Breastfeeding is described as the gold standard of infant feeding and is beneficial to both infant and maternal health. Breastfeeding protects infants against diarrhoea and respiratory infections, sudden infant death syndrome and necrotising enterocolitis (Ip et al, 2007; O'Connor et al, 2016; Victora et al, 2016). In women, breastfeeding is protective against breast cancer and potentially ovarian cancer; it also facilitates maternal postpartum weight normalisation, protection against type 2 diabetes, and improves birth spacing (Chowdhury et al, 2015; Riordan and Wambach, 2015; Victora et al, 2016). Breastfeeding is economically advantageous, in comparison to the cost of formula milk, and results in a substantial reduction in healthcare costs (Brown, 2017; Pollard, 2018). The World Health Organization (WHO, 2020) recommends exclusive breastfeeding until an infant reaches the age of 6 months and the continuation of breastfeeding alongside the introduction of solids up to 2 years of age and beyond. In spite of this recommendation, breastfeeding rates in Ireland are low (Health Service Executive [HSE], 2018) and, of the women who do breastfeed, many give up sooner than intended, especially in situations were combination feeding was introduced (Hemmingway et al, 2020).
Women are most likely to stop breastfeeding within the first 6 weeks of the postnatal period (Brown et al, 2017). Therefore, interventions that support and protect breastfeeding during this crucial period are important. There are many factors that contribute to early cessation of breastfeeding, including sore nipples, insufficient milk supply and expressing (Odom et al, 2013; Pickett and Jones, 2020). In addition, Leahy-Warren et al (2017) and more recently Hauck et al (2020) identify embarrassment and stigma as major barriers to women breastfeeding in Ireland, and advocate normalisation of breastfeeding.
Breastfeeding support, in particular support from trained professionals, can increase the duration and exclusivity of breastfeeding (McFadden et al, 2017). In Ireland, a range of breastfeeding support groups are available, including public health nurse-led groups and volunteer-led groups (Mulcahy et al, 2012; McCarthy Quinn et al, 2019). This study aimed to conduct a service evaluation of a hospital-based specialist postnatal breastfeeding clinic.
Methods
The clinical midwife specialists in lactation at an urban Irish hospital pioneered a specialist breastfeeding clinic in 2013, where women (and their partners) could attend weekly for up to 6 weeks postnatally. All of the clinical midwife specialists in lactation were international board-certified lactation consultants (IBCLC).
Expert clinical support and management of breastfeeding challenges were provided by the clinical midwife specialists. Each breastfeeding woman received a one-to-one consultation with a clinical midwife specialist within a group session. Challenges to breastfeeding were identified at each individual consultation, a breastfeeding care plan was provided to women, and they were encouraged to return the following week to the clinic to evaluate progress. Great emphasis was placed on correct position and attachment of the baby at the breast. Women were taught further breastfeeding positions, effective feeding at the breast and indicators that they were breastfeeding well, such as audible swallowing and observation of urinary and stool output.
A total of 99 women who attended the clinic in 2017 were contacted by telephone in 2018 and invited to participate in a service evaluation. A telephone questionnaire was administered to each participant. Data collected included nationality, parity, reason for attending the clinic and the duration of their breastfeeding experience. Participants were also asked if they would like to comment on their experience of the clinic. Each participant was given a unique identification (ID) number to anonymise the data. Descriptive analysis was conducted on quantitative data. The qualitative data were anonymised and subjected to thematic analysis. These data are presented using IDs.
Results
There were 8 524 births in the hospital in 2017 (Central Statistics Office, 2017). Overall, 76% of women initiated breastfeeding and, of these women, 829 (10.2%) women attended the specialised breastfeeding clinic. A random selection of 99 women who attended the clinic were selected by two clinical midwife specialists in lactation. An evaluation of 100 women was initially planned and the final number of 99 women was reached as the result of a duplicate woman. The selected participants were contacted by telephone and invited to participate in the service evaluation.
