Assessing learning needs for breastfeeding: setting the scene

Abstract

Breastfeeding has a major contribution to make to public health, yet the UK, like many other developed countries, has low rates of breastfeeding. A contributing factor is that practitioners are ill‐prepared to support breastfeeding women. There is a mismatch between the care professionals provide and the support women desire. A national breastfeeding learning needs assessment (LNA) was carried out in England to provide a comprehensive picture of professional and practitioner learning needs and existing training opportunities and resources. The LNA comprised five elements, and sought the views of service users through consumer organizations and voluntary breastfeeding supporters. Two elements of the LNA are reported here. A search of RDLearning, a web‐based national resource, provided details of existing accredited courses in the UK for practitioners. Ten short courses provided by higher education institutions were identified, along with a range of courses offered by voluntary and other organizations, such as the National Childbirth Trust and UNICEF Baby Friendly Initiative. Second, an e‐mail survey of 28 key stakeholder organizations was undertaken, with a response rate of 68% (n = 18). All but one acknowledged that their members could benefit from further breastfeeding knowledge and expertise and were supportive of a national breastfeeding education initiative. The most popular forms of education provision were workshops and seminars, online and written information. The topic considered most important for all practitioners was the health outcomes of breastfeeding. Other contributions which stakeholder organizations felt they could make were the provision of information resources and setting up specialist interest groups.

Introduction

Breastfeeding is a major public health issue of global importance, promoting health in both the short and long term for mothers and babies. To achieve the greatest benefits from breastfeeding, the World Health Organization (WHO 2003) recommends exclusive breastfeeding for the first 6 months of life and continued breastfeeding for 2 years and beyond. It is of concern therefore that the UK has low rates of breastfeeding initiation and continuation compared with other European countries (Yngve & Sjostrum 2001). The breastfeeding initiation rate in England and Wales was 62% in the 2000 feeding survey (standardized rate for the composition of the sample, Hamlyn et al. 2002). Recent statistics show an increase in initiation rates between 2000 and 2005 to 78% in England and 67% in Wales (Bolling 2006). There is then a sharp decline in breastfeeding in England and Wales following birth, with only 43% of women breastfeeding at 6 weeks (Hamlyn et al. 2002). Furthermore, breastfeeding rates in the UK are lowest in women from lower socio‐economic groups, with only 28% of these women breastfeeding up to 6 weeks compared with 60% of women in higher socio‐economic occupations (Hamlyn et al. 2002).

Breastfeeding is a key strategy in addressing health inequalities in England and Wales (Department of Health 2002a) and contributes to several Public Service Agreement (PSA) targets, including reducing infant mortality and tackling childhood obesity (Department of Health 2004). The government aims to increase breastfeeding initiation in England by two percentage points annually, especially among communities with the lowest rates (Department of Health 2002b). Currently, there is no national target for breastfeeding continuation.

Breastfeeding education

One of the many and complex factors contributing to low breastfeeding rates in the UK is lack of education and preparation of health practitioners to support breastfeeding effectively (Renfrew et al. 2005). In spite of evidence that professional support can be successful in promoting breastfeeding (Sikorski et al. 2004), there is increasing awareness that health professionals are not equipped to meet the needs of breastfeeding women. Studies in the UK, Australia and the USA have highlighted some of the implications for breastfeeding women of poor breastfeeding knowledge and skills of key health professionals. Participants in a survey of Australian midwives’ breastfeeding knowledge reported that advice given was often conflicting and unhelpful (Cantrill et al. 2003). Evidence from the UK indicates that women experience inconsistent information and inappropriate attitudes from health professionals (Simmons 2003; McFadden & Toole 2006; Smale et al. 2006). Freed et al. (1995) found that many medical practitioners in the USA lacked the skills and knowledge to help women with common breastfeeding problems, and suggested that this lack of knowledge may be putting some women at risk of harm.

Encouragingly, there is evidence that good practice breastfeeding education can be effective in improving support for breastfeeding women. In a study by Bernaix (2000), a high level of breastfeeding knowledge was the best predictor of supportive breastfeeding behaviour, including providing information, technical (skills) support and emotional encouragement. There is evidence that implementing the UNICEF UK Baby Friendly Initiative (BFI) best practice standards, which combine staff training with a range of practice and policy changes, can increase breastfeeding rates (Cattaneo & Buzzetti 2001; Kramer et al. 2001; Broadfoot et al. 2005). Other studies have suggested that the UNICEF UK BFI 20‐hour Breastfeeding Management Course is effective in increasing participants’ knowledge (Valdes et al. 1995; Hall Moran et al. 2000; Wissett et al. 2000). In a systematic review of interventions to promote initiation of breastfeeding, Dyson et al. (2005) found strong evidence that some forms of breastfeeding education were effective at increasing initiation rates among women on low incomes in the USA. None of this is to suggest that breastfeeding education of healthcare practitioners on its own is sufficient to increase initiation and continuation rates of breastfeeding, but it is a necessary component of multifaceted strategies.

