our study, the Cronbach's alpha value of the scale was 0.86 in the pretest, 0.86 in the posttest, and 0.94 in the retest. Ethical and Legal Aspects of Research The study was initiated with the permission of Hasan Kalyoncu University Health Sciences Non-Interventional Ethics Committee in June 2022 (Decision no: 2022/043). Written permission was obtained from the Bitlis Provincial Health Directorate for the hospital where the study was conducted (Number: E-916-54458-040-99). All participants were asked for verbal and written consent before data collection by the Declaration of Helsinki, and all information was kept confidential. Inclusion and exclusion criteria Age 18 and over, Mothers whose babies were admitted to the neonatal unit after birth and who stayed in the mother's hotel, Mothers of babies who are not breastfed within the first 30–60 minutes after birth, who have not had skin-to-skin contact, and who are immediately admitted to the neonatal unit. Exclusion criteria Mothers who did not meet the inclusion criteria; Mothers with incomplete and inconsistent data Mothers who wish to leave the study at any stage of the study were excluded from the study. Application of the Research Education was performed individually to prevent the influence of one another. The data collection and implementation stages of the research were carried out as shown in Fig. 1 . Our study was registered with the International Clinical Trials Registry Platform under number NCT05735821 (2022/043). Informed consent forms were obtained from the mothers. A pretest was applied to mothers who volunteered to participate in the study and who stayed in mothers’ hotels after birth. Mothers are unable to see and breastfeed their babies after birth, so they express milk and leave it in the intensive care unit. Some babies were fed with formula only, some with breast milk + plus formula, and some with breast milk only. Trainings were given during this period. Volunteered mothers were randomly divided into three groups: the control group (n = 37), the video group (n = 37), and the simulator group (n = 37), as represented below. Control Group (n = 37) A pretest was administered to volunteer mothers who stayed at their mother's hotel after birth. Mothers in the control group (n = 37) did not receive any training, only the standard training in the hospital protocol (in the hospital protocol, the training nurse verbally provided information about the duration and time of breastfeeding), and the posttest was applied 4 weeks after the pretest (mothers and babies were discharged when the last test was applied, so they were contacted, and the last test was applied n = 33; 4 participants refused to participate in the posttest and were excluded from the study). Video Group (n = 37) A pretest was applied to the mothers in the Video group. Following the determination of the average time babies were held in the NICU, a video education process was planned. Mothers in this group were exposed to a video prepared by the researcher on the basis of the IMB model (benefits of breast milk for mothers and babies, enhancement of breastfeeding behavior, right breastfeeding positions, time to start breastfeeding, maintenance, frequency, duration of breastfeeding, milking, storing and skin-to-skin contact). The training period continued from approximately 45 minutes to 1 hour. Individual and group counseling education was provided, and mothers were allowed to ask questions about issues they did not understand 15 minutes after training. After training, a posttest was given to the mothers (n = 33, 4 mothers refused to participate in the posttest and were excluded from the study). Four weeks after the last test, a retesting was performed (n = 33; when retesting was performed, mothers and babies had been discharged, contacted, and retested). Simulator Group (N = 37) Women in the simulator group were trained with a breastfeeding simulator following the pretest application. The training duration and content were the same as those of the video group. The breastfeeding simulator is a wearable technique. Mothers wore simulators and trained for approximately 45 minutes − 1 hour. After training, a posttest was given to the mothers (n = 34; 3 mothers refused to participate in the posttest and were excluded from the study). Four weeks after the last test, a retesting was conducted (n = 34; when retesting was performed, mothers and babies had been discharged, contacted, and retested). Breastfeeding simulator features It is a simulator that simulates the breasts of a woman's upper body with realistic soft breasts, resulting in a realistic feeling of soft contact with the skin. The demonstration and management of breastfeeding are more vivid. It is a practical and wearable breastfeeding model that educators can use for interactive education. It can be worn over the shoulders, placed on the chest, and secured with a seat belt from behind. During training, there is a newborn baby model with flexible joints and soft legs. This allows mothers to practice skin-to-skin contact during breastfeeding training. Application Scheme of the Research Statistical analysis of data Data analysis was performed with SPSS 21.0. Normality was ensured according to skewness and kurtosis scores between + 3 and − 3, and parametric tests were used. Independent groups t tests were used for two groups, and variables with three or more groups were analyzed by ANOVA. The relationships between categorical variables were analyzed and reported via the chi-square test. The significance level is presented as α = 0.05. RESULTS Results obtained from data collected between June 2022 and March 2023; Table 1. Comparison of the Sociodemographic Information Distribution of Mothers and Babies Group Video Simulator Control Total Chi-square p n % n % n % n % Current gestational age of the mother 25 years and under 26-30 years old 31 years and over 16 7 10 48,5 21,2 30,3 8 10 16 23,5 29,4 47,1 17 8 8 51,5 24,2 24,2 41 25 34 41,0 25,0 34,0 7,096 ,131 Education status Did not finish school Primary school Middle school High school and above 4 12 10 7 12,1 36,4 30,3 21,2 12 10 7 5 35,3 29,4 20,6 14,7 4 12 11 6 12,1 36,4 33,3 18,2 20 34 28 18 20,0 34,0 28,0 18,0 7,803 ,253 Length of stay at mother hotel (days) 1,0 2,0 3,0 23 7 3 69,7 21,2 9,1 24 9 1 70,6 26,5 2,9 23 7 3 69,7 21,2 9,1 70 23 7 70,0 23,0 7,0 1,485 ,829 Age of Baby (Weeks-days) 1,0 2,0 3,0 23 7 3 69,7 21,2 9,1 23 10 1 67,6 29,4 2,9 23 8 2 69 25 6 69 25 6 69,0 25,0 6,0 1,531 ,821 Baby's Gender Girl Male 18 15 54,5 45,5 13 21 38,2 61,8 9 24 27,3 72,7 40 60 40,0 60,0 5,093 ,087 Nutritional status of baby Breast milk Just Formula Breast Milk + Formula 13 3 17 39,4 9,1 51,5 9 8 17 26,5 23,5 50,0 13 2 18 39,4 6,1 54,5 35 13 52 35,0 13,0 52,0 5,111 ,279 Clinical picture of a baby in intensive care Followed by CPAP Oxygen support in an incubator Followed in incubator 2 1 30 6,1 3,0 90,9 5 5 5 14,7 14,7 14,7 2 4 27 6,1 12,1 81,8 9 10 81 9,0 10,0 81,0 5,094 ,266 Our sociodemographic information questionnaire results are presented in Table 1. These results indicated that the distribution of the sociodemographic results of the groups was homogenous. According to the results, there was no statistically significant difference in the sociodemographic information of the groups, indicating homogeneity (p>0.05; Table 1). Additionally, babies' birth week (38.06±2.41) and birth weight (3,051.21±1.119 g) did not significantly differ according to group (p>0,05). Table 2. Normality Test Statistics of Scale Score Averages n Skewness Kurtosis Breastfeeding Self-Efficacy Pretest 100 -,577 -,244 Breastfeeding Self-Efficacy Posttest 100 -,824 -,299 Breastfeeding Self-Efficacy Retest 67 -1,143 ,061 Maternal Attachment Pretest 100 -,893 1,913 Maternal Attachment Posttest 100 -,513 ,818 Maternal Attachment Retest 67 -,330 -,803 The normality test results are presented in Table 2. According to the normality test, the scale scores were between +3 and -3, normality was ensured, and parametric tests were used. Table 3. Comparison of the Pretest Scale Scores of the Educational Training Methods Group F P Video Simulator Control Mean ss Mean ss Mean ss Breastfeeding Self-Efficacy Pretest 55,18 9,61 58,24 7,00 55,70 6,39 1,483 ,232 Maternal Attachment Pretest 82,55 5,94 86,47 6,66 84,70 7,14 2,968 ,056 When the pretest mean scores were analyzed, the pretest mean scores did not significantly differ (Table 3) (p>0.05). Table 4. Comparison of Post-Test Scale Scores of Educational Training Methods Group F P Multiple to compare Video Simulator Control Mean ss Mean ss Mean ss Breastfeeding Self-Efficacy Posttest 57,21 9,24 63,38 5,19 57,09 9,04 6,775 ,002* 13 Maternal Attachment Posttest 84,45 7,82 92,62 4,92 90,36 7,01 13,279 ,000* 1<2; 1<3 *p<0.05 ANOVA test, Tukey test; independent groups t test for retesting Our results revealed that the mean breastfeeding self-efficacy posttest scale scores of the simulator group were significantly higher than those of the video and control groups. The mean breastfeeding self-efficacy scores were 63.38±5.19 for the simulator group, 57.21±9.24 for the video group, and 57.09±9.04 for the control group. The