Implementation and evaluation of community-based drop-in centres for breastfeeding support in Victoria, Australia

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Women's experiences of infant feeding support: Findings from a cross-sectional survey in Victoria, Australia

OBJECTIVE

To evaluate new mothers' experiences of infant feeding support.

DESIGN

A postal survey developed for this study was sent to all new mothers in ten local government areas in Victoria, Australia when their baby was six months of age. Questions explored infant feeding methods, feeding support services, and experiences of infant feeding support. This survey made up one component of the Supporting breastfeeding In Local Communities (SILC) cluster randomised controlled trial.

FINDINGS

997/4127 women (24%) completed the survey between 15 April 2013 and 31 July 2013. Women received infant feeding support from multiple sources, including professionals, family members, and peers. Overall, 88% reported receiving adequate infant feeding support. Women who reported not receiving adequate infant feeding support were less likely to be giving any breast milk at six months compared to those reporting adequate support (OR = 0.59; 95% CI 0.40, 0.88). Adjusting for breastfeeding intention and parity did not alter the association (Adj. OR = 0.60; 95% CI 0.40, 0.90). Women were most satisfied when they received accessible, available, consistent professional infant feeding support provided in a non-judgemental and reassuring way. Women were dissatisfied when there were barriers restricting access to support, or when they received conflicting advice or support that made them feel guilty, pressured or judged.

KEY CONCLUSIONS

Regardless of infant feeding method, women wanted accessible, non-judgemental support. Given that receiving adequate support was associated with more breast milk feeding at six months, care providers should ensure accessible infant feeding support is available to all new mothers.

Breastfeeding support at an Australian Breastfeeding Association drop-in service: a descriptive survey

Background

In Australia, during the early establishment phase of breastfeeding, women can access telephone peer support counselling provided by the Australian Breastfeeding Association (ABA) however options for face-to-face peer support are limited. The known factors which improve ongoing and exclusive breastfeeding include face-to-face support, peer and/or professional support, and trained personnel. This study aimed to examine women’s experiences of accessing one breastfeeding drop-in peer support service provided by trained peer support volunteer counsellors from the ABA.

Methods

Women who accessed the service were invited, in 2014, to participate in an anonymous online survey which collected both quantitative and qualitative data. Participants were asked about their experiences of breastfeeding support, as well as their experiences of the drop-in service. In total, 53 women completed the online survey, and subsequent analysis generated descriptive statistics and qualitative themes.

Results

Responses to the survey revealed that women attended the drop-in service with infants ranging in age from less than 1 week through to 12 months of age. Most women reported attending with infants aged 0–8 weeks of age (72%). The predominant presenting problems identified were sore/damaged nipples, difficulties with infant latching to the breast, or concerns about using nipple shields. Analysis of the open text qualitative responses revealed one overarching theme ‘Support to continue breastfeeding’ and four subthemes: ‘feeling listened to and not judged’; ‘emotional support and confidence building’; ‘the importance of face-to-face, practical support’; and ‘the need for ongoing, free access’.

Discussion

In this study many women were seeking support for ongoing breastfeeding difficulties. Health professionals who had limited breastfeeding knowledge and skills were identified as most unhelpful in providing support with ongoing breastfeeding difficulties. Women valued having access to trained peer counsellors, who had the capacity to provide non-judgemental, face-to-face support; who could sit through a feed; in a space that was ‘safe’; and who could enhance a woman’s confidence with breastfeeding over the course of her full breastfeeding journey.

Conclusions

Reactive peer support, provided in response to need, at an Australian Breastfeeding Association drop-in service, was described by participants as pivotal to enabling their ongoing breastfeeding.

Place of sanctuary: an appreciative inquiry approach to discovering how communities support breastfeeding and parenting

Background

Significant efforts by governments at a global and national level have not resulted in a significant increase in the duration of breastfeeding to six months. The views of family and social networks, and community attitudes particularly around breastfeeding in public, influence infant feeding decisions. Yet many interventions designed to increase breastfeeding focus on the individual woman and have not been developed from the 'ground up' in consultation with women and communities. This study aimed to identify the key components of Mother Infant Caring Communities that promote and support breastfeeding and early parenting.

Methods

Appreciative Inquiry was used to facilitate a 'Community Conversation' workshop in two local councils in Australia. Thirty-five participants attended the community conversation workshops including new parents, grandparents, children's services, local government, and representatives from maternity and child health services. In addition, one focus group discussion was conducted with six retail business owners or managers. Qualitative content analysis was used to analyse data. This paper presents the findings of the first phase (the Discovery phase) of the study.

Results

Four major themes emerged: "PLACE - A community for everyone"; "A PLACE for children and families"; "Sometimes a PLACE to breastfeed" and "The parent room: a hidden and unsafe PLACE to breastfeed". Participants described the characteristics of communities that provided a sanctuary and fostered well-being for parents and infants including, open green spaces, safe playgrounds, walking tracks and community hubs. Shopping centres were described as having the potential to be the 'village'. Community-based services to support breastfeeding and parenting were highly valued. Yet in both sites, participants stated that breastfeeding was rarely observed in public and bottle feeding was more evident.

Conclusion

Breastfeeding and parenting are embedded in the places where women and families live. Community spaces including shopping centres, should be designed to include infants and young children and offer appropriate facilities such as safe and clean parenting rooms. Health services must work with local government, businesses, and diverse community members to identify what parents' value about their community and design and implement innovative local strategies to support breastfeeding.

Breastfeeding: uncovering barriers and offering solutions

PURPOSE OF REVIEW

The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend exclusive breastfeeding for 6 months after an infant is born. Although the recommendations are well known, mothers face barriers that make breastfeeding difficult. This article reviews the recent literature on barriers to breastfeeding as well as strategies for pediatricians to use to help women overcome them.

RECENT FINDINGS

The mode of delivery, mother's socioeconomic status, return to work, and prenatal breastfeeding education have been reported as factors that influence breastfeeding. Family-centered models for breastfeeding, peer support groups, and technology have been studied as potential ways to help women meet their breastfeeding goals.

SUMMARY

Pediatricians are the first providers to care for babies after hospital discharge and are likely the first doctors that mothers see after childbirth. These early visits create opportunities for pediatricians to learn about the barriers that their patients face and open the doors to addressing these barriers.