Team-Based Breastfeeding Support at a Federally Qualified Health Center: Efficacy,Utilization,and Patient Satisfaction

Abstract

Background:

A team-based, integrated lactation consultant (LC) and primary care provider (PCP) program improves breastfeeding rates in some outpatient settings, but only a limited number of studies have assessed efficacy in socioeconomically and racially diverse communities.

Objectives:

Following implementation of team-based LC/PCP care at a Federally Qualified Health Center (FQHC), quality improvement efforts assessed utilization, breastfeeding rates, and patient satisfaction.

Method:

A retrospective chart review examined feeding status pre- and postimplementation. Analysis compared feeding rates at the 2-week, 2-month, 4-month, and 6-month well visits (well child care). Subanalysis of patients who initiated breastfeeding postimplementation examined feeding status and LC support. Patient survey evaluated satisfaction.

Results:

Among patients who initiated breastfeeding, those who received a LC/PCP visit were significantly more likely to be breastfeeding at 2 weeks (94% versus 80%, p = 0.004) and 4 months (68% versus 45%, p = 0.01). However, breastfeeding rates for the whole practice were not significantly different before and after implementation. Seventy-two percent of breastfeeding families saw a LC (n = 204). Median LC visit per breastfeeding patient was 1.18 (standard deviation [SD] +1.2). Patient survey reported that the three most commonly helpful aspects of the visit were “latch instruction” (60%), “breastfeeding questions answered” (80%) and “learning about massage and hand expression” (50%).

Discussion:

Team-based LC/PCP care is feasible at a FQHC. Patients found it helpful. Among families who initiated breastfeeding, receiving LC/PCP care was associated with increased breastfeeding duration through 4 months.

Introduction

Breastfeeding significantly lowers infant mortality and improves health outcomes for both mother and infant.^1,2 The World Health Organization (WHO) recommends breastfeeding for 2 years and exclusive breastfeeding (EBF) for 6 months.³ While breastfeeding initiation rates in the United States have risen to 84% through measures such as the Baby Friendly Hospital Initiative, only 35.3% of infants in the United States are breastfed through 1 year, falling below WHO recommendations.^4,5

Multifactorial barriers contribute to racial and ethnic disparities in breastfeeding initiation and duration.^6–8 The 2011, U.S Surgeon General Call to Action for Supporting Breastfeeding identified common barriers to be lack of knowledge, lactation problems, poor family and social support, social norms, embarrassment, employment & child care, and health services.⁹ For women who have initiated breastfeeding, the most common lactation problems causing weaning are pain and low milk supply.^10–12 Low income, minority women experience additional barriers, including lack of social, work, and cultural acceptance/support; language and literacy barriers; lack of maternal access to information that promotes and supports breastfeeding; acculturation; and lifestyle choices, including tobacco and alcohol use.¹³ These barriers faced by minority families contribute to the observed racial and ethnic disparities in breastfeeding initiation and duration in the United States.^6,7 As of 2017, African American families have the lowest rates of breastfeeding initiation (73.7%) and continuation at 6 (47.8%) and 12 months (26%) when compared with all other racial and ethnic groups in the United States.⁵ Families of Hispanic origin have high rates of initiation, but are more likely to supplement breastfeeding with formula earlier.^5,8 Additionally, immigrant women across various racial and ethnic groups had higher breastfeeding initiation and longer duration rates than women born and raised in the United States.^13,14

Addressing barriers to and disparities in breastfeeding initiation and duration is essential to improving breastfeeding outcomes.^7,9 Once breastfeeding is initiated, support in the early postpartum period is critical for establishing breastfeeding and resolving difficulties.^15–18 Primary care provider (PCP) support in the early weeks of postpartum is one option to address barriers such as lactation problems and health services. Effective primary care strategies include increasing both lay and professional support, face-to face support, and combining pre- and postnatal breastfeeding interventions.^15–17 Given PCPs' lack of time and education to routinely provide breastfeeding counseling,^19–21 some interventions examine adding lactation consultant (LC) support in the primary care setting and found increased breastfeeding duration.^22–24 Bonuck et al. found that LCs integrated into routine prenatal and postnatal care increased breastfeeding duration at 3 months postpartum.²² Witt et al. found that routine LC support at the initial pediatric outpatient visit improved breastfeeding duration through 9 months in a suburban, well-educated population intending to breastfeed.²³ In a low-income population, Brent et al. found that LC support prenatally and at all well child care (WCC) visits through the first year increased initiation and duration of breastfeeding at 2 and 6 months postpartum.²⁴ These studies support the efficacy of LC/PCP support; however, it is important to further evaluate LC/PCP support in diverse patient populations given disparities in breastfeeding rates and multifactorial barriers among different racial, socioeconomic groups.

