With this report, we aim to disseminate the experiences and clues of the planning process that led to its start-up, the implementation and the outcomes.

6. Specific Aims

Methods
Context
In Spain, public insurance allows citizens to receive healthcare without direct payment. Universal healthcare coverage is offered by the Autonomic Communities’ Health Services through health departments (HD). These are administrative districts (one board of directors with one budget) where one or more hospitals, outpatient specialty policlinics and PCHCs serve subsectors of the population. Breastfeeding clinical care and support fall within the role of different professionals in both primary and specialized care. However, breastfeeding training is not required and lactation specialization is not recognized (not even for IBCLCs). Both prenatally and after discharge from the maternity ward (where most births take place), the care of mother-infant dyads is on the PCHC team (family medicine doctors, pediatricians, midwives and nurses). Antenatal education is included in the midwives’ portfolio. (Hernández-Aguilar et al., 2014). A few neonatal units offer individual breastfeeding clinical care for their clients but there are no BSS. There are a few private breastfeeding clinics, staffed by IBCLCs and other HPs, but fees-for-service exclude many families from this care. There are more than 200 independent breastfeeding-mothers support-groups (BMSG) in Spain (IHAN, 2018).
At “Dr. Peset” HD in Valencia (our HD), a University Hospital and 17 PCHC serve around 55,000 women and 4,000 infants less than two years old at. The population is not wealthy: Mean per capita rent (PCR) is at / yr (PCR in Spain is \euro27,000 /yr) (Valencia, 2018; INE, 2018). The Hospital, at Stage 1D of the BFHI accreditation, reported a 74.9% breastfeeding initiation rate in 2012. Other breastfeeding rates were unknown. Electronic records allowed for shared clinical information and facilitated continuity of care among levels.
Intervention
Planning
Breastfeeding rates were assessed with a cross-sectional telephone survey. A final population-representative random sample of N : 400 infants was selected; calculated sample was N : 382 (alpha error: five percent, precision: five percent, worst scenario prevalence: 50%), we aimed for N :400 to allow for losses, we were not able to contact with eight families. A final sample of 392 primary caretakers were contacted (oral consent was requested at the start). Data were collected with an Spanish version of the infant and young child feeding module of the World Health Organization (WHO) questionnaires for assessing infant feeding practices (questions five to seven and thirteen were used) (World Health Organization, 2010). The data analysis disclosed low rates of exclusive breastfeeding (EBF) (eight percent) and of partial breastfeeding (54,6 %) among infants less than six months old.
The needs assessment also included: (a) face-to-face interviews with key informants (hospital and PCHCs medical and nursing directors, heads of the pediatric and obstetric services, and local BFSG leaders) to assess breastfeeding needs and available resources; (b) a self-administered survey (directed to all staff working with mothers and/or infants, at the hospital or in primary care) to evaluate awareness and use of breastfeeding resources; (c) individual interviews with key informants from the community (BMSGs’ mothers and dedicated professionals) to obtain their insight on barriers, needs and resources.
SWOT and TOWS analysis were used to identify strengths, weaknesses, opportunities, and threats, and to set strategies and actions (Helms et al., 2010). SQUIRE 2.0 guidelines have been used to describe this health care improvement intervention (Goodman et al., 2016).
Three main areas of need were identified: (a) Breastfeeding families facing breastfeeding challenges needed specialized clinical care, (b) HPs’ breastfeeding attitudes, knowledge and skills needed improvement, and (c) Families needed support that was available from local BMSG but links were lacking. Aims, activities (Table 1) and strategies were set (Figure 1), and the new BSS started operating in November, 2013.