TUGAS REVIEW INDIVIDU

TEKNOLOGI TEPAT GUNA DALAM PELAYANAN KEBIDANAN

“Review Jurnal Ilmiah dalam Ruang Lingkup Nifas dan Menyusui”

Dosen Pengajar :
Evi Pratami, M. Keb

Oleh :
VELLA MERYTA PUSPITASARI
NIM. P27824418002

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

BADAN PENGEMBANGAN DAN PEMBERDAYAAN
SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KEMENKES SURABAYA
JURUSAN KEBIDANAN
PRODI SARJANA TERAPAN KEBIDANAN
TAHUN 2021
 KATA PENGANTAR

Dengan menyebut nama Allah SWT yang Maha Pengasih lagi Maha Penyayang. Saya
panjatkan puji syukur atas kehadirat-Nya, yang telah melimpahkan Berkah Rahmat Hidayah dan
Karunia-Nya kepada saya, sehingga penulis dapat melakukan penyusunan dan menyelesaikan
tugas mata kuliah Teknologi Tepat Guna dalam Pelayanan Kebidanan tentang “Review Jurnal
Ilmiah dalam ruang lingkup Nifas dan Menyusui”. Dalam penyusunan review jurnal ini, penulis
tidak lepas dari bantuan berbagai pihak. Untuk itu, penulis mengucapkan terima kasih kepada :
1. Evi Pratami, M. Keb. selaku dosen pembimbing.
2. Orang tua yang selalu memberikan bantuan dan dorongan baik materi maupun spiritual.
3. Teman-teman kelas D4 Kebidanan yang selalu memberikan kritik dan sarannya.
4. Semua pihak yang tidak mungkin penulis sebutkan satu persatu.
Penulis menyadari, makalah ini masih banyak kekurangan. Untuk itu, penulis
mengharapkan kritik dan saran yang bersifat membangun dari berbagai pihak demi sempurnanya
makalah. Semoga makalah ini dapat bermanfaat bagi penulis maupun bagi pembaca.

Jombang, 04 September 2021

Penulis
 DAFTAR ISI

KATA PENGANTAR.....................................................................................................................ii
DAFTAR ISI..................................................................................................................................iii
BAB 1 PENDAHULUAN...............................................................................................................1
1.1 Latar Belakang..................................................................................................................1
1.2 Tujuan Penulisan...............................................................................................................2
BAB 2 ISI........................................................................................................................................3
2.1 Nama Jurnal......................................................................................................................3
2.2 Judul Artikel......................................................................................................................3
2.3 Tahun Terbit......................................................................................................................3
2.4 Nama Peneliti....................................................................................................................3
2.5 Abstrak..............................................................................................................................3
2.6 Klasifikasi EBM................................................................................................................4
BAB 3 ISI ARTIKEL......................................................................................................................5
3.1 Pendahuluan......................................................................................................................5
3.2 Latar Belakang..................................................................................................................5
3.3 Rumusan Masalah.............................................................................................................6
3.4 Tujuan...............................................................................................................................6
3.5 Metode..............................................................................................................................7
3.6 Hasil..................................................................................................................................8
3.7 Pembahasan.......................................................................................................................8
3.8 Simpulan.........................................................................................................................11
BAB 4 PEMBAHASAN................................................................................................................12
BAB 5 SIMPULAN.......................................................................................................................13
LAMPIRAN....................................................................................................................................1
Lampiran 1 : Daftar 24 Artikel....................................................................................................1
Lampiran 2 : Full Text Artikel yang direview.............................................................................4
 BAB 1
PENDAHULUAN

1.1 Latar Belakang

Setelah persalinan wanita akan mengalami masa puerperium, untuk dapat

mengembalikan alat genitalia interna kedalam keadaan normal, dengan tenggang waktu
sekitar 42 hari atau enam minggu atau satu bulan tujuh hari.
Masa nifas atau puerperium dimulai setelah kelahiran plasenta dan berakhir ketika
alat-alat kandungan kembali seperti keadaan sebelum hamil. Masa nifas berlangsung kira-
kira selama 6 minggu.
Masa nifas (Puerperium) adalah masa pulih kembali, mulai dari persalin selesai sampai
alat-alat kandungan kembali seperti pra- hamil. Lama nifas ini yaitu 6-8 minggu. (Mochtar,
1998 : 115).
Nifas ialah masa sesudah persalinan yang diperlukan untuk pulihnya kembali alat
kandungan yang lamanya 6 minggu. Masa nifas mulai setelah partus selesai, dan berakhir
setelah kira-kira 6 minggu. (Saifudin, 2000 : 35)
Pada masa ini terjadi perubahan-perubahan fisiologis,yaitu :
1. Perubahan fisik
2. Involusi uterus dan pengeluaran lochia
3.  Laktasi/pengeluaran ASI
4.  Perubahan psikis
Dalam masa nifas, alat-alat genitalia interna maupun eksterna akan berangsur-angsur
pulih kembali seperti keadaan seblum hamil. Perubahan-perubahan alat-alat genital ini
dalam keseluruhannya disebit involusi.
ASI eksklusif adalah pemberian ASI saja, tanpa memberikan makanan atau minuman
lain kepada bayi, kecuali vitamin, mineral, obat-obatan, dan garam rehidrasi oral. World
Health Organisation (WHO) menganjurkan agar pemberian ASI dilakukan secara eksklusif
sejak bayi lahir hingga bayi berusia enam bulan. Anjuran tersebut telah diikuti oleh berbagai
negara di dunia, salah satunya Indonesia. Walaupun ASI eksklusif telah dianjurkan oleh
pemerintah, kegagalan ASI eksklusif sangat umum terjadi di Indonesia (WHO, 2010).
 ASI eksklusif sangat penting bagi kelangsungan hidup bayi. ASI mengandung growth
factor dan zat antibodi. Growth factor dalam ASI berperan dalam membantu proses
pematangan organ dan hormon, sedangkan zat antibodi berfungsi membantu proses
pematangan sistem imun. Proses pematangan sistem imun sangat penting karena sistem
imun bayi baru lahir belum sempurna (Ballard, 2013). Apabila ASI tidak diberikan secara
eksklusif, proses pematangan sistem imun akan terganggu dan menyebabkan bayi mudah
terserang infeksi. Penanganan infeksi yang terlambat dapat memicu kematian (Buonocore,
2012).
Dampak dari rendahnya pemberian ASI eksklusif pada bayi 0-6 bulan dapat
memperberat penyakit seperti ISPA dan diare. Rendahnya prevalensi dan singkatnya masa
penyusuan akan meningkatkan risiko angka kesakitan dan kematian pada bayi di negara-
negara berkembang, terutama ISPA dan diare. Selain itu kegagalan pemberian ASI eksklusif
pada bayi dapat menimbulakan gangguan gizi dan dapat mengganggu proses pematangan
organ dan hormon (Kurniawati & Hargono, 2014).

1.2 Tujuan Penulisan

Tujuan dari penulisan ini yaitu untuk review jurnal dalam mengetahui pengarug
pengalaman ibu yang rentan menyusui dengan program dukungan laktasi komunitas yang
ditingkatkan.
 BAB 2
ISI

2.1 Nama Jurnal

Artikel yang akan di-review telah dipublikasikan dalam Maternal and Child Nutrition.

2.2 Judul Artikel

Judul dari artikel yang direview yaitu “Vulnerable mothers' experiences breastfeeding with
an enhanced community lactation support program”

2.3 Tahun Terbit

Artikel diterima pada tanggal 7 Agustus 2019 dan dipublikasikan pada tanggal 6 Januari
2019.