breastfeeding self-efficacy posttest mean scores were significantly different (F: 6.77; p<0.05). The mean maternal attachment score was 92.62±4.92 in the simulator group, 90.36±7.01 in the control group, and 84.45±7.82 in the video group. Posttest attachment scores significantly differed according to group (F=13.27; p<0.05). When the results were examined, the average of those in the simulator or control group was significantly greater than the average of those in the video group (Table 4). Table 5. Comparison of the Retest Scale Scores of the Educational Training Methods Group Retest F p Multiple to compare Mean ss -2,731 ,009* 1<2 Breastfeeding Self-Efficacy Video Simulator 62,91 66,44 6,37 3,88 Maternal Attachment Video Simulator 91,88 94,88 8,47 6,18 -1,661 ,102 1<2 *p<0.05 Repeated ANOVA and dependent groups t test for Repeat; Dependent groups t test for retesting The breastfeeding self-efficacy test revealed statistically significant differences by group (F: -2,731; p<0,05). The average score of the simulator group was calculated as 66.44±3.88, and the average score of the video group was calculated as 62.91±6.37. Maternal attachment retesting did not significantly differ by group (F: -1,661; p>0,05). However, when the results were examined, the average value of those in the simulator group was significantly greater (Table 5). DISCUSSION This study aimed to investigate the effectiveness of video and simulator education based on the IMB model for improving the breastfeeding behavior of nonbreastfeeding mothers whose babies were in a neonatal intensive care unit and who resided in a mother's hotel. To the best of our knowledge, this study is the first work based on such an educational process to ensure mother and baby attachment by enhancing breastfeeding behavior. According to our sociodemographic information of the mother participants, the variables of the groups did not significantly differ. These findings suggested that the distribution of the groups was homogeneous. The similarity of the groups at baseline is important for evaluating the effectiveness of training on breastfeeding success, the perception of breastfeeding self-efficacy, and maternal attachment. When the pretest scores were analyzed in terms of groups, there was no statistically significant difference according to group (Table 1 , Table 3 ; p > 0.05). In similar studies in the literature, the distributions among mothers, infants, and groups and the pretest were homogenous ( 5 , 10 , 11 , 12 , 13 , 14 ). One of the most important factors affecting breastfeeding success is mothers’ sense of self-efficacy. The mother's high level of confidence in her self-efficacy affects her efforts in breastfeeding, as believing that her milk is sufficient and having positive thoughts and feelings about breastfeeding increases breastfeeding success ( 3 ). Breastfeeding education is very important in developing breastfeeding skills and increasing breastfeeding success ( 15 , 16 ). In this context, evidence-based guidelines specifically recommend practical training to support breastfeeding ( 5 , 17 ). In our study, breastfeeding self-efficacy posttest scores after training significantly differed according to group (F = 6,77; p < 0.05). The results revealed that the breastfeeding training provided with simulator support increased the breastfeeding self-efficacy of the women in the simulator group at a high rate. The breastfeeding self-efficacy test scores of the training groups 4 weeks after the posttest were significantly different according to group (F = 2,731; p < 0.05). When the results were analyzed, the mean of those in the simulator group was found to be significantly greater. The findings of our study are similar to the findings of the literature ( 5 , 18 , 19 ). In this context, learning in a realistic environment with simulation is a more effective training method for developing breastfeeding skills and success. When all the studies were examined, it was observed that breastfeeding was important, as recommended by the WHO, and that formula feeding was rarely preferred. In some studies, formula in addition to breastmilk was given because the babies were hospitalized in the neonatal intensive care unit immediately after birth, and the first breastfeeding started late. The findings of our study are similar to the findings in the literature ( 12 , 20 , 21 ). In our study, the rate of receiving breast milk and formula was 52.0%. The reason for this is that the babies were in intensive care, and breastfeeding was started late. One of the most important conditions for successful breastfeeding is establishing skin-to-skin contact between mothers and babies after birth to start breastfeeding within the first hour and to ensure frequent breastfeeding optionally ( 22 ). The WHO recommends ensuring skin-to-skin contact between the baby and the mother within 1 hour after birth, encouraging the mother to breastfeed her baby, and supporting the mother in breastfeeding her baby ( 23 ). In our study, maternal attachment posttest scores after training significantly differed according to group (F = 13,279; p < 0.05). When the results were analyzed, the maternal attachment levels of women in the simulator group were found to be greater. The training provided with simulator support increased the maternal attachment levels of women in the simulator group at a high rate. The posttest was administered to the control group 4 weeks after the pretest while their babies were with them. This is thought to be the reason why attachment to the mother was slightly greater in the control group than in the video group at the posttest (Table 4 ). There was no statistically significant difference between the maternal attachment test scores applied to the training groups 4 weeks after the posttest (F = 1,661; p > 0.05). However, when the retest rates were examined, the mean maternal attachment scores of the women in the simulator group were higher than the mean scores of the women in the video group. The findings of our research are similar to the findings of the literature ( 24 , 25 ). Simulation training enables the learning of situations that can be encountered in real life through practice and improves the knowledge, skills, competencies, and behaviors of the learner ( 5 ). Within the scope of the study, it is thought that women in the simulation training group practice breastfeeding in a realistic environment in the postpartum period, seeing situations in which they are deficient or inadequate in breastfeeding and learning what they need to do to overcome them increase women's self-confidence in breastfeeding, reduce their feelings of inadequacy and anxiety about breastfeeding and increase their maternal attachment levels. In this context, women feel competent in breastfeeding, their self-efficacy perceptions increase, and the bond between mothers and babies is strengthened. CONCLUSION Breastfeeding education with a simulator was determined to be the most effective breastfeeding method for enhancing breastfeeding success, perceptions of breastfeeding self-efficacy, and maternal attachment. In conclusion, simulator-supported education was more effective than video-assisted education in improving breastfeeding behavior and ensuring attachment security between mothers and babies. Additionally, our hypotheses H2, H4, H6, H7 and H8 were confirmed. Thus, in hospitals, training to be given to pregnant women, mothers who have given birth, and mothers whose babies are in intensive care via a breastfeeding simulator will support mothers in starting and continuing breastfeeding. RELEVANCE FOR CLINICAL PRACTICE On the basis of the findings of this study, breastfeeding education provided to women with simulator support was the most effective method for increasing breastfeeding success, perceptions of breastfeeding self-efficacy, maternal attachment, attitudes, and knowledge levels toward breastfeeding. In this context, in hospitals, neonatal intensive care units, and pregnancy schools, breastfeeding simulator training can be extended to expectant mothers and mothers whose babies are taken to neonatal intensive care immediately after birth. Limitations of the study It was made in a single province. Generalizability This study can be applied to all mothers. The results cannot be generalized. Declarations CONFLICT OF INTEREST STATEMENT The authors declare that they have no potential conflicts of interest concerning the research, authorship, and/or publication of this article. 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Prımıpar Mothers In Postpartum Perıod Gıven Maternıty And Newborn Educatıon Increased Attachment: Post Test Wıth Control Group Semı Experımental Research. Balıkesır Health Scıences Journal 2017; 5(3). doi: 10.5505/bsbd.2016.63325 Boybay Koyuncu S. Effect of Yoga on Breastfeeding Qualification and Maternal Attachment in Postpartum Primiparous Mothers. [Doctoral Thesis, İnönü University], Council of Higher Education National Thesis Center (Thesis No:539133). 