This process evaluation increases understanding about the feasibility, acceptability and mediating or moderating processes for the effectiveness of the FEST intervention within routine postnatal care. Particularly important themes were:
- the value of daily proactive telephone care
- women's reluctance to initiate requests for help with breast feeding
- continuity of care from hospital to home
- a woman-centred approach
- difficulty observing an entire breast feed prior to hospital discharge
- the importance of a dedicated team with protected time to establish constructive relationships and prioritise breast feeding.
The intervention integrated well with existing postnatal care, and women were very satisfied with the frequency, length and content of proactive calls. However, in the context of an overstretched health service, women seemed to undervalue breast feeding as a reason to initiate calls to the team.
The participatory approach embedding a rigorous RCT within a before-and-after cohort study and using mixed methods to evaluate implementation processes and costs are strengths that will enable us to design a feasible and acceptable definitive trial. A mixed-methods approach is an emerging discipline, which adds value when designing RCTs of complex interventions within complex systems. Limitations include the lack of a free mobile and landline service, potentially limiting access to care, which would need to be addressed in a definitive trial. There are challenges for four researchers to prospectively collect and analyse qualitative data for a 3-month intervention period, including the skills needed to use qualitative data management software, which we decided against using. There are trade-offs when collecting process evaluation data between minimising interference with the intervention or the trial outcomes, sources of potential bias and the resources necessary for a rigorous qualitative evaluation. Interviewing more women who did not wish to be randomised and community staff caring for trial women at home might have added different perspectives. However, we did reach theoretical saturation for the perspectives of women randomised to the telephone intervention.
Telephone calls were shorter than staff expected lasting about 5 min, which is similar to other studies.23
Importantly proactive care may counteract the inverse care law whereby more disadvantaged women are less likely to seek help,24
which may explain the low number of women-initiated calls in our study. This warrants further investigation, as it has implications for reactive breastfeeding telephone helplines. Telephone interventions are private, potentially less stigmatising than face-to-face care and may reduce differences due to socioeconomic factors.9
Continuity of care was important and is known to increase breastfeeding initiation,25
but its effect on breastfeeding duration or exclusivity is less clear. An informal, reassuring, caring, woman-centred communication style was valued and increases women's self-confidence, supporting the findings of qualitative research synthesis.26
‘Care’ captures the FEST intervention compared with ‘support’ referred to in other studies,27
and it may be the perception that ‘support’ is being provided that matters most.10
It is unknown how possible it is to train professionals to ‘gel’ and ‘care’, and the jury is out on the benefits of specialised breastfeeding training, as interventions with health professionals have been inconclusive.28
Observing a breast feed on the ward adds value to telephone breastfeeding support by helping to establish a rapport. Observing a breast feed is a requirement to achieve the Unicef Baby-friendly accreditation,29
which is endorsed as a minimum standard in UK postnatal care guidelines.30
The small observed increase from 15% (n=60) to 19% (n=73) of women who had an entire breast feed observed after the intervention may have contributed to the lack of team impact on breastfeeding outcomes in the before-and-after study.7
Even with the dedicated team, finding uninterrupted time to watch an entire breast feed on the postnatal ward was difficult when faced with other institutional routines and priorities, as reported by others.31
Increased hours of availability of the feeding team on the ward are indicated for the definitive trial in order to facilitate breastfeed observation, as operationally it would probably be more difficult and costly to achieve in the community, particularly in rural areas.
Our data generate several further research questions:
- Would establishing a relationship, regardless of who it is with (skills, personal characteristics, salary band, professional or lay status), immediately after birth with continuity of care once home be effective?
- Could effective telephone support be delivered without a dedicated feeding team?
- Would FEST be as effective and cost-effective if delivered entirely within primary care?
- Would extended team hours translate into more women having a breast feed observed and improved breastfeeding outcomes?
- Would training in woman-centred communication and telephone skills add value?
There are many components and interactions in this complex intervention operating at the individual level that could either mediate or moderate the breastfeeding outcomes. However, we would argue that further attempts to isolate individual components might not add value, prior to assessing wider generalisability to other teams and settings. Ecological16
and systems theory5
would suggest focusing on organisational processes at the macro, meso and micro levels rather than on how individual women behave.