Breastfeeding women have contact with a wide range of health practitioners, all of whom can influence the initiation and duration of breastfeeding, and yet many have little or no formal breastfeeding education. Smale et al. (2006) identified a deficit in education and training for all professional groups included in their study in northern England. Other studies have found a lack of appropriate training for nurses, nurse‐midwives and obstetrics‐gynaecology practitioners in the USA (1995, 1996; Hellings & Howe 2000); midwives in Australia (Cantrill et al. 2003); and a range of practitioners, but particularly general medical practitioners, in Northern Ireland (Bleakney & McErlain 1996). Specific criticisms of breastfeeding education include a lack of appropriate clinical experience for the development of skills (Freed et al. 1996; Cantrill et al. 2003), theoretical rather than problem‐solving approaches to learning, and the lack of evaluation of breastfeeding programmes (Smale et al. 2006).

A worrying theme in some studies addressing breastfeeding education is a tendency for many health professionals to believe themselves to be competent while simultaneously demonstrating knowledge deficits related to supporting breastfeeding women (Freed et al. 1996; Hellings & Howe 2000; Cantrill et al. 2003). This is corroborated by Bernaix (2000), who compared nurses’ breastfeeding attitudes and intentions to offer support with breastfeeding mothers’ perceptions of the actual support provided. She concluded that many breastfeeding mothers did not identify the nurse as helpful and supportive, whereas nurses believed that they were providing effective support. Smale et al. (2006) also found a mismatch between the breastfeeding support women wanted and what health professionals were providing. A further consistent theme is that health professionals who have personal breastfeeding experience are much more positive about breastfeeding in general and more confident in their abilities to assist breastfeeding mothers (1995, 1996; Hellings & Howe 2000; Arthur et al. 2003; Cantrill et al. 2003). Freed et al. (1996) found that practitioners with personal breastfeeding experience were twice as likely to rate their training as inadequate. This suggests that the more knowledge practitioners have of the needs of breastfeeding women, the more aware they are of their own learning deficits and needs.

Most of the studies cited above are small‐scale; some have methodological weaknesses. With the exception of Smale et al. (2006) and Bleakney & McErlain (1996), they present difficulties of application to the UK. However, they highlight a consistent pattern of poor preparation of health professionals to support breastfeeding women. Consequently, addressing health professionals’ breastfeeding learning needs must be a key, although not the only, component of strategies aimed at meeting national and international recommendations for increasing breastfeeding initiation and duration rates.

Recently there has been acknowledgement of the importance of education if breastfeeding policy recommendations are to be achieved. UNICEF UK BFI has responded to the challenge by launching best practice standards for pre‐registration training for midwives and health visitors (UNICEF UK BFI 2002) and developing training packages for general practitioners and paediatricians (UNICEF UK BFI 2005). In 2003, UNICEF UK BFI was commissioned by National Health Service (NHS) Education for Scotland and Health Scotland to develop an information and teaching resource CD‐ROM to support education of public health nursing and midwifery students (UNICEF UK BFI 2005). This resource can be purchased by practitioners and educators who have attended UNICEF UK BFI breastfeeding courses. In Australia, the Royal Australian College of Physicians has a breastfeeding policy, which recommends ‘the inclusion of breastfeeding topics in the undergraduate medical curriculum, and in postgraduate courses for paediatricians, obstetricians, general practitioners, midwives, maternal and child health nurses and relevant others’ (RACP 2002). A forthcoming National Institute for Health and Clinical Excellence (NICE) document on breastfeeding (Dyson et al. 2006) includes professional training as a key part of its strategy for promoting the initiation and/or duration of breastfeeding in population groups experiencing disadvantaged circumstances.

Learning needs assessment

There is clearly a need to systematically assess and respond to the training needs of all practitioners involved in the care of pregnant and breastfeeding women. An analysis of learning needs is the first step in what should be a cyclical process in an overall strategy for training and education (Furze & Pearcey 1999). According to Gould et al. (2004), learning or training needs analysis can be ‘viewed as a means of improving service delivery through training’ and ‘making sure the right training is done’. Identification of the learning needs of the target population, in this case all practitioners who may encounter pregnant or breastfeeding women within their role, is fundamental to understanding the nature and extent of the problem prior to developing educational interventions. The ensuing training programmes can then be designed to be needs responsive and cost‐effective. A learning needs assessment can also provide a framework for evaluating existing and new education programmes.

