A feasibility study of a multidimensional breastfeeding-support intervention in Ireland

Author’s Accepted Manuscript A feasibility study of a multi-dimensional breastfeeding-support intervention in Ireland Goiuri Alberdi, Elizabeth J O'Sullivan, Helena Scully, Niamh Kelly, Regina Kincaid, Rosie Murtagh, Stephanie Murray, Denise McGuinness, Ashamole Clive, Mary Brosnan, Lucille Sheehy, Elizabeth Dunn, Fionnuala M McAuliffe

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S0266-6138(17)30281-4 https://doi.org/10.1016/j.midw.2017.12.018 YMIDW2158

To appear in: Midwifery Received date: 3 July 2017 Revised date: 26 October 2017 Accepted date: 21 December 2017 Cite this article as: Goiuri Alberdi, Elizabeth J O'Sullivan, Helena Scully, Niamh Kelly, Regina Kincaid, Rosie Murtagh, Stephanie Murray, Denise McGuinness, Ashamole Clive, Mary Brosnan, Lucille Sheehy, Elizabeth Dunn and Fionnuala M McAuliffe, A feasibility study of a multi-dimensional breastfeeding-support intervention in Ireland, Midwifery, https://doi.org/10.1016/j.midw.2017.12.018 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Title: A feasibility study of a multi-dimensional breastfeeding-support intervention in Ireland Authors: Goiuri Alberdi1, Elizabeth J O’Sullivan1, Helena Scully1, Niamh Kelly1, Regina Kincaid2, Rosie Murtagh2, Stephanie Murray3, Denise McGuinness2, Ashamole Clive2,4, Mary Brosnan2, Lucille Sheehy2, Elizabeth Dunn3 & Fionnuala M McAuliffe1,2. Affiliations: 1 UCD Perinatal Research Centre, School of Medicine, University College Dublin, Ireland. 2 The National Maternity Hospital, Dublin 2, Ireland. 3 Wexford General Hospital, Wexford, Ireland. 4 School of Nursing and Midwifery, Trinity College, Dublin (Present address). Corresponding author: Fionnuala M McAuliffe, [email protected] Co-authors’ email addresses: Goiuri Alberdi: [email protected] Elizabeth J O’Sullivan: [email protected] Helena Scully: [email protected] Niamh Kelly: [email protected] Regina Kincaid: [email protected] Rosie Murtagh: [email protected] Stephanie Murray: [email protected] Denise McGuinness: [email protected] Ashamole Clive: [email protected] Mary Brosnan: [email protected] Lucille Sheehy: [email protected] Elizabeth Dunn: [email protected]

Abstract Background: Breastfeeding is the optimum mode of infant feeding. Despite this, most global populations do not achieve the World Health Organisation’s recommendation of exclusive breast milk for the first 6 months of life. Irish breastfeeding rates are among the lowest in Europe, necessitating a well-designed breastfeeding-support intervention. Aim: To evaluate the feasibility and acceptability of a multidimensional breastfeeding intervention in a rural and an urban maternity setting in Ireland. Design: A feasibility study of a breastfeeding-support intervention. 1

Setting: Participants were recruited from The National Maternity Hospital (Dublin, urban) and Wexford General Hospital (Wexford, rural). Questionnaires were completed antenatally, at 6 weeks postpartum and at 3 months postpartum to assess acceptability of the intervention and determine breastfeeding status. Participants: Pregnant women were recruited in the 3rd trimester, alongside a support partner. Intervention: The intervention consisted of an antenatal class (including the physiology and practical approaches to breastfeeding), a one-to-one breastfeeding consultation with a lactation consultant after birth, access to a breastfeeding helpline, online resources, and a postnatal breastfeeding support group which included a one-to-one consultation with the lactation consultant. Results: One hundred women from The National Maternity Hospital, Dublin and 27 women from Wexford General Hospital were recruited. The antenatal class was attended by 77 women in Dublin and 23 in Wexford; thus, 100 women participated in the intervention. Seventy-six women had a one-to-one postnatal consultation with a lactation consultant in Dublin and 23 in Wexford. Fifty and 45 women in Dublin, and 15 and 15 in Wexford responded to the 6-week and 3-month questionnaires, respectively. At 3 months postpartum, 70% of respondents from Dublin and 60% from Wexford were breastfeeding. Mothers perceived the one-to-one consultation with the lactation consultant during postnatal hospitalization as the most helpful part of the intervention. Inclusion of a support partner was universally viewed positively as a means to support the mother’s decision to initiate and continue breastfeeding. Conclusion: This multidimensional intervention is well-accepted and feasible to carry out within an Irish cohort, in both urban and rural areas. Data from this feasibility study will be used to design a randomized controlled trial of a breastfeeding-support intervention.

