Applying a knowledge translation model to the uptake of the Baby Friendly Health Initiative in the Australian health care system

BackgroundThe Baby Friendly Hospital Initiative is a global, evidence-based, public health initiative. The evidence underpinning the Initiative supports practices promoting the initiation and maintenance of breastfeeding and encourages women's informed infant feeding decisions. In Australia, where the Initiative is known as the Baby Friendly Health Initiative (BFHI) the translation of evidence into practice has not been uniform, as demonstrated by a varying number of maternity facilities in each State and Territory currently accredited as ‘baby friendly’. This variance has persisted regardless of BFHI implementation in Australia gaining ‘in principle’ support at a national and governmental level as well as inclusion in health policy in several states. There are many stakeholders that exert an influence on policy development and health care practices.AimIdentify a theory and model to examine where and how barriers occur in the gap between evidence and practice in the uptake of the BFHI in Australia.ResultsKnowledge translation theory and the research to practice pipeline model are used to examine the identified barriers to BFHI implementation and accreditation in Australia.ConclusionAustralian and international studies have identified similar issues that have either enabled implementation of the BFHI or acted as a barrier. Knowledge translation theory and the research to practice pipeline model is of practical value to examine barriers. Recommendations in the form of specific targeted strategies to facilitate knowledge transfer and supportive practices into the Australian health care system and current midwifery practice are included.     

An historical document analysis of the introduction of the Baby Friendly Hospital Initiative into the Australian setting

Background

Breastfeeding has many known benefits yet its support across Australian health systems was suboptimal throughout the 20th Century. The World Health Organization launched a global health promotion strategy to help create a ‘breastfeeding culture’. Research on the programme has revealed multiple barriers since implementation.

An instrumental case study examining the introduction and dissemination of the Baby Friendly Health Initiative in Australia: Participants’ perspectives

Background

Australia experiences high breastfeeding initiation but low duration rates. UNICEF introduced the global breastfeeding strategy, the Baby-Friendly Hospital Initiative, to Australia in 1992, transferring governance to the Australian College of Midwives (ACM) in 1995. In 2017 23% of facilities were registered as ‘baby-friendly’ accredited.

Normalisation process theory as a conceptual framework for continuity of carer implementation

ProblemDespite long standing strategic level ambitions to increase access to continuity of carer (CoC) models in maternity services, implementation of CoC in the United Kingdom (UK) has been generally small-scale and short lived. This indicates problems in implementing and sustaining CoC as the main model of care provision, and as such a need to better understand the process of implementation itself.AimTo use normalisation process theory (NPT) to underpin development of a conceptual implementation framework for CoC in order to improve understanding of the implementation process.MethodsLiterature review on CoC implementation and NPT development and use, combined with immersion in the implementation of CoC context.Results and DiscussionA conceptual framework for the implementation of CoC is developed and individual components discussed, with a view to better understanding the implementation process for CoC models. The will of a critical mass of midwives to work in a CoC model and the provision and maintenance of the ‘organisational space’ required for CoC within the National Health Service (NHS) emerge as key barriers to mainstreaming CoC in the UK.ConclusionThere is utility in NPT as a means of understanding and conceptualising large scale implementation of CoC. With testing and further development into a practical tool, the conceptual framework developed here could become a useful aid to those involved in implementing and evaluating CoC in the context of renewed strategic direction and Governmental level support in the UK.     

‘It requires something drastic’: Interviews with health care leaders about organisational responses to social disadvantage

ProblemPersisting disparities in maternal and child health outcomes in high income countries require new insights for health service response.BackgroundSignificant social hardship, including factors related to migration, are associated with perinatal morbidity and mortality. The universality of maternity and child health care offers opportunities to reduce health disparities. Process evaluation of health service initiatives to address refugee health inequalities in Melbourne, Australia, is the setting for the study.AimTo explore the views of health service leaders about health system and service capacity to tailor care to address social adversity and reduce disparities in maternal and child health outcomes.MethodsIn-depth interviews with leaders of maternity and maternal and child health services with questions guided by a diagram to promote discussion. Thematic analysis of transcribed interviews.FindingsHealth care leaders recognised the level of social complexity and diversity of their clientele. The analysis revealed three key themes: grappling with the complexity of social disadvantage; ‘clinical risk’ versus ‘social risk’; and taking steps for system change.DiscussionPriority given to clinical requirements and routine practices together with the rising demand for services is limiting service response to families experiencing social hardship and hampering individualised care. System change was considered possible only if health service decision makers engaged with consumer and community perspectives and that of front-line staff.ConclusionAchieving equity in maternal and child health outcomes requires engagement of all key stakeholders (communities, clinicians, managers) to facilitate effective system re-design.     

Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge

ProblemEarly discharge following birth has become an emerging phenomenon in many countries. It is likely early discharge has an impact on the establishment of breastfeeding.ObjectiveTo critically appraise the evidence on what women value in relation to breastfeeding initiation and support, and investigate the impact early discharge can have on these values.MethodA literature search was conducted for publications since 2005 using the following databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, Scopus and PsycINFO; 21 primary articles were selected and included in the review.FindingsThere is no standard definition for ‘early discharge’ worldwide. Due to inconsistent definitions worldwide and minimal literature using a 24 h definition, research defining early discharge as up to 72 h postpartum is included. Seven key factors in relation to breastfeeding initiation and support following early discharge were identified, namely trust and security, consistent advice, practical breastfeeding support, breastfeeding education, comfortable environment, positive attitudes and emotional support, and individualised care.ConclusionThe findings suggest individualised postnatal lengths of stay may be beneficial for the initiation of breastfeeding. Five values were not impacted by early discharge, but rather individual midwives’ practice. There is consensus in the literature that early discharge promoted a comfortable environment to support breastfeeding initiation. Wide variations in the definition of early postnatal discharge made it difficult to draw influential conclusions. Therefore, further research is required.     

Indicators of ‘good’ feeding,breastfeeding latch,and feeding experiences among healthy women with healthy infants: A qualitative pathway analysis using Grounded Theory

BackgroundBreastfeeding behaviour remains a public health priority worldwide. Despite evidence-based guidelines, healthy women who give birth to healthy, term infants continue to face barriers to breastfeeding. Understanding women’s experiences of feeding in the early postnatal period is crucial to identify how support may be better tailored to improve breastfeeding outcomes, including women’s experiences.QuestionTo understand women’s experiences of infant feeding amongst healthy women who give birth to healthy, average-weight, term infants.MethodsGrounded Theory methodology was used to analyse data from a nested qualitative interview study. Twelve women between four and twelve months postpartum were recruited from a longitudinal cohort study and public advertisements. Semi-structured face-to-face interviews were audio-recorded and transcribed for analysis.FindingsThree distinct themes were found, subsuming identified super-categories: Perceived indicators of ‘good’ feeding (infant ‘output’; infant crying; weight gain; feeding frequency and duration); Women’s experiences of breastfeeding latch (‘good’ latch; ‘bad’ latch with pain and discomfort); and Overall breastfeeding experience (positive; negative; and uncertain). Data suggest women give precedence to their latch experiences over indicators of ‘good’ feeding, highlighting breastfeeding latch as a possible mediating factor to the overall breastfeeding experience. Feeding experience can be achieved through four distinct pathways.DiscussionThe physical and psychological impacts of latch pain were pronounced. Even amongst healthy women with healthy infants, a positive breastfeeding experience overall was uncommon, highlighting the difficulties women continue to encounter. Understanding women’s perceptions of ‘good’ feeding, and ensuring a pain-free latch, may better support women to have a positive breastfeeding experience.     