2.4 Nama Peneliti

Nama-nama peneliti pada artikel ini yaitu : Jane Francis1,2 | Alison Mildon1 | Stacia Stewart3 |
Bronwyn Underhill3 | Valerie Tarasuk1,4 | Erica Di Ruggiero4 | Daniel Sellen1,4,5 | Deborah L.
O'Connor1,2.
1. Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
2. Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario,
Canada
3. Health Promotion & Community Engagement, Parkdale Queen West Community Health
Centre, Toronto, Ontario, Canada
4. Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
5. Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto,
Ontario, Canada
2.5 Abstrak
The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and
nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not
have a formal framework for postnatal lactation support. Breastfeeding duration and
exclusivity rates in Canada fall well below global recommendations, particularly among
 socially and economically vulnerable women. We aimed to explore CPNP participant
experiences with breastfeeding and with a novel community lactation support program in
Toronto, Canada that included access to certified lactation consultants and an electric
breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n =
46 women) were conducted between September and December 2017. Data were analysed
using inductive thematic analysis. Study participants reported a strong desire to breastfeed
but a lack of preparation for breastfeeding-associated challenges. Three main challenges
were identified by study participants: physical (e.g., pain and low milk supply), practical
(e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self-
efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that
the free lactation support helped to address breastfeeding challenges. In their view, the key
element of success with the new program was the in-home visit by the lactation consultant,
who was highly skilled and provided care in a non-judgmental manner. They reported this
support would have been otherwise unavailable due to cost or travel logistics. This study
suggests value in exploring the addition of postnatal lactation support to the well-established
national CPNP as a means to improve breastfeeding duration and exclusivity among
vulnerable women.
Keywords : breastfeeding, breastfeeding support, food security, infant and child
nutrition, nutrition, qualitative methods.

2.6 Klasifikasi EBM

Telah ditelusuri melalui Scimago bahwa jurnal ini berada dalam Q1.
 BAB 3
ISI ARTIKEL

3.1 Pendahuluan
Breastfeeding duration and exclusivity rates in Canada fall well below global
recommendations, particularly among socially and economically vulnerable women. We
aimed to explore CPNP participant experiences with breastfeeding and with a novel
community lactation support program in Toronto, Canada that included access to certified
lactation consultants and an electric breast pump, if needed. Mothers reported that the free
lactation support helped to address breastfeeding challenges. In their view, the key element
of success with the new program was the in-home visit by the lactation consultant, who was
highly skilled and provided care in a non-judgmental manner. They reported this support
would have been otherwise unavailable due to cost or travel logistics

3.2 Latar Belakang

The benefits of breastfeeding for infants, nursing mothers, and society are well
established in the literature (Kramer & Kakuma, 2012; Victora et al., 2015; Victora et al.,
2016). Consequently, exclusively breastfeeding for the first 6 months of life with
introduction of solids and continued breastfeeding thereafter is recommended (World
Health Organization [WHO], 2003; Health Canada, 2015). However, gaps remain between
recommended and actual breastfeeding practices worldwide, including in Canada
(Statistics Canada, 2012; WHO & UNICEF, 2017). Despite a national 90% initiation rate,
at 6 months postpartum, only 30% of Canadian mothers are exclusively breastfeeding, and
47% have stopped breastfeeding entirely (Chalmers et al., 2009; Statistics Canada, 2019).
Breastfeeding inequalities continue to persist, and women who have lower education, lower
income, or who are adolescents or single have the lowest breastfeeding rates (Best Start
Resource Centre, 2014; Gionet, 2013; Nickel et al., 2014). For example, national Canadian
data indicate that 23% of mothers in the lowest income quintile breastfed exclusively for 6
months compared with 33% of mothers in the highest income quintile (Statistics Canada,
2012). Similarly, 17% of mothers with less than high school education breastfed exclusively
for 6 months compared with 29% of mothers with post-secondary education. McFadden et
 al. (2017) concluded in their systematic review that postnatal breastfeeding support can
improve breastfeeding outcomes. However, there are limited data on what support might be
most effective for vulnerable groups, particularly within the Canadian context. Currently,
community breastfeeding support is typically implemented by local public health or non-
profit agencies resulting in fragmentation of service delivery and high variation based on
location. An opportunity exists to strengthen access to postnatal lactation support for
vulnerable mothers through the Canada Prenatal Nutrition Program (CPNP). The CPNP,
funded by the federal Public Health Agency of Canada, provides support for community-
based maternal–infant health interventions delivered at over 250 sites across Canada to
more than 51,000 women (CPNP, 2015). The CPNP aims to increase healthy birth weights
and promote and support breastfeeding among women in challenging life circumstances
that could impact their or their infant's health because of social determinants of health.
These vulnerable women may include those with lower income, lower education, history of
trauma and/or substance use, social isolation, and adolescents. In some CPNP sites, other
resources such as charitable donations enhance CPNP support. There is currently limited
evaluation of CPNP's impact on infant feeding practices, particularly breastfeeding
duration and exclusivity, and no formal framework or funding for postnatal breastfeeding
support, which would likely enhance outcomes. However, one CPNP site in Toronto is using
charitable donations to offer lactation services as an enhancement to their program. This
paper presents findings from a qualitative evaluation of this initiative. Our study aimed to
explore participants' experiences with breastfeeding and enhanced community lactation
support.

3.3 Rumusan Masalah

How does the experience of mothers who are vulnerable to breastfeeding affect the
enhanced community lactation support program?

3.4 Tujuan
To analyze the effect of breastfeeding-prone mothers experience with lactation support
program
3.5 Metode
We recruited women registered in the CPNP implemented by Parkdale Queen West
Community Health Centre in Toronto, which has been operating for 25 years (hereafter
referred to as “the prenatal program”). The prenatal program serves a diverse group of
approximately 200 women annually, over 75% of whom report income below the 2012
Statistics Canada size-adjusted low-income cut-off (Statistics Canada, 2015) and
approximately 85% of whom report being born outside of Canada (e.g.,
immigrants/newcomers primarily from East Asia, Africa, and South Asia). Weekly services
at the prenatal program include group education sessions, individualized support from
public health nurses and dietitians, community referrals, snacks, public transit tokens,
CDN$10 grocery store gift card, self-serve food bank, and childcare. Education sessions
include breastfeeding information and promotion in the curriculum approximately once
every 4–6 weeks. Clients who attend the prenatal program a minimum of three times are
offered access to postnatal lactation support as a program enhancement. Charitable
donations are used to fund skilled lactation support that is usually accessible only to higher
income women. The goals of the lactation support are to (a) increase support to mothers
facing challenges with infant feeding, particularly breastfeeding and (b) reduce barriers to
accessing professional breastfeeding support. Approximately 70% (138/200) of prenatal
program clients who gave birth in the 2017/2018 fiscal year accessed the enhanced
lactation support. The enhanced lactation support includes up to two free consultations by
an International Board-Certified Lactation Consultant (IBCLC) delivered in-home or at the
prenatal program site, a gift package of breastfeeding and infant care supplies (e.g.,
diapers and nursing pillow), and, if recommended by an IBCLC or public health nurse, a
double-electric breast pump (Medela™ Pump in Style). For mothers provided with a breast
pump, the IBCLC demonstrates how to use it and advises on best practices for collecting
and storing breast milk. Additional free consultations are arranged (telephone, text, or e-
mail) at the client's request and at the discretion of the IBCLC. If needed, the IBCLC
provides herbal galactagogues and lactation aids such as a supplemental nursing system.
3.6 Hasil
Among 114 prenatal program participants who delivered infants in the target-sampling
period, 34 were no longer connected to the program and could not be contacted by
telephone/e-mail (Figure 1). Fifty-one women consented and enrolled in the study, among
whom five did not attend a focus group or interview. Of the 46 adult women who
participated in this research (n = 25 focus groups, n = 21 interviews), 25 were first-time
mothers. The age range of study participants' most recent infant was 2–17 months. Focus
groups lasted a mean duration of 46 min (range 32–51 min), and interviews lasted a mean
duration of 39 min (range 20–90 min). There were 5–9 participants in three of the focus
groups, whereas one focus group had two participants. Five interviews were conducted with
an in-person interprete

3.7 Pembahasan
This qualitative study evaluated vulnerable mothers' experiences with breastfeeding
and lactation support offered as an enhancement to one Toronto CPNP site. Study
participants reported planning to breastfeed, and attempting to do so, but were unprepared
for the challenges.