2019 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 12 Aug, 2024 Editor assigned by journal 12 Aug, 2024 Submission checks completed at journal 08 Aug, 2024 First submitted to journal 08 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4879620","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":339350202,"identity":"84943c22-106e-4d4e-a930-afbbd7589c71","order_by":0,"name":"Hatice Tetik Metin","email":"data:image/png;base64,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","orcid":"","institution":"Bitlis Eren University","correspondingAuthor":true,"prefix":"","firstName":"Hatice","middleName":"Tetik","lastName":"Metin","suffix":""},{"id":339350203,"identity":"55d98f3a-5b04-4748-9592-b91b4d038442","order_by":1,"name":"Feride Yiğit","email":"","orcid":"","institution":"İstanbul Topkapı University","correspondingAuthor":false,"prefix":"","firstName":"Feride","middleName":"","lastName":"Yiğit","suffix":""}],"badges":[],"createdAt":"2024-08-08 08:54:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4879620/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4879620/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-08025-w","type":"published","date":"2025-09-30T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64712529,"identity":"acc685c1-dfee-46bb-8426-aafed03bd076","added_by":"auto","created_at":"2024-09-18 02:05:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58214,"visible":true,"origin":"","legend":"\u003cp\u003eApplication Scheme of the Research\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4879620/v1/6dc4e0a60f09b3b6b2f934b0.png"},{"id":92884417,"identity":"8ef8c1a8-1e16-4408-aad3-08ed16747f59","added_by":"auto","created_at":"2025-10-06 16:12:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":971721,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4879620/v1/693aa589-0686-46a3-b40a-62f9f23e7fff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study","fulltext":[{"header":"Key points","content":"\u003cul\u003e\n \u003cli\u003eSimulator-supported breastfeeding training increases mothers' breastfeeding self-efficacy\u003c/li\u003e\n \u003cli\u003eSimulator-assisted breastfeeding training strengthens mother–infant bonding.\u003c/li\u003e\n \u003cli\u003eThe Mother Hotel helps mothers breastfeed their babies in the NICU until the babies mature.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eThere are a number of different reasons why newborn babies are admitted to the neonatal intensive care unit (NICU) after birth; thus, skin-to-skin contact between mothers and babies may not be possible in the first hour, and breastfeeding may be delayed until an indefinite time (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This indefinite period of time can be eliminated when the baby's health condition is stable and when the mother is allowed to hold and breastfeed her baby.\u003c/p\u003e \u003cp\u003eWhen we look at our country in general, it is known that in some regions of our country, pregnant women who are about to give birth or whose birth has already started have difficulty reaching health institutions because of the winter months and adverse weather conditions. The 'Guest Mother Application' of the Turkish Republic Ministry of Health has established mother hotels on behalf of all hospitals containing NICUs. This enforcement ensures that mothers and newborns are settled comfortably and receive better treatment in hospitals. It has been scientifically proven that breast milk is the best nutritional quality for newborns and that it enhances the immınity of newborns (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Owing to the use of breast milk, the respiratory, gastrointestinal, and immune systems of newborn babies are strengthened. Thus, the rates of infant and child mortality and morbidity are reduced (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The mother needs to breastfeed her baby within the first hour after birth, provide skin-to-skin contact, and provide colostrum milk, which strengthens the baby's immunity within the first five days (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Considering that mothers and babies should immediately have to come together following birth to establish a strong bond and stimulate an increase in the amount of breast milk, it is understandable that mothers should not be apart from their babies after birth. Since contamination is not allowed in the NICU, babies are relatively deprived of skin-to-skin contact and breast milk. Mothers of NICU babies must visit the hospital every two hours to feed their babies. These mothers must cope with breastfeeding under difficult conditions along with physical and psychological trauma after giving birth (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the literature, factors that negatively affect breastfeeding include weak bonding between mothers and infants, feeding the infant with a bottle or pacifier, giving formula in the early period, and allowing the infant to stay in the NICU for a long period of time (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The separation of infants who have to spend the first days of their lives in the NICU due to health problems from their mothers will lead to an inability to initiate and interrupt interaction, and the attachment process will be negatively affected (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMothers\u0026rsquo; Hotels help mothers breastfeed their NICU babies until the babies become mature. In this study, we hypothesized that educating mothers of NICU babies would increase their awareness of the importance of breastfeeding among mothers. We also aimed to relieve mothers' anxiety, make them feel better, encourage breastfeeding, establish a bond between mothers and babies, and continue breastfeeding after discharge. Therefore, we designed an education method with video and simulator methods based on the information-motivation-behavioral skills (IMB) model (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The aim of the present study will significantly contribute to the field and has unique value.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Design\u003c/h2\u003e\n \u003cp\u003eThe study was established with a randomized controlled pretest/posttest control group trial model method to evaluate the effectiveness of video and breastfeeding simulator education for enhancing breastfeeding behavior in mothers of hotel-residing mothers whose babies need intensive care after birth.\u003c/p\u003e\n \u003cp\u003eThe research was performed between June 2022 and March 2023 at the Mother\u0026rsquo;s Hotel of Bitlis State Hospital with the approval of Bitlis Provincial Health Directorate (Turkey).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eHypotheses\u003c/h2\u003e\n \u003cp\u003eH1: Video-assisted breastfeeding education enhances the breastfeeding self-efficacy of mothers.\u003c/p\u003e\n \u003cp\u003eH2: Simulator-assisted breastfeeding education enhances the breastfeeding self-efficacy of mothers.\u003c/p\u003e\n \u003cp\u003eH3: Video-assisted breastfeeding education is more effective than simulator-supported breastfeeding education in enhancing breastfeeding self-efficacy.\u003c/p\u003e\n \u003cp\u003eH4: Simulator-supported breastfeeding education is more effective than video-assisted breastfeeding education in enhancing breastfeeding self-efficacy.\u003c/p\u003e\n \u003cp\u003eH5: Video-assisted breastfeeding education strengthens mother\u0026ndash;baby attachment.\u003c/p\u003e\n \u003cp\u003eH6: Simulator-supported breastfeeding education strengthens mother\u0026ndash;baby attachment.\u003c/p\u003e\n \u003cp\u003eH7: Compared with the control group, video-assisted training increases mothers\u0026apos; breastfeeding self-efficacy and maternal attachment levels.\u003c/p\u003e\n \u003cp\u003eH8: Compared with control training, simulator-assisted training increases mothers\u0026apos; breastfeeding self-efficacy and maternal attachment levels.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eSample\u003c/h2\u003e\n \u003cp\u003eThe participants consisted of volunteer mothers whose babies were hospitalized in the neonatal unit of Bitlis State Hospital and who resided in the Mother Hotel.\u003c/p\u003e\n \u003cp\u003eThe sample size of the study was 0.6 for 80% power, within the 95% confidence interval, and it was calculated that at least 90 individuals in total should be included in the study. Since the study was conducted with 2 interventions and 1 control group, 30 people were included in each group (n\u0026thinsp;=\u0026thinsp;30). The study was completed with a total of 100 mothers: n\u0026thinsp;=\u0026thinsp;33 in the control group, n\u0026thinsp;=\u0026thinsp;33 in the video-educated group, and n\u0026thinsp;=\u0026thinsp;34 in the simulator-trained group. To ensure homogeneity between groups and to eliminate selection bias in the research, \u0026apos;block\u0026apos; was used as a fixed probability randomization method. In accordance with block randomization, mothers who met the inclusion criteria were homogeneously allocated to each group according to the time they spent in the mother\u0026apos;s hotel (according to their planned discharge day).