Illinois Breastfeeding Blueprint - Qualitative Data by HealthConnect One

Illinois Breastfeeding Blueprint Qualitative Data Report Table of Contents Background…………………………………………………………………………………………………………………….2 Methods…………………………………………………………………………………………………………………………2 Results……………………………………………………………………………………………………………………………3 Theme 1: Negative Attitudes of Mothers, Their Social Networks and Society…………………………………………………………………………………………………………….….3 Theme 2: Importance of Multi-level Support....................................................…...4 Theme 3: Breastfeeding Education for Mothers and Service Providers………………………………………………………………………………………………….…………5 Theme 4: Policy Issues and Opportunities…………………………………………………………..6 Conclusions………………………………………………………………………………………………………………….…7

Background Throughout 2009 and 2010 HealthConnect One hosted multiple forums to gather input from Illinois stakeholders regarding the barriers to breastfeeding in Illinois and their suggested strategies for resolving these barriers to obtain desired breastfeeding rates. A diverse group of stakeholders participated in these forums including mothers, doulas, breastfeeding peer counselors, lactation consultants, CLCs (Certified Lactation Consultant), IBCLCs (International Board Certified Lactation Consultant), health educators, case managers, program coordinators, nurses, physicians, and other social service providers. Five forums were convened: two forums with service providers (10, 25 participants), two forums with predominantly mothers (10, 12 participants), and one forum with physicians specifically (5 participants) for a total of 62 participants.

Date

Place John H. Stroger, Jr. Hospital of Cook 5/27/2009 County (Chicago, IL) John H. Stroger, Jr. Hospital of Cook 7/4/2009 County (Chicago, IL) Rush University Medical Center 9/17/2009 (Chicago, IL) Mile Square Health Center (Near 1/7/2010 West Side, Chicago, IL) Saint Mary of Nazareth Hospital Center: Nazareth Family Center 1/21/2010 (Humboldt Park, Chicago, IL)

# of Participants

Type of Participants

10 service providers 25 service providers 5 physicians predominantly African American 10 WIC participants predominantly Hispanic WIC 12 participants

The qualitative data gathered at these forums helps add to our understanding, giving a voice to the statistics and providing first-hand knowledge and experience from mothers and those whose work involves supporting mothers and promoting breastfeeding.

Methods A convenience sample of 62 mothers and service providers were recruited to participate in 5 group discussions, a few took the form of a larger community forum and a few took the form of a smaller focus group. Due to the nature of the discussions as a community forum and not formal research, socio-demographic information on participants was not collected. Two discussions, one with 10 and one with 25, were held with service providers; two groups (with 10 and 12 participants respectively), consisted predominantly of mothers; and one discussion was held with 5 physicians. The social service providers were the most diverse group and included doulas, breastfeeding

peer counselors, lactation consultants (both certified and non-certified), CLCs (Certified Lactation Consultant), IBCLCs (International Board Certified Lactation Consultant), health educators, case managers, program coordinators, and nurses. Participants were presented with the Illinois Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2000-2005 pertaining to breastfeeding initiation, duration, and exclusivity. Some of this data was broken out by race/ethnicity, age, and whether or not the pregnancy was intended. After the data was shared, participants were asked to share what they felt were the barriers to breastfeeding in their communities and the communities that they served. Participants were also asked to discuss possible strategies to improve breastfeeding outcomes. Detailed notes were taken during the meetings, and these notes were transcribed into word processing documents and subjected to a Thematic Network Analysis (process of organizing qualitative data into thematic networks to facilitate the structuring and depiction of themes), using Atlas Ti, a qualitative data analysis (QDA) software program.

Results Seven cross-cutting codes, grounded in the narrative data, were used to categorize text passages. These were: perceptions, support, education, health care delivery system, media/advertising, data/research, and policy. These codes were used to thematically group text passages from across the group discussion, and to identify the following set of emergent themes. Theme 1: Negative Attitudes of Mothers, Their Social Networks and Society Many of the barriers to breastfeeding identified by all groups included negative attitudes towards breastfeeding by both mothers and members of their social networks, including friends, family, and partners along, with a lack of social acceptability for breastfeeding. Some of the feelings were expressed by mothers themselves, but others were attributed to mothers and network members by service providers. Mothers’ negative feelings towards breastfeeding included comments such as “it’s yucky”, “it is nasty”, and “don’t like it”. Formula feeding was perceived as easier, more convenient, and less time consuming compared to breastfeeding. Some mothers were apathetic towards breastfeeding with reasons such as they never thought about it, didn’t care, didn’t want to or lacked motivation. Mothers also shared a number of concerns that included barriers they felt prevented initiation or disrupted continuation of breastfeeding.