In addition to assessing the efficacy of LC/PCP support, soliciting patient feedback—including evaluation of satisfaction—is important for transforming health care delivery and services.²⁵ However, only a few studies have surveyed patient experiences with breastfeeding support.^26,27 These surveys, given at breastfeeding clinics, identify that patients are generally satisfied with their support. The surveys also show that patients seek reassurance, latch instruction, answers to general breastfeeding questions, and assistance with crying/fussy babies, pain, and low milk supply. Studies on patient satisfaction with LC/PCP care are needed.

Building on prior work implementing LC/PCP team-based breastfeeding visits at a Federally Qualified Health Center (FQHC),²⁸ this study aims to further evaluate the efficacy of this approach in a socioeconomically and racially diverse population while also gathering patient feedback. This evaluation and feedback can inform efforts at transforming delivery of care to help address breastfeeding disparities and barriers.

Methods

Study site

The study was conducted at a FQHC in Cleveland, Ohio. In 2018, the organization served 18,931 patients, 85% of which qualified for financial aid, 65% of which used Medicaid, 27% of which identified as Hispanic, and 17% of which identified as African American.²⁹ Twenty-seven percent of the patients speak in a primary language other than English, with refugees comprising ∼20% of the FQHC patient population.³⁰ The FQHC provides prenatal care with five certified nurse midwives (CNMs) on staff. High-risk obstetrical care was referred to outside the practice. Families did not need to receive prenatal care at the FQHC to receive primary care for their infants.

Baseline standard of care

Before team-based LC/PCP implementation, breastfeeding support at the clinic was provided by the PCPs. A 2017 provider survey identified that only 12% of PCPs felt very confident in managing common breastfeeding problems. Only 6% of providers stated their medical training prepared them well.²⁸ When further breastfeeding support was needed, providers referred to LCs outside of the practice.

Intervention

The study intervention implemented routine LC/PCP visits for families at their first newborn visit to the FQHC following hospital discharge. Implementation occurred over the course of a year following a practice needs assessment as previously described.²⁸ At the beginning of implementation in spring of 2018, there was one Advanced Practice Registered Nurse/International Board-Certified Lactation Consultant (APRN/IBCLC) and one Registered Nurse/Certified Lactation Consultant (RN/CLC) available for LC/PCP visits. The RN/CLC worked 4 days per week and the APRN/IBCLC worked 1.5 days per week. As described in an earlier publication,²⁸ a visit was scheduled depending on LC availability with either the RN/CLC and PCP, or with the APRN/IBCLC serving as both the PCP and the LC. A typical team-based visit was scheduled for 40 minutes with the RN/LC present for the entire visit and the PCP joining for ∼10 minutes to examine the infant and coordinate plan of care. The remaining 30 minutes was dedicated to lactation support, including addressing latch, milk supply, decreasing maternal pain, and breastfeeding anticipatory guidance. Both the LC and PCP documented their portion of the visit in the electronic medical record. If the visit was scheduled with the APRN/IBCLC, then the APRN/IBCLC conducted the entire visit. If an LC was not available at the first visit or if additional breastfeeding support was needed, additional LC/PCP visits were scheduled.

After initial implementation, additional funding was obtained for further health care provider training. Training occurred in 2019 and resulted in a RN/IBCLC, a CNM/CLC and a Medical Doctor/CLC.

Study design

Data were collected from a retrospective chart review of consecutive newborns seen at the FQHC for WCC 1 year pre- and 1 year postimplementation of the LC/PCP team-based program. Program implementation occurred gradually from July 2017 to 2018. Preimplementation data were collected from July 2016 to June 2017. Postimplementation data were collected from infants born in 2019. Infants who transferred into the practice after 1 month of age and patients who visited the practice only for sick visits were excluded.