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eInstrumentation\u003c/h2\u003e\n \u003cp\u003eData were collected with a sociodemographic information questionnaire, a breastfeeding self-efficacy scale (short form), and a maternal attachment scale.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eSociodemographic Data Survey\u003c/h2\u003e\n \u003cp\u003eThe content was prepared on the basis of the recommendations of academics specializing in midwifery, obstetrics, and women\u0026apos;s health nursing and a detailed literature review (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eBreastfeeding Self-Efficacy Scale (short form)\u003c/h2\u003e\n \u003cp\u003eIt is a 33-item scale developed by Dennis in 1999 to assess mothers\u0026apos; breastfeeding self-efficacy. In 2003, a 14-item short scale was developed. Aluş Tokat et al. (2010) conducted a study of the validity and reliability of the scale in Turkey and reported that the Cronbach\u0026apos;s alpha value was 0.86 (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). In our study, the Cronbach\u0026apos;s alpha value of the scale was 0.83 in the pretest, 0.85 in the posttest, and 0.88 in the retest.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eMaternal Attachment Scale\u003c/h2\u003e\n \u003cp\u003eScale is a unidimensional scale developed by Muller in 1994. The scale is a 4-point Likert-type scale and consists of 26 items. In our country, Kavlak et al. (2009) conducted a validity and reliability study of the scale, and Cronbach\u0026apos;s alpha values were determined to be 0.77 for mothers with a 1-month-old baby and 0.82 for mothers with a 4-month-old baby (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). In our study, the Cronbach\u0026apos;s alpha value of the scale was 0.86 in the pretest, 0.86 in the posttest, and 0.94 in the retest.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical and Legal Aspects of Research\u003c/h2\u003e\n \u003cp\u003eThe study was initiated with the permission of Hasan Kalyoncu University Health Sciences Non-Interventional Ethics Committee in June 2022 (Decision no: 2022/043). Written permission was obtained from the Bitlis Provincial Health Directorate for the hospital where the study was conducted (Number: E-916-54458-040-99). All participants were asked for verbal and written consent before data collection by the Declaration of Helsinki, and all information was kept confidential.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eAge 18 and over,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMothers whose babies were admitted to the neonatal unit after birth and who stayed in the mother\u0026apos;s hotel,\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMothers of babies who are not breastfed within the first 30\u0026ndash;60 minutes after birth, who have not had skin-to-skin contact, and who are immediately admitted to the neonatal unit.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eExclusion criteria\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eMothers who did not meet the inclusion criteria;\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMothers with incomplete and inconsistent data\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eMothers who wish to leave the study at any stage of the study were excluded from the study.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003cp\u003e\u003cstrong\u003eApplication of the Research\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEducation was performed individually to prevent the influence of one another. The data collection and implementation stages of the research were carried out as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Our study was registered with the International Clinical Trials Registry Platform under number NCT05735821 (2022/043). Informed consent forms were obtained from the mothers. A pretest was applied to mothers who volunteered to participate in the study and who stayed in mothers\u0026rsquo; hotels after birth. Mothers are unable to see and breastfeed their babies after birth, so they express milk and leave it in the intensive care unit. Some babies were fed with formula only, some with breast milk\u0026thinsp;+\u0026thinsp;plus formula, and some with breast milk only. Trainings were given during this period. Volunteered mothers were randomly divided into three groups: the control group (n\u0026thinsp;=\u0026thinsp;37), the video group (n\u0026thinsp;=\u0026thinsp;37), and the simulator group (n\u0026thinsp;=\u0026thinsp;37), as represented below.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group (n\u0026thinsp;=\u0026thinsp;37)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA pretest was administered to volunteer mothers who stayed at their mother\u0026apos;s hotel after birth. Mothers in the control group (n\u0026thinsp;=\u0026thinsp;37) did not receive any training, only the standard training in the hospital protocol (in the hospital protocol, the training nurse verbally provided information about the duration and time of breastfeeding), and the posttest was applied 4 weeks after the pretest (mothers and babies were discharged when the last test was applied, so they were contacted, and the last test was applied n\u0026thinsp;=\u0026thinsp;33; 4 participants refused to participate in the posttest and were excluded from the study).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVideo Group (n\u0026thinsp;=\u0026thinsp;37)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA pretest was applied to the mothers in the Video group. Following the determination of the average time babies were held in the NICU, a video education process was planned. Mothers in this group were exposed to a video prepared by the researcher on the basis of the IMB model (benefits of breast milk for mothers and babies, enhancement of breastfeeding behavior, right breastfeeding positions, time to start breastfeeding, maintenance, frequency, duration of breastfeeding, milking, storing and skin-to-skin contact). The training period continued from approximately 45 minutes to 1 hour. Individual and group counseling education was provided, and mothers were allowed to ask questions about issues they did not understand 15 minutes after training. After training, a posttest was given to the mothers (n\u0026thinsp;=\u0026thinsp;33, 4 mothers refused to participate in the posttest and were excluded from the study). Four weeks after the last test, a retesting was performed (n\u0026thinsp;=\u0026thinsp;33; when retesting was performed, mothers and babies had been discharged, contacted, and retested).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSimulator Group (N\u0026thinsp;=\u0026thinsp;37)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWomen in the simulator group were trained with a breastfeeding simulator following the pretest application. The training duration and content were the same as those of the video group. The breastfeeding simulator is a wearable technique. Mothers wore simulators and trained for approximately 45 minutes \u0026minus;\u0026thinsp;1 hour. After training, a posttest was given to the mothers (n\u0026thinsp;=\u0026thinsp;34; 3 mothers refused to participate in the posttest and were excluded from the study). Four weeks after the last test, a retesting was conducted (n\u0026thinsp;=\u0026thinsp;34; when retesting was performed, mothers and babies had been discharged, contacted, and retested).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eBreastfeeding simulator features\u003c/h2\u003e\n \u003cp\u003eIt is a simulator that simulates the breasts of a woman\u0026apos;s upper body with realistic soft breasts, resulting in a realistic feeling of soft contact with the skin. The demonstration and management of breastfeeding are more vivid. It is a practical and wearable breastfeeding model that educators can use for interactive education. It can be worn over the shoulders, placed on the chest, and secured with a seat belt from behind. During training, there is a newborn baby model with flexible joints and soft legs. This allows mothers to practice skin-to-skin contact during breastfeeding training.