It was recognized that such an analysis was needed in the UK, and a national multidisciplinary learning needs assessment (LNA) was commissioned by the former Health Development Agency, subsequently funded by NICE, and undertaken by the Public Health Collaborating Centre for Maternal and Child Nutrition in 2004–05. Although conducted only in the UK, it is likely to have relevance for other countries with low breastfeeding rates.

Materials and methods

The learning needs assessment was unique in that it was a large‐scale national study, used a systematic and multi‐method approach, and included a wide range of health practitioners who may encounter pregnant and breastfeeding women. It also sought the views of some service users through inclusion of consumer organizations and voluntary breastfeeding supporters. The learning needs assessment was designed to provide a comprehensive picture of professional and practitioner learning needs and existing training opportunities and resources. It specifically aimed to identify, from the range of practitioners who are involved with pregnant and breastfeeding women, the formal and informal ways of learning that are valued by practitioners and what educational opportunities could be made available in the future. Of particular interest were the learning needs of professionals working in areas with high levels of socio‐economic deprivation, and this informed the sites selected for the case studies. The learning needs assessment comprised five elements, as indicated in Table 1. The findings of the first two elements are discussed below. The last three elements are discussed in detail in separate papers in this supplement (Abbott et al. 2006; Dykes 2006; Renfrew et al. 2006; Wallace & Kosmala‐Anderson 2006). An additional related paper is to be published in a forthcoming issue of Maternal & Child Nutrition (Wallace & Kosmala‐Anderson in press).

Table 1.

Elements of the learning needs assessment

Title	Methods and participants
Provision of formal breastfeeding education opportunities in UK.	A search of RDLearning, a web‐based national resource, which provided details of existing courses for practitioners at a range of academic levels.
Breastfeeding learning needs assessment: national stakeholder survey	An email survey of 28 professional and other organizations providing educational opportunities or resources for health professionals in England.
	There was a 68% (n = 19) response rate.
The education of health practitioners supporting breastfeeding women: time for critical reflection	A critical reflection on the literature.
Dykes (2006)
‘Informal’ learning to support breastfeeding: local problems and opportunities	A case study in three health economies, each in an area of socio‐economic deprivation.
Abbott et al. (2006)	Semi‐structured telephone interviews were conducted with key informants in each site.
	A total of 31 informants participated in the study.
A training needs survey of doctors’ breastfeeding support skills in England.	A survey of practitioners who, within their roles, may care for breastfeeding women. Three versions of a self‐report questionnaire were developed and circulated to health practitioners and voluntary breastfeeding supporters, general medical practitioners and paediatric medical practitioners. Both online and paper versions of the questionnaire were used. Contact lists were established using clinical, professional and research networks. Ethics approval was obtained, and site registration achieved for numerous trusts. 752 returns 575 healthcare personnel, including midwives, health visitors, nurses, support workers and voluntary breastfeeding supporters 120 paediatric medical practitioners 57 general medical practitioners
Wallace & Kosmala‐Anderson (2006)
Training needs survey of midwives, health visitors and voluntary sector breastfeeding support staff in England.
Wallace & Kosmala‐Anderson (in press)

Search for existing accredited education and training opportunities

A range of opportunities exist for breastfeeding education and training in the UK, and it was important to know which formal courses were available to healthcare practitioners. A search was undertaken of RDLearning (http://www.rdlearning.org.uk/), a web‐based national resource, which provided details of existing courses for practitioners at a range of academic levels. The RDLearning project aims to establish an accessible, comprehensive database of all health‐related training for NHS staff in the UK. The website includes all post‐qualification courses, short courses, workshops and conferences throughout the UK. In addition to courses run by higher education institutions, there are also those run by professional bodies, research networks, NHS Trusts and health‐related conference organizers. The comprehensive resource is searchable by a number of mechanisms, including subject, geographical area, institution, qualification and keywords to enable NHS staff to find courses on a variety of subjects appropriate to their skills and in their preferred place of study. As well as courses provided by higher education institutions, the search also provided information about courses provided by voluntary and other organizations, namely, the National Childbirth Trust, UNICEF UK BFI and Lactation Consultants of Great Britain.