A pilot survey of patients receiving LC/PCP was conducted in both English and Spanish in June and July of 2019. Patients completed this survey in the office after their visit. In July 2020, another patient survey was conducted. This survey was sent electronically through the WELL text messaging platform³¹ in both English and Spanish to patients whose babies were delivered with practice midwives from January 2019 to June 2020 as well as to families who established care while their child was less than 2 months of age.

The Institutional Review Board of Case Western Reserve University approved the study procedures.

Measures

The main exposure variable was seeing a LC. The main outcome variable was the feeding method, which was assessed from the child's WCC note during the infant's first year (first practice visit after hospital discharge, 2 weeks, and 2, 4, 6, 9, and 12 months). For both pre- and postimplementation data, the feeding method was recorded as either EBF, any breastfeeding, or exclusive formula feeding (FF). Preimplementation, EBF did not have a discrete field and was obtained through a careful review of provider notes. Postimplementation, well child notes had discrete EPIC^® electronic health record fields to record EBF, breastfeeding, or FF.

For exposure measurements, breastfeeding patients were categorized by lactation counseling support received at the practice: noLC (never received an LC visit) or sawLC (saw lLC at the clinic at some point). Breastfeeding patients who sawLC were further categorized by the timing of their first LC visit: either LC/PCP initial (sawLC at the first visit to the practice after newborn hospital discharge) or no LC/PCP initial (did not see, a LC at the first visit to the practice)

Other sample characteristic variables collected included insurance, race, ethnicity, language, planned return to work, marital status, prenatal care, breastfeeding intent, prior breastfeeding experience, gestational age (GA), full term, maternal age and parity, age of infant at first visit, days between discharge and first visit, and neonatal intensive care unit (NICU) admission after delivery. Prenatal care was defined as receiving care from practice midwives or from outside the practice. GA was categorized as full term (>39 weeks GA), early term (37 0/7 through 38 6/7 weeks), late preterm (34 0/7 through 36 6/7 weeks), and preterm (<34 weeks).

Both the 2019 pilot survey and 2020 survey included questions on what was helpful about the visit, what type of help patients needed, if staff members were professional, and patients' suggestions to improve support. The 2020 survey included additional questions on prenatal intent to breastfeed, knowledge about the clinic's breastfeeding program, and if they were offered a lactation visit. See Table 1 for specific survey questions and variables.

Table 1.

Patient Survey 2019 and 2020

	% (n = 58)
Breastfeeding support	n = 58
Q: How would you rate your breastfeeding support today?^a
A: Much better than I expected	76% (44)
Q: What was helpful about the visit?
(1) Latch instruction	71% (41)
(2) Breastfeeding questions answered	71% (41)
(3) Learned how to manage breast pain	47% (27)
(4) Learned how often to feed the baby	38% (22)
(5) Learned about hand expression and breast massage	50% (29)
(6) Nothing was helpful.
(7) Other
Q: I Needed help with:	n = 55
(1) Latching difficulties	60% (33)
(2) Nipple damage	33% (18)
(3) Low milk supply	29% (16)
(4) Painful feedings	33% (18)
(5) Slow weight gain for my baby	20% (11)
(6) Nipple and/or breast thrush	11% (6)
(7) Feeding too often and/or for too long	7% (4)
(8) Tongue-tie	11% (6)
(9) Mastitis	7% (4)
(10) Premature baby	4% (2)
(11) Other	5% (3)
Q: Staff members were professional: Yes^b	83% (48)
Q: I felt understood by my PCP and/or LC: Yes^b	84% (47)
Q: I was given helpful advice and information: Yes^b	89% (50)
Q: I was given the opportunity to discuss concerns: Yes^b	88% (51)
Q: Please offer suggestions on how we can improve our services:
Q: Please share any additional comments or suggestions so that we can continue to improve our breastfeeding support program
Patient Survey additional questions for 2020 survey
Prenatal questions:	n = 46
Q: When you were pregnant with your baby, did you consider breastfeeding?	100% (46)
Q: At your prenatal visits, was breastfeeding information provided	93% (43)
Q: Was your prenatal care received at the clinic?	80% (37)
Q: Before delivering, were you aware that you could receive lactation support at the FQHC after delivery?	100% (43)
Formula question:
Q: If you started using formula while you were breastfeeding what were the reasons?	n = 30
(1) I was concerned about my milk supply	27% (8)
(2) I was concerned about my baby getting enough to eat at the breast	23% (7)
(3) I had always planned to use a combination of breast milk and formula	13% (4)
(4) It was painful to breastfeed	3% (1)
(5) My baby's medical provider recommended formula supplementation	7% (2)
(6) Other reasons	33% (10)
LC access and use of service:	n = 45
Q: Were you offered a visit with the LC? Yes	96% (43)
Q: Did you see a LC at your baby's first visit? Yes	71% (32)
Q: Did you see a LC at some point? Yes	84% (37)

