Perceptions of Primary Care-Based Breastfeeding Promotion Interventions: Qualitative Analysis of Randomized Controlled Trial Participant Interviews

Introduction

While national breastfeeding initiation rates are trending upward, duration and exclusivity remain low, ¹ particularly among U.S.-born non-Hispanic black and U.S.-born Hispanic women,^2,3 low-income women,^3–5 and Women, Infants and Children program enrollees.^6,7 Reviews and meta-analyses find that key facilitators to breastfeeding involve relation-based support ⁸ spanning the pre-and postnatal periods^9–11 through multiple modalities. ¹⁰ However, providers cite deficits in knowledge, time, and counseling skills as barriers to effective counseling. ¹² Conversely, trained International Board of Certified Lactation Consultants (LCs) integrated in primary care are associated with increased breastfeeding duration in a review of the literature. ¹³

To test interventions targeting breastfeeding disparities, we conducted two randomized controlled trials (RCTs) of routine prenatal care-based interventions to increase breastfeeding intensity and duration [“Boosting Breastfeeding in Low-Income, Multi-ethnic Women: A Primary Care Based RCT (BINGO)” and “Provider Approaches to Improved Rates of Infant Nutrition and Growth Study (PAIRINGS)”, sponsored by the Albert Einstein College of Medicine of Yeshiva University, among nearly 1,000 multiethnic low- to middle-income women. This article reports findings from the RCTs' 6-month exit interviews. As a qualitative inquiry, it presents participants' perspectives of study participation, utility of the interventions, and intervention effects upon infant feeding.

We sought to answer the following research questions: (1) How did research interviews affect infant feeding practices? (2) Did perceptions of study effects differ by prenatal feeding intention? (3) What were the perceived effects of study interventions (electronic prompts [EP] and/or LC) on breastfeeding knowledge, attitudes, and practices? In a “triangulation of methods,” qualitative data were analyzed alongside feeding outcomes.

Subjects and Methods

Results

Discussion

At 6 months postpartum, we explored participants' perceptions of the study's effect upon feeding knowledge, attitudes, and behaviors. Simply asking women about infant feeding increased their consciousness of feeding practices, replicating results from prior work. ¹⁵ However, those in a treatment group (EP and/or LC) focused more on how the interviews affected breastfeeding, while controls emphasized food intake. Results thus suggest that brief standardized assessments of feeding by staff from the mother or child's medical home, in conjunction with provider-expressed support for breastfeeding, may support and increase breastfeeding.

Women intending to combine breastmilk with formula reported the strongest study effects upon feeding attitudes and knowledge of breastfeeding benefits. Thus, interventions for these women, 45% of the sample, may forestall exclusive formula feeding. Strong statements in support of LCs suggest that this intervention, in particular, may have “shifted the balance” for these women. Of women who intended to exclusively breastfeed at baseline, those enrolled in an EP and/or LC group were more likely to report a study influence on breastfeeding than controls, suggesting that interventions are potent even among those intending to exclusively breastfeed.

Providers tend to underestimate their influence upon infant feeding, ¹⁶ which can be significant, ¹⁷ particularly when adequately trained. ¹⁸ EPs bolstered this influence by encouraging providers to offer concrete details about breastfeeding benefits as part of routine and continuous prenatal care. Those in the EP-only group cited an even stronger provider influence upon breastfeeding than those in the EP+LC group, but this may reflect, comparatively, the latter groups' greater recollection of the ongoing, intensive LC intervention versus the (prenatal only) EP intervention. Indeed, the EP+LC group was most able to recall specific breastfeeding benefits at the 6-month exit interview. By contrast, recall by controls of provider support was tepid and tended toward generic comments, such as “Breast is best.”

LC group participants provided frequent, strong, and detailed statements about how the LCs facilitated breastfeeding initiation and duration. All but one voluntarily recalled useful advice or technical assistance from the study LC. The primary reasons for early weaning are concerns about milk supply or quality and latching difficulties; both reflect a lack of skilled, personalized lactation support. ¹⁹ Our results bear this out. Those in an LC group were least likely to cite low milk supply or contraindicated maternal medications as a barrier to breastfeeding, and all LC group participants who experienced difficulty with breastfeeding mechanics in the hospital were still breastfeeding at 1 month.

Limitations of this study include the potential for recall and social desirability biases and the limited data on what transpired during the EP interventions. Regarding recall bias, we note participants' recall of nongeneric, specific details (e.g., reports of LCs researching whether acetaminophen was consistent with breastfeeding). With regard to social desirability, although participants expressed some negative opinions, we imagine some were not shared with us. In addition, provider notes about the EP encounters were brief—often only a signature that they had addressed the EP. Still, the detailed prenatal discussion recalled by those in the EP groups, and the EP groups' greater likelihood of reporting provider support for breastfeeding, lead us to assume that the EPs were delivered as planned.

Conclusions

Although low-income minority women are often aware of breastfeeding benefits and express the desire to breastfeed, sociocultural and practical challenges lead to ambivalence in practice.^19,20 Our findings affirm women's perceptions of the utility of combined prenatal and postpartum provider and LC interventions in reinforcing breastfeeding intention and duration, especially when faced with lack of support from family or medical professionals, ²¹ and in addressing early postpartum lactation difficulties. ²² They thus underscore the need for breastfeeding interventions across the continuum of care.