Breastfeeding can improve health and survival, diminish economic losses
and avoid perpetuation of generational health inequality gradients
(Sacker, 2013; Bartick, 2016; Pérez-Escamilla,
2015; Rollins, 2016). Mothers have learned the message and many initiate breastfeeding but duration rates still fall short of
recommendations (Victora, 2016). Poorly
trained healthcare providers (HPs) and absence of collaboration with the community contribute to undesired early breastfeeding cessation
(Odom, 2013; Wagner, 2013; Stuebe, 2014; Garner,
2015; Rosin, 2016). But access to lactation support has been associated with improved breastfeeding rates {Ray, 2018}. Breastfeeding support services (BSS) that
offer clinical care at the individual level and opportunities for
professional training may help fill this gap in care and are being
successfully formalized in some countries (Kapinos et al., 2016;
Rosen-Carole, 2017). Most of these BSSs are private experiences, probably because meshing a BSS within a public national health
system (PNHS), generally suffering from rigid structures, scarce
resources and high resistance to innovation can be challenging. However, by offering structured breastfeeding support the public healthcare system might add to providing equitable access to it for all families,
including the most vulnerable (McVicar, 2015).
. A rising demand for
services was noticed after certain HPs in our Primary Care Health Center
(PCHC) started offering specialized breastfeeding clinical care in
addition to usual care. This alerted to a possible gap in care. A
thorough needs assessment and a careful strategic analysis followed.
Aiming to improve the quality and equity of breastfeeding care within
our NPHS, we planned a comprehensive, structured BSS that would be the
first in Spain. This article describes the planning process that led to
its start-up, the implementation clues and experience, and the process and outcomes assessment.
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.