Abbreviations FTE, Full-Time Equivalent IBCLC, International Board Certified Lactation Consultant NMH, National Maternity Hospital WGH, Wexford General Hospital 2

WHO, World Health Organisation

Keywords Breastfeeding; lactation consultant; multidimensional breastfeeding support; feasibility study.

Introduction Breastfeeding is the gold standard infant feeding method from birth (World Health Organization 2001). Strong evidence has demonstrated numerous short- and long-term health benefits of breastfeeding for both mother and infant. In brief, breastfeeding protects infants from infections, particularly gastrointestinal infections (Kramer et al. 2001) and otitis media, is associated with a reduction in sudden infant death syndrome (Vennemann et al. 2009), may reduce the risk of obesity later in life (McCrory and Layte 2012, Yan et al. 2014), as well as the risk of developing type 1 and 2 diabetes mellitus (Martens et al. 2016) and asthma (Kashanian et al. 2017). Breastfeeding has also been linked with increased cognitive development (Kramer et al. 2008) and educational attainment (Horwood and Fergusson 1998, Horta et al. 2015). Benefits for the mothers involve rapid uterine involution, a quicker return to pre-pregnancy weight (Jarlenski et al. 2014), contraceptive effect, reduced cardiovascular disease later in life (Schwarz et al. 2009, Natland et al. 2012), may be protective against breast and ovarian cancers, as well as diseases such as rheumatoid arthritis in later life (Chowdhury et al. 2015, Victora et al. 2016). Furthermore, international studies have outlined the potential significant cost savings to health services through increases in breastfeeding rates (Pokhrel et al. 2015, Hansen 2016, Rollins et al. 2016). The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life, with the introduction of appropriate solid foods thereafter, and continued breastfeeding until 2 years or beyond (World Health Organization 2001). Despite this, breastfeeding rates in Ireland are low. Ireland has the lowest breastfeeding rates in the world (Cattaneo et al. 2005, World Health Organization 2017). Any breastfeeding before discharge from the hospital is reported at 57%, and 47% of infants are exclusively breastfeeding at

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hospital discharge (Health Service Executive 2016), which in Ireland is typically within 2 days after delivery (Healthcare Pricing Office 2016). Those percentages fall dramatically within the first month postpartum as more than half of mothers stop breastfeeding within this time (Gallagher et al. 2016). Among those mothers who ever breastfed in Ireland, around 6% are exclusively breastfeeding at 6 months (Layte and McCrory 2014). Moreover, differences exist in breastfeeding rates between rural and urban areas of Ireland, with lower rates found in rural areas in compared with urban ones. This highlights the need to assess the different requirements of both populations (Tarrant and Kearney 2008, Healthcare Pricing Office 2016). The determinants of breastfeeding initiation are diverse and include socio-demographic influences, infant characteristics including gestational age, birthweight, jaundice, type of delivery (Lau et al. 2015), ethnicity and mother’s support network, as well as maternal attitudes to breastfeeding and maternal confidence in her ability to breastfeed (Tarrant and Kearney 2008). Similarly, the attitude among mothers that breastfeeding is a ‘social taboo’ and ‘embarrassing’ was reported in a Irish study (Connolly et al. 1998). Along with the strong cultural obstacle, other reasons for breastfeeding cessation in Ireland include a perception of inadequate milk supply, a priori plan to stop breastfeeding earlier than recommended, inconvenience/fatigue, difficulty with breastfeeding technique, sore nipples/engorged breasts (Tarrant et al. 2009, Layte and McCrory 2014). All these factors point to a lack of education, skills, and support. Eighty percent of women in the UK stop breastfeeding sooner than they intended, due to feeding difficulties and lack of adequate support (Fox et al. 2015). The importance of support has also been highlighted in the Irish literature (Tarrant and Kearney 2008). In addition, the postnatal hospital stay period has shortened considerably, limiting the amount of support and assistance parents receive at the hospital. It has previously been reported that some parents leave the hospital insecure and given insufficient and inconsistent advice (Hannula et al. 2008). To effectively raise breastfeeding rates, multidimensional interventions are needed to simultaneously tackle interrelated aspects of breastfeeding (Fairbank et al. 2000, Guise et al. 2003, Nabulsi et al. 2014, Balogun et al. 2016). In an Irish study, Tarrant and colleagues concluded that it would be useful to add greater emphasis on informing and motivating mothers to breastfeed during the antenatal period (Tarrant et al. 2011). Su and colleagues in Singapore, suggested that while antenatal education and counselling is helpful, 68% of