Mothers who used the enhanced lactation support reported that it helped to address
breastfeeding challenges. According to study participants, key elements included in-home,
skilled help provided in a caring, non-judgmental manner. Mothers in this study felt there
was a disconnect between prenatal promotion of “breast is best” and the reality of learning
breastfeeding skills while caring for a newborn. The majority of breastfeeding concerns
described by study participants, including low milk supply, align with those reported in the
literature (Brown, Dodds, Legge, Bryanton, & Semenic, 2014; Li, Fein, Chen, &
GrummerStrawn, 2008; Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2013; Rollins et
al., 2016; Wagner, Chantry, Dewey, & Nommsen-Rivers, 2013). According to the 2011–
2012 Canadian Community Health Survey, women indicated insufficient milk supply as the
number one reason for early breastfeeding cessation (Gionet, 2013), consistent with studies
worldwide (Balogun, Dagvadorj, Anigo, & Sasaki, 2015; Gatti, 2008). Previous research
suggests that breastfeeding intention is a significant predictor for initiation and duration,
but early breastfeeding experiences may mediate its effect on duration (DiGirolamo,
Thompson, Martorell, Fein, & Grummer-Strawn, 2005; Mitra, Khoury, Hinton, &
Carothers, 2004). Unfortunately, qualitative and quantitative studies have highlighted that
there are gaps in breastfeeding support, and this disproportionately affects vulnerable
women (Chalmers et al., 2009; Garner et al., 2016).

Mothers described the lactation support as helping to address a variety of physical,

practical, and self-efficacy breastfeeding challenges. These findings are consistent with a
recent Cochrane review that reported positive effects of postnatal breastfeeding support on
breastfeeding outcomes up to 6 months (McFadden et al., 2017). However, very few studies
in the review examined vulnerable women outside African–American and Hispanic
communities in the United States. Additionally, there was high heterogeneity between study
contexts, interventions, and outcomes. Authors of the Cochrane review noted that the type of
breastfeeding support likely requires adaptations to fit the needs of different population
groups. Our study suggests that inhome skilled help provided in a non-judgmental manner
are key program elements in postnatal support for low-income women and/or those who
self-identified as immigrants/newcomers to Canada. Mothers also reported that
accessibility of services is key. They noted that community breastfeeding services were not
always accessible due to the inability to make appointments, limited hours of operation,
family responsibilities, and inadequate transportation. Key components of the lactation
support identified by study participants coincide with the recommendations of McFadden et
al. (2017) and Schmied, Beake, Sheehan, McCourt, and Dykes (2011) from their systematic
review and metasynthesis of the literature; specifically, breastfeeding support should be in-
person, proactive, predictable, and provided in an empathetic and trusting manner. We
posit that appropriate and accessible skilled lactation support, described above, may help
to establish breastfeeding, resolve early difficulties, and increase breastfeeding selfefficacy.
Breastfeeding self-efficacy has been shown to be a modifiable factor that can be targeted to
improve breastfeeding outcomes (Brockway, Benzies, & Hayden, 2017; Dennis, 1999).

Mothers in the present study reported that, in addition to skilled help, breast pumps
were an important component of lactation support. Results from the U.S. 2005–2007 Infant
Feeding Practices Study II found that 85% of breastfeeding mothers of infants 1.5–4.5
months of age (n = 1,564) reported using a breast pump (Labiner-Wolfe, Fein, Shealy, &
Wang, 2008). As far as we know, limited Canadian data are available on breast pump
practices in general. However, among 2,870 children in the Canadian Healthy Infant
Longitudinal Development study, 57% of those who were breastfed at 3 months of age also
received pumped breast milk (Azad et al., 2018). Our study participants used breast pumps
for a range of reasons also identified in the literature: to maintain milk supply, to provide
breast milk during breastfeeding problems, and to increase flexibility and allow others to
help with infant feeding (Chamberlain, McMahon, Phillip, & Merewood, 2006; Labiner-
Wolfe et al., 2008; Win, Binns, Zhao, Scott, & Oddy, 2006). Our research showed high
uptake of breast pumps, but further research is needed as to why and how breast pumps
may or may not help low-income women to breastfeed. Although the benefits of using an
electric breast pump to establish milk supply and enable the provision of human milk in a
mother's absence are well described, the longer term impact of using breast pumps on the
duration and exclusivity of feeding at the breast, and feeding human milk generally, are
unknown (Felice, Cassano, & Rasmussen, 2016; Rasmussen & Geraghty, 2011; Win et al.,
2006). Previous research recommends that breast pump use and type should be based on
the mother–baby dyad's individual situation (e.g., stage of lactation and pump dependency;
Meier, Patel, Hoban, & Engstrom, 2016; Becker, Smith, & Cooney, 2015).
 The evaluated lactation support addressed key breastfeeding needs, but other social
and structural factors may influence infant feeding practices. This study did not aim to
investigate these issues in detail, but participants did report that breastfeeding problems
might be further compounded by social determinants of health, including low-income and
food insecurity. This is supported by Canadian and U. S. data demonstrating that
breastfeeding may simply be “too much” for some low-income women (Frank, 2015a;
Hardison-Moody, MacNeil, Elliot, & Bowen, 2018). Although infant feeding practices were
not formally assessed in the current study, it was not uncommon for mothers to discuss
feeding a combination of breast milk and formula. Previous research indicates that low-
income women may have greater concerns about milk supply and that those experiencing
food insecurity are more likely to stop breastfeeding exclusively earlier than recommended
(Frank, 2015b; Li et al., 2008; Orr, Dachner, Frank, & Tarasuk, 2018). Formula must be
provided if infants are not breastfeeding, but accessing formula is challenging for
vulnerable mothers due to its high cost and precarious availability from community
agencies. This was identified by our study participants and in previous research (Frank,
2015b; Partyka, Whiting, Grunerud, Archibald, & Quennell, 2010). This would suggest that
such efforts are needed to ensure infant food security regardless of feeding type while also
cultivating an enabling environment for breastfeeding. The conceptual model developed by
Rollins et al. (2016) illustrates the complex determinants of breastfeeding, including
structural, settings, and individual factors. They emphasize that “breastfeeding is generally
thought to be an individual's decision and the sole responsibility of a woman to succeed,
ignoring the role of society in its support and protection” (Rollins et al., 2016, p. 500).

A key strength of this research was the focus on vulnerable mothers' perspectives of
breastfeeding and lactation support in Canada, which is lacking in the literature and
needed in order to create effective breastfeeding support. Other strengths of this work
include the strategies used to increase its rigour including a collaborative, iterative process
to generate codes; analysis of all verbatim transcripts from interviews and focus groups,
providing rich detail; a relatively large sample size, with saturation reached; and notes on
reflections and discussions with the research team, including community partners,
throughout the research process (Green & Thorogood, 2014). Breastfeeding is a complex
physical, emotional, and social practice, therefore, qualitative methods are needed to better
understand the implementation and effectiveness of interventions (Leeming, Marshall, &
Locke, 2017; Zamora, Lutter, & Pena-Rosas, 2015).

These results are specific to the program described, but key themes are transferable.
Challenges described by study participants are commonly found in the literature, and
postnatal breastfeeding support has been shown to be effective. The issue at hand is
determining how to tailor breastfeeding support to different populations. The use of
interpreters in the present study allowed us to gauge the experiences of women who do not
speak English that comprise a significant fraction of CPNP participants; however, we
 acknowledge we did not assess the reliability of the interpretation. In future studies,
confirmation of high-level results with study participants, both nonEnglish and English
speaking, should be considered. Selection bias is another limitation as study participants
were those who self-selected to participate. Those who declined participation or who could
not be reached may not have had the same views regarding breastfeeding and the lactation
support as study participants. Lastly, social desirability may be a limitation because study
participants all received extensive support and free services from the prenatal and lactation
support program, which might have made them hesitant to criticize aspects of the lactation
support.

