Experience and clues
Even the best national health systems can suffer from shortfalls in the
provision of breastfeeding support services. In our case a high demand
for breastfeeding specialized care alerted about a possible gap of care.
The thorough needs assessment that followed proved useful to discover
needs that went beyond merely opening a breastfeeding clinic. Monitoring
breastfeeding rates is recommended to adequately assess the situation of
breastfeeding and to measure the impact of interventions (World Health
Organization, 2010). However, consistent with the situation in other
countries we did not have current detailed data (Victora et al., 2016).
Therefore, we implemented an initial infant feeding survey and planned
for a second one. Determining breastfeeding rates was important, however
in-person interviews and the “usage and awareness of resources“ survey
were decisive to map the situation.
The SWOT and TOWS tools were very helpful to identify aims for service
and implementation strategies. One example was the decision to locate
the BFU inside the university hospital premises to take advantage of
available space. This choice minimized costs but also facilitated
providing breastfeeding clinical care in an academic training and
research environment (Rosen-Carole, 2017). Consistent with other
experiences we faced opposition from staff members who did not perceive
the need for breastfeeding-training nor for specialized
breastfeeding-care, or who envisioned the BFU as a menace to their
status (Garner, 2015). To overcome this challenge we promoted
participation and sense of ownership: We involved key leaders in the
planning process and knowledgeable peers in the training program, we
disseminated the project widely, we invited HPs to visit and we made
ourselves available for consultation. We have partially succeeded and
although we still face opposition, it has diminished over the years. It
has been described that HPs’ own breastfeeding experience may change
their breastfeeding advocacy (Sattari, 2013). Indeed, we found that
breastfeeding HPs who benefited from the clinic’s services themselves
became our best ambassadors among colleagues.
Our first aim was to improve the attitudes, knowledge and skills of all
HPs responsible of mother-infant care, in our HD (hospital and primary
care) because of their important role in breastfeeding support
(Geoghegan-Morphet et al., 2014). We chose WHO’s 20-hr course because it
is required for BFHI accreditation in Spain. The Hospital Breastfeeding
Committee was already working for the BFHI accreditation thereby we
decided to target primary care first. Scarcity of resources impeded
reaching the hospital staff, but we are at present collaborating with
the hospital breastfeeding committee in devising a program that
specifically addresses their learning needs.
By opening a breastfeeding clinic we provided equitable access to
specialized breastfeeding clinical to the underserved population in our
HD. The exclusivity rates observed at six months were too impressive and
we should notice that these results were obtained through a
self-selected on-line survey that did not represent all clients, and
could just offer an approximation to the reality. Successful mothers
were probably overrepresented. Besides, many of our clients were
determined to breastfeed against any odds and it is possible that less
determined mothers had weaned before being referred.
We assumed that well trained HPs would offer better breastfeeding
support (first level) and would refer only more complicated
breastfeeding challenges. However, families who came from other HDs were
referred by untrained HPs who found referring easier than providing
support. This has probably contributed to overcrowding in the clinic,
thereby hindering evolution in our services. A high demand for services
threatens to overburden staff and force other activities to slow down.
To overcome these difficulties we have asked for increased resources and
better incorporation into the system. We are currently advocating that
the health authorities extend services by implementing a network of BFUs
in the AC Health Services.
Integrated care and working with the community has been described as
necessary and useful (Rosin et al., 2016). We found collaboration with
BMSGs easy and rewarding and we received gratitude and support.
Furthermore, we helped to build extra community resources based on the
new technologies that have proved useful (Blixt et al., 2014).
We were pioneers in formalizing a BSS inside the NPHS and have been
asked to prove its efficacy and efficiency periodically. The managers
specially valued the high demand for services, client satisfaction (some
families sent thank you letters to the HD director and even to the
Ministry of Health) and the training program we implemented. However, we
were specially proud of the many women who were satisfied with their
breastfeeding experience, many of whom could breastfeed exclusively for
up to 6 months, even after facing important breastfeeding challenges.
The recognition by the MOH and the following dissemination of this
initiative has ignited the opening of breastfeeding clinics in hospitals
all over the country, thereby improving the equality of access to
breastfeeding individualized clinical care. However, in our opinion, the
NPHS must provide comprehensive, equally accessible, integrated
breastfeeding support by implementing the BFHI in hospitals and primary
care and through services provided by well trained and supportive HPs
who jointly work with the community in addition to breastfeeding clinics
(Rosin et al., 2016).