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003cp\u003eApplication Scheme of the Research\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis of data\u003c/h2\u003e\n \u003cp\u003eData analysis was performed with SPSS 21.0. Normality was ensured according to skewness and kurtosis scores between +\u0026thinsp;3 and \u0026minus;\u0026thinsp;3, and parametric tests were used. Independent groups t tests were used for two groups, and variables with three or more groups were analyzed by ANOVA. The relationships between categorical variables were analyzed and reported via the chi-square test. The significance level is presented as \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eResults obtained from data collected between June 2022\u0026nbsp;and\u0026nbsp;March 2023;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Comparison of the Sociodemographic Information Distribution of Mothers and Babies\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.264900662251655%\" colspan=\"2\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.33112582781457%\" colspan=\"8\" valign=\"top\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.403973509933774%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.437340153452684%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.20460358056266%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSimulator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.437340153452684%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.67007672634271%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.764705882352942%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eChi-square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.485933503836318%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.513157894736842%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.81578947368421%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.842105263157896%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.144736842105264%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.18421052631579%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.486842105263158%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.18421052631579%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.828947368421053%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eCurrent gestational age of the mother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25 years and under\u003c/p\u003e\n \u003cp\u003e26-30 years old\u003c/p\u003e\n \u003cp\u003e31 years and over\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e48,5\u003c/p\u003e\n \u003cp\u003e21,2\u003c/p\u003e\n \u003cp\u003e30,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e23,5\u003c/p\u003e\n \u003cp\u003e29,4\u003c/p\u003e\n \u003cp\u003e47,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e51,5\u003c/p\u003e\n \u003cp\u003e24,2\u003c/p\u003e\n \u003cp\u003e24,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e41,0\u003c/p\u003e\n \u003cp\u003e25,0\u003c/p\u003e\n \u003cp\u003e34,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7,096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e,131\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eEducation status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDid not finish school\u003c/p\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003cp\u003eMiddle school\u003c/p\u003e\n \u003cp\u003eHigh school and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e12,1\u003c/p\u003e\n \u003cp\u003e36,4\u003c/p\u003e\n \u003cp\u003e30,3\u003c/p\u003e\n \u003cp\u003e21,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e35,3\u003c/p\u003e\n \u003cp\u003e29,4\u003c/p\u003e\n \u003cp\u003e20,6\u003c/p\u003e\n \u003cp\u003e14,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e12,1\u003c/p\u003e\n \u003cp\u003e36,4\u003c/p\u003e\n \u003cp\u003e33,3\u003c/p\u003e\n \u003cp\u003e18,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e20,0\u003c/p\u003e\n \u003cp\u003e34,0\u003c/p\u003e\n \u003cp\u003e28,0\u003c/p\u003e\n \u003cp\u003e18,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7,803\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e,253\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eLength of stay at mother hotel (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003e1,0\u003c/p\u003e\n \u003cp\u003e2,0\u003c/p\u003e\n \u003cp\u003e3,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e69,7\u003c/p\u003e\n \u003cp\u003e21,2\u003c/p\u003e\n \u003cp\u003e9,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e70,6\u003c/p\u003e\n \u003cp\u003e26,5\u003c/p\u003e\n \u003cp\u003e2,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e69,7\u003c/p\u003e\n \u003cp\u003e21,2\u003c/p\u003e\n \u003cp\u003e9,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e70,0\u003c/p\u003e\n \u003cp\u003e23,0\u003c/p\u003e\n \u003cp\u003e7,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e,829\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eAge of Baby (Weeks-days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003e1,0\u003c/p\u003e\n \u003cp\u003e2,0\u003c/p\u003e\n \u003cp\u003e3,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e69,7\u003c/p\u003e\n \u003cp\u003e21,2\u003c/p\u003e\n \u003cp\u003e9,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e67,6\u003c/p\u003e\n \u003cp\u003e29,4\u003c/p\u003e\n \u003cp\u003e2,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e69,0\u003c/p\u003e\n \u003cp\u003e25,0\u003c/p\u003e\n \u003cp\u003e6,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e,821\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eBaby\u0026apos;s Gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e54,5\u003c/p\u003e\n \u003cp\u003e45,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e38,2\u003c/p\u003e\n \u003cp\u003e61,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e27,3\u003c/p\u003e\n \u003cp\u003e72,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e40,0\u003c/p\u003e\n \u003cp\u003e60,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e5,093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e,087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eNutritional status of baby\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003eBreast milk\u003c/p\u003e\n \u003cp\u003eJust Formula\u003c/p\u003e\n \u003cp\u003eBreast Milk + Formula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e39,4\u003c/p\u003e\n \u003cp\u003e9,1\u003c/p\u003e\n \u003cp\u003e51,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e26,5\u003c/p\u003e\n \u003cp\u003e23,5\u003c/p\u003e\n \u003cp\u003e50,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e39,4\u003c/p\u003e\n \u003cp\u003e6,1\u003c/p\u003e\n \u003cp\u003e54,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e35,0\u003c/p\u003e\n \u003cp\u003e13,0\u003c/p\u003e\n \u003cp\u003e52,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5,111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e,279\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.355371900826448%\"\u003e\n \u003cp\u003eClinical picture of a baby in intensive care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.016528925619834%\" valign=\"top\"\u003e\n \u003cp\u003eFollowed by CPAP\u003c/p\u003e\n \u003cp\u003eOxygen support in an incubator\u003c/p\u003e\n \u003cp\u003eFollowed in incubator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.785123966942149%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9421487603305785%\"\u003e\n \u003cp\u003e6,1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3,0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e90,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.950413223140496%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.107438016528926%\"\u003e\n \u003cp\u003e14,7\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14,7\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\"\u003e\n \u003cp\u003e6,1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12,1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.619834710743802%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.446280991735537%\"\u003e\n \u003cp\u003e9,0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10,0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.603305785123967%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5,094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.776859504132231%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e,266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOur sociodemographic information questionnaire results are\u0026nbsp;presented\u0026nbsp;in Table 1. These results indicated that the distribution of\u0026nbsp;the\u0026nbsp;sociodemographic results of\u0026nbsp;the\u0026nbsp;groups was homogenous. According to the results, there\u0026nbsp;was\u0026nbsp;no statistically significant difference\u0026nbsp;in the sociodemographic\u0026nbsp;information of\u0026nbsp;the\u0026nbsp;groups,\u0026nbsp;indicating homogeneity (p\u0026gt;0.05; Table 1).