Over three-quarters of the women attending the clinic were Irish. The majority (61%) of women who attended were first-time mothers and for 33% of women, this was their second baby. Of the 99 women, 99% of them were breastfeeding at 6 weeks, 92% at 3 months and 77% at 6 months, respectively. The majority of women attended with one breastfeeding challenge (63%), while 24% of women attended with two breastfeeding challenges. (Table 1).
Table 1. Sociodemographic characteristics of participants
| Characteristic | Frequency, n=99 (%) |
|---|---|
| Nationality | |
| Irish | 84 (85) |
| European Union | 10 (10) |
| Non-European Union | 5 (5) |
| Parity | |
| 1 | 60 (61) |
| 2 | 33 (33) |
| 3 | 2 (2) |
| 4 | 2 (2) |
| Missing | 2 (2) |
| Duration of breastfeeding | |
| 6 weeks | 98 (99) |
| 3 months | 91 (92) |
| 6 months | 76 (77) |
| 12 months | 27 (29)* |
| Number of breastfeeding problems on presentation to the clinic | |
| 1 | 62 (63) |
| 2 | 24 (24) |
| 3 | 11 (11) |
| 4 | 2 (2) |
Benefit of professional support at the clinic
The main reason women gave for attending the specialised breastfeeding clinic was to receive further support with position and attachment of baby at the breast. Additionally, women wished to receive advice in relation to sore nipples and breasts. Some women had concerns in relation to their milk supply.
On discharge from hospital, one participant (ID:6, breastfed for 7 months), was exclusively expressing milk and felt the support provided at the clinic helped her overcome her breastfeeding challenges. Her baby was small and would ‘latch with short feeds only’. She described the clinic as ‘brilliant’ as it had been ‘hard to establish feeding’.
Another participant reported that she would not have breastfed her baby for 10 months had it not been for the help she received at the clinic.
‘The support with position and attachment, the support to wean off nipple shields.’
Participant 40, breastfed for 10 months
Professional breastfeeding support was important for the women at the clinic. They received a one-to-one lactation consultation where breastfeeding challenges were identified and a plan was put in place. Women then returned the following week to report on their breastfeeding progress and any further challenges were identified, with further support offered.
This individualised approach, described by a participant (ID:37, breastfeeding at 11 months) as ‘one-to-one personal care’ with a ‘focus on mother and baby’, was very much appreciated.
‘The one-to-one is very important, as everyone is so different.’
Participant 37, breastfeeding at 11 months
‘Everything was good about the clinic, the one-to-one time…weekly review was helpful.’
Participant 9, breastfed for 9 and a half months
Women reported that they found the clinic to be a supportive environment.
‘Very supportive, positive experience…marvellous.’
Participant 15, breastfeeding at 9 months
In addition to support from the clinical midwife specialists, women clearly enjoyed interaction and support from peers.
‘Other mothers chat was important.’
Participant 18, breastfed for 6 months
‘I made friends there.’
Participant 84, breastfeeding at 18 months
One mother reported that the women attending the clinic were ‘learning the skill together’ (ID:38, breastfeeding at 11 months).
One participant reported that herself and three other women who met at the clinic became friends and still met regularly (ID:21, breastfed for 11 months).
Empowerment to breastfeed
The importance of the clinical midwife specialists in building the women's confidence and ability to breastfeed in the early days was significant. It empowered their ability to breastfeed and was the key to successful breastfeeding. They felt motivated, more confident and in control of their breastfeeding.
‘[name of the clinical midwife specialist] at the clinic was very motivating, she made me feel I could do it.’
Participant 13, breastfed for 18 months
Another woman described her initial breastfeeding experience as a ‘rocky start’ and highlighted that attending the breastfeeding assessment clinic at the hospital helped her to ‘turn the corner with breastfeeding’ (ID:53, breastfed fed for 13 months).
The support given at the clinic encouraged women to continue breastfeeding.
‘[I] would not have fed but for the help at the clinic.’
Participant 40, breastfeeding at 10 months
‘[I] would have given up breastfeeding after a month.’