3.8 Simpulan
The CPNP promotes breastfeeding among vulnerable women, including low-income
mothers and newcomers to Canada; it does not formally fund postnatal lactation support.
Our qualitative research examining the experiences of participants in one Toronto-based
CPNP with breastfeeding and enhanced community lactation support suggests provision of
in-home services by a skilled, non-judgmental lactation consultant and an electric breast
pump, if required, helped to address breastfeeding challenges. Next steps for this research
include introduction of the described lactation support to additional CPNP sites and
evaluation of its impact on breastfeeding outcomes. This research will help to assess
scalability within the CPNP and should include a cost-effectiveness analysis to ensure
sustainability.
 BAB 4
PEMBAHASAN

Studi kualitatif ini mengevaluasi pengalaman ibu yang rentan dengan dukungan
menyusui dan laktasi ditawarkan sebagai peningkatan satu situs CPNP Toronto. Peserta
studi melaporkan berencana untuk menyusui, dan mencoba melakukannya, tetapi tidak siap
untuk tantangan. Ibu yang menggunakan dukungan laktasi yang ditingkatkan melaporkan
bahwa itu membantu untuk mengatasi tantangan menyusui. Menurut teori diatas untuk
mempelajari peserta, elemen kunci termasuk di rumah, bantuan terampil yang diberikan
dengan cara yang penuh perhatian dan tidak menghakimi. Sayangnya, kualitatif dan studi
kuantitatif telah menyoroti bahwa ada kesenjangan dalam dukungan menyusui, dan ini
secara tidak proporsional mempengaruhi rentan perempuan

CPNP mempromosikan menyusui di antara wanita yang rentan, termasuk ibu

berpenghasilan rendah dan pendatang baru ke Kanada; itu tidak secara resmi mendanai
dukungan laktasi pascakelahiran. Penelitian kualitatif kami memeriksa pengalaman peserta
dalam satu berbasis di Toronto. CPNP dengan menyusui dan dukungan laktasi komunitas
yang ditingkatkan menyarankan penyediaan layanan di rumah oleh orang yang terampil dan
tidak menghakimi konsultan laktasi dan pompa payudara elektrik, jika diperlukan,
membantu untuk mengatasi tantangan menyusui.
 BAB 5
SIMPULAN

Dukungan laktasi sebagai bantuan untuk mengatasi berbagai tantangan menyusui, fisik,
praktis, dan kepercayaan diri. Dalam penelitian ini merasa ada keterputusan antara promosi
prenatal "payudara adalah yang terbaik" dan realitas pembelajaran keterampilan menyusui saat
merawat bayi baru lahir. Sebagian besar dari masalah menyusui dijelaskan oleh peserta studi,
termasuk rendah pasokan susu, sejajar dengan yang dilaporkan dalam literature. Dukungan
menyusui kemungkinan memerlukan adaptasi agar sesuai dengan dengan kebutuhan tiap
individu.
Dengan menyusui dan dukungan laktasi komunitas yang ditingkatkan menunjukkan
penyediaan layanan di rumah oleh konsultan yang terampil , jika diperlukan dapat membantu
mengatasi tantangan menyusui.
 LAMPIRAN
Lampiran 1 : Daftar 24 Artikel

1. Relationships between types of father breastfeeding support and breastfeeding

outcomes PMID: 27460557 PMCID: PMC6865933 DOI: 10.1111/mcn.12337
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865933/pdf/MCN-13-e12337.pdf
2. Individual breastfeeding support with contingent incentives for low-income mothers in
the USA: the ‘BOOST (Breastfeeding Onset & Onward with Support Tools)’
randomised controlled trial protocol
PMID: 32554737 PMCID: PMC7304794 DOI: 10.1136/bmjopen-2019-034510

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304794/pdf/bmjopen-2019-034510.pdf
3. Focused breastfeeding counselling improves short‐ and long‐term success in an early‐
discharge setting: A cluster‐ randomized study
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df

Lampiran 2 : Full Text Artikel yang direview

Received: 7 August 2019 Revised: 12 November 2019 Accepted: 6 January 2020
DOI: 10.1111/mcn.12957

ORIGINAL ARTICLE

Vulnerable mothers' experiences breastfeeding with an enhanced

community lactation support program

Jane Francis1,2 | Alison Mildon1 | Stacia Stewart3 | Bronwyn Underhill3 |

Valerie Tarasuk1,4 | Erica Di Ruggiero4 | Daniel Sellen1,4,5 | Deborah L.
O'Connor1,2
1
Department of
Nutritional Sciences,
Abstract
University of Toronto, The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition
Toronto, Ontario, Canada
2
supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal
Translational Medicine Program,
The Hospital for Sick Children, framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada
Toronto, Ontario, Canada fall well below global recommendations, par- ticularly among socially and economically
3
Health Promotion & Community vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and
Engagement, Parkdale Queen West
Community Health Centre, Toronto, with a novel community lacta- tion support program in Toronto, Canada that included access to
Ontario, Canada certified lactation consultants and an electric breast pump, if needed. Four semistructured focus
4
Dalla Lana School of Public
groups and 21 individual interviews (n = 46 women) were conducted between September and
Health, University of Toronto,
Toronto, Ontario, Canada December 2017. Data were analysed using inductive thematic analysis. Study participants
5
Joannah and Brian Lawson reported a strong desire to breastfeed but a lack of preparation for breastfeeding-associated
Centre for Child Nutrition,
University of Toronto, Toronto, challenges. Three main challenges were identified by study participants: physical (e.g., pain and
Ontario, Canada low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and
Correspondence breastfeeding self-efficacy (e.g., concern about milk supply and conflicting information). Mothers
Deborah L. O'Connor, reported that the free lactation support helped to address breastfeeding challenges. In their view,
Department of Nutritional
Sciences, University of Toronto, the key element of success with the new program was the in-home visit by the lacta- tion
Medical Sciences Building, consultant, who was highly skilled and provided care in a non-judgmental man- ner. They
Room 5253,
1 King's College Circle, Toronto,
reported this support would have been otherwise unavailable due to cost or travel logistics. This
ON M5S 1A8, Canada. study suggests value in exploring the addition of postnatal lac- tation support to the well-
Email: deborah.oconnor@utoronto.ca
established national CPNP as a means to improve breastfeeding duration and exclusivity
Funding information among vulnerable women.
The Sprott Foundation; Joannah
and Brian Lawson Centre for
KE YWOR DS
breastfeeding, breastfeeding support, food security, infant and child nutrition, nutrition, qualitative
methods
Child Nutrition

Deborah L. O'Connor, PhD, RD and Daniel Sellen, PhD are co-senior authors.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.