\u003c/p\u003e\n\u003cp\u003eAdditionally, babies\u0026apos; birth week (38.06\u0026plusmn;2.41) and birth weight (3,051.21\u0026plusmn;1.119 g)\u0026nbsp;did\u0026nbsp;not\u0026nbsp;significantly differ\u0026nbsp;according to\u0026nbsp;group\u0026nbsp;(p\u0026gt;0,05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Normality Test Statistics of Scale Score Averages\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003eSkewness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003eKurtosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\"\u003e\n \u003cp\u003eBreastfeeding Self-Efficacy Pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003e-,577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e-,244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\"\u003e\n \u003cp\u003eBreastfeeding Self-Efficacy Posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003e-,824\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e-,299\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\"\u003e\n \u003cp\u003eBreastfeeding Self-Efficacy Retest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003e-1,143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e,061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\"\u003e\n \u003cp\u003eMaternal Attachment Pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003e-,893\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e1,913\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\"\u003e\n \u003cp\u003eMaternal Attachment Posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003e-,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e,818\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.91752577319588%\"\u003e\n \u003cp\u003eMaternal Attachment\u0026nbsp;Retest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\"\u003e\n \u003cp\u003e-,330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e-,803\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe normality test results are\u0026nbsp;presented in Table 2. According to the normality test, the scale scores were between +3 and -3, normality was ensured, and parametric tests were used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Comparison of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe Pretest\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Scale Scores of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEducational Training Methods\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.755102040816325%\" rowspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.97959183673469%\" colspan=\"6\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\" rowspan=\"3\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.1020408163265305%\" rowspan=\"3\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003eSimulator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.94736842105263%\"\u003e\n \u003cp\u003eBreastfeeding Self-Efficacy Pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e55,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e9,61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e58,24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e7,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e55,70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e6,39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\"\u003e\n \u003cp\u003e1,483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e,232\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.94736842105263%\"\u003e\n \u003cp\u003eMaternal Attachment Pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e82,55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e5,94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e86,47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e6,66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e84,70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e7,14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\"\u003e\n \u003cp\u003e2,968\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e,056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen the pretest mean scores were analyzed, the pretest mean scores did not significantly differ (Table 3) (p\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Comparison of Post-Test Scale Scores of Educational Training Methods\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.428571428571427%\" rowspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.97959183673469%\" colspan=\"6\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\" rowspan=\"3\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.122448979591836%\" rowspan=\"3\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.306122448979592%\" rowspan=\"3\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003cp\u003eto compare\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003eSimulator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.105263157894736%\"\u003e\n \u003cp\u003eBreastfeeding Self-Efficacy Posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e57,21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e9,24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e63,38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e5,19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e57,09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e9,04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\"\u003e\n \u003cp\u003e6,775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\"\u003e\n \u003cp\u003e,002*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.789473684210526%\"\u003e\n \u003cp\u003e1\u0026lt;2; 2\u0026gt;3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.105263157894736%\"\u003e\n \u003cp\u003eMaternal Attachment Posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e84,45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e7,82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e92,62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e4,92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.526315789473685%\"\u003e\n \u003cp\u003e90,36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.2631578947368425%\"\u003e\n \u003cp\u003e7,01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\"\u003e\n \u003cp\u003e13,279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\"\u003e\n \u003cp\u003e,000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.789473684210526%\"\u003e\n \u003cp\u003e1\u0026lt;2; 1\u0026lt;3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 ANOVA test, Tukey test;\u0026nbsp;independent\u0026nbsp;groups t test for retesting\u003c/p\u003e\n\u003cp\u003eOur results revealed that the mean breastfeeding self-efficacy posttest scale scores of the simulator group were significantly higher than those of the video and control groups. The mean breastfeeding self-efficacy scores were 63.38\u0026plusmn;5.19 for the simulator group, 57.21\u0026plusmn;9.24 for the video group, and 57.09\u0026plusmn;9.04 for the control group. The breastfeeding self-efficacy posttest mean scores were significantly different (F: 6.77; p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eThe mean maternal attachment score was 92.62\u0026plusmn;4.92 in the simulator group, 90.36\u0026plusmn;7.01 in the control group, and 84.45\u0026plusmn;7.82 in the video group. Posttest attachment scores significantly differed according to group (F=13.27; p\u0026lt;0.05).\u0026nbsp;When the results were examined, the average of those in the simulator or control group was significantly greater than the average of those in the video group (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Comparison of the Retest Scale Scores of the Educational Training Methods\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"501\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.932270916334662%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.932270916334662%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.286852589641434%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eRetest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.354581673306773%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.354581673306773%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.139442231075698%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003cp\u003eto compare\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.89156626506024%\" valign=\"top\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.879518072289155%\" valign=\"top\"\u003e\n \u003cp\u003ess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16867469879518%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-2,731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16867469879518%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e,009*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.89156626506024%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u0026lt;2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eBreastfeeding Self-Efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003cp\u003eSimulator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.358974358974358%\" valign=\"top\"\u003e\n \u003cp\u003e62,91\u003c/p\u003e\n \u003cp\u003e66,44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e6,37\u003c/p\u003e\n \u003cp\u003e3,88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.932270916334662%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal Attachment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.932270916334662%\" valign=\"top\"\u003e\n \u003cp\u003eVideo\u003c/p\u003e\n \u003cp\u003eSimulator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.139442231075698%\" valign=\"top\"\u003e\n \u003cp\u003e91,88\u003c/p\u003e\n \u003cp\u003e94,88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.147410358565738%\" valign=\"top\"\u003e\n \u003cp\u003e8,47\u003c/p\u003e\n \u003cp\u003e6,18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.354581673306773%\" valign=\"top\"\u003e\n \u003cp\u003e-1,661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.354581673306773%\" valign=\"top\"\u003e\n \u003cp\u003e,102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.139442231075698%\" valign=\"top\"\u003e\n \u003cp\u003e1\u0026lt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 Repeated ANOVA and dependent groups t test for Repeat; Dependent groups t test for retesting\u003c/p\u003e\n\u003cp\u003eThe breastfeeding self-efficacy test revealed statistically significant differences by group (F: -2,731; p\u0026lt;0,05). The average score of the simulator group was calculated as 66.44\u0026plusmn;3.88, and the average score of the video group was calculated as 62.91\u0026plusmn;6.37. Maternal attachment retesting did not significantly differ by group (F: -1,661; p\u0026gt;0,05). However, when the results were examined, the average value of those in the simulator group was significantly greater (Table 5).