Q = Survey Question; Answer choices are noted.

Survey questions adapted from Chin and Amir.²⁶

Answer choices = Much better than I expected/A little better than I expected/As I expected/A little worse than I expected/A lot worse than I expected

Answer choices: Strongly agree/Agree/Neither agree or disagree/Disagree/Strongly disagree.

FQHC, Federally Qualified Health Center.

Analysis

Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Case Western Reserve University REDCap. REDcap is a secure, web-based software platform designed to support data capture for research studies.³² Following collection, data were imported into SPSS statistical software version 27. After excluding infants who transferred in after the 1 month of age or were seen for only sick visits, 442 newborns were included in the final data set for analysis. Descriptive statistics were performed for both the chart review and surveys.

The primary analysis assessed the outcome of infant feeding method and breastfeeding rates before and after implementation of the LC study intervention. A secondary analysis was performed among families who initiated breastfeeding postimplementation when LC/PCP care was available at the practice. Univariate analysis with Pearson's chi-squared tested the association between the LC pre/post study intervention and feeding method rates, as well as the association between LC study intervention and feeding method among those who initiated breastfeeding after implementation.

Results

Sample characteristics

Both pre (N = 197) and post (N = 245) LC implementation groups had similar characteristics with regard to maternal age, ethnicity, race, insurance, language, first pregnancy, delivery method, full-term delivery, returning to work, prior breastfeeding experience, and marital status (Table 2). Of the postintervention newborns, 82.9% were breastfeeding at their first visit (n = 203) to the practice after delivery. Preimplementation infants were more likely to be admitted to the NICU (7.9% versus 2.9%, p = 0.031) and less likely to receive prenatal care from the practice midwives (66.0% versus 75.7%, p = 0.031). To further explore any differences in patient populations between prenatal groups, we compared sample characteristics. We did not find a significant difference between groups, except those families receiving prenatal care from the practice CNMs were significantly more likely to have a vaginal delivery (82.5% versus 69%, p = 0.01) and be married (58.4% versus 25.6%, p = 0.003) when compared with those families receiving prenatal care outside of the practice. Of those infants admitted to the NICU, 12 were full term, 3 were early term, and 3 were late preterm.

Table 2.

Sample Characteristics Pre- and Postlactation Consultant/Primary Care Provider Intervention

Sample characteristics	Total (N = 442)	Pre (N = 197)	Post (N = 245)	p
Maternal age, median (range)	27 (16–43)	26 (16–43)	28 (18–42)	0.126
Ethnicity: Hispanic/Latino	32.70%	33% (65)	32.4% (79)	0.891
Race: Caucasian	67.20%	64.1% (125)	69.7% (168)	0.293
Race: Black/African American	23.60%	25.6% (50)	22.5% (53)	0.293
Public insurance	88.80%	87.6% (162)	89.7% (209)	0.277
Primary language: English	72.70%	72.1% (142)	73.3% (170)	0.177
First pregnancy	24.70%	25.4% (50)	24.1% (59)	0.753
Vaginal delivery	79.00%	77.7% (150)	80% (192)	0.098
Infant admitted to NICU after delivery	5%	7.9% (12)	2.9% (6)	0.031
Full term	73.00%	73.2% (139)	72.9% (175)	0.467
Prenatal care received from practice midwives	71.10%	66% (126)	75.7% (162)	0.031
Prior breastfeeding experience	63.40%	65.7% (67)	61.8% (89)	0.534
Married	35.50%	36.5% (72)	34.7% (85)	0.686

The intervention is implementation of LC/PCP team-based visits at the study site.