Participant 48, breastfeeding at 15 months
Areas for improvement
Notwithstanding the benefits of the specialised breastfeeding clinic, there were areas identified by women where improvements could be made. Some women commented on the waiting time, with a number of women reporting that they waited 1–2 hours before being seen by a clinical midwife specialist. One participant reported the need for extra resources to deal with the demand.
‘A lot of people and you just have to wait your turn.’
Participant 27, breastfed for 10 weeks
‘Clinic numbers are too large after 11:00.’
Participant 17, breastfeeding at 8 months
‘The room was overcrowded; a second session is needed.’
Participant 21, breastfed for 11 months
Most women attended the specialist breastfeeding clinic alone. However, a number of women attended with their partner, or mother, particularly during the first and/or second visit to the clinic and this was encouraged by the clinical midwife specialist. Interestingly, three women who took part in the service evaluation remarked on the presence of men at the breastfeeding clinic.
‘[she felt a] little intimidated by males in the room.’
Participant 88, breastfeeding at 13 months
Access to the specialist breastfeeding clinic with a pram was also a challenge, according to the participants. The clinic was located on the second floor of the hospital education centre, which did have an internal lift. However, there were steps to navigate to enter the building.
Some women attending the clinic with their baby required assistance to lift the baby pram up the steps. This was particularly challenging for new postpartum women, not to mention women following caesarean birth. A purposeful external lift is now in place.
Discussion
In Ireland, the Health Service Executive (2018) reported that 60% of mothers recorded any breastfeeding and 50% of mothers were exclusively breastfeeding on discharge from hospital. The breastfeeding rates identified in this service evaluation are significantly higher than the national rates, with 76% of women breastfeeding on discharge from hospital, and breastfeeding rates of 99%, 92% and 77% at 6 weeks, 3 months, and 6 months, respectively. Data on women's age and socioeconomic group were not collected as part of this service evaluation. However, anecdotally the clinical midwife specialists reported that the majority of women were over 30 years old and employed in professional roles. This is reflective of the fact that, in Ireland, breastfeeding rates increase with mothers' age and higher rates are associated among women of professional socioeconomic groups (Health Service Executive, 2018).
The variation of breastfeeding rates in Ireland is multifactorial, and factors affecting it include geographical location, and mother-and-infant factors, in addition to skilled breastfeeding support. It is well recognised that skilled breastfeeding support is paramount in the early days postpartum as breastfeeding is being initiated (Brown, 2017). There is evidence to suggest that exclusive breastfeeding rates in women during the early postpartum period may be associated with the breastfeeding education and skills training of the midwife, nurse or physician supporting women (Radzymhski and Callister, 2015; Pemo et al, 2019). Midwives are recognised as key breastfeeding advocates and more recently dedicated lactation specialists, IBCLCs play a key role in the provision of education to pregnant and breastfeeding women. In Ireland, the majority of IBCLCs are healthcare professionals who have completed additional training and education in the field of lactation (Association of Lactation Consultants Ireland, 2020). Interestingly, a systematic review of the literature by Patel and Patel (2016) identified positive outcomes from breastfeeding interventions facilitated by IBCLCs, including increased breastfeeding initiation rates, breastfeeding exclusivity and duration of breastfeeding at 1 month. In contrast, Whelan and Kearney (2014) and Leahy-Warren et al (2014) question the current medicalisation of breastfeeding and the importance women place on the specialist care of the lactation consultant. Continuous professional development in the field of breastfeeding and lactation education for healthcare professionals may be the key to improving breastfeeding rates; with breastfeeding and lactation education offered at a level specific to the role of the individual healthcare professional (Gallagher et al, 2015)
It is well documented that breastfeeding duration and exclusivity increases when support, either by professionals or peers, is provided to the breastfeeding mother (McFadden et al, 2017). While some women breastfeed without challenges, some women struggle to establish breastfeeding and if they do not find skilled breastfeeding support and guidance, will reluctantly stop breastfeeding sooner than they had wished (Brown, 2017). Women, particularly first-time mothers, may lack the knowledge to overcome early challenges, such as sore nipples, painful latch on and concerns in relation to available milk supply (McAndrew et al, 2012). This can give mothers a sense of lacking self-efficacy in their ability to breastfeed. This is particularly challenging in Ireland, where many women do not have the family support of a mother or grandmother who breastfed, as a result of a lost generation of breastfeeding. Social support and cultural norms in a country can affect breastfeeding, for example, in Ireland, Bennett et al (2016) reported that fathers felt unprepared for supporting their partner with breastfeeding challenges. Therefore, women are particularly reliant on skilled healthcare professionals to support them on their breastfeeding journey.