Matern Child Nutr. 2020;16:e12957. wileyonlinelibrary.com/journal/mcn 1 of

11
https://doi.org/10.1111/mcn.12957
FRANCIS ET AL. 2 of 11

1 | INTRODUCTION Key messages

Vulnerable mothers who participated in one program delivered under

the Canada Prenatal Nutrition Program reported planning and
attempting to breastfeed but were unprepared for the challenges.
Three main challenges were identified by participants: physical
(e.g., pain and low milk supply), practical (e.g., cost of breastfeeding
sup- port and time pressures), and breastfeeding self-efficacy (e.g.,
milk supply concerns and conflicting information).
Mothers identified in-home skilled help provided in a non-
judgmental manner as key elements of the commu- nity lactation
support.
Mothers perceived in-home lactation consultant services and double-
electric breast pumps helped mitigate various breastfeeding
challenges.
FRANCIS ET AL. 3 of 11

The benefits of breastfeeding for infants, nursing mothers, and society are well
established in the literature (Kramer & Kakuma, 2012; Victora et al., 2015;
Victora et al., 2016). Consequently, exclusively breastfeeding for the first 6
months of life with introduction of solids and continued breastfeeding thereafter is
recommended (World Health Organization [WHO], 2003; Health Canada,
2015). However, gaps remain between recommended and actual breastfeeding
practices worldwide, including in Canada (Statistics Canada, 2012; WHO &
UNICEF, 2017). Despite a national 90% initiation rate, at 6 months
postpartum, only 30% of Canadian mothers are exclusively breastfeeding, and
47% have stopped breastfeeding entirely (Chalmers et al., 2009; Statistics Canada,
2019). Breastfeeding inequalities con- tinue to persist, and women who have
lower education, lower income, or who are adolescents or single have the lowest
breastfeeding rates (Best Start Resource Centre, 2014; Gionet, 2013; Nickel et
al., 2014). For example, national Canadian data indicate that 23% of mothers in
the lowest income quintile breastfed exclusively for 6 months compared with 33% of
mothers in the highest income quintile (Statistics Canada, 2012). Similarly, 17%
of mothers with less than high school education breastfed exclusively for 6
months compared with 29% of mothers with post-secondary education. McFadden
et al. (2017) concluded in their systematic review that postnatal breastfeeding
support can improve breastfeeding outcomes. However, there are limited data on
what sup- port might be most effective for vulnerable groups, particularly within
2 | METHODS
the Canadian context. Currently, community breastfeeding support is typically
2.1 | Context and study participants
implemented by local public health or non-profit agencies resulting in
fragmentation of service delivery and high variation based on location. An
We recruited women registered in the CPNP implemented by Par- kdale
opportunity exists to strengthen access to postnatal lac- tation support for vulnerable
Queen West Community Health Centre in Toronto, which has been operating
mothers through the Canada Prenatal Nutrition Program (CPNP).
for 25 years (hereafter referred to as “the prenatal program”). The prenatal
The CPNP, funded by the federal Public Health Agency of Can- ada,
program serves a diverse group of approxi- mately 200 women annually, over
provides support for community-based maternal–infant health interventions
75% of whom report income below the 2012 Statistics Canada size-adjusted
delivered at over 250 sites across Canada to more than 51,000 women (CPNP,
low-income cut-off (Statis- tics Canada, 2015) and approximately 85% of
2015). The CPNP aims to increase healthy birth weights and promote and
whom report being born outside of Canada (e.g., immigrants/newcomers
support breastfeeding among women in challenging life circumstances that
primarily from East Asia, Africa, and South Asia). Weekly services at the
could impact their or their infant's health because of social determinants of
prenatal program include group education sessions, individualized support from
health. These vulner- able women may include those with lower income, lower
public health nurses and dietitians, community referrals, snacks, public transit
education, history of trauma and/or substance use, social isolation, and adoles-
tokens, CDN$10 grocery store gift card, self-serve food bank, and childcare.
cents. In some CPNP sites, other resources such as charitable dona- tions
Education sessions include breastfeeding information and promotion in the
enhance CPNP support.
curriculum approximately once every 4–6 weeks.
There is currently limited evaluation of CPNP's impact on infant feeding
Clients who attend the prenatal program a minimum of three times are
practices, particularly breastfeeding duration and exclusivity, and no formal
offered access to postnatal lactation support as a program enhancement.
framework or funding for postnatal breastfeeding sup- port, which would likely
Charitable donations are used to fund skilled lactation support that is usually
enhance outcomes. However, one CPNP site in Toronto is using charitable
accessible only to higher income women. The goals of the lactation support are
donations to offer lactation services as an enhancement to their program. This
to (a) increase support to mothers facing challenges with infant feeding,
paper presents findings from a qualitative evaluation of this initiative. Our study
particularly breastfeeding and
aimed to explore participants' experiences with breastfeeding and enhanced
(b) reduce barriers to accessing professional breastfeeding support.
commu- nity lactation support.
Approximately 70% (138/200) of prenatal program clients who gave birth in
the 2017/2018 fiscal year accessed the enhanced lactation support.
The enhanced lactation support includes up to two free consulta- tions by
an International Board-Certified Lactation Consultant (IBCLC) delivered in-
home or at the prenatal program site, a gift package of
FRANCIS ET AL. 4 of 11

breastfeeding and infant care supplies (e.g., diapers and nursing pil- low), and, TA B L E 1 Sample of focus group/interview questions
if recommended by an IBCLC or public health nurse, a dou- ble-electric breast
Focus group/interview questions
pump (Medela™ Pump in Style). For mothers provided with a breast pump,
What was your original plan for feeding your baby and then how did you
the IBCLC demonstrates how to use it and advises on best practices for
actually feed your baby after they were born?
collecting and storing breast milk. Additional free consultations are arranged
In general, who and what helped you to feed your baby?
(telephone, text, or e-mail) at the client's request and at the discretion of the
What are some challenges that families face when trying to feed their baby?
IBCLC. If needed, the IBCLC provides herbal galactagogues and lactation
aids such as a supplemental nursing system. What did you find most helpful about the infant feeding services you received
through the health center? This might have included the lactation
consultant and breast pump.
If you didn't see a lactation consultant or get a breast pump, how could it
2.2 | Recruitment and consent have helped you or other mothers feed their baby?
What other services do you wish the Parkdale Parents’ Primary Prevention
Project (5P's) had to help parents feed their babies?
Participants were recruited by the first author from women who had enrolled in
the prenatal program and gave birth between June 1, 2016 and August 16,
organization. Interviews took place at either the participant's home or a public
2017. Women were approached in person if they were still participating in
library. All discussions were audio-recorded, and data collec- tion continued
programming, or by telephone/e-mail if not. Study participants were informed that
until saturation (e.g., no new information) was reached (Saunders et al., 2017).
the researcher wanted to learn more about what they liked about the prenatal
program and aspects that could be improved in relation to infant feeding. Each
participant provided written, informed consent. For non-English speaking clients,
sequential interpretation was used for the recruitment and consent process. 2.4 | Data analysis
Ethics approval was obtained from the University of Toronto research ethics
board. Recordings were professionally transcribed verbatim, checked for accuracy
against recordings, and imported into NVivo Version
12 (QRS International, Burlington, MA, USA). Data were analysed using
the iterative process of thematic analysis outlined by Braun and Clarke (2006).
2.3 | Data collection
This method was chosen because of its appropriateness for applied health
research, its flexibility, and its robust framework that allows researchers to
This study used a qualitative research design involving two methods of data
identify, analyse, and report thematic pat- terns of meaning across data sets
collection: focus groups and individual interviews. For non- English speaking
(Braun & Clarke, 2006, 2013). Anal- ysis included data immersion, generating
clients or those who did not want to attend a focus group, interviews were
initial codes, searching for themes, and reviewing and defining themes (Braun
arranged and sequential interpretation was used if required. A single
& Clarke, 2006). The first author was responsible for inductively generating
semistructured guide of open-ended ques- tions was developed for use in
initial codes across the data based on relevance to the research aim. The
focus groups and interviews. Ques- tions were developed in conjunction with
second author independently reviewed all coding, including the place- ment of
key informants, including the prenatal program Coordinator, Parkdale Queen
quotations under each code, and provided feedback on collat- ing codes into
West Community Health Centre's Director of Health Promotion and
potential themes. Discrepancies in coding were discussed and resolved
Community Engagement, and an IBCLC providing the lactation support. Questions
between the first two authors. We acknowl- edge that engagement with the data
were pretested among five clients and found to be acceptable and
was shaped by our own assump- tions, disciplinary backgrounds, and professional
understandable (Table 1; Table S1 for complete guide). They were designed to
experiences, which may have in turn influenced the analysis (Bourke, 2014).
explore (a) experiences with infant feeding, particularly breastfeeding and (b)
However, our interpretation of the data was guided by multiple perspectives
experiences, perceptions, and attitudes toward the enhanced lactation support.
through regular feedback from our interdisciplinary team (Cresswell & Miller,
The first author, a Registered Dietitian, conducted focus groups between
2000). Our team included our community partners who provide perinatal
September and December 2017. As recommended when working with low-
programming and researchers with a variety of backgrounds, including public
income and/or multi-ethnic women (Barnett, Aguilar, Brittner, & Bonuck,
health, anthropology, and nutrition and dietetics. Notes were kept to document
2012), the first author regularly attended the prenatal program to develop
discussions and data analysis decisions made during these meetings. Group
rapport with clients. The second author, also a Registered Dietitian, attended all
discussions enhanced the devel- opment, refinement, and interpretation of
four focus groups and 5 of 21 interviews to record notes. The first two
themes, which were reviewed against the transcripts to ensure relevance to the
authors debriefed and discussed reflections following these focus groups and
experi- ences shared by participants (Braun & Clarke, 2013). Final themes were
interviews. To ensure study participants felt comfortable speaking openly, focus
organized under two overarching domains aligning with the
groups were conducted off-site at a local non-profit community
FRANCIS ET AL. 5 of 11
FRANCIS ET AL.
study aim: infant feeding experiences and experiences with the lacta- tion
support.
3 | ETHICAL STATEMENT
The Office of Research Ethics, University of Toronto approved this study.
4 | RESULTS
Among 114 prenatal program participants who delivered infants in the target-
sampling period, 34 were no longer connected to the pro- gram and could not
be contacted by telephone/e-mail (Figure 1). Fifty-one women consented and
enrolled in the study, among whom five did not attend a focus group or
interview. Of the 46 adult women who participated in this research (n = 25
focus groups, n = 21 inter- views), 25 were first-time mothers. The age range
of study partici- pants' most recent infant was 2–17 months. Focus groups
lasted a mean duration of 46 min (range 32–51 min), and interviews lasted a
mean duration of 39 min (range 20–90 min). There were 5–9 partici- pants in
three of the focus groups, whereas one focus group had two participants. Five
interviews were conducted with an in-person interpreter.
6 of 11
All but a few study participants reported they had decided during
pregnancy to breastfeed and attempted to do so. Discussions indi- cated that
exclusive breastfeeding for 6 months was not the norm; most women reported
feeding with a combination of breast milk and formula. Multiparous study
participants also referred to previous breastfeeding experiences. Themes are
described using representative quotes below.
4.1 | Unprepared for breastfeeding
challenges
Participating mothers reported awareness that breastfeeding is the
recommended food for infants. A common theme was that study par- ticipants
were unaware that they might experience difficulties while attempting to
breastfeed and were unprepared for these challenges.
You know, once it actually happened, I realized I know
nothing about it [breastfeeding] … So one thing is the theory,
another thing is actually practicing that. (Focus Group [FG];
primiparous)
I thought [it would be] easy and I never expected that I will
face a very difficult time with breastfeeding … when I see
people [breastfeeding] I feel like it's so easy, but when I do it,
it's so difficult … I have a very, very tough time …
(Interview; primiparous)
FRANCIS ET AL. 7 of 11

