The benefits of phone support and home visits: an evaluation of the City Of Kingston's breastfeeding support service.
Abstract: This paper presents an evaluation of the City of Kingston Breastfeeding Support Service that was performed in 2006. The evaluation utilised a mail-out questionnaire designed to investigate mothers' breastfeeding expectations, experiences, issues and support received, in addition to their experience of using the Service. Seventy-seven percent of mothers contacted the service for support due primarily to problems with positioning and attachment, nipple pain or mastitis. Other reasons were also cited, reflecting that it takes time and experience for women to learn to breastfeed and to develop an understanding of their lactation. The study found that on discharge from hospital, 59% of mothers were fully breastfeeding; this figure decreased to 32% at the time of contacting the service, but increased to 42% two weeks after contacting the service. Satisfaction with both the model of service and the support received was very high. Mothers were able to feel more comfortable with their breastfeeding (75%), to breastfeed for longer (59%) and with more confidence (71%) and greater knowledge (68%) about breastfeeding and lactation. The majority of mothers (96%) reported they would contact the service again if they needed further breastfeeding advice and support.

Keywords: breastfeeding, breastfeeding support
Author: Coffield, Karen
Pub Date: 11/01/2008
Publication: Name: Breastfeeding Review Publisher: Australian Breastfeeding Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 Australian Breastfeeding Association ISSN: 0729-2759
Issue: Date: Nov, 2008 Source Volume: 16 Source Issue: 3
Accession Number: 200921830
Full Text: [ILLUSTRATION OMITTED]

INTRODUCTION

The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of a baby's life (Dennis 2002). Breastfeeding is associated with both short term and long term health benefits for both the mother and the baby, including reduced infant mortality and morbidity (Sikorski et al 2003). Breastfeeding problems are associated with maternal anxiety, stress and higher levels of postnatal depression (Shakespeare, Blake & Garcia 2004). The promotion of breastfeeding, and provision of support for mothers to breastfeed, is a major health promotion strategy.

The City of Kingston is a local government municipality in the middle southern suburbs of Melbourne. It has an ethnically diverse population (City of Kingston 2001), and is a growing municipality with 1725 births in 2005 (City of Kingston 2005). As part of the Maternal and Child Health Service, a Maternal and Child Health Nurse Lactation Consultant (MCHN/LC) is employed for 16 hours per week, to provide breastfeeding support to mothers and babies (subsequently referred to as the City of Kingston Breastfeeding Support Service, or the Service). Women can self-refer, or are referred to the Service by midwives at hospitals, General Practitioners, or by their Maternal and Child Health Nurse (MCHN) (City of Kingston 2004).

This Service model provides both home visits and telephone support, by one MCHN/LC, to provide continuity of care. To date there has not been a published study of an identical service model. However relevant research does support the aims of the service. The support of 'field nurse' home visits for the duration of a mother's breastfeeding was demonstrated to increase duration of breastfeeding (Hoyer & Horvat 2000). In-depth interviews with 21 mothers identified that the most helpful support was provided by one-to-one contact with the same midwife, who actually demonstrated and assisted them to develop breastfeeding skills (Hoddinott & Pill 2000).

This study was designed to evaluate the City of Kingston Breastfeeding Support Service and its success in supporting breastfeeding mothers and promoting breastfeeding in the City of Kingston. The following key questions were addressed:

1. What are the characteristics of mothers who access the Service? Are there any differentials across age, educational background, suburbs of residence, ethnic background, parity, previous breastfeeding experience, family support, and breastfeeding expectations of the mother?

2 What are the breastfeeding issues that mothers seek support for?

3. Did the support, advice and counselling provided by the Service

i. improve the mother's satisfaction with breastfeeding?

ii. enable the mother to breastfeed for a longer period of time?

iii. prove to be helpful to the mother?

iv. improve the mother's sense of comfort with breastfeeding?

4. What are the obstacles or difficulties in contacting and accessing the Service?

METHOD

Design and Sample

This study utilised a descriptive design involving a postal questionnaire surveying all mothers (n = 96) who used the Service over a three month period from February to April 2006. Ethics approval was granted by the City of Kingston Family Services Management Ethics Committee. Complete confidentiality was assured by the questionnaires being coded, and the list of names and addresses secured in the MCHN Coordinator's office. This list was destroyed once the final reminder letter was mailed out. There is no permanent record of the identity of the mothers surveyed.

