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).