Concerns about Breastfeeding Identified by Mothers 1. Feeling that breastfeeding is embarrassing (“moms feel weird doing it”) 2. Fears that weaning will be difficult as children get older

3. Concerns that breasts are seen as sex objects and that breastfeeding would cause breasts to become saggy or worn out 4. Need to change activities in order to breastfeed, such as drinking alcohol, smoking, diet and medication 5. Belief that nipples that are “too big” or “too small” would make breastfeeding difficult 6. Lack of confidence in ability to provide enough milk 7. Perception that breastfeeding is painful 8. Fear that baby will refuse to nurse or won’t latch on 9. Don’t want to breastfeed when infant is sick or concerned that breastfeeding made baby sick Partner, peer, and family attitudes towards breastfeeding were seen as influencing the mother’s choice. One provider felt that women from families without a history of breastfeeding were more likely to have negative feelings toward breastfeeding, particularly in the African-American community. The combination of the social stigma of breastfeeding and a lack of privacy or places to breastfeed contributed to the negative feelings towards breastfeeding. It was perceived that it is difficult for mothers to obtain privacy in public places, and therefore inconvenient and uncomfortable for mothers to breastfeed when not at home. Although no specific strategies were identified by the groups to address negative attitudes the strategies outlined in the next two themes, breastfeeding support and education, have the potential to improve attitudes towards breastfeeding. Theme 2: Importance of Multi-level Support Participants observed a general lack of support for breastfeeding from all environments that mothers encountered in their lives including family members, employers, medical field, and the general public, especially for adolescent mothers. The availability of support for breastfeeding mothers was seen as extremely insufficient. In all discussion groups, the individuals that mothers interact with on a daily basis were some of the most often cited as being unsupportive, such as family members, mothers, grandmothers, friends, fathers of the baby, partners, or anyone living with the mother. The health care delivery system, especially maternity care, was repeatedly stated as providing inadequate support to new mothers. Hospital nurses and physicians were identified as not interested in breastfeeding, unsupportive, or even actively discouraging breastfeeding by “pushing” bottles. It was consistently mentioned that there was a lack of hospital staff who specialized in lactation services including peer counselors, lactation

consultants, certified lactation consultants, doulas, and health educators to serve mothers in the hospital. With respect to follow-up, service providers felt that there is poor help after birth and that there aren’t enough peer counselors to provide extensive postpartum support for women. The other environments that participants highlighted as not providing sufficient support for breastfeeding included the WIC program, employers, schools, and community organizations. Mothers who were WIC participants saw this program as discouraging breastfeeding because WIC provides mothers with free formula and does not provide enough breastfeeding support. A lack of employer support for current workplace breastfeeding laws was identified, including having a space to pump and store breast milk as well as the number and frequency of break times given to pump. Strategies for Enhancing Lactation Support Family

1. Support and give praise to breastfeeding mothers

Health Care/ WIC

2. Increase baby-friendly hospitals 3. Increase number of breastfeeding peer counselors, lactation specialists 4. Increase focus on post-partum professional support

Employer

5. Incentive and recognition programs for supportive employers

Other

6. Push for breastfeeding promotion in other institutions that support families (e.g., schools, child care centers, churches) 7. Websites and hotlines

Theme 3: Breastfeeding Education for Mothers and Service Providers Even though education is a type of support, it deserved separate attention because this theme was particularly salient, as it was the most frequently mentioned. Many gaps in education for both mothers and health care providers were acknowledged, with adolescents being mentioned as a specific group that needed special attention. Providers felt that mothers lacked a clear understanding of the benefits of breastfeeding and risks of not breastfeeding. The mothers felt that the education they received relating to breastfeeding was poor or completely missing because they either got “all the wrong facts” or, as one mother said, “no one told me that I should breastfeed”. It was also noted that prenatal education was lacking because there is not enough time to educate about breastfeeding during prenatal visits. The identified strategies suggested to address the barrier of mothers’ lack of breastfeeding education are listed below. 5