The Questionnaire

The questionnaire was developed by the researcher and reviewed by City of Kingston Maternal and Child Health Nurses/Lactation Consultants prior to its administration. Their familiarity with both the Service and the client base enabled valuable feedback on validity.

The questionnaire consisted of thirty-five questions and took approximately fifteen minutes to complete. The questions were closed and required response by either ranking on a Likert scale or 'tick' boxes. Space was provided for comments and 74% of respondents added comments (not analysed in this paper). The themes covered by the questions included demographic data, previous breastfeeding experience, partner and family support for breastfeeding, intention to breastfeed, reasons for contacting the Service, and a variety of questions about contacting and using the Service, breastfeeding exclusivity, and breastmilk supplements. A plain language statement accompanied the questionnaire to explain the reasons for the evaluation and assure mothers of confidentiality.

The statistical computer package 'SPPS' (V.14) was used for data analysis.

RESULTS

Participants

The response rate was 73% (69 of 96 posted questionnaires), which lies within the acceptable range of 60-75% (De Vaus 2000). This rate can be considered high given the extra demands on a mother with a new baby.

Older mothers used the Service at a proportionally higher rate than younger mothers (Table 1). Twenty-eight percent of respondents were in the 36-40 age group, whereas in Victoria in 2004, women aged 35-39 years account for 19% of births (Riley, Davey & King 2005).

More than half of the respondents (59%) had completed university degrees at bachelor level or higher (Table 1). Unfortunately, statistics on the specific level of education of all new mothers in the City of Kingston is not recorded, for a comparison to be made with the sample of mothers using the Service.

Mothers from all suburbs across the City of Kingston accessed the Service. Comparison of suburb of residence with Birth Notices gave proportional use across suburbs relative to number of births.

The Service is used by significant numbers of women not born in Australia. One third of respondents were born overseas, with 19% stating that their birth country was not English speaking. Of these women born overseas, 29% arrived aged five or less, 33% aged between 6 and 19 years (school-aged), and the remaining 38% arrived aged 20-30 years.

A large number of respondents (51 of 69 mothers) were primipara. The remaining 18 mothers were breastfeeding a subsequent baby, and all of these mothers had breastfed before, for various lengths of time. Eighty-four per cent of mothers contacted the service within the first 6 weeks of breastfeeding, 4 % in the first weeks, 16% in the first week.

Mothers' breastfeeding experience

In order to gain insights into the context of the respondent's breastfeeding experience, questions were asked about how the reality has compared to expectations about breastfeeding, the timing of the decision to breastfeed, and family support or attitudes to breastfeeding. More than half the mothers responded that breastfeeding had been harder (58%) or somewhat harder (18%) than expected. The majority of mothers (91%) made a conscious choice about infant feeding and breastfeeding, and 69% of mothers made this decision before conception.

Results suggest that there is a high level of community support for mothers to breastfeed, particularly from partners and family (Table 2). However, 4% of partners and 7% of families were not supportive, presenting the potential for stress and conflicting emotions in coping with breastfeeding problems.

Reasons why mothers contacted the Service

Mothers were asked to identify, from a list of breastfeeding issues, the 'main reason' they contacted the Service, and then in a separate question, to identify any additional or other reasons. Table 3 demonstrates that 52% of respondents identified pain associated with breastfeeding as the 'main reason' for contacting the service ('painful breastfeeding', 'nipple pain or damage', 'mastitis or breast infection'). Difficulties with attachment were the next most common 'main reason' for contacting the Service.

Breastfeeding rates

Mothers were asked to specify how they were feeding their baby on discharge, at the time of contacting the Service, and two weeks after contacting the Service. Categories included: fully feeding at the breast; breastfeeding and supplementing with expressed breastmilk (ebm); breastfeeding and supplementing with artificial baby milk (af); not attaching to the breast, but expressing and feeding ebm; not attaching to the breast, but expressing and feeding ebm and af. This information was sought to gain a baseline on breastfeeding rates on discharge, and to assess the impact of contact with, and the breastfeeding support of, the Service upon the quality of breastfeeding.