FIG U R E 1 Participant flow diagram

 Study participants noted that breastfeeding is a learned behaviour for infant
4.2.1 | Physical breastfeeding challenges
and mother, therefore, prenatal and postnatal guidance should be provided on
what to expect and how to deal with potential challenges.
The most commonly noted “physical” breastfeeding issue was discom- fort,
including pain, cracked nipples, engorgement, and mastitis. Another concern
But I didn't know that breastfeeding is so difficult; I thought
for study participants was milk supply, including the perception of postpartum
it came naturally … mothers and babies they know it … The
delay in milk production or low milk supply thereafter. Breastfeeding
[prenatal] classes only teach you about different positions for
technique, including infant latch, was also cited as problematic. Finally, some
breastfeeding and what are the benefits of breastfeeding,
study participants referred to slow infant weight gain, jaundice, and dehydration
that's it. (Interview; primiparous)
as reasons for introduc- ing formula.

Because it's such a big surprise … because everybody prepares

And when I first feed the baby, uh, … it was a little bit of
for labour, “oh labour is going to be painful”, but what about
milk, so it was very hard for me … even though baby latched
breastfeeding? (FG; multiparous)
properly. But I don't know, maybe I don't know how to feed
the baby. Uh, my nipple was cracked and it was hurt so I
keep on crying, crying … it was so diffi- cult … (FG;
4.2 | Breastfeeding challenges multiparous)

Breastfeeding challenges were common, with the majority of mothers referring to

multiple difficulties when describing their experience (Fig- ure 2). Three main
types of breastfeeding challenges (subthemes) were identified by study
participants: physical, practical, and self- efficacy.
4.2.2 | Practical breastfeeding challenges
Practical challenges included constructs that made breastfeeding less realistic in
the context of the mother's life. The first “practical” breastfeeding
challenge was maternal time pressures. Study
FIG U R E 2 Thematic representation. BF, breastfeeding
participants commented on the time required to breastfeed, the infant's
breastfeed otherwise you're a bad mom. (FG; primiparous)
reliance on the mother, busy lifestyles (including caring for other children),
and returning to work/school as problematic.
So, I had that anxiety all through the early months. I'll never
really know if I could have fed her a little more … because,
I had to take her everywhere … she never took a bot- tle.
um, I could get into a loop of fretting … (FG; multiparous)
Oh my, it was tough, 'cause I couldn't leave her.
Everywhere I had to take her. (Interview; primiparous)
The receipt of conflicting breastfeeding information and opinions, whether
from family and friends or health care professionals, further compromised
For me, I feel like, you know, I keep all the time
breastfeeding self-efficacy.
breastfeeding like two … [every] two hours. Any time he
needs, I give. You know, I have no rest, no rest. (Interview;
… there's a lot of input on how to breastfeed your child, when
multiparous)
to breastfeed them, like, and how you should do it if you're out
in public … it's like one person saying, “No, don't do it this
Another practical challenge was the time and cost associated with
way” and another person saying, “Oh yeah, you need to do it
accessing breastfeeding support. Study participants recognized that if the enhanced
this way” …” Don't feed them formula”, “Oh yeah, do feed
lactation support was not available, they might not have known there was such
them formula”, back and forth. (FG; primiparous)
a thing as a lactation consultant or about using a breast pump and would not
have been able to afford these supports.
Study participants indicated they were not necessarily confident in their
ability to provide sufficient milk volume for their infant's needs and voiced
Because I checked on the internet, it [breast pump] will cost
concern regarding the adequacy of nutrients available in their breast milk.
around $300-$400, which is a lot of investment … because
there are a whole lot of things to buy. (Inter- view;
I give her, um, formula because I found that, um, she didn't get
primiparous)
every like vitamins, whatever she needs. In the formula it is
written like DHA and so many vitamin, which are good for
That lady [lactation consultant] costs so much money if you
her. And that's why sometimes I feel like it's important to
call her … I felt really lucky. (FG; primiparous)
give her [formula]. (Interview; multiparous)

Some study participants received lactation support outside of the lactation

Generally, study participants who previously breastfed indicated that it
support program, for example, from midwives, family doctors, in-hospital
helped them through their current experience, but they noted that this was not
IBCLCs, and public health breastfeeding clinics. It was noted, though, that
always the case since each infant and each breastfeeding experience could be
community breastfeeding services were not always accessible. Several study
different. A minority of study par- ticipants reported a generally positive
participants also had experience using manual breast pumps but noted they
breastfeeding experience with minimal challenges.
were more painful to use and less efficient than the double-electric pump.