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mothers report early problems with breastfeeding as the main reason for stopping before two months postpartum (Su et al. 2007), which is supported by data from the US among obese mothers (O'Sullivan et al. 2015). Mannan and colleagues also explained that in Bangladesh counselling and hands-on support on breastfeeding techniques by trained professionals within first 3 days of birth should be part of community-based postpartum interventions (Mannan et al. 2008). Evidence indicates that encouraging the implementation of professionally-mediated peer-support groups at local level can increase breastfeeding duration rates as well as maternal satisfaction with breastfeeding (Vari et al. 2000, Tarrant and Kearney 2008, LeahyWarren et al. 2017). The importance of the partner in breastfeeding success cannot be underestimated. The strong influence of the father’s support on a mother's decision to initiate and continue breastfeeding has been described in the literature (Britton et al. 2007). Research has shown the need for fathers to be knowledgeable and informed about breastfeeding; including how best to support their breastfeeding partner in a practical way (Kenosi et al. 2011, Sherriff et al. 2014). There is a need to re-establish and normalise the breastfeeding practice within a formulafeeding culture in Ireland (Leahy-Warren et al. 2017), a country with one of the highest birth rates in Europe and one with rapidly increasing childhood and adult obesity levels. This study examines the feasibility and acceptability of a breastfeeding-support intervention in the perinatal period, focusing on theoretical and technical skills, with the support of online resources, in both an urban and a rural area. The outcomes will aid in the design of a randomized control trial to improve breastfeeding rates (initiation, exclusivity, and/or duration) in Ireland.

Methods Population Primiparous women aged between 18-45 years, between 32-38 weeks’ gestation, with singleton pregnancies and easy access to the internet were recruited in the antenatal outpatient clinic of The National Maternity Hospital (NMH, Dublin, Ireland) and Wexford General Hospital (WGH, Wexford, Ireland), by a research assistant and a research midwife, respectively. Recruitment dates in Dublin were from February to July 2016 and in Wexford from July to November 2016. A support figure (i.e. partner, grandmother, sister, etc.) 5

participated in the study along with the pregnant woman. Participants received detailed oral and written information about the study. Sufficient time for reflection was allowed before written informed consent was obtained from all participants. This study was approved by the Research Ethics Committee of The National Maternity Hospital (Dublin, Ireland) and the Research Ethics Committee of the Health Service Executive South-Eastern Area (Dublin, Ireland). Study design This is a one-arm multicentre feasibility study; all participants received the intervention. Two 50% Full-Time Equivalent (FTE) lactation specialists (one International Board Certified Lactation Consultant (IBCLC) and one preparing to sit the IBCLC exam) and one 20% FTE IBCLC delivered the intervention in the NMH and WGH, respectively. Materials provided to participants were developed by the research team with input from an IBCLC. The two centres depicted an urban (NMH in Dublin) and a rural (WGH in Wexford) population. Intervention components The intervention components from the present study are in line with some of the steps from the WHO/UNICEF Ten Steps to Successful Breastfeeding (specifically steps 3 and 10). Mothers attended an antenatal breastfeeding class with their support partner at approx. 36 weeks’ gestation. The standard of care of both hospital settings included also antenatal classes but the class for the intervention was designed with a more physiological, practical and realistic approach to breastfeeding, avoiding the idealized picture of an effortless, painless and extremely beautiful activity that is pictured in many societies, and not always occurs. It was compulsory for the support partner to attend the class, where specific information was given on supporting the breastfeeding mother. Various breastfeeding information leaflets were also distributed. After delivery, the lactation specialist visited the mothers for a consultation prior to hospital discharge, unlike the standard of care that just provides the lactation consultant services if problems arise. Topics covered included positioning and attachment at the breast, effective feeding and the frequency of feeds, indicators of milk supply (wet/soiled nappies), hunger cues, hand expression and where to go for extra support. The number of visits with the lactation specialist depended on several factors: if a mother had all questions answered and was happy with the information provided, she was only seen once. However, those who had a 6