Table 4 reveals an increase in the proportion of babies fully breastfeeding, and an increase in babies attaching to the breast for some of their feeds, weeks after contact with the Service.

Mothers' impressions of the support, advice and counseling provided

Mothers were asked to respond, by ticking one or more of the statements, about the support they received from the lactation consultant (Table 5). Only one mother felt contact with the Service did not support her breastfeeding and three mothers responded that the Service did not solve their breastfeeding problems.

Home visits and phone calls

The majority of mothers (93%) received a phone call within two days of contacting the Service, and almost half received a home visit within the same time period. However, the remainder had to wait between three and five days for a home visit from the lactation consultant.

Sixty-five per cent of mothers had one home visit, a further 23% had a second, and 3% had a third home visit. All mothers received at least one phone call, with 30% having one or more follow-up calls.

Accessibility of the Service

Mothers found it easy (60%) or somewhat easy (25%) to contact the service. Only two mothers reported finding it difficult to contact the Service, although it is not known what this difficulty was.

DISCUSSION

A quarter of the Service's yearly caseload was mailed the questionnaire to achieve the highest probability of a representative sample. Since response to the questionnaire was voluntary, however, the potential bias of a self-selecting sample must be acknowledged. In addition, the questionnaire was in English only and this may have excluded mothers without English reading skills.

The results have generated a large amount of descriptive data about the mothers who utilise the City of Kingston Breastfeeding Support Service. There was a general uptake of the Service across all suburbs of the City of Kingston. Notably, mothers from suburbs with high levels of culturally diverse backgrounds, and mothers not born in Australia, were well represented in the study population. There was a proportionally greater uptake of the Service by older mothers and mothers with high educational levels. The reasons younger mothers do not access the Service to the extent that older mothers do cannot be answered by this evaluation, although previous research has found that younger mothers are less confident in seeking support and in dealing with health professionals (Avery et al 1998; Dennis 2002). Dennis (2002) also found that mothers of lower socio-economic status do not seek breastfeeding support. Strategies to become accessible to, and engage younger mothers and those of lower socio-economic status need to be developed and implemented.

The results reveal that most mothers need breastfeeding support during the first six weeks postpartum. In particular, respondents utilised the service at much higher rates in their first two weeks of breastfeeding. This result endorses Kronborg and Vaeth's (2004) recommendation of targeting women early in the breastfeeding period for support to improve breastfeeding outcomes. Indeed when examining reasons for contacting the Service, many mothers had concerns about their supply, perceived or real, pointing to a lack of confidence or knowledge about managing their breastmilk and supply. Strategies to increase knowledge about lactation and build maternal confidence have been discussed by Blyth and colleagues (2002). Notably, this evaluation of the City of Kingston's Service reveals that mothers felt contact with the Service increased their knowledge and confidence, and improved their breastfeeding outcomes.

The Service's model of providing consistent support by the same MCHN/LC was strongly endorsed by the results. Continuity of carer was valued by mothers, with 90% responding that seeing the same lactation consultant was important to them. This data supports the findings of Hoddinott and Pill (2002) that mothers identified continuity of carer as important to the quality of consultation, as well as breastfeeding skill development.

Mothers who contacted the Service were experiencing breastfeeding difficulties, and sought support to continue their feeding choice. Scott and colleagues (2001) acknowledge the importance of the image a woman has of herself as a mother. Other research also highlights the importance of a mother's satisfaction with and adjustment to this new role, for her own, and her baby's wellbeing (Hauck & Irurita 2003). For many mothers, this is linked to successful breastfeeding and for these mothers, support and assistance is vital in facilitating not only their breastfeeding, but the fulfillment of their maternal image and sense of success as a mother. It has also been suggested that breastfeeding difficulties and failure of achievement of the maternal imagining are associated with postnatal depression (Henderson et al 2003). Hence, the enhancement of maternal health is mirrored by the significance of breastfeeding for the baby's health and wellbeing.