Factors found to be most effective in successful breastfeeding include support being provided by trained personnel, face-to-face support and support services that respond to the specific needs of the particular group (McFadden et al, 2017). The attendance at breastfeeding support groups was described as beneficial in the present study, with both public health nurses and breastfeeding women recognising the importance of a social support network. The key to the success of a public health nurse-led breastfeeding support group described by Whelan and Kearney (2014) was the presence of an experienced healthcare provider, in addition to breastfeeding women supporting each other. While this is a formal approach to breastfeeding support, it provides a stepping stone effect, as women progress to a more informal peer support group, as breastfeeding is established (McCarthy Quinn et al, 2019).
‘Peer support occurs when people provide knowledge, experience, and emotional, social or practical help to each other’.
Although the women surveyed in this service evaluation attended primarily to receive support from the clinical midwife specialist, the power of reciprocal support from their peers was evident.
‘Centering Breastfeeding’ evolved from the concept ‘Centering Pregnancy’ and is described in the American studies by Hahn et al (2017) and Fiset et al (2016) as a group care model approach to breastfeeding, incorporating assessment and education, whereby, women participate in their healthcare and learn from their peers. This model of care ensures breastfeeding mothers receive individual clinical expertise and targeted guidance (Huang et al, 2019) by the IBCLC in addition to peer support. The model of care offered at the specialist breastfeeding clinic mirrors the ‘Centering Breastfeeding’ approach.
Limitations
This service evaluation was confined to women attending one hospital and the sample size was small. Anecdotally, the clinical midwife specialists in lactation reported that the majority of women in this evaluation were aged over 30 years and employed in a professional capacity. This is not representative of the general breastfeeding population.
Conclusions
Breastfeeding rates in Ireland are low by international standards. It is well documented that supporting breastfeeding mothers during the early weeks postpartum results in improved breastfeeding outcomes. This service evaluation identified that skilled professional breastfeeding support, in addition to peer support, is a positive and acceptable way to promote the continuation of breastfeeding among women who present with common breastfeeding challenges. As reported by the participants in this service evaluation, the specialist breastfeeding clinic is highly valued and is perceived as an essential breastfeeding service. This is reflected in the consistent demand for the service. In addition, the duration of breastfeeding among the participants dramatically exceeds the national average and is testament to the importance of this novel approach to breastfeeding support offered at this specialist breastfeeding clinic. Further resources for such breastfeeding services could contribute to increasing breastfeeding rates in Ireland and similar settings.
Key points
- Breastfeeding is described as the gold standard of infant feeding and is beneficial to both infant and maternal health, therefore reducing healthcare costs.
- Many women stop breastfeeding because of early challenges, such as sore nipples or breasts, or perceived insufficient milk supply.
- Breastfeeding challenges should be identified early, with professional support and management strategies implemented to support women to achieve their breastfeeding goals.
- Continuity of breastfeeding support by clinical midwife specialists in lactation, up to 6 weeks postnatally, promotes an increase in the duration of breastfeeding.
- The model of care at the Specialist breastfeeding clinic incorporated individual clinical expertise and targeted guidance, in addition to peer support, and mirrors a ‘Centering Breastfeeding’ approach that was adapted in the US.
CPD reflective questions
- Why is breastfeeding important?
- What is the main key to successful breastfeeding?
- What are the early challenges to breastfeeding experienced by mothers?
- What support is available to breastfeeding mothers?