Views of national stakeholder organizations

Pregnant women, breastfeeding mothers and their babies are likely to encounter a wide range of health professionals, voluntary counsellors and support workers. These situations provide opportunities for information‐giving, support and management of problems. An important element of the learning needs assessment therefore was to consult stakeholder organizations representing this range of practitioners.

A survey was undertaken to elicit the views of key national stakeholder organizations, including relevant Royal Colleges and voluntary organizations, of their existing training provision and future training needs and plans. Twenty‐eight professional and other relevant organizations, excluding educational establishments, which provided educational opportunities or resources for health professionals and other breastfeeding supporters, were surveyed using an email questionnaire. The questionnaire explored existing educational provision in relation to breastfeeding, views on the potential benefit of breastfeeding education, topics of particular relevance, possible methods of delivery and interest in participating in any national educational initiatives in the future. Responses were requested within 3 weeks either by email or post. Non‐responders were followed up with a telephone reminder and an offer to complete the survey by phone. Nineteen responses were received, eight by email, two by post and nine by telephone, a response rate of 68%. No assumptions can be made about the characteristics of the organizations who did not respond to this survey. However, it is a limitation of the survey that some of them represented key groups of practitioners who provide care for pregnant and breastfeeding women, and in particular, some relevant medical Royal Colleges.

Results

What formal breastfeeding courses exist?

Ten short courses provided by higher education institutions were identified, ranging from 1‐day workshops to a 12‐week module. These university courses were targeted at healthcare professionals, mainly midwives, heath visitors and nurses, for their continuing professional development, and were at a diploma or degree level. One university provides a 4‐week masters‐level course, which is aimed at senior health professionals and medical staff. This course is run in conjunction with the WHO and UNICEF and attracts international participants. Courses run by Lactation Consultant Great Britain also include graduates of lactation consultant education programmes and breastfeeding counsellors. These courses are aimed at those preparing for the International Board of Lactation Consultants examination. UNICEF UK BFI provides two courses, a 3‐day breastfeeding management course for health professionals (UNICEF UK BFI 2006a) and a 2‐day course for support workers (UNICEF UK BFI 2006b). Both of these courses are designed to prepare participants to implement best practice standards. The content of all of these courses varies but most frequently covers health benefits of breastfeeding, social and cultural issues, principles of lactation and related anatomy, and supporting breastfeeding women, including dealing with common problems. The National Childbirth Trust runs a workshop on ‘Leading a Dynamic Breastfeeding Session’, which prepares participants to deliver breastfeeding education for women and their families.

What are the views of national stakeholder organizations about breastfeeding education and training?

Eighteen (95%) of the 19 stakeholder organizations that responded agreed that care provided by their members could be enhanced by greater knowledge and expertise in the field of breastfeeding, and there was overwhelming support (n = 18) and commitment for a multidisciplinary and multi‐agency breastfeeding education initiative. Eighteen of the responding organizations felt that their main contribution was to enhance their own members’ breastfeeding knowledge. The most appropriate formats of delivering education varied, but were said to include study days/conferences (58%, n = 11), workshops/seminars (68%, n = 13) or online and written information (68%, n = 13). Three organizations suggested ‘on‐line’ information would be helpful where it is difficult to get practitioners together, particularly in medical speciality training. In relation to the content of education, knowledge of health outcomes was considered important for most (79%, n = 15), whereas management of breastfeeding problems was felt to be appropriate for more specialist groups (47%, n = 9). Those organizations most closely involved in breastfeeding support advocated the inclusion of topics related to social inequalities and diverse populations (16%, n = 3). Other roles which the stakeholder organizations felt they could play included provision of information resources (58%, n = 11), setting up special interest groups (58%, n = 11), development of guidelines (47%, n = 9), and funding educational activities (37%, n = 7).

Discussion and conclusion

Improving the breastfeeding knowledge and skills of a wide range of practitioners has the potential to have substantial impact on breastfeeding rates in communities that have low breastfeeding prevalence (Dykes 2003; Dyson et al. 2005). As women and babies from these communities have the most health benefits to gain from breastfeeding (Renfrew et al. 2005), improving breastfeeding education is an important element of addressing inequalities in health. However, there is a lack of evidence to direct the development of such education. A national, multidisciplinary, multi‐method breastfeeding learning needs assessment was conducted to try to fill this gap. Two of the elements of the LNA have been discussed here. These identified that there is a range of formal courses available to practitioners from a variety of providers, and that there appears to be some consensus around the content of formal breastfeeding courses for practitioners. National stakeholder organizations that responded to the survey acknowledged that their members could benefit from further breastfeeding knowledge and expertise, and were overwhelmingly supportive of a national multidisciplinary breastfeeding education initiative.