CONCLUSION

The results of this evaluation indicate that the Service is a highly effective and valued component of the City of Kingston's Maternal and Child Health Program. The questionnaire provided specific information about mothers using the Service, their breastfeeding experiences, and their perceptions of the support and counselling offered by the Service. Mothers reported very high levels of satisfaction with both the interpersonal and professional skills of the lactation consultant, and felt that the continuity of carer was important for the success of the Service. Responses were very positive; the support of the Service enabled mothers to feel more comfortable with their breastfeeding, to breastfeed for longer and with more confidence, and with greater knowledge about breastfeeding and lactation. Comparisons of feeding methods revealed a positive association between the support of the Service and babies attaching to the breast, fully breastfeeding and reduction in complements offered. This association represents significant positives outcomes for mothers and babies in the City of Kingston.

RECOMMENDATIONS

As a result of the evaluation the following recommendations were made to the City of Kingston to improve the Service:

1. The hours of Service should be increased from the currently funded 16 hours per week to reduce the lengthy waiting times for home visits.

2. The Service should continue the current model of phone consultations and home visits by the same MCHN/LC.

3. A Maternal and Child Health sub-committee should be formed to develop strategies for improving access to the Service for all mothers in the municipality. The findings of the Service evaluation should be disseminated to all health professionals in the municipality and referral pathways more widely publicised amongst all health professionals.

4. The early weeks of breastfeeding need to be targeted. Strategies to inform mothers, families and the community about the Service and expedite referral should be developed.

5. Community breastfeeding education and awareness strategies should be developed since mothers often make their decision to breastfeed, and develop their image of themselves as a mother before becoming pregnant, or early in their pregnancy.

REFERENCES

Avery M, Duckett L, Dodgson J, Savik K, Henly SJ 1998, Factors associated with very early weaning among primiparas intending to breastfeed. Matern Child Health J2: 167-179.

Blyth R, Creedy DK, Dennis C, Moyle W, Pratt J, De Vries SM 2002, Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory. Birth 9: 278-284.

City of Kingston 2001, Health Data Profile. City of Kingston, Mentone.

City of Kingston 2004, Policy and Procedure Manual, Maternal and Child Health Service. Unpublished.

City of Kingston 2005, Maternal and Child Health Nurse Annual Report (2004). Unpublished.

Dennis C 2002, Breastfeeding initiation and duration: a 1990-2000 literature review. J Obstet Gynecol Neonatal Nurs 31(1): 12-32.

De Vaus DA 2002, Surveys in Social Research. 5th edn. Allen Unwin, Crows Nest.

Hauck YL, Irurita VF 2003, Incompatible expectations: the dilemma of breastfeeding mothers. Health Care for Women Int 24(1): 62-78.

Huack Y, Langton D, Coyle K 2002 The path of determination: exploring the lived experience of breastfeeding difficulties. Breastfeeding Rev 10(2): 5-12.

Henderson JJ, Evans SF, Straton JA, Priest SR, Hagan R 2003, The impact of postnatal depression on breastfeeding duration. Birth 30: 175-180.

Hoddinott P, Pill R 2000, A qualitative study of women's views about how health professionals communicate about infant feeding. Health Expect 3: 224-233.

Hoyer S, Horvat L 2000, Successful breast-feeding as a result of a health education programme for mothers. J Adv Nurs 32: 1158-1167.

Kronborg H, Vaeth M 2004, The influence of psychosocial factors on the duration of breastfeeding. Scand J Public Health 32: 210-216.

Riley M, Davey M-A, King J 2005, Births in Victoria 2003-2004. Victorian Government Department of Human Services, Melbourne.

Scott JA, Landers MCG, Hughes RM, Binns CW 2001, Psychological factors associated with the abandonment of breastfeeding prior to hospital discharge. J Hum Lact 17: 24-30.

Shakespeare J, Blake F, Garcia J 2004, Breast-feeding difficulties experienced by women taking part in a qualitative interview study of postnatal depression. Midwifery 20: 251-260.

Sikorski J, Renfrew MJ, Pindoria S, Wade A 2003, Support for breastfeeding mothers: a systematic review. Paediatr Perinat Epidemiol 17: 407-417.