specific issue—or were in the hospital for longer than 2 days—may have received a second visit from the lactation specialist. Mothers also had the option to attend a breastfeeding clinic up to the 6th week postpartum (with or without their support partner). Within the NMH, the breastfeeding clinic was already in place prior to the commencement of the study and was available to all mothers who delivered in the hospital until 6 weeks postpartum. This clinic was facilitated by both research staff and hospital Clinical Midwife Specialists and typically had many attendees each week who were not involved in the study. In WGH, a clinic was set up exclusively for the study that functioned as a support group/clinic specifically for mothers recruited into the study. Additional support available postnatally included (i) a direct breastfeeding helpline with the lactation consultant for advice and/or help within the first 6 weeks postpartum. The helpline was available Monday to Friday from 9am to 2pm, (ii) weekly, standardized, encouraging emails from the research team up to 6 weeks postpartum, and monthly thereafter until the 6th month, and (iii) exclusive access to a study website with information on breastfeeding. Data collection After the antenatal class, both the pregnant woman and the support partner completed a questionnaire about attitudes towards breastfeeding and support for breastfeeding. At 6 weeks and 3 months postpartum, online questionnaires were emailed to the participant mothers about infant-feeding practices and satisfaction with the intervention components. Reminders were sent to those who had not responded within one week after the first email. All questionnaires contained closed questions, with response options determined by the investigators. However, an “other” option was consistently provided so that respondents could also respond in their own words. To evaluate the satisfaction with the intervention, two questions were posed: one of the questions consisted of choosing one component of the intervention that the participant perceived as most helpful. The other question required mothers to score each component of the intervention on a Likert scale from 1 (not at all helpful) to 5 (extremely helpful). Statistical analysis

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Categorical data are summarised in frequency tables using counts and percentages. Continuous data are presented with the number of observations (n), mean, SD, and median. All statistical analyses were carried out using SPSS (Statistical Package for the Social Sciences) software version 20.0 (IBM, Armonk, NY). Results Demographic characteristics Urban women were slightly older and a higher proportion achieved a 3rd level education when compared with rural women (Table 1). Most participants in both centres were married or in a relationship and came to the antenatal class with their male partner/the baby’s father. Feasibility of the intervention In the NMH, the urban setting, 144 women were approached in the outpatient’s clinic to assess their interest in participating in the study, 92 of these agreed to participate and were recruited. A further 8 women contacted the research team after finding out about the study through clinical staff. Of those who declined to participate, the primary reasons were that they were undecided about breastfeeding and just unsure about participating (n=30), they had no interest in breastfeeding at all (n=6), and they were unavailable or didn’t have enough time (n=3). In WGH, the rural setting, 52 women were approached in the outpatient’s clinic and 23 of these agreed to participate. Of those who declined to participate, the primary reasons were embarrassment/lack of support (n=9), no time (n=5), and no interest in breastfeeding (n=4). A total of 127 women were recruited into the study (Figure 1) and 100 women attended the antenatal class. Reasons for drop out prior to the antenatal class included: missed antenatal intervention due to delivery of their infant prior to the estimated due date, time and travel constraints, medical and family issues and the research team being unable to contact the participant. By 6-weeks postpartum, 50 women from the NMH and 15 from WGH responded to the online questionnaire. At 3 months’ postpartum 45 women from the NMH and 15 from WGH responded to the online questionnaire. Respondents’ satisfaction with the intervention Intervention components were scored only by those that availed of the component. All participants attended the antenatal class and all but one had a one-to-one session with an 8

IBCLC prior to hospital discharge. In WGH, 43% of participants received one individual one-to-one session and 57% received >1 session. In the NMH, one mother did not receive a one-to-one session, 63% received 1 session and 36% received >1 session. Half of the urban respondents at 6 weeks stated that they had attended the breastfeeding clinic at least once. In the rural area, 86.6% attended the breastfeeding clinic. The helpline was used by 30.6% of the cohort in the NMH and 12.5% in WGH. The website was accessed by 22% of the subjects from the NMH and 46.7% of participants from WGH. Sixty percent of participants from the NMH and 40% from WGH reported that the most useful component of the intervention was the one-to-one consultation with the lactation specialist prior to discharge from the hospital (Figure 2). The breastfeeding support group and the helpline were preferred by rural women compared with women from the urban setting. When scoring the different parts of the intervention using the Likert scale, positive feedback was obtained for most intervention components (Figure 3). Regarding the postnatal emails, 46.7% of participants in the NMH and 33.3% in WGH agreed that the emails encouraged them to continue breastfeeding.

