Outpatient Breastfeeding Champion Program: Breastfeeding Support in Primary Care

Abstract

Background:

Breastfeeding support offered by trained professionals can increase breastfeeding success. The Outpatient Breastfeeding Champion (OBC) program creates a network of Breastfeeding Champions (typically nurses) who are trained to identify and resolve common breastfeeding issues and refer to lactation professionals as needed. The objective of this study was to evaluate the impact the OBC program on nurses' attitudes toward breastfeeding and self-confidence in providing breastfeeding care.

Materials and Methods:

The OBC program was implemented in 11 medical offices within a health care system. Nurses were surveyed before (n = 9) and immediately after (n = 9) participating in OBC training sessions, and 6 months following the implementation of the OBC training (n = 15). Data were collected on their breastfeeding attitude and self-confidence in providing breastfeeding care, and the responses at the different time points were compared using Wilcoxon Rank-Sum tests.

Results:

Nurses' attitudes toward breastfeeding (p = 0.049) and self-confidence in managing breastfeeding position and attachment (p = 0.09) were higher immediately after completion of the OBC training than they were before training. There was no significant difference in either response between immediately after completion and 6 months following training.

Conclusion:

This study presents a model of breastfeeding care that extends the reach of an International Board Certified Lactation Consultant to improve breastfeeding support in the primary care setting. Nurses' more positive breastfeeding attitudes and self-confidence in providing breastfeeding care following training suggest that the use of a breastfeeding training program may improve the breastfeeding support provided by nurses, which could be sustained over time.

Introduction

Health care is uniquely suited to provide mothers with support needed to promote successful breastfeeding during a period in time when women are considering breastfeeding and initiating breastfeeding. Labbok and Taylor illustrated the relative importance of influence of obstetric, maternity, and pediatric staff as the highest when maternal breastfeeding concerns are approaching their peak.¹ This presents a critical window when breastfeeding support may be most important to long-term breastfeeding initiation and continuation. Breastfeeding support offered by trained health care professionals is associated with increased duration and exclusivity of breastfeeding.² However, most primary care practices are not prepared to treat the mother–baby dyad leading to a discontinuity of care.^3,4 Discontinuity of breastfeeding-related care results from health care providers relying on lactation specialists for even the most basic breastfeeding management issues. This generally means referring patients to someone outside of the office. Other significant challenges to providing breastfeeding support for mothers in primary care include health care professionals' attitudes toward breastfeeding and lack of confidence in providing breastfeeding care, along with a perceived lack of time to address breastfeeding.^4–7 All of these factors combined suggests the need for a systematic way to support breastfeeding within the primary care setting.

To create a breastfeeding-friendly primary care office, the Academy of Breastfeeding Medicine (ABM) recommends breastfeeding education for all staff members and the identification of one or more breastfeeding resource personnel on staff as a strategy.⁸ The American College of Obstetricians and Gynecologists also recommends office staff be prepared to manage common breastfeeding concerns and refer as needed to a lactation professional, such as an International Board Certified Lactation Consultant (IBCLC) or Certified Lactation Counselor (CLC).⁹ According to the 2016 United States Breastfeeding Report Card, most states have three to four IBCLCs and four to five CLCs per 1,000 live births.¹⁰ This ratio highlights the need to extend the reach of these lactation specialists. One way to accomplish this is by training primary care office staff to identify and manage common breastfeeding problems, and refer to a lactation professional as needed. This model meets the need identified by the ABM to have a breastfeeding resource in the primary care setting while at the same time maximizing the availability of IBCLCs for more intensive interventions.

The Outpatient Breastfeeding Champion (OBC) program is a 16-hour breastfeeding education program that creates a network of Breastfeeding Champions working in primary care offices.¹¹ The OBC program generally trains one or more office staff member as Breastfeeding Champions on how to identify and manage common breastfeeding problems and refer to IBCLCs as needed for higher acuity care. The model includes identifying an IBCLC from within the health care system to conduct the OBC training. This creates a bridge between the IBCLC and primary care staff. In addition, the model creates a network for ongoing training for OBC staff, as well as a referral pattern that connects mothers presenting in primary care with an IBCLC for more intensive breastfeeding interventions. The goal of the 16-hour training program is to provide the OBC Breastfeeding Champions the skills, and therefore self-confidence, to manage the mother–baby dyad for breastfeeding support. This organizational structure provides a model that may increase the continuity of breastfeeding care from the prenatal period through the postnatal period.