ABOUT THE AUTHOR

Karen Coffield is currently working as a Maternal and Child Health Nurse (MCHN) with the City of Melbourne, in both Maternal and Child Health Nursing Service delivery and on rotation in the City of Melbourne's Breastfeeding Support Drop-In Clinic. Karen has completed a Master of Nursing in Child and Family Health (La Trobe University), a BA (La Trobe University), a Bachelor of Nursing (Deakin University), and a Graduate Diploma of Midwifery (Monash University). She is also an IBCLC and has worked in a variety of contexts, both in midwifery and maternal and child health, and as a lactation consultant. This work has taken Karen to India (two placements with Australian Volunteers International) and Sri Lanka (post Tsunami).

Correspondence to:

Karen Coffield

10 John Street

Elwood 3184 Victoria
Table 1. Demographic and personal characteristics of respondents

Characteristic of participants of    Number (%)

Mothers                              n=69

Age (years)

[less than or equal to] 20           0         (0)
21-25                                3         (4)
26-30                                10        (14)
31-35                                35        (51)
36-40                                19        (28)
41-50                                2         (3)

Highest educational attainment

Secondary school                     11        (16)
Certificate/TAFE                     17        (25)
University Bachelor                  29        (42)
University Higher Degree             12        (17)

Children

Baby's age when contacting
the Service (weeks)

[less than or equal to]1                       (16)
2                                              (26)
3                                              (7)
4-6                                            (35)
7-12                                           (6)
13-18                                          (9)
19+                                            (1)

Sex

Male                                           (49)
Female                                         (51)

Table 2. Partner and family support for breastfeeding

                    Number (%)
                    n = 69

Level of support    Partner      Family

very supportive     57 (83)      50 (72)
supportive          3 (4)        7 (10)
ambivalent          4 (6)        7 (10)
unsupportive        3 (4)        3 (4)
very unsupportive   -            2 (3)
not available       2 (3)        -

Table 3. Reasons for contacting the Service

                            Number %

                            Main reason   Other reason
Reason                      n = 69        n = 67

Mastitis/breast infection   8 (12)        2 (3)
Nipple pain/damage          11 (16)       5 (9)
Painful breastfeeding       17 (24)       16 (24)
Baby not suckling well      1 (1)         3 (4)
Baby not attaching          8 (12)        8 (12)
Baby refusing breast        8 (12)        2 (3)
Frequent breastfeeding      2 (3)         1 (1)
Unsettled baby potential    6 (9)         8 (12)
Not enough breastmilk       3 (4)         11 (16)
Blocked ducts               2 (3)         -
Baby born at <37 wks        2 (3)         2 (3)
Baby not gaining weight     1 (1)         1 (1)
Engorged breasts            -             2 (3)
Twins or triplets           -             2 (3)
Medications and feeding     -             2 (3)
Help with expressing        -             2 (3)

Table 4. Changes in breastfeeding rates (a)

                  Number (%)
                  n = 67

Feeding method    on discharge   at time of   2 weeks later
                                 contact

Fully breastfed   41 (61)        22 (32)      29 (44)
BF + ebm          8 (12)         15 (23)      11 (16)
BF + af           6 (9)          15 (23)      17 (26)
ebm only          4 (6)          4 (6)        1 (1)
ebm + af          8 (12)         11 (6)       9 (13)

* BF, breastfed; ebm, expressed breastmilk; af; artificial baby
milk

Table 5. Mothers' perceptions of the Service (a)
                                                          Number (%)
Mothers felt ...                                          n = 69

they were listened to                                     57 (82)
concern was shown for their feelings                      52 (75)
useful advice was given                                   61 (88)
they learnt more about breastfeeding                      44 (64)
consultation time was adequate                            57 (82)
it was important to see the same lactation consultant     62 (90)
satisfaction with the support of the Service              62 (90)
their breastfeeding was not supported                     1 (1)
their breastfeeding problems were not solved              3 (4)
they were able to breastfeed for longer                   27 (39)
they gained more confidence                               49 (71)
they gained more knowledge about their breastfeeding      47 (69)
they learnt to solve their breastfeeding problems         41 (57)
more comfortable breastfeeding                            52 (75)
they would contact the service again                      66 (95)
they would recommend the service to family and friends    64 (92)

(a) Mothers could respond to more than one of the
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