Significant p-value < 0.05 identified in bold.

LC, lactation consultant; NICU, neonatal intensive care unit; PCP, primary care provider.

Data on breastfeeding intent and weeks returning to work were not collected before implementation of the study intervention; however, postimplementation data (n = 200) indicate that 57% of mothers wanted to breastfeed for more than a year. Of the remaining families, 16.5% intended to breastfeed for less than 3 months, 14.5% between 3 and 6 months, and 12% between 6 and 12 months. Of those families where planned return to work data were available (n = 84), the median weeks at return to work was 11 (range 2–40).

Feeding outcomes pre/postintervention

The primary analysis aimed to assess differences in feeding outcomes pre and postintervention through the 6-month WCC because of the loss to follow-up at 9 and 12 months. No significant difference in breastfeeding rates was seen (Table 3). For the whole cohort, EBF rates were 51.3% at the 2-week, 34.5% at the 2-month, and 30% at the 4-month WCC. There was no significant difference noticed between pre and postimplementation in EBF.

Table 3.

Any Breastfeeding Rate Outcomes

Breastfeeding rates pre- and postimplementation^a
Visit	Total ^b (N = 445)	Preimplementation (N = 197)	Postimplementation (N = 245)	p
Initial outpatient visit	438	77.7% (150)	82.9% (203)	0.177
2 week WCC	387	74.4% (116)	75.8% (175)	0.755
2 month WCC	412	54% (94)	60.5% (144)	0.188
4 month WCC	351	44.2% (69)	50.3% (98)	0.261
6 month WCC	292	32.4% (47)	37.4% (55)	0.37

Breastfeeding rates and prenatal care
	Total (N = 445)	Prenatal care received from practice midwives (N = 291)	Prenatal care received outside practice (N = 117)	p
Initial Outpatient visit	404	86.1% (248)	69.8% (81)	<0.001
2 week WCC	354	80.6% (208)	62.5% (60)	<0.001
2 month WCC	379	61.8% (168)	49.5% (53)	0.03
4 month WCC	322	53.2% (125)	33.3% (29)	0.002
6 month WCC	270	38.7% (77)	23.9% (17)	0.025

Breastfeeding rates and NICU admission
	Total (N = 445)	Admitted to NICU (N = 18)	Not admitted to NICU (N = 344)	p
Initial outpatient visit	359	50.0% (9)	82.1% (280)	0.001
2 week WCC	315	46.7% (7)	76.7% (230)	0.009
2 month WCC	336	17.6% (3)	59.9% (191)	0.001
4 month WCC	285	14.3% (2)	49.4% (134)	0.01
6 month WCC	248	14.3% (2)	37.2% (87)	0.083

Significant p-value < 0.05 identified in bold.

The intervention is implementation of LC/PCP team-based visits at the study site.

Total column reflects sample size for a given time period.

WCC, well child care.

While the primary analysis assessing feeding outcomes pre and postintervention was not significant, we further explored the association of prenatal care and admission to the NICU on feeding outcomes given these characteristics were significantly different between the pre and postintervention. A univariate analysis on feeding rates found significantly higher rates of breastfeeding through 4 months in those not admitted to the NICU and higher rates of breastfeeding through 6 months in those who received prenatal care from the practice midwives (Table 3). To explore if these associations were dependent or independent, a multivariate analysis was run with the three variables (pre/postintervention, NICU admission, prenatal care). Multivariate analysis showed that, for those receiving prenatal care from practice midwives, BF rates remained significantly higher at 2 week WCC (p = 0.004, Odds Ratio [OR] = 2.38, 95% Confidence Interval [CI] = 1.42–4.25), 4 month WCC (p = 0.004, OR = 2.35, CI = 1.42–4.21) and 6 month WCC (p = 0.024, OR = 2.18, CI = 1.11–4.29). For those infants not admitted to the NICU, BF rates also were significantly higher at 2 week WCC (p = 0.025, OR = 3.47, CI = 1.25–10.2), 2 month WCC (p = 0.006, OR = 6.06, CI = 1–2.62), and 4 month WCC (p = 0.033, OR = 5.39, CI = 1.25–25) suggesting independent effects on feeding outcomes.