The objective of this study was to evaluate the breastfeeding attitudes and self-confidence in providing breastfeeding support of those nurses who participated in the OBC training.

Materials and Methods

Study design

Multiple independent cross-sectional surveys were administered to evaluate the training sessions for, and implementation of, the OBC program among office nurses. This study was certified as Exempt by the University of Wisconsin-Madison Institutional Review Board.

Setting

The study took place within a health care organization located in a predominantly non-Hispanic White (78.7%), well-educated (56.3% with Bachelor's degree or above) metropolitan area in the Midwest.¹² The health care organization includes 11 medical clinics that care for breastfeeding mothers and infants (family medicine, obstetrics/gynecology, and pediatrics clinics) with a total of 54 medical providers and 16 Registered Nurses. An IBCLC provides direct support for 4 of the 11 clinics, but is available for lactation consultations for the entire health care organization. This health care organization provides primary care for ∼600 infants each year (Eng, O., e-mail communication, November 15, 2016).

Training and program implementation

The OBC program was implemented in Fall, 2016. This study was observational as the research team did not direct or inform the implementation of the OBC program. The training focused on the following key areas: (1) identifying and prioritizing breastfeeding concerns, (2) education on common breastfeeding issues, (3) identifying community resources for family support, and (4) breastfeeding skills (e.g., measuring pre and postfeed weights, assessing interval weight gain, checking a breastfeeding latch, and advising on proper pump use).¹³ The organization that created the OBC program offered ongoing support to nurses through a listserv that could be used to ask breastfeeding-related questions and provided information on additional opportunities for education and training.

In addition to the training, a protocol for managing breastfeeding patients was created by the health care organization to facilitate the OBC program implementation. The protocol included: (1) screening questions, built into the electronic medical record, to evaluate breastfeeding concerns at each visit; (2) phone calls to mothers by the nurses within 1–2 weeks of breastfeeding initiation; and (3) availability of in-clinic weight checks performed by nurses. Medical providers did not receive the training but were oriented to the program during a department meeting.

Participants and measurements

Fifteen of the 16 nurses who worked in the health care organization primary care clinics participated in the OBC training sessions offered in February 2016 (n = 6) and October 2016 (n = 9). Nurses who participated in the October 2016 OBC training session were recruited to participate in a survey immediately before and after this training session. Six months following implementation of the OBC program in the health care organization, all nurses who participated in either training session (n = 15) were invited to participate in a survey.

A survey was administered to the nurses that measured their attitudes toward breastfeeding and self-confidence in providing breastfeeding support. The survey used was originally created by Scott et al.¹⁴ One IBCLC and two researchers evaluated the chosen questions to obtain content validity for the OBC program, resulting in removal of three items. The attitude toward breastfeeding measure was obtained by scoring 17 five-point Likert scale (strongly agree, agree, neutral, disagree, strongly disagree) questions; those with agree or strongly agree as the response were assigned a +1 and those with strongly disagree or disagree as the response were assigned a −1. Neutral responses were assigned a zero. Reverse scoring was used when agreement was not supportive of breastfeeding. The attitude toward breastfeeding score was normalized to 100% due to missing data in two surveys collected.

Two questions measured nurses' self-confidence in managing positioning and attachment, and ability to manage common breastfeeding problems, using a five-point Likert scale (not at all confident, a little confident, somewhat confident, pretty confident, very confident). Potential confounders measured included: (1) gender, (2) whether they had children, (3) method of feeding their youngest child during the first 6 months of life, and (4) the quality of nurses' most recent personal experience with breastfeeding.

The same survey was used to measure breastfeeding attitudes and self-confidence in managing breastfeeding care at each time period.

Statistical methods

Data analysis was performed with the R statistical package (version 3.1.1) using RStudio^© software (version 0.99.902) as an interface.¹⁵ Data were analyzed using Wilcoxon rank-sum tests.

Nurses' responses regarding attitude toward breastfeeding and self-confidence in providing breastfeeding support were compared immediately before participating in the OBC training session to responses immediately following completion of the OBC training session. Responses immediately following the training session were compared with responses collected 6 months after the OBC program was implemented in medical offices. Due to privacy concerns of the organization where the study took place, before and after measurements were not paired.