Education Strategies for Mothers, Fathers, and Families 1. Emphasize prenatal education for mothers, fathers, and families 2. Empower women to advocate for breastfeeding rights 3. Increase peer to peer education for mothers and fathers (e.g., support groups) 4. Include breastfeeding information in school health education curriculum 5. Educational materials should be culturally and community specific and printed in both English and other languages Both medical and social service providers were seen as not receiving enough education about breastfeeding in their training to enable them to provide ”evidencebased lactation care for mom and mom’s support system”. Providers were defined as anyone providing health education, including but not limited to doctors, nurses, obstetricians/gynecologists, WIC staff, case managers, and health educators. Current breastfeeding curricula were thought to be uncoordinated and unsystematic. This lack of appropriate training was identified as the reason that healthcare professionals were seen as being uninformed, lacking knowledge and not giving consistent and accurate information to mothers.

Education/Training Strategies for Service Providers 1. Improve/provide training in formal and continuing education 2. Provide regular, regional training on evidence-based guidelines Theme 4: Policy Issues and Opportunities An overall lack of policies that promote breastfeeding in Illinois (particularly workplace, WIC, and insurance policies) was seen as discouraging women from breastfeeding. The participants suggested multiple policy strategies to increase breastfeeding rates across the state of Illinois. Many of these were strategies to support breastfeeding mothers and increase society’s awareness, understanding, and appreciation for the benefits of breastfeeding.

Policy Barrier 1. Insufficient funding, therefore a lack of lactation staff (â&#x20AC;&#x153;little funding for the work that we doâ&#x20AC;?) 2. Formula promotion in the hospital and by WIC (free formula) 3. Insufficient coordination and networking of available services 4. Short and unpaid maternity/family leave 5. Current breastfeeding laws not well enforced 6. Lack of reimbursement for lactation services and breast pumps by public and private insurance

Policy Strategy Increase funding available for breastfeeding promotion and to expand breastfeeding peer counselor workforce Limit formula marketing by banning formula bags in hospitals and enacting laws against formula distribution Establish a state-wide network responsible for promoting a comprehensive system of breastfeeding services in Illinois Require employers to offer 12 weeks paid maternity leave and the option of six months maternity leave Establish fines for violation of breastfeeding laws Mandate private insurance companies to cover lactation services and breast pumps Preferred reimbursement through Medicaid for service providers who provide lactation care

Conclusions It is apparent from these data that mothers face numerous obstacles when breastfeeding. To be successful with breastfeeding, they need continuous support from their families, service providers and the environments where they learn and work. Participant responses provided insights into the attitudes, perceptions, and behaviors of mothers that influence their choice to breastfeed. In addition to individual barriers, the providers shared systemic barriers that they encountered in their work. The input gathered at these forums, from service providers and mothers, was extremely useful for identifying the perceived barriers to breastfeeding in Illinois, as well as strategies to address these barriers. A number of important themes emerged out of the forums. Mothers had many negative feelings towards breastfeeding that were greatly influenced by the attitudes of others in their social network. It is clear that mothers need the right information and technical support regarding breastfeeding to have confidence in their ability to exclusively breastfeed their infants and avoid pain from improper latching. A lack of awareness of the benefits and importance of breastfeeding is most likely contributing to the negative attitudes and increasing awareness of the risks of not breastfeeding for all

groups could help to establish breastfeeding as the norm. Also education for medical providers needs to give providers the skills to provide evidence-based information and support. The maternity care system emerged as a significant setting that is currently problematic for the successful initiation and continuation of breastfeeding. The participants called for an increase in lactation services while in the hospital and also in the early postpartum period through home visits and breastfeeding peer counselors that can provide round-the-clock support. It appears that certain policy changes have potential to improve the breastfeeding environment in Illinois, but the feasibility of implementing these policy suggestions needs further examination. Considering the nature of barriers which were both interpersonal and environment, breastfeeding promotion efforts should aim to address all of these different factors, before, during, and after birth. Prioritizing breastfeeding through supportive policies that create an encouraging, coordinated system will be vital in improving breastfeeding initiation, duration, and exclusivity in Illinois.