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study aimed to investigate the effectiveness of video and simulator education based on the IMB model for improving the breastfeeding behavior of nonbreastfeeding mothers whose babies were in a neonatal intensive care unit and who resided in a mother's hotel. To the best of our knowledge, this study is the first work based on such an educational process to ensure mother and baby attachment by enhancing breastfeeding behavior.\u003c/p\u003e \u003cp\u003eAccording to our sociodemographic information of the mother participants, the variables of the groups did not significantly differ. These findings suggested that the distribution of the groups was homogeneous. The similarity of the groups at baseline is important for evaluating the effectiveness of training on breastfeeding success, the perception of breastfeeding self-efficacy, and maternal attachment. When the pretest scores were analyzed in terms of groups, there was no statistically significant difference according to group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e; p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In similar studies in the literature, the distributions among mothers, infants, and groups and the pretest were homogenous (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the most important factors affecting breastfeeding success is mothers\u0026rsquo; sense of self-efficacy. The mother's high level of confidence in her self-efficacy affects her efforts in breastfeeding, as believing that her milk is sufficient and having positive thoughts and feelings about breastfeeding increases breastfeeding success (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Breastfeeding education is very important in developing breastfeeding skills and increasing breastfeeding success (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In this context, evidence-based guidelines specifically recommend practical training to support breastfeeding (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In our study, breastfeeding self-efficacy posttest scores after training significantly differed according to group (F\u0026thinsp;=\u0026thinsp;6,77; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The results revealed that the breastfeeding training provided with simulator support increased the breastfeeding self-efficacy of the women in the simulator group at a high rate. The breastfeeding self-efficacy test scores of the training groups 4 weeks after the posttest were significantly different according to group (F\u0026thinsp;=\u0026thinsp;2,731; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). When the results were analyzed, the mean of those in the simulator group was found to be significantly greater. The findings of our study are similar to the findings of the literature (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In this context, learning in a realistic environment with simulation is a more effective training method for developing breastfeeding skills and success.\u003c/p\u003e \u003cp\u003eWhen all the studies were examined, it was observed that breastfeeding was important, as recommended by the WHO, and that formula feeding was rarely preferred. In some studies, formula in addition to breastmilk was given because the babies were hospitalized in the neonatal intensive care unit immediately after birth, and the first breastfeeding started late. The findings of our study are similar to the findings in the literature (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In our study, the rate of receiving breast milk and formula was 52.0%. The reason for this is that the babies were in intensive care, and breastfeeding was started late.\u003c/p\u003e \u003cp\u003eOne of the most important conditions for successful breastfeeding is establishing skin-to-skin contact between mothers and babies after birth to start breastfeeding within the first hour and to ensure frequent breastfeeding optionally (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The WHO recommends ensuring skin-to-skin contact between the baby and the mother within 1 hour after birth, encouraging the mother to breastfeed her baby, and supporting the mother in breastfeeding her baby (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In our study, maternal attachment posttest scores after training significantly differed according to group (F\u0026thinsp;=\u0026thinsp;13,279; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). When the results were analyzed, the maternal attachment levels of women in the simulator group were found to be greater. The training provided with simulator support increased the maternal attachment levels of women in the simulator group at a high rate. The posttest was administered to the control group 4 weeks after the pretest while their babies were with them. This is thought to be the reason why attachment to the mother was slightly greater in the control group than in the video group at the posttest (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere was no statistically significant difference between the maternal attachment test scores applied to the training groups 4 weeks after the posttest (F\u0026thinsp;=\u0026thinsp;1,661; p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, when the retest rates were examined, the mean maternal attachment scores of the women in the simulator group were higher than the mean scores of the women in the video group. The findings of our research are similar to the findings of the literature (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Simulation training enables the learning of situations that can be encountered in real life through practice and improves the knowledge, skills, competencies, and behaviors of the learner (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the scope of the study, it is thought that women in the simulation training group practice breastfeeding in a realistic environment in the postpartum period, seeing situations in which they are deficient or inadequate in breastfeeding and learning what they need to do to overcome them increase women's self-confidence in breastfeeding, reduce their feelings of inadequacy and anxiety about breastfeeding and increase their maternal attachment levels. In this context, women feel competent in breastfeeding, their self-efficacy perceptions increase, and the bond between mothers and babies is strengthened.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eBreastfeeding\u0026nbsp;education with a simulator was\u0026nbsp;determined to be\u0026nbsp;the most effective breastfeeding method for\u0026nbsp;enhancing\u0026nbsp;breastfeeding success,\u0026nbsp;perceptions of\u0026nbsp;breastfeeding self-efficacy, and maternal attachment.\u003c/p\u003e\n\u003cp\u003eIn conclusion,\u0026nbsp;simulator-supported education was more effective than video-assisted education in improving breastfeeding behavior and ensuring attachment security between\u0026nbsp;mothers\u0026nbsp;and\u0026nbsp;babies. Additionally, our hypotheses H2, H4, H6, H7 and H8 were confirmed. Thus, in hospitals, training\u0026nbsp;to be given to pregnant women, mothers who have given birth, and mothers whose babies are in intensive care\u0026nbsp;via\u0026nbsp;a breastfeeding simulator will support mothers in starting and continuing breastfeeding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRELEVANCE FOR CLINICAL PRACTICE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn the basis of the\u0026nbsp;findings of this study, breastfeeding education\u0026nbsp;provided\u0026nbsp;to women with simulator support was\u0026nbsp;the\u0026nbsp;most effective method\u0026nbsp;for\u0026nbsp;increasing breastfeeding success,\u0026nbsp;perceptions of\u0026nbsp;breastfeeding self-efficacy, maternal attachment, attitudes, and knowledge\u0026nbsp;levels toward\u0026nbsp;breastfeeding. In this context, in hospitals, neonatal intensive care units, and pregnancy schools, breastfeeding simulator training can be extended to expectant mothers and mothers whose babies are taken to neonatal intensive care immediately after birth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was made in a single province.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneralizability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study can be applied to all mothers. The results cannot be generalized.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors\u0026nbsp;declare that they have\u0026nbsp;no potential conflicts of interest concerning\u0026nbsp;the\u0026nbsp;research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING INFORMATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.T.M wrote the main manuscript text and H.T.M prepared figures 1-5. F.Y, analysed statistics and tables. H.T.M and FY reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAltuntaş N. How does hospitalization in the neonatal intensive care unit affect the breastfeeding process? Pamukkale Medical Journal. 