Breastfeeding experiences and perspectives among women with postnatal depression: A qualitative evidence synthesis

BackgroundStudies show that postnatal depression affects around 10–16% of women globally. It is associated with earlier cessation of breast feeding, which can negatively impact infants’ long-term development. Mechanisms underpinning associations between mental health and women’s decision to commence and continue to breastfeed are complex and poorly understood.AimThe aim of this review was to investigate breastfeeding experiences, perspectives, and support needs of women with postnatal depression. No previous reviews were identified which had addressed this aim.MethodA systematic search was conducted of six databases to identify relevant qualitative studies. Six included studies were critically appraised and synthesised using thematic synthesis.FindingsFive themes were identified: (1) desire to breastfeed and be a ‘good mother’, (2) struggles with breastfeeding, (3) mixed experiences of support from healthcare professionals, (4) importance of practical and social support, (5) support for mental health and breastfeeding. Most women with postnatal depression expressed strong intentions to breastfeed, although some perceived ‘failure’ to breastfeed triggered their mental health problems. Practical and non-judgemental support for their mental health needs and for successful breastfeeding from healthcare professionals, family and friends are needed.ConclusionMost women with postnatal depression desired to breastfeed but experienced breastfeeding difficulties that could impact on their mental health. By offering women with postnatal depression tailored and timely support, healthcare professionals could help women minimize breastfeeding problems which could consequently impact on their mental well-being and ensure they and their infants have opportunity to benefit from the advantages that breastfeeding offers.     

Understanding staff views and experiences of a clinical practice change to reduce stillbirth in South Asian women: A cross-sectional survey

BackgroundIn July 2017, Victoria’s largest maternity service implemented a new clinical practice guideline to reduce the rates of term stillbirth in women of South Asian background.AimTo capture the views and experiences of clinical staff following the implementation of the new clinical guideline.MethodsCross sectional survey of clinical staff providing maternity care in August 2018, 12 months post implementation. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Open-ended questions provided opportunities to express concerns and offer suggestions for improvement. The frequency of responses to each question were tabulated. Open ended responses were grouped together to identify themes.FindingsA total of 120 staff completed the survey, most (n = 89, 74%) of whom were midwives. Most staff thought the rationale (n = 95, 79%), the criteria for whom they applied (83%, n = 99), and the procedures and instructions within the guideline were clear (74%, n = 89). Staff reported an increase in workload (72%, n = 86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for both staff and pregnant South Asian women, increased workload and insufficient resources, patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified.DiscussionThis study has identified key barriers to and opportunities for improving implementation and highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse women.     

Midwifery-led care in South Australia: Looking back to move forward

BackgroundFrom the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established.AimTo better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future.MethodsSemi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis.FindingsThree overarching themes and several sub-themes were identified, these included: ‘Midwifery suffragettes’ which explored ‘activism’, ‘adversity’ and ‘advocacy’; ‘Building bridges’ captured the importance of ‘gathering midwives’, a ‘movement of women’ and ‘champions and influencers’; and ‘Recognising midwifery’ identified the strong ‘sense of identity’ needed to outface ‘ignorance and opposition’ and the importance of ‘role reformation’.ConclusionThese midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models.     

Putting evidence into practice: A quality activity of proactive pain relief for postpartum perineal pain

BackgroundPerineal pain associated with perineal trauma is often underestimated. Offering regular pain relief may be advantageous compared to waiting for women to request it. Changing clinical practice in a sustained way needs a whole of team approach.AimTo reduce women's pain following perineal trauma in the first 48 h following childbirth and to undertake this as multidisciplinary, quality activity.MethodsIn November 2008 a questionnaire was distributed to 18 new mothers who had sustained perineal trauma during the birth in order to assess pain levels in the first 48 h and to investigate pain management therapies used. Following this survey a multidisciplinary project team undertook a series of brainstorming sessions, reviewed the literature and undertook staff surveys to identify key factors impacting on women's perineal pain. A process of decision making led to education and support of women and staff. An evidence based guideline, which involved prescribing regular pain relief for women and offering an ice pack within 1 h of giving birth was implemented, and a brochure was designed for women. A follow up questionnaire was distributed in June 2010 to 18 women and pain scores before and after the change in policy were compared.ResultsPrior to the practice change in 2008 67% of the women surveyed rated their pain as ‘moderate’ to ‘a lot’ 48 h following the birth. Following the change in practice and implementation of a new guideline a second survey in 2010 at 48 h postpartum found 60% of women in the post intervention group rated their perineal pain as ‘a lot’ to ‘moderate’. There had been a 33% increase in women's use of pain relief options compared to the pre-intervention survey. The practice change was sustained and adopted by all the staff.ConclusionBy taking a multidisciplinary quality activity an effective practice change was facilitated that appeared to decrease women's perineal pain in the 48 h following birth.     