Feeding outcomes among families initiating breastfeeding postintervention

To further examine the impact of LC/PCP support on those families initiating breastfeeding, a secondary analysis examined the relationship between feeding outcomes and LC support. There were similiar characteristics with regard to maternal age, ethnicity, race, insruance, language, delivery method, NICU admissions, infant term, prior breastfeeding experience and marital statues between breastfeeding families who saw an LC and those who did not see an LC (Table 4). Mothers who saw an LC were significantly more likely to have completed a first pregnancy (30.8% versus 8.8%, p = 0.001), return to work (63.0% versus 41.9%, p = 0.014), and receive prenatal care with the practice midwives (88.1% versus 55.3%, p < 0.001). Those families who initiated breastfeeding postintervention and saw a LC at some point, were significantly more likely to be breastfeeding at 2 weeks (93.7% versus 79.6%, p = 0.004) and 4 months (67.8% versus 45.2%, p = 0.001) in comparison to those who did not see a LC (Table 5). They were also significantly more likely to be EBF at 2 weeks (61.5% versus 49.0%, p = 0.015) and 4 months (45.2% versus 28.6%, p = 0.035).

Table 4.

Sample Characteristics Postimplementation, Patients Initiating Breastfeeding

Sample characteristics	Total (N = 203)	2019 sawLC (n = 146)	2019 noLC (n = 57)	p
Maternal age, median (range)	28 (18–42)	27.5 (18–42)	28 (17–42)	0.503
Ethnicity: Hispanic/Latino	34.16%	31% (45)	32.1% (18)	0.135
Race: Caucasian	66.83%	67.1% (96)	66.1% (37)	0.82
Race: Black/African American	23.12%	23.1% (33)	23.2% (13)	0.82
Public Insurance	88.08%	87.7% (121)	89.1% (49)	0.785
Primary language: English	69.47%	67.2% (92)	75.5% (40)	0.7
First pregnancy	24.63%	30.8% (45)	8.8% (5)	0.001
Vaginal delivery	81.82%	83.9% (120)	76.4% (42)	0.422
Infant admitted to NICU after delivery	2.33%	2.4% (3)	2.1% (1)	0.916
Full term	74.75%	72.9% (105)	79.6% (43)	0.229
Returning to work	58.01%	63% (87)	41.9% (18)	0.014
Prenatal care with practice midwives	79.56%	88.1% (118)	55.3% (26)	<0.001
Prior breastfeeding experience	62.04%	59.8% (73)	80% (12)	0.129
Married	39.90%	40.4% (59)	38.6% (22)	0.812

Significant p-value < 0.05 identified in bold.

noLC, never saw a lactation consultant at the primary care providers office; sawLC, saw a lactation consultant at the primary care providers office.

Table 5.

Postintervention Breastfeeding Rates for Patients Initiating Breastfeeding and Breastfeeding at First Primary Care Visit

Any breastfeeding rates for main outcome of seeing a LC
Visit	Total ^a (N = 203)	sawLC (N = 146)	No LC (N = 57)	p
2 week WCC	192	93.7% (134)	79.6% (39)	0.004
2 month WCC	197	75.5% (108)	63% (34)	0.08
4 month WCC	157	67.8% (78)	45.2% (19)	0.01
6 month WCC	116	49.4% (42)	38.7% (12)	0.307

Breastfeeding rates and prenatal care
		Prenatal care received from practice midwives (N = 144)	Prenatal care received outside practice (N = 37)
2 week WCC	172	90.8% (128)	90.3% (28)	0.937
2 month WCC	175	71.9% (100)	77.8% (28)	0.481
4 month WCC	139	63.9% (76)	50% (10)	0.237
6 month WCC	102	46.6% (41)	42.9% (6)	0.795

Breastfeeding rates and planned returning to work
		Returning to work (N = 105)	Not returning to work (N = 76)
2 week WCC	175	93.3% (97)	87.3% (62)	0.18
2 month WCC	176	77.5% (79)	70.3% (52)	0.281
4 month WCC	145	64.4% (56)	60.3% (35)	0.624
6 month WCC	106	46.9% (30)	47.6% (20)	0.94

Breastfeeding rates and first delivery (primiparous)
		Primiparous (N = 50)	Multiparous (N = 153)
2 week WCC	192	86% (43)	91.5% (130)	0.258
2 month WCC	197	75.5% (37)	70.9% (105)	0.537
4 month WCC	157	69% (29)	59.1% (68)	0.258
6 month WCC	116	41.4% (12)	48.3% (42)	0.519

Significant p-value < 0.05 identified in bold.