2020;13(3):579-586. doi:https://dx.doi.org/10.31362/patd.670659\u003c/li\u003e\n \u003cli\u003eYarar O, Bağcıoğlu B. Product Diversification Policies in Health Services and Social Projects-Mother Hotel \u0026amp; Guest Mother Project. Marmara Health Services Journal. 2017;1(1), 35-39. DOI: 10.26567/marsag.2017130065.\u003c/li\u003e\n \u003cli\u003eYal\u0026ccedil;ın \u0026Ouml;zsoylu D. Effect Of Breastfedıng, Self-Effıcıency And Anxıety Levels On Breastfeedıng Success Of Mothers Wıth Baby In Neonatal Intensıve Care Unıt. [Master\u0026apos;s Thesis, İstinye University], Council of Higher Education National Thesis Center. (Thesis Number: 637765). 2019\u003c/li\u003e\n \u003cli\u003eTetik Metin H, Kınay G\u0026uuml;ndoğdu E. Importance of Breast Milk and Support of Breastfeeding in Neonatal Intensive Care. ICDAH2022 III. International Conference on Different Aspects of Health, \u0026Ccedil;anakkale, 23 December 2022, pp.39-43.\u003c/li\u003e\n \u003cli\u003eArslan H. Evaluation of effects of simulation-based breastfeeding training on women\u0026apos;s breastfeeding success, breastfeeding self-efficacy, breastfeeding attitude and knowledge\u003cem\u003e\u0026nbsp;\u003c/em\u003e[Master\u0026apos;s Thesis, Sakarya University], Council of Higher Education National Thesis Center (Thesis No:638209). 2020\u003c/li\u003e\n \u003cli\u003eG\u0026uuml;leşen A, Yıldız D. Examination of Mother-Baby Attachment in Early Postpartum Period with Evidence-Based Practices. TAF Preventive Medicine Bulletin, 2013;12.2: 177-182.\u003c/li\u003e\n \u003cli\u003eFisher JD, Fisher WA, Bryan AD, Misovich SJ. InformationMotivation-Behavioral Skills Model Based HIV Risk Behavior Change Intervention for Inner-City High School Youth. \u003cem\u003eHealth Psychology\u003c/em\u003e, 2002;21(2): 177-186.\u003c/li\u003e\n \u003cli\u003eKavlak O, Şirin A. Turkish version of Maternal Attachment Inventory International Journal of Human Sciences. 2009;6(1): 188-202.\u003c/li\u003e\n \u003cli\u003eAluş Tokat M, Okumuş H, Dennis CL. Translation and psychometric assessment of Breast-feeding Self-Efficacy Scale-Short Form among pregnant and postnatal women in Turkey. Midwifery. 2010;26(1):101-108.\u003c/li\u003e\n \u003cli\u003eTekin N. Determination of factors affecting state-trait anxiety level of mothers whose babies stay in newborn intensive care unit and their breastfeeding success.\u003cem\u003e\u0026nbsp;\u003c/em\u003e[Master\u0026apos;s Thesis, Bursa Uludağ University], Council of Higher Education National Thesis Center (Thesis No: 604314). 2019\u003c/li\u003e\n \u003cli\u003eBalcı ME, Ge\u0026ccedil;kil E. Determination of Maternal Attachment Level and Related Factors in Mothers of Premature Babies Staying in Neonatal Intensive Care Unit for a Long Time. Journal of Education and Research in Nursing. 2021;18(4): 383\u0026ndash;388 DOI: 10.5152/jern.2021.93695\u003c/li\u003e\n \u003cli\u003eDuman G. 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The effect of antenatal education based on strengthening breastfeeding self-efficacy perception on breastfeeding self-efficacy perception and breastfeeding success. Journal of Education and Research in Nursing. 2013;10(1):21-30.\u003c/li\u003e\n \u003cli\u003eDurmazoğlu G, Okumuş H. Investigation of Breastfeeding Trainings Using Innovative and Current Education Methods. Samsun Journal of Health Sciences, 2019;4(1):23-31.\u003c/li\u003e\n \u003cli\u003eMart\u0026iacute;n-Iglesias et al. Effectiveness of an educational group intervention in primary healthcare for continued exclusive breastfeeding: Prolactin study. BMC Pregnancy and Childbirth, 2018\u003cem\u003e;\u003c/em\u003e 18(59):1-10\u003c/li\u003e\n \u003cli\u003eCang\u0026ouml;l E, Hotun Şahin N. A Model of Breastfeeding Support: Motivational Interviews Based On Pender\u0026rsquo;s Health Promotion Model. Education and Research in Nursing. 2017\u003cem\u003e;\u003c/em\u003e14 (1): 98-103.\u003c/li\u003e\n \u003cli\u003eTuthıll EL, Butler LM, Pellowskı JA, Mcgrath JM, Cusson RM, Gable RK, Fısher JD. Exclusive breastfeeding promotion among HIV-infected women in South Africa: An Information-Motivation-Behavioral Skills model-based pilot intervention. Public Health Nutrition. 2017; 20(8), 1481\u0026ndash;1490. http://doi.org/10.1017/S1368980016003657\u003c/li\u003e\n \u003cli\u003eGonz\u0026aacute;lez de Oliveira, M., Valle Volkmer , D. (2020). Factors Associated With Breastfeeding Very Low Birth Weight Infants at Neonatal Intensive Care Unit Discharge: A Single-Center Brazilian Experience. Journal of Human Laktation, 37(4):775-783 doi: 10.1177/0890334420981929.\u003c/li\u003e\n \u003cli\u003eApaydın K. Determination of postpartum depression and maternal attachment levels of mothers whose babies were hospitalized. [Master\u0026apos;s Thesis, Erciyes University], Council of Higher Education National Thesis Center (Thesis No:767725). 2022\u003c/li\u003e\n \u003cli\u003eB\u0026ouml;l\u0026uuml;kbaşı H. The Effect of Postpartum Depression on Breastfeeding Self-Efficacy, Breastfeeding Success and Nutritional Status in the Six-Month Postpartum Period. [Master\u0026apos;s Thesis. Gazi University], Council of Higher Education National Thesis Centre (Thesis No: 445489). 2016\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zt\u0026uuml;rk R. Effect of Breast Milk and Breastfeeding Education Given in Antenatal Period on Breastfeeding Success and Breastfeeding Self-Efficacy. [Master\u0026apos;s Thesis, Balıkesir University], https://hdl.handle.net/20.500.12462/3481. 2018\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zt\u0026uuml;rk S, Erci B. (2017). Prımıpar Mothers In Postpartum Perıod Gıven Maternıty And Newborn Educatıon Increased Attachment: Post Test Wıth Control Group Semı Experımental Research. Balıkesır Health Scıences Journal 2017; 5(3). doi: 10.5505/bsbd.2016.63325\u003c/li\u003e\n \u003cli\u003eBoybay Koyuncu S. Effect of Yoga on Breastfeeding Qualification and Maternal Attachment in Postpartum Primiparous Mothers.\u003cem\u003e\u0026nbsp;\u003c/em\u003e[Doctoral Thesis, İn\u0026ouml;n\u0026uuml; University], Council of Higher Education National Thesis Center (Thesis No:539133). 2019\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mother Hotel, Simulator-assisted Education, Video-assisted Education","lastPublishedDoi":"10.21203/rs.3.rs-4879620/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4879620/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study was conducted to evaluate the effectiveness of breastfeeding behavior development training involving the use of videos and simulators with mothers whose babies were in the neonatal intensive care unit and who were staying in mothers’ hotels. The study was conducted in June 2022 and March 2023 in a state hospital with 100 volunteer participating mothers. Study control group (n=33), video training group (n=33), simulator training group (n=34). The study was conducted with a randomized controlled pretest/posttest control group trial model. Data were collected with a sociodemographic information questionnaire, a breastfeeding self-efficacy scale (short form), and a maternal attachment scale. Pretest scores did not significantly differ between groups (p\u0026gt;0.05). The breastfeeding self-efficacy, maternal attachment and retest mean scores significantly increased in the simulator group (p\u0026lt;0.05). This study revealed that breastfeeding training given to women with simulator support was more effective than training given via video methods in terms of breastfeeding success, the perception of breastfeeding self-efficacy, and maternal attachment.\u003c/p\u003e","manuscriptTitle":"Comparison of the Effectiveness of Video and Breastfeeding Simulator Support to Mothers Who Could Not Breastfeed Their Babies in the Neonatal Intensive Care Unit: A Randomized Controlled Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-18 02:05:54","doi":"10.21203/rs.3.rs-4879620/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-12T18:51:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-12T04:32:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-08T23:52:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-08-08T08:53:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5a2f59b-4f47-4cb5-99ae-6ff51cf0798a","owner":[],"postedDate":"September 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:08:26+00:00","versionOfRecord":{"articleIdentity":"rs-4879620","link":"https://doi.org/10.1186/s12884-025-08025-w","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-09-30 15:57:15","publishedOnDateReadable":"September 30th, 2025"},"versionCreatedAt":"2024-09-18 02:05:54","video":"","vorDoi":"10.1186/s12884-025-08025-w","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08025-w","workflowStages":[]},"version":"v1","identity":"rs-4879620","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4879620","identity":"rs-4879620","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}