4.3 | Lactation consultant support helped

4.2.3 | Breastfeeding self-efficacy
challenges address key breastfeeding challenges
Study participants described IBCLCs as providing numerous supports, aligning
Study participants referred to breastfeeding challenges that directly relate to
with the above-mentioned categories of breastfeeding chal- lenges (Figure 2).
the components of breastfeeding “self-efficacy,” or a mother's confidence
Physical support included hands-on guidance with hand expression, latching,
in her ability to breastfeed her child (Dennis, 1999). Many mothers perceived
positioning, engorgement, and blocked ducts. Generally, mothers referred to
that feelings of guilt, stress, anxiety, depression, loneliness, and pressure
IBCLCs as teaching them how to breastfeed. Practically speaking, study
affected their ability to feed their infant and their emotional health in the
participants spoke about the accessibility of the services. The in-home support
prenatal and post- natal period. These feelings were linked to the availability of
with flexible hours was highly valued because it was challenging to leave their
support from family and friends. About one-third of study participants indi-
home to seek support soon after delivery as they were overwhelmed with car-
cated they had limited or no family in Canada.
ing for a newborn, they were recovering from childbirth and/or they

For me, I think the main challenge is, aside from I'm by
myself most of the time, it's the pressure … I felt really
pressured because I really want [to breastfeed], you know,
and people around you will say, you have to breastfeed …
it's like there's no other way, you have to
lacked a support system at home. Study participants reported the con- venience
beginning and I needed to empty my breasts. They were
of the continued contact with IBCLCs by telephone, e-mail, or text message
really huge. To rest, I use it to rest too. And to store milk as
after the initial home visit.
well. (Interview; multiparous)
The majority of study participants reportedly accessed the IBCLC services
and were grateful for the individualized support that helped to enhance their
I was pumping for more than four months, but it was very
breastfeeding self-efficacy. There was an overall appreciation for the
useful. And because, you know, when my breasts are full I
empathetic and encouraging attitude of the IBCLC and emotional support
don't want to waste the milk, and at the same time it was
provided. Participant narratives described the IBCLC with terms such as
very painful. So I had the relief of pain, and I was feeding my
“helpful,” “nice,” “amazing,” and “awesome.”
baby my breast milk, so it was very, very useful.
(Interview; multiparous)
… And that was so nice, that it was, like, coming to my house
because I was too sore to move and she, like, worked with
The vast majority of study participants who used a breast pump reported
my schedule and, like, I felt really impor- tant to her, like she
that it was helpful overall. However, it is important to note that approximately
cares … It was very convenient because, like, if I had to
five mothers indicated they had issues using a breast pump. Issues included
leave the house at that point, like, I was just a mess physically
difficulty in expressing sufficient milk, not finding it effective to increase their
and, like, emotionally, like so many hormones. So to have
milk supply, physical discomfort, and the time and effort required to pump and
someone just come to me was really useful. (FG;
clean associated bottles.
primiparous)
Study participants identified that the IBCLC and breast pump worked
hand in hand to target breastfeeding issues. The IBCLC pro- vided hands-on
Wonderful, wonderful person. She went twice to my place
support and was the link to providing the breast pump and demonstrating how
and she gave me a lot of work and tools to improve … I was
to use it. Although the majority of study par- ticipants did use the enhanced
really depressed, and desperate, and so she came again. And
lactation support, about five did not. Personal reasons included no issues with
very accessible over the phone, over e-mail, giving me all the
breastfeeding, did not want a breast pump or already had one, or moved outside
information … (Interview; primiparous)
the prenatal pro- gram catchment area.