Total column reflects sample size for given time period.

Given significant differences were noted between groups in the sample characteristics of first pregnancy, return to work, and prenatal care, a univariate analysis on feeding outcomes was performed to determine if these variables impacted the primary outcome of breastfeeding rates. No significant difference was found (Table 5).

LC utilization

To understand the frequency of LC visits among those patients initiating breastfeeding, descriptive statistics examined utilization of services at the practice. Of the 203 infants who initiated breastfeeding postimplementation, 71.9% (146) had a lactation visit with 55.2% (112) having a lactation visit at their first appointment, and 21.9% (59) having multiple LC visits. Of those patients who saw a LC at their first visit, 54% saw the RN/CLC and 46% saw the APRN/IBCLC. There was no difference in feeding outcomes between those who saw the RN/CLC with their PCP at the first visit versus those who saw the APRN/IBCLC. On average, patients who initiated breastfeeding had 1.18 lactation visits (standard deviation [SD] 1.15). The median age of the infants at their first visit to the office was significantly younger in those who saw an LC as compared with those who did not (4 [2–20] versus 5 [2–20], p < 0.001).

Patient surveys

Twenty-six patients were offered the 2019 pilot patient satisfaction survey after a LC/PCP visit in the office with a 77% response rate (n = 20). The 2020 survey, sent electronically to 486 families through the WELL text platform, had a 10% response rate (n = 48). Overall survey results were positive (Table 1). The breastfeeding support was much better than expected for 76% of respondents. The three most helpful parts of the LC visit were latch instruction (71%), answering of breastfeeding questions (71%), and instruction on hand expression and breast massage (50%). Respondents most commonly noted needing help with latching difficulties (60%), nipple damage (33%), painful feeding (33%), and low milk supply (29%).

Discussion

For families initiating breastfeeding at the FQHC, a team-based LC/PCP model of support significantly increased the likelihood of continued breastfeeding at the 2-week and 4-month WCC visits. Our study focused on team-based support in the first week postpartum, a few days after hospital discharge. Offering team-based visits at the first outpatient appointment (median age = 4 days old) may account for the finding that the benefit of the team-based intervention was most strongly observed at the 2-week WCC. Breastfeeding patients who saw a LC were 3.8 times more likely to be breastfeeding at the 2-week WCC than breastfeeding patients who did not see a LC. Receiving this support in the early postpartum addresses lactation difficulties such as pain and milk supply concerns, the two most commonly cited reasons for weaning.^10,12 Our surveys confirmed that patients shared these common breastfeeding concerns, including latching difficulties, nipple damage, and low milk supply.

More sustained, regular LC/PCP support may be needed to further improve duration past 4 months and to fill in the gap in significance observed at 2 months. Our study standardized LC/PCP visits at the first outpatient visit with additional LC visits scheduled as desired. This approach resulted in a median number of 1.1 LC visits per patient. Given studies identify that more frequent visits can improve breastfeeding intensity and duration,^22,24 it may be necessary to increase the frequency of LC/PCP visits to improve breastfeeding duration beyond 4 months.

Despite the improvements in feeding outcomes observed within patients initiating breastfeeding, the team-based LC/PCP intervention did not significantly improve breastfeeding rates for the whole practice. Instead, multivariate analysis showed that prenatal care and infant NICU admissions did affect feeding outcomes for the entire practice. These findings reinforce the importance of prenatal breastfeeding support.^15,22 Additionally, we identify NICU graduates as a vulnerable breastfeeding population.

When examining the impact of prenatal care on feeding, it is possible that care received outside of the practice is a marker for other breastfeeding risk factors, as in general midwife deliveries are lower risk pregnancies. Not having details on pregnancy risk is a study limitation for the pre/post study intervention feeding outcome analysis. However, our multivariate analysis identified that prenatal care did not impact feeding outcomes for the postintervention analysis, confirming that LC/PCP support helps improve duration in those families initiating breastfeeding.