Involvement of the support partner in the study When the support partner was asked about their opinion on breastfeeding in the antenatal questionnaire after attending the study-specific class, the majority stated that participation in the study somewhat changed their opinion on breastfeeding, especially with regards to awareness of breastfeeding benefits [40.8% in the NMH and 65.1% in WGH]. They also perceived that the antenatal class made them better prepared to support the mother during breastfeeding [86.7% in the NMH and 91.3% in WGH]. At 6-weeks follow up, 53% and 57% of women from the NMH and WGH agreed that the involvement of a support partner in the study at least somewhat reinforced their decision to breastfeed. At 3 months, those proportions were even higher with 100% of WGH participants and 90% from the NMH agreeing that including a support partner was helpful. Similar patterns were observed when women were asked about their perception of the support partner being more supportive towards breastfeeding due to participating in the study. At 6 weeks, 53.8% of participants from the NMH and 60.9% of those from WGH agreed that 9

partners were more supportive because of their participation in the study. The proportions increased considerably at 3 months when all the participants from WGH and 86.7% from the NMH perceived that the participation of the support partner in the study made them more supportive towards breastfeeding. Initiation and duration of breastfeeding All 100 participants who attended the antenatal class initiated breastfeeding. Of those that were followed up at 6 weeks, 70% fed their child with breast milk, either at the breast or expressed. This proportion was largely maintained at 3 months, with 70% of respondents from the NMH and 60% from WGH still feeding their infant breast milk (Table 2). At 6 weeks postpartum, around 50% of women in the NMH and 73.3% of women in WGH felt that they breastfed for longer than they would have if they had not participated in the study. At 3 months 42.2% of NMH participants and 86.7% of WGH participants thought they breastfed for longer due to participation in the study. A large proportion of women in the NMH (42% at 6 weeks and 53.3% at 3 months) felt that participation in the study had no impact on the length of time they breastfed, compared with the proportions in WGH of 26.7% at 6 weeks and 13.3% at 3 months. Discussion A multidimensional breastfeeding support intervention in an Irish population, in both urban and rural areas, proved to be well accepted and was perceived as helpful by mothers. The majority of our cohort (60% from the NMH and 73% from WGH) stated that the one-to-one consultation with a lactation consultant prepared them to deal with challenges with breastfeeding techniques and helped them with concerns they had. Other authors have already shown the importance of support from a health professional (including lactation consultant support) to improve confidence and ability to initiate and continue breastfeeding (Vari et al. 2000, Mannan et al. 2008, Balogun et al. 2016, McFadden et al. 2017). One-to-one breastfeeding consultations are particularly useful to show mothers techniques for an optimum latch and appropriate solutions when challenges arise (Lukac et al. 2006, Witt et al. 2012). Currently, breastfeeding resources in Ireland are scarce and there are not enough lactation consultants within maternity hospitals for each mother to have an individual session with an IBCLC (Department of Health 2016). This, coupled with the increasing demands on midwives working on postnatal wards, and fewer staff thank required, results in a lack of 10

breastfeeding-specific assistance for mothers. The lack of technical assistance and general insecurities of the mother make 80% of mothers that start breastfeeding cease due to the lack of support (Oakley et al. 2014, Fox et al. 2015). Considering the significant short- and longterm benefits of breastfeeding for the mother and the offspring, investing in services to support women breastfeeding for longer could results in considerable healthcare savings (Pokhrel et al. 2015). Postnatal breastfeeding support was especially appreciated in the rural setting in the present study, and may highlight the importance of community care on breastfeeding as well as the lack of resources in the rural area. Therefore, it seems prudent to advise that Ireland needs to invest in resources to increase the proportion of mothers who receive a one-to-one consultation with a lactation consultant prior to hospital discharge and improve postnatal support services in order that women are supported by a health professional who has the knowledge and skills to protect and support breastfeeding women. The involvement of the support partner as part of the intervention is novel, and it was well accepted by the participants in the present study. Breastfeeding promotion is often solely focused on the mother, forgetting about the partners and close relatives that influence a mothers’ breastfeeding behaviour (Britton et al. 2007, Grassley et al. 2012). The lack of knowledge of how to support the partner and their own insecurities impact a partner’s ability to support a breastfeeding mother (Bennett et al. 2016). We, and others, have shown that offering solutions and showing the partner the role they have within the breastfeeding relationship increases their satisfaction (Pisacane et al. 2005, Tohotoa et al. 2011), which could affect breastfeeding initiation and duration. Breastfeeding prevalence at 6 weeks was approximately 70% in our study population, and this was largely maintained at 3 months. Most Irish mothers discontinue breastfeeding between hospital discharge and 6 weeks postpartum (Tarrant and Kearney 2008). While our study design does not allow us to compare our breastfeeding rates with those from Irish society in general, and bearing in mind the respondent bias present, this intervention may have a potential positive impact on breastfeeding prevalence at 6 weeks and 3 months. These positive results warrant a randomized controlled trial to prove the effectiveness of this intervention at increasing breastfeeding initiation and duration.