4.4 | Breast pump helped 4.5 | Suggested program improvements

address key breastfeeding
Study participants identified additional areas where the prenatal and lactation
challenges
support program could improve support of their infant feed- ing goals, including
guidance on weaning and introducing solids, pre- natal education on breastfeeding
The majority of study participants reported to have received a dou- ble-electric
challenges and what to expect, and prenatal information on lactation
breast pump and indicated various ways in which it helped them feed their
consultant services.
infants. These aligned with the main identified catego- ries of breastfeeding
Study participants noted that infant feeding problems might be further
challenges (Figure 2). Mothers reported primarily using the breast pump to
compounded by social determinants of health, including low- income and food
establish or increase milk supply. When mothers experienced latch issues,
insecurity. For example, some mothers discussed the positive relationship between
using the pump provided peace of mind that they could feed their infant
healthy eating and the quantity and quality of breast milk. They noted that
breast milk. The storage of breast milk for future use was important so
this is hindered by the high cost of food, leading to concerns about their breast
mothers could rest and have others help with feedings. The pump was also used
milk. Because the majority of study participants were not exclusively
for comfort measures to relieve pain and pressure. Study participants were
breastfeeding, mothers also reported concerns about the affordability of
grate- ful for the high-quality electric breast pump and acknowledged the fact
formula. Therefore, study participants highlighted a need for access to formula and
that it was fast and easy to use, in comparison to hand expression or a manual
additional food and grocery store gift cards.
pump. The importance of the pump when going back to work or school was
discussed but only by a few study participants; therefore, this appeared not to
… It's [formula] extremely expensive. My husband was
be a primary reason for using a breast pump in this group.
praying for my milk to come because we cannot afford this.
It's very, very expensive, like it cost us so much for a week
I was crying. The tears were of happiness because I was
only. (Interview; multiparous)
really concerned that the baby was not able to eat. And that
machine allow me, for me to pump out my breast milk and
Some study participants commented on additional intersecting determinants
give it to my baby … I use it because the baby wasn't
of health, including social isolation, settlement issues, unemployment, and
latching properly at the
language barriers. These issues merit further
investigation for their impact on infant feeding but were not explored in-depth
in this study.
5 | DISCUSSION
This qualitative study evaluated vulnerable mothers' experiences with breastfeeding
and lactation support offered as an enhancement to one Toronto CPNP site.
Study participants reported planning to breastfeed, and attempting to do so,
but were unprepared for the challenges. Mothers who used the enhanced
lactation support reported that it helped to address breastfeeding challenges.
According to study participants, key elements included in-home, skilled help pro-
vided in a caring, non-judgmental manner.
Mothers in this study felt there was a disconnect between prena- tal
promotion of “breast is best” and the reality of learning breastfeeding skills
while caring for a newborn. The majority of breastfeeding concerns described
by study participants, including low milk supply, align with those reported in the
literature (Brown, Dodds, Legge, Bryanton, & Semenic, 2014; Li, Fein,
Chen, & Grummer- Strawn, 2008; Odom, Li, Scanlon, Perrine, & Grummer-
Strawn, 2013; Rollins et al., 2016; Wagner, Chantry, Dewey, & Nommsen-
Rivers, 2013). According to the 2011–2012 Canadian Community Health
Survey, women indicated insufficient milk supply as the number one reason for
early breastfeeding cessation (Gionet, 2013), consistent with studies worldwide
(Balogun, Dagvadorj, Anigo, & Sasaki, 2015; Gatti, 2008). Previous research
suggests that breastfeeding intention is a significant predictor for initiation and
duration, but early breastfeeding experiences may mediate its effect on
duration (DiGirolamo, Thompson, Martorell, Fein, & Grummer-Strawn, 2005;
Mitra, Khoury, Hinton, & Carothers, 2004). Unfortunately, qualitative and
quantitative studies have highlighted that there are gaps in breastfeeding
support, and this disproportionately affects vulnerable women (Chalmers et al.,
2009; Garner et al., 2016).
Mothers described the lactation support as helping to address a variety of
physical, practical, and self-efficacy breastfeeding challenges. These findings are
consistent with a recent Cochrane review that reported positive effects of
postnatal breastfeeding support on breastfeeding outcomes up to 6 months
(McFadden et al., 2017). How- ever, very few studies in the review examined
vulnerable women out- side African–American and Hispanic communities in the
United States. Additionally, there was high heterogeneity between study
contexts, interventions, and outcomes. Authors of the Cochrane review noted
that the type of breastfeeding support likely requires adaptations to fit the needs
of different population groups. Our study suggests that in- home skilled help
provided in a non-judgmental manner are key pro- gram elements in postnatal
support for low-income women and/or those who self-identified as
immigrants/newcomers to Canada. Mothers also reported that accessibility of
services is key. They noted that community breastfeeding services were not always
accessible due to the inability to make appointments, limited hours of operation,
family responsibilities, and inadequate transportation. Key components of the
lactation support identified by study participants coincide with the
recommendations of McFadden et al. (2017) and Schmied, Beake, Sheehan,
McCourt, and Dykes (2011) from their systematic review and metasynthesis of
the literature; specifically, breastfeeding support should be in-person, proactive,
predictable, and provided in an empa- thetic and trusting manner. We posit that
appropriate and accessible skilled lactation support, described above, may help
to establish breastfeeding, resolve early difficulties, and increase breastfeeding self-
efficacy. Breastfeeding self-efficacy has been shown to be a modifiable factor
that can be targeted to improve breastfeeding outcomes (Brockway,
Benzies, & Hayden, 2017; Dennis, 1999).
Mothers in the present study reported that, in addition to skilled help, breast
pumps were an important component of lactation support. Results from the U.S.
2005–2007 Infant Feeding Practices Study II found that 85% of breastfeeding
mothers of infants 1.5–4.5 months of age (n = 1,564) reported using a breast
pump (Labiner-Wolfe, Fein, Shealy, & Wang, 2008). As far as we know, limited
Canadian data are available on breast pump practices in general. However,
among 2,870 children in the Canadian Healthy Infant Longitudinal Development
study, 57% of those who were breastfed at 3 months of age also received
pumped breast milk (Azad et al., 2018). Our study participants used breast pumps
for a range of reasons also identified in the litera- ture: to maintain milk
supply, to provide breast milk during breastfeeding problems, and to increase
flexibility and allow others to help with infant feeding (Chamberlain, McMahon,
Phillip, & Merewood, 2006; Labiner-Wolfe et al., 2008; Win, Binns, Zhao,
Scott, & Oddy, 2006). Our research showed high uptake of breast pumps, but
further research is needed as to why and how breast pumps may or may not help
low-income women to breastfeed. Although the benefits of using an electric
breast pump to establish milk supply and enable the provi- sion of human milk in
a mother's absence are well described, the longer term impact of using breast
pumps on the duration and exclusivity of feeding at the breast, and feeding human
milk generally, are unknown (Felice, Cassano, & Rasmussen, 2016; Rasmussen &
Geraghty, 2011; Win et al., 2006). Previous research recommends that breast pump
use and type should be based on the mother–baby dyad's individual situa- tion
(e.g., stage of lactation and pump dependency; Meier, Patel, Hoban, &
Engstrom, 2016; Becker, Smith, & Cooney, 2015).
The evaluated lactation support addressed key breastfeeding
needs, but other social and structural factors may influence infant feeding
practices. This study did not aim to investigate these issues in detail, but
participants did report that breastfeeding problems might be further
compounded by social determinants of health, including low-income and food
insecurity. This is supported by Canadian and U.
S. data demonstrating that breastfeeding may simply be “too much” for some
low-income women (Frank, 2015a; Hardison-Moody, Mac- Neil, Elliot, &
Bowen, 2018). Although infant feeding practices were not formally assessed in
the current study, it was not uncommon for mothers to discuss feeding a
combination of breast milk and formula. Previous research indicates that low-
income women may have greater concerns about milk supply and that those
experiencing food insecu- rity are more likely to stop breastfeeding exclusively
earlier than rec- ommended (Frank, 2015b; Li et al., 2008; Orr, Dachner,
Frank, & Tarasuk, 2018). Formula must be provided if infants are not
breastfeeding, but accessing formula is challenging for vulnerable mothers due
formally fund postnatal lactation support. Our qualitative research examining
to its high cost and precarious availability from commu- nity agencies. This
the experiences of participants in one Toronto-based CPNP with breastfeeding
was identified by our study participants and in pre- vious research (Frank,
and enhanced community lactation support suggests provision of in-home
2015b; Partyka, Whiting, Grunerud, Archibald, & Quennell, 2010). This would
services by a skilled, non-judgmental lactation consultant and an electric breast
suggest that such efforts are needed to ensure infant food security regardless of
pump, if required, helped to address breastfeeding challenges. Next steps for this
feeding type while also cultivating an enabling environment for breastfeeding.
research include introduction of the described lactation support to additional
The con- ceptual model developed by Rollins et al. (2016) illustrates the com-
CPNP sites and evaluation of its impact on breastfeeding outcomes. This
plex determinants of breastfeeding, including structural, settings, and individual
research will help to assess scalability within the CPNP and should include a
factors. They emphasize that “breastfeeding is generally thought to be an
cost-effectiveness analysis to ensure sustainability.
individual's decision and the sole responsibility of a woman to succeed,
ignoring the role of society in its support and pro- tection” (Rollins et al.,
ACKNOWLEDGMENTS
2016, p. 500).
We thank all mothers who took the time to participate in our focus groups
A key strength of this research was the focus on vulnerable mothers'
and interviews. College-Montrose Children's Place provided space to conduct
perspectives of breastfeeding and lactation support in Can- ada, which is
focus group discussions. This study was supported by The Sprott Foundation
lacking in the literature and needed in order to create effective breastfeeding
and the Joannah and Brian Lawson Centre for Child Nutrition. The sources of
support. Other strengths of this work include the strategies used to increase its
funding had no role in the design or conduct of the research study, statistical
rigour including a collaborative, iter- ative process to generate codes; analysis of
analysis, data interpreta- tion, or writing of the manuscript.
all verbatim transcripts from interviews and focus groups, providing rich detail;
a relatively large sample size, with saturation reached; and notes on reflections
CONFLICTS OF INTEREST
and discussions with the research team, including community part- ners,
The authors declare that they have no conflicts of interest.
throughout the research process (Green & Thorogood, 2014). Breastfeeding is a
complex physical, emotional, and social practice, therefore, qualitative methods
CONTRIBUTIONS
are needed to better understand the implementation and effectiveness of
JF, DS, and DLO conceptualized the study. JF, AM, DS, and DLO
interventions (Leeming, Mar- shall, & Locke, 2017; Zamora, Lutter, & Pena-
designed the study with input from SS, BU, VT, and EDR. The research was
Rosas, 2015).
performed by JF and AM. Primary data analysis was con- ducted by JF, and
These results are specific to the program described, but key themes are
AM assisted with data analysis. SS, BU, VT, EDR, DS, and DLO provided
transferable. Challenges described by study participants are commonly found in
primary guidance on data interpretation. JF drafted the initial manuscript, and
the literature, and postnatal breastfeeding support has been shown to be
all authors approved the final manuscript.
effective. The issue at hand is deter- mining how to tailor breastfeeding
support to different populations. The use of interpreters in the present study
ORCID
allowed us to gauge the experiences of women who do not speak English that
Jane Francis https://orcid.org/0000-0001-6676-6533
comprise a sig- nificant fraction of CPNP participants; however, we
Alison Mildon https://orcid.org/0000-0002-5550-0040
acknowledge we did not assess the reliability of the interpretation. In future
Deborah L. O'Connor https://orcid.org/0000-0001-6331-091X
studies, confirmation of high-level results with study participants, both non-
English and English speaking, should be considered. Selection bias is another
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SUPPORTING INFORMATION
Additional supporting information may be found online in the Supporting Information section at the end of this article.

How to cite this article: Francis J, Mildon A, Stewart S, et al.

Vulnerable mothers' experiences breastfeeding with an enhanced
community lactation support program. Matern Child Nutr.
2020;16:e12957. https://doi.org/10.1111/mcn.12957