Aboriginal women in rural Australia; a small study of infant feeding behaviour

BackgroundAboriginal women in rural areas have lower rates of breastfeeding than Australian averages. The reasons for this are poorly understood. Aboriginal people experience higher morbidity and increased rates of chronic disease throughout the life cycle. The protective effects of sustained breastfeeding could benefit rural Aboriginal communities.ObjectiveTo explore the factors impacting upon infant feeding choices in a rural Aboriginal Community.MethodsSemi-structured interviews were conducted with eight Aboriginal rural dwelling first time mothers. These women received a continuity of midwife and Aboriginal Health Worker model of care. Interviews were also undertaken with five Aboriginal Health Workers and two Aboriginal community breastfeeding champions. The analysis was integrated with a conventional literature review and was further developed and illustrated with historical literature. Indigenist methodology guided the study design, analysis and the dissemination of results.ResultsThree key themes were identified. These were “I’m doing the best thing for…” which encompasses the motivations underpinning infant feeding decisions; “this is what I know…” which explores individual and community knowledge regarding infant feeding; and “a safe place to feed” identifying the barriers that negative societal messages pose for women as they make infant feeding decisions. It appears loss of family and community breastfeeding knowledge resulting from colonisation still influences the Aboriginal women of today.DiscussionAboriginal women value and trust knowledge which is passed to them from extended family members and women within their Community. Cultural, historical and socioeconomic factors all strongly influence the infant feeding decisions of individuals in this study.ConclusionsEfforts to normalise breastfeeding in the culture of rural dwelling Aboriginal women and their supporting community appear to be necessary and may promote breastfeeding more effectively than optimal professional care of individuals can do.     

Women who experience feelings of aversion while breastfeeding: A meta-ethnographic review

ProblemLimited literature is available about women who wish to breastfeed but experience unexpected feelings of aversion in reaction to their infant suckling at the breast while breastfeeding.BackgroundBreastfeeding benefits mothers, infants and society yet breastfeeding rates continue to fall below recommendations in part due to inadequate tailored support after hospital discharge. Influences on breastfeeding are complex and include many physiological, psychosocial and cultural factors.AimTo better understand the experience of women who have feelings of aversion during breastfeeding by synthesising the existing literature.MethodsMEDLINE, CINAHL, PsycINFO, Maternity and Infant Care databases were searched for relevant literature published between 2000 to 2019. Using Covidence software, five qualitative research studies were identified. Studies were then analysed using meta-ethnographic qualitative synthesis.FindingsFeelings of aversion during breastfeeding were described as visceral and overwhelming; leading to feelings of shame and inadequacy. This synthesis identified five findings; a central conceptual category of “it’s such a strong feeling of get away from me” with four key metaphors translated from this central conceptual category: “I do it because I feel it is best for my baby”, “I can’t control those feelings”, “I should be able to breastfeed my son and enjoy it”, and “I’m glad I did it”. This phenomenon may negatively affect a women’s sense of self and impact on the mother-infant relationship.ConclusionSome women who want to breastfeed can experience feelings of aversion while breastfeeding. The feelings of ‘aversion’ while breastfeeding can inhibit women from achieving their personal breastfeeding goals.     