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A notable difference exists between both sites regarding the proportion of women that believed they breastfed for longer due to participating in this study. There are several possible explanations for this that are worthy of exploration in a larger study. First, perhaps mothers from the NMH were more self-motivated initially and, thus, felt that their breastfeeding success was not attributable to the intervention. Second, it could be because the participants in the rural area had the same health professional delivering the whole intervention through the perinatal period, as opposed to the urban area where there were 2 health professionals. Literature has shown that continuity of care by the same professional can have a positive impact in the breastfeeding outcome through the establishment of confidence and trust (Hoddinott and Pill 2000, Bäckström et al. 2010). Third, the format of the breastfeeding support group differed between the two settings. In WGH, the breastfeeding clinic was only available to mothers recruited into the study, which meant that sessions were smaller and more intimate (up to 3 mothers) and the lactation consultant likely had more time to spend with each mother. In contrast, the breastfeeding clinic in the NMH was available to all mothers who delivered their infants in the hospital; there were typically a minimum of 20 mothers in attendance each week, and these women often needed support with specific breastfeeding challenges. Although the lactation specialists employed to work on this study prioritised mothers involved in the study, it is possible that these mothers received less attention than mothers in WGH because of the additional workload. This feasibility study is not without limitations. Those who agreed to participate were interested in breastfeeding, or at least not entirely opposed to it, therefore they were more likely to be the most motivated women to breastfeed and to give positive feedback. Additionally, they were highly-educated women, which has been shown to impact positively on breastfeeding (Gallagher et al. 2016). Therefore, there is participant bias and response bias. Furthermore, the high dropout level in the Dublin centre suggests that the intervention design will have to be carefully reviewed in order to obtain the highest attrition in a wellpowered randomized controlled trial. This study was not powered to analyse differences between centres statistically. This study has also some strengths. The implementation of the intervention in two different settings, rural vs. urban, helps to draw clearer deductions on the most useful intervention package design to tackle the poor breastfeeding initiation and continuation rates in Ireland. However, breastfeeding practices tend to depend on the cultural context of the country. As such, an intervention developed in Ireland may need to be modified before it is appropriate to be implemented in another country. 12

Conclusion This multidimensional intervention to support breastfeeding is acceptable and feasible to be implemented within an Irish cohort. Data suggest that this type of intervention can improve current breastfeeding rates. The one-to-one consultation with a lactation specialist prior to hospital discharge was the most appreciated component by mothers in the urban setting, and postnatal support was most appreciated in rural areas. The involvement of the support partner as part of the intervention is a novel approach, and was well accepted by the participants in the present study. Further research with a powered randomized controlled trial is required to gather empirical evidence on the effect of this multidimensional intervention on increasing breastfeeding rates in Ireland.

1. Conflict of Interest: The authors have no conflicts of interest to report. 2. Ethical Approval: This study was approved by the Research Ethics Committee of The National Maternity Hospital (Dublin, Ireland) and the Research Ethics Committee of the Health Service Executive South-Eastern Area (Dublin, Ireland). 3. Funding Sources: This study was generously funded by the Nursing and Midwifery Innovation Initiative funding by the National Maternity Hospital in Dublin. 4. Clinical Trial Registry and Registration Number: Not applicable.