Results

Table 1 describes the characteristics of the nurses that were included in this study. The nurses were female and the majority had children, with their youngest child at least partially breastfed. Overall, those breastfeeding reported a good to very good quality of personal experience with breastfeeding.

Table 1.

Descriptive Data for Nurses Before and After Participation in the Outpatient Breastfeeding Champion Program Training Sessions and at the 6-Month Follow-Up Assessment

Nurses (n)	Gender	Children^a	Method of feeding youngest child (first 6 months)		Quality of personal breastfeeding experience^b
Before training (9)	Female: 100%	Yes: 78%	Formula only	0%	4.14
			Mixed feeding	57%
			Exclusively breast milk	43%
After training (9)	Female: 100%	Yes: 78%	Formula only	0%	3.93
			Mixed feeding	57%
			Exclusively breast milk	43%
Follow-up (15)	Female: 100%	Yes: 80%	Formula only	8%	4.09
			Mixed feeding	25%
			Exclusively breast milk	67%

Percent of nurses who reported having children in each time period measured.

Personal breastfeeding experience was measured using a Likert scale that ranged from 1 to 5 [very poor (1) to very good (5)].

Table 2 shows the results of nurse training. Nurses' attitudes toward breastfeeding were significantly higher after versus before the training (p value = 0.049). Nurses' self-confidence in teaching positioning and attachment and managing common breastfeeding problems was higher after versus before the completion of training, although this did not reach statistical significance. There was no significant difference between attitude toward breastfeeding and self-confidence in providing support when comparing data collected 6 months following the implementation of the OBC program and that collected immediately following the training session.

Table 2.

Results from Nurse Participants in the Outpatient Breastfeeding Champion Program Pre- and Posttraining Session (n = 9) and 6 Months Following the Implementation of the Outpatient Breastfeeding Champion Program in the Health Care Organization (n = 15)

Outcome	Mean (pretraining)	Mean (posttraining)	p-Value ^a (pretraining vs. posttraining)	Mean (postimplementation)	p-Value ^a (posttraining vs. postimplementation)
Breastfeeding attitude (0–100)^b	75.00	85.44	0.049	87.20	0.663
Self-confidence in teaching positioning and attachment (1–5)^c	2.63	3.67	0.088	3.20	0.337
Self-confidence in managing common breastfeeding problems (1–5)^c	2.88	3.67	0.147	3.40	0.510

p-Value obtained from Wilcoxon independent samples test.

Data were normalized due to two missing responses on the pretraining survey and two missing responses on the postimplementation survey. Calculated score based on attitude-related questions on the survey and expressed as a percent. A higher score represents a more positive breastfeeding attitude.

The 1–5 Likert scale represents the range in scores from not at all confident (1) to very confident (5).

Discussion

This study evaluated the impact of the OBC program on nurses' attitudes toward breastfeeding and self-confidence in providing breastfeeding support. Nurses' more positive attitudes toward breastfeeding following the training suggest that the use of an evidenced-based breastfeeding training program may improve attitudes toward such support. The finding that these attitudes were maintained over 6 months suggests that the program is sustainable. This is similar to another study that found the use of an evidence-based breastfeeding training program resulted in improved health care professionals' attitudes toward breastfeeding, which were also sustained over time.¹⁶ Improving nurses' attitudes toward breastfeeding is an important outcome measure as attitudes toward breastfeeding are predictive of actual supportive behavior and associated with increased maternal satisfaction with professional breastfeeding support.^16,17 Difficulty with latch, sore or painful nipples are leading reasons mothers report not meeting their breastfeeding intentions.^18,19 A program like the OBC program, which in our study suggested an increase in nurses' self-confidence managing common breastfeeding problems, or identifying problems that need to be addressed through collaboration with a medical provider or IBCLC, is important to improve breastfeeding support offered to mothers.

