An Analysis of the Adoption and Implementation of Breastfeeding Policies in Washington State Clinics

Background: The benefits of breastfeeding for the mother-infant dyad and broader society are well documented. While U.S. breastfeeding initiation rates have improved over the past decade, rates for exclusive breastfeeding and breastfeeding duration remain low, particularly for families from communities of color, low income households, and rural regions. Given the social and environmental barriers many families face, breastfeeding policies are a promising systems-level approach to address the disparities in breastfeeding support. Within the healthcare sector, increased coordination of care across healthcare settings can improve the consistency of support for families. While there have been increased efforts to improve hospital maternity care practices, less attention has been focused on the adoption and implementation of similar breastfeeding support strategies in clinics that reach families during prenatal and postnatal care. To achieve breastfeeding equity, breastfeeding policy initiatives must incorporate policy process research pertaining to clinics.

Objective: To investigate how the process of developing evidence-based breastfeeding policies and practices is supported or hindered in clinic settings.

Methods: This article describes a secondary qualitative analysis derived from a larger breastfeeding policy study in Washington State. For the primary study, the interview guide and coding scheme were developed based upon the Greenhalgh “Diffusion of Innovation in Service Organization Framework”. Members of a study advisory board initially invited clinic breastfeeding stakeholders to participate in the study; research team members followed-up with interested participants. Qualitative, semi-structured interviews were conducted with 19 clinic staff at 17 Washington state clinics via phone or in-person. Interviews were audio-recorded, transcribed, and analyzed using Atlas.ti software and thematic content analysis. The secondary analysis included an independent thematic content analysis of coded clinic transcripts and synthesis of the themes using the Greenhalgh framework.

Results: Five components of the Greenhalgh framework help to describe the complex dynamics of policy adoption in clinics included characteristics of the innovation (in this case clinic breastfeeding policies), system antecedents, system readiness, communication & influence, and outer context. Factors that hindered breastfeeding policy adoption and implementation included negative perceptions of breastfeeding policies, inadequate knowledge-sharing networks, limited devoted resources, and lack of leadership buy-in. Components that facilitated the adoption of breastfeeding policies included positive perceptions of breastfeeding policies, engaged champions, adequate staff training, and external motivation through incentives and mandates. External mandates and incentives were catalysts for change.

Discussion: The Greenhalgh framework provided an organization-level model to capture the complex dynamics in breastfeeding policy adoption and implementation. This study can inform future qualitative research and intervention strategies to increase the adoption and effective implementation of breastfeeding policies. The study findings support the need for coordinated breastfeeding services throughout the healthcare system, comprehensive mandates/incentives from accrediting bodies, and adequate technical support from public agencies.

Conclusion: The systematic evaluation of dynamic breastfeeding policy adoption and implementation provides valuable insight into the drivers and obstacles of policy development. Clinics play an integral role in the breastfeeding continuum of care and would benefit form further policy process research, inclusion in breastfeeding initiatives, and adequate financial and technical support.