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35. Natland, S.T., Nilsen, T.I., Midthjell, K., Andersen, L.F.,Forsmo, S., 2012. Lactation and cardiovascular risk factors in mothers in a population-based study: the HUNTstudy. International Breastfeeding Journal 7(1): 8. 36. O'Sullivan, E.J., Perrine, C.G.,Rasmussen, K.M., 2015. Early Breastfeeding Problems Mediate the Negative Association between Maternal Obesity and Exclusive Breastfeeding at 1 and 2 Months Postpartum. The Journal of Nutrition 145(10): 23692378. 37. Oakley, L.L., Henderson, J., Redshaw, M.,Quigley, M.A., 2014. The role of support and other factors in early breastfeeding cessation: an analysis of data from a maternity survey in England. BMC Pregnancy and Childbirth 14: 88. 38. Pisacane, A., Continisio, G.I., Aldinucci, M., D'Amora, S.,Continisio, P., 2005. A controlled trial of the father's role in breastfeeding promotion. Pediatrics 116(4): e494-498. 39. Pokhrel, S., Quigley, M.A., Fox-Rushby, J., McCormick, F., Williams, A., Trueman, P., Dodds, R.,Renfrew, M.J., 2015. Potential economic impacts from improving breastfeeding rates in the UK. Archives of Diseases in Childhood 100(4): 334-340. 40. Rollins, N.C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C.K., Martines, J.C., Piwoz, E.G., Richter, L.M., Victora, C.G.,Group, L.B.S., 2016. Why invest, and what it will take to improve breastfeeding practices? The Lancet 387(10017): 491-504. 41. Schwarz, E.B., Ray, R.M., Stuebe, A.M., Allison, M.A., Ness, R.B., Freiberg, M.S.,Cauley, J.A., 2009. Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and Gynecology 113(5): 974-982. 42. Sherriff, N., Hall, V.,Panton, C., 2014. Engaging and supporting fathers to promote breast feeding: a concept analysis. Midwifery 30(6): 667-677. 43. Su, L.L., Chong, Y.S., Chan, Y.H., Chan, Y.S., Fok, D., Tun, K.T., Ng, F.S.,Rauff, M., 2007. Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial. British Medical Journal 335(7620): 596. 44. Tarrant, R.C., K.M., Y., M., S.-P., MJ., W.,JM., K., 2009. The prevalence and determinants of breast-feeding initiation and duration in a sample of women in Ireland. Public Health Nutrition 13(6): 760-770. 45. Tarrant, R.C.,Kearney, J.M., 2008. Session 1: Public health nutrition. Breast-feeding practices in Ireland. The Proceedings of the Nutrition Society 67(4): 371-380. 46. Tarrant, R.C., Younger, K.M., Sheridan-Pereira, M.,Kearney, J.M., 2011. Factors associated with duration of breastfeeding in ireland: potential areas for improvement. Journal of Human Lactation 27(3): 262-271. 47. Tohotoa, J., Maycock, B., Hauck, Y., Howat, P., Burns, S.,Binns, C., 2011. Supporting mothers to breastfeed: the development and process evaluation of a father inclusive perinatal education support program in Perth, Western Australia. Health Promotion International 26(3): 351-361. 48. Vari, P.M., Camburn, J.,Henly, S.J., 2000. Professionally mediated peer support and early breastfeeding success. The Journal of Perinatal Education 9(1): 22-30. 49. Vennemann, M.M., Bajanowski, T., Brinkmann, B., Jorch, G., Yücesan, K., Sauerland, C., Mitchell, E.A.,Group, G.S., 2009. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics 123(3): e406-410. 50. Victora, C.G., Bahl, R., Barros, A.J., França, G.V., Horton, S., Krasevec, J., Murch, S., Sankar, M.J., Walker, N., Rollins, N.C.,Group, L.B.S., 2016. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 387(10017): 475-490.

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51. Witt, A.M., Smith, S., Mason, M.J.,Flocke, S.A., 2012. Integrating routine lactation consultant support into a pediatric practice. Breastfeeding Medicine 7(1): 38-42. 52. World Health Organization. (2001). "The optimal duration of exclusive breastfeeding: report of an expert consultation.", 2002, from http://www.who.int/nutrition/publications/infantfeeding/WHO_NHD_01.09/en/. 53. World Health Organization. (2017). "European Health Information Gateway, % of infants breastfed at age 3 months." Retrieved July 3rd, 2017, from https://gateway.euro.who.int/en/indicators/hfa-indicators/hfa_615-7250-of-infantsbreastfed-at-age-3-months/. 54. Yan, J., Liu, L., Zhu, Y., Huang, G.,Wang, P.P., 2014. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health 14: 1267.