The OBC program provides a model that incorporates a Breastfeeding Champion in primary care offices across the prenatal to postnatal breastfeeding continuum. Included in The Surgeon General's Call to Action to Support Breastfeeding is a need for health care systems to create a model to integrate assistance with breastfeeding into routine practice settings, conduct analyses on models of care, and disseminate findings.²⁰ The current health care structure, which may not be treating the breastfeeding mother and her baby as a dyad, along with the lack of health professionals' time and skills, can lead to missed opportunities in providing adequate breastfeeding support.⁴ The OBC program model creates a network between IBCLCs and a trained Breastfeeding Champion within the primary care setting, thus providing a potential solution to treat mothers and babies as a dyad. Given the approximately four million babies born each year in the United States²¹ and breastfeeding initiation rates of 83%,²² health care systems and medical practices need a structure in place that can provide mother–baby dyads with better continuity of breastfeeding support. Providing training for a Breastfeeding Champion in primary care can extend the reach of an IBCLC to identify and manage breastfeeding concerns. Breastfeeding champions can also be the breastfeeding resource person in the office, not only for patient care but also to help providers and other staff find answers to their questions. Future research studies should evaluate the ability of the OBC to identify and manage mothers' breastfeeding concerns along with the number of referrals generated to the IBCLC. A follow-up study should evaluate the impact of this training program on breastfeeding patterns observed in clinics served.

One year following the OBC program training all nurses who completed the training were invited to participate in a debriefing session to discuss barriers and facilitators to the implementation of the program along with additional breastfeeding training needs. Due to the limited number of participants (n = 4), we could not conduct a true qualitative analysis, therefore information obtained from this debrief has been summarized below.

A key strength of the program noted by nurses was an increased comfort level with managing common breastfeeding problems both in person and over the phone. Having screening questions built in the electronic medical record helped prompt breastfeeding conversations, and they expressed greater comfort asking mothers breastfeeding-related questions. The nurses felt that the training helped them have more “knowledge at their fingertips,” which saved time when they were triaging breastfeeding problems by phone or seeing mothers in the clinic. They also felt it elevated their role in the eyes of the medical providers. Nurses reported that following the training, medical providers began asking them to provide on-the-spot assistance to mothers who were having difficulties. Mothers who needed additional assistance were still scheduled with the IBCLC, but the breastfeeding champions felt capable in supporting mothers until their scheduled appointment with the IBCLC. Aspects of the training nurses found most helpful were: (1) training on the use of different breast pumps, (2) medications that can impact milk supply, (3) overall anatomy and physiology of breastfeeding, and (4) how to assess adequate growth of an infant. Training opportunities that were identified that would be of assistance for nurses were how to manage cultural differences with breastfeeding as well as resources and strategies to help encourage and support a mother who may not have a home environment that supports breastfeeding. Most nurses felt like they could use additional training on assessing a latch, and expressed interest in additional shadowing opportunities with the IBCLC to practice skills and refresher in-services to ensure knowledge is up to date.

By taking advantage of a natural experiment of the OBC program being implemented across the health care system, this study was limited by the lack of a control group. A limitation of this study was the small sample size and lack of paired comparison, which may have resulted in the lack of significant differences in the nurses' self-confidence.

Conclusion

In summary, the primary care setting is uniquely suited to provide breastfeeding support at a window in a time in which mothers are making decisions about breastfeeding. Unfortunately, due to medical providers' lack of confidence in providing breastfeeding care, time constraints to proactively support breastfeeding mothers and disconnect between treating mothers and babies as a dyad, the primary care setting has failed to provide optimal support for breastfeeding. A possible solution is to extend the reach of an IBCLC by training Breastfeeding Champions to identify breastfeeding problems, provide breastfeeding support, and refer as needed to a medical provider or IBCLC for higher-level breastfeeding issues. This study suggests the potential to positively influence nurses' breastfeeding attitudes and confidence in providing breastfeeding care. Future research should explore if this model of breastfeeding support in the primary care setting results in mothers' perception of increased breastfeeding support and improved breastfeeding rates using a controlled, randomized experimental design.

Footnotes

Acknowledgments

The authors thank Group Health Cooperative of South Central Wisconsin for allowing them to observe the implementation of the Outpatient Breastfeeding Champion program in their medical offices. They thank Dana Loo, undergraduate student at the University of Wisconsin-Madison, for technical assistance. Funding: University of Wisconsin-Madison College of Agricultural and Life Sciences, Department of Nutritional Sciences, and the Wisconsin Alumni Research Foundation.

Disclosure Statement

The Outpatient Breastfeeding Champion training curriculum was created by A.R.E. and is owned by the nonprofit 501c3. The Institute for the Advancement of Breastfeeding and Lactation Education. A.R.E. is president of this nonprofit. A.R.E.'s husband's company is a contractor with this nonprofit organization. No competing financial interests exist applies to all remaining authors.

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