Partner behaviours improving breastfeeding outcomes: An integrative review

ProblemThe impact of specific supportive behaviours of a woman’s partner on breastfeeding outcomes is unclear.BackgroundBreastfeeding is beneficial for the infant, mother, and society. Partner support plays a significant role in promoting breastfeeding. Strategies to improve breastfeeding rates have had limited success with rates worldwide remaining well below World Health Organization recommendations, contributing to significant morbidity, mortality, and economic burden globally.AimTo determine what specific supportive behaviours of a breastfeeding woman’s partner increase breastfeeding initiation, exclusivity, and duration rates in Western-culture settings.MethodsA Population-Interest-Context framework-based search strategy was applied to the Cumulative Index to Nursing Allied Health Literature Plus with full-text, Web of Science, Scopus, and PubMed databases, limited to primary research published January 2008–December 2018 in English conducted in Western-culture settings.FindingsFrom 652 articles, after critical appraisal seven articles (eight studies) satisfied the requirements of this integrative review. Supportive behaviours were categorised as knowledge, help, encouragement, and responsiveness. Help and encouragement behaviours were associated with increased initiation. Results were mixed regarding behaviours affecting exclusivity and duration; however, responsiveness was found to ameliorate otherwise generally negative effects of knowledge, help, and encouragement on these outcomes.DiscussionConsistent with wider social support research, awareness of receiving support is associated with negative health consequences. However, where partner support is provided in a responsive manner as part of a ‘breastfeeding team’, thereby promoting the woman’s sense of autonomy and self-efficacy, breastfeeding outcomes improve.ConclusionResponsive partner behaviours improved breastfeeding outcomes in Western-culture settings. Further primary research is needed.     

‘I really needed help’: What mothers say about their post-birth care in Queensland,Australia

BackgroundAustralian mothers consistently rate postnatal care as the poorest aspect of their maternity care, and researchers and policymakers have widely acknowledged the need for improvement in how postnatal care is provided.AimTo identify and analyse mothers’ comments about postnatal care in their free text responses to an open ended question in the Having a Baby in Queensland Survey, 2010, and reflect on their implications for midwifery practice and maternity service policies.MethodsThe survey assessed mothers’ experiences of maternity care four months after birth. We analysed free-text data from an open-ended question inviting respondents to write ‘anything else you would like to tell us’. Of the final survey sample (N = 7193), 60% (N = 4310) provided comments, 26% (N = 1100) of which pertained to postnatal care. Analysis included the coding and enumeration of issues to identify the most common problems commented on by mothers. Comments were categorised according to whether they related to in-hospital or post-discharge care, and whether they were reported by women birthing in public or private birthing facilities.ResultsThe analysis revealed important differences in maternal experiences according to birthing sector: mothers birthing in public facilities were more likely to raise concerns about the quality and/or duration of their in-hospital stay than those in private facilities. Conversely, mothers who gave birth in private facilities were more likely to raise concerns about inadequate post-discharge care. Regardless of birthing sector, however, a substantial proportion of all mothers spontaneously raised concerns about their experiences of inadequate and/or inconsistent breastfeeding support.ConclusionWomen who birth in private facilities were more likely to spontaneously report concerns about their level of post-discharge care than women from public facilities in Queensland, and publically provided community based care is not sufficient to meet women's needs. Inadequate or inconsistent professional breastfeeding support remains a major issue for early parenting women regardless of birthing sector.     

Factors influencing Aboriginal and Torres Strait Islander women’s breastfeeding practice: A scoping narrative review

BackgroundThe nutritional and health benefits of breastfeeding for infants and young children are well-established however rates of breastfeeding initiation and duration for Aboriginal and Torres Strait Islander children are lower than non-Indigenous children.AimTo describe factors influencing breastfeeding practice amongst Aboriginal and Torres Strait Islander women.MethodsA scoping narrative review was conducted using the Joanna Briggs Institute framework. A search was conducted in four online databases (PubMed, Scopus, ANU SuperSearch, and Science Direct). Findings were analysed using [30] narrative synthesis.FindingsThis review included 9 journal articles, a conference summary and a book. This review identified four factors influencing women’s breastfeeding practice; sources of support, culturally appropriate care, intention to breastfeed and social determinants.ConclusionMultiple social determinants resulting from colonization have interrupted traditional infant feeding practices and women’s sources of support. Although Aboriginal and Torres Strait Islander women have strong intention to breastfeed, their breastfeeding outcomes are impacted by lack of pro-breastfeeding support when encountering breastfeeding challenges as well as norms surrounding the use of infant formula milk. Culturally appropriate care is essential for identifying women’s needs and avoiding stereotyping. Further research is needed to investigate the effectiveness of breastfeeding interventions for this group of women.