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WGH Rural Setting Recruited (n=27)

NMH Urban Setting Recruited (n=100)

Drop-out / Lost to follow-up (n=23)

Drop-out / Lost to follow-up (n=4) Un-contactable (n=1) Pulled out from study (n=3)

Un-contactable (n=8) Delivered prior to EDD (n=5) Pulled out from study (n=9)

Antenatal Class

Attended with support partner (n=72) Attended without support partner (n=5) Attended with two support partners (i.e. partner and mother) (n=4)

Attended class (n=23)

One-to-one Session

Received 1:1 postnatal session (n=76) Did not receive postnatal session (discharged prior to 1:1 session) (n=1)

Received 1:1 postnatal session (n=23)

Data Collected

Antenatal Questionnaires:

Antenatal Questionnaires:

Mother (n=23) Partner (n=21) Grandmother/other (n=1+1)

Mother (n=77) Partner (n=65) Grandmother/other (n=7+4)

Postnatal questionnaires:

Postnatal questionnaires:

6-week questionnaire returned (n=15) 3-month questionnaire returned (n=15)

6-week questionnaire returned (n=50) 3-month questionnaire returned (n=45)

Analysis

Figure 1: Flow through the study in both centres

NMH, National Maternity Hospital; WGH, Wexford General Hospital 18

70

60

60

Percent

50

40

40

NMH

20

20 10

WGH

26.7

30

0

10

8

6.7 6

4

2

6.7

0 2

0

2

0 Antenatal One to one Information classes leaflets

Helpline

Online resources

BF support group

Weekly email

Nothing

Intervention component

Likert scale score

Figure 2: Perceived most helpful part of the intervention by hospital setting.

5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

5 4

5

5

5

4

5

4 3.5 3

3

3 WGH NMH

antenatal class one-to-one session

helpline

study website breastfeeding weekly follow support groups up email

Intervention component

Figure 3: Median values of the Likert scale for each of the components of the intervention

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Table 1: Descriptive characteristics of the participants. NMH

WGH

Maternal characteristics Age at recruitment Pre-pregnancy body mass index (kg/m2) Marital status Married In a relationship (±Cohabiting) Single Non-smoker Achieved 3rd-level education Nationality/Ethnicity Irish Other Employed Yes No Missing Participating with Partner Mother figure Both No-one Type of Delivery Vaginal Caesarean Instrumental Support-partner characteristics Age (years) Partner Close relative

n 77

Mean (SD) 32.3 (4.4)

n 23

Mean (SD) 29.4 (5.3)

77

24.6 (3.3)

22

25.0 (3.5)

n

%

n

%

47 25

61 32.5

10 13

43.5 56.5

5 76 68

6.5 98.7 88.3

23 15

100 68.2

56 21

72.7 27.3

17 6

73.9 26.1

71 5 1

92.2 6.5 1.3

16 2 5

69.5 8.8 21.7

61 7 4 5

79.2 9.1 5.2 6.5

21 2 -

91.3 8.7 -

37 19 22

47.4 24.4 28.2

14 4 5

60.9 17.4 21.7

n

Mean (SD)

n

Mean (SD)

65 11 n

33.6 (4.8) 46.9 (13.0) %

21 2 n

32.9 (4.8) 48.5 (3.5) %

Nationality (Irish %) Partner 51 78.5 18 Close relative 5 45.5 2 Employed Partner 60 92.3 18 Close relative 4 36.4 1 Achieved 3rd-level education Partner 54 83.1 11 Close relative 6 54.5 1 NMH: National Maternity Hospital; WGH: Wexford General Hospital

85.7 100.0 85.7 50 55 50

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Table 2: Prevalence of human-milk feeding among participants at 6 weeks and 3 months postpartum. NMH n % Feeding mode at 6 weeks n=50 Only fed breast milk at the breast 20 40.0 Only fed breast milk, both at the breast and expressed breast milk from a 15 30.0 bottle Fed both breast milk and infant 10 20.0 formula Only fed infant formula, but was 4 8.0 previously fed breast milk Only ever fed formula, never fed 1 2.0 breast milk Feeding mode at 3 months n=45 Only fed breast milk at the breast 22 48.9 Only fed breast milk, both at the breast and expressed breast milk from a 10 22.2 bottle Fed both breast milk and infant 9 20.0 formula Only fed infant formula, but was 4 8.9 previously fed breast milk Only ever fed formula, never fed breast milk NMH: National Maternity Hospital; WGH: Wexford General Hospital

WGH n % n=15 3 20.0 8

53.3

1

6.7

3

20.0

0

0.0

3

n=15 20.0

6

40.0

3

20.0

3

20.0

-

-

Highlights  Multidimensional interventions are needed to raise breastfeeding rates  Interest in a breastfeeding-support intervention in Ireland was high  Mothers valued an in-hospital consultation with a lactation consultant  Involving a support partner was well-accepted and increased breastfeeding support

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