In our study, patients who received prenatal care at the practice were more likely to receive LC support. This is most likely because the practice midwives scheduled the initial newborn appointment for the family after delivery. Those patients who received prenatal care outside of the practice scheduled through central phone scheduling and reasons for declining a visit were not recorded. The difference in LC appointments between the cohorts identifies logistical considerations involved when implementing practice changes. The practice is now working on a quality improvement effort to improve access, including auditing scheduling of patients, availability of LC appointments, and reasons for patients not receiving a LC visits

The sample size for our NICU graduates is small (n = 9); however, we found a significant impact on feeding outcomes with a small sample size. Given our significant findings and limited studies assess the impact of NICU admission on breastfeeding outcomes,³³ it is worth exploring further breastfeeding support for this cohort. While exact details on the reason for NICU admission is unknown and is a study limitation, the majority of these admissions were term infants. Although NICU admission could be a marker for other risk factors for breastfeeding difficulties, our analysis suggests that additional support may be needed for late preterm and full-term infants admitted to the NICU and future study on breastfeeding outcomes within this cohort should be considered.

Further study limitations to consider when interpreting our findings include the retrospective design and the inability to control for provider breastfeeding education. We used a multivariate analysis to help control for the biases of a retrospective design, in which variables, such as prenatal care, return to work, and breastfeeding intent, may affect feeding outcomes. While provider education was not formally part of the intervention, the initiation of the program resulted in the opportunity for further provider education; it is possible this provider education improved general breastfeeding knowledge at the practice and contributed to improvement in breastfeeding rates.^22,34 However, the catalyst for the education was implementation of the team-based program, so any increase in rates from provider education can be attributed to the LC/PCP program. As provider education can be a means of addressing the barrier of health care provider support and knowledge,^35,36 future study could examine the impact of LC/PCP care implementation on provider knowledge.

Although some barriers to breastfeeding may be addressed with further health care provider education, PCPs have limited time during visits to provide all needed counseling.²¹ Our patient surveys, a study strength, confirm that patients need and value the LC/PCP support with 89% of families receiving helpful advice and information. Most commonly, families had difficulties with latching and found instruction on latch correction helpful; this is especially important given that poor latch is a common cause of nipple pain,³⁷ a common cause of weaning.¹² Independent of the impact of LC/PCP care on feeding outcomes, the surveys help quantify the value of this service to patients, which is an important measure when implementing changes.³⁸

Our study confirms that patients value breastfeeding support in the primary care office and that while multiple factors impact feeding outcomes, providing team-based LC/PCP is one effective means to improve breastfeeding duration for those families initiating breastfeeding. Future study could examine the use of team-based LC/PCP outpatient visits in combination with other interventions, such as prenatal breastfeeding counseling or more frequent outpatient postnatal LC visits, to more effectively increase both breastfeeding initiation and duration in a racially and socioeconomically diverse patient population.

Conclusions

For families initiating breastfeeding at the FQHC, a team-based LC/PCP model of support significantly increases breastfeeding duration, and patients value the service. Future study is needed to examine if more frequent team-based LC/PCP care visits, or implementing the care as part of a comprehensive program, would be more effective in addressing the multiple factors influencing feeding outcomes in a socioeconomically and racially diverse community.

Footnotes

Disclaimer

The article contents are solely the responsibility of the authors and do not represent the official views of the Centers for Disease Control and Prevention. The funder did not participate in the study design, collection, analysis, and interpretation of the data or in the writing of this article.

Acknowledgments

The authors want to thank Neighborhood Family Practice for their collaboration with Breastfeeding Medicine of Northeast Ohio to implement team-based LC/PCP care at the FQHC. Data collection was made possible through Clinical and Translational Science Award—UL1TR002548 for REDCap project utilization.

Disclosure Statement

No competing financial interests exist.

Funding Information

This article is based in part on work from a project for breastfeeding support and training partially funded by the Centers for Disease Control and Prevention; National Center for Chronic Disease Prevention and Health Promotion; Division of Nutrition, Physical Activity, and Obesity; and Racial and Ethnic Approaches to Community Health (REACH) Program, Grant Number: 5 NU58DP006586-03-00

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