Context

It is recommended that breastfeeding is initiated within the first hour after birth and continued exclusively for 6 months of life.1 In Hong Kong, 86.8% of women initiate breastfeeding, while exclusive breastfeeding at hospital discharge is only 18.9%.2 This study by Lok et al implemented a Baby-Friendly Community Initiative (BFCI) model to assess its effectiveness and ability to improve breastfeeding knowledge and breastfeeding attitudes among the community as well as pregnant and breastfeeding mothers.3 The BFCI model that was implemented aims to build on the Baby-Friendly Hospital Initiative (BFHI) to improve exclusive breastfeeding rates in Hong Kong.3

Findings

Statistically significant improvements were noted for both groups in breastfeeding knowledge and breastfeeding attitude (p<0.01). Frontline staff had a pre-workshop breastfeeding self-efficacy (BSE-S) mean score of 33.1 (SD=3.8) and post-workshop mean score of 38.9 (SD=6.2) demonstrating a significant improvement in BSE-S scores (p<0.001). Similarly, mean breastfeeding attitude scores significantly increased from 56.8 (SD=6.4) before workshop to M=62.9 (SD=9.3) after workshop (p<0.001). Pregnant and breastfeeding mothers also experienced significant improvements in mean BSE-S scores, increasing from M=37.6 (SD=9.8) before workshop to M=45.7 (SD=10.4, p<0.001) after workshop. Similarly, breastfeeding attitudes of mothers significantly increased from M=59.5 (SD: 6.3) before workshop to M=62.8 (SD: 7.0, p<0.001) after workshop.

Commentary

Despite high breastfeeding rates at hospital discharge, typically the sharpest decline in any or exclusive breastfeeding occurs during the first month of life,4 partially because challenges with breastfeeding that arise in the first weeks after hospital discharge are one of the biggest predictors of continued breastfeeding. The BFCI aims to provide continued breastfeeding support for women in the community and is an important factor in the continuation of breastfeeding to meet recommended guidelines.

Lok et al’s objective to improve breastfeeding rates and breastfeeding support in Hong Kong by implementing a BFCI throughout shopping malls is an innovative way to raise community breastfeeding support. Improving knowledge of breastfeeding in shopping malls while simultaneously improving BSE in pregnant and breastfeeding women may be an effective way to enhance community support for breastfeeding. Raising awareness of staff and mothers about the challenges mothers face while breastfeeding in public brings about confidence and compassion around supporting a safe, baby-friendly environment. While Lok et al found statistical improvements in breastfeeding attitudes and self-efficacy at 1 month post intervention, it is unclear if this translated into higher breastfeeding rates. However, improving maternal BSE is an evidence-based, modifiable factor that is effective at improving breastfeeding exclusivity and duration.5

Integration of SCT into the research framework may enhance the sustainability and applicability of this study to other contexts. SCT is a theoretical framework focused on organisational context and is gaining popularity with implementation researchers and in healthcare research to better ensure research findings are successfully incorporated into practice.6 Lok et al demonstrated sustained effects of their intervention on breastfeeding attitudes and self-efficacy at 1 month post-intervention. This study is an important step in rethinking BFCI implementation, as it places the responsibility on the community, rather than the individual to build baby-friendly spaces to improve community breastfeeding supports.