Background
“the management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.”
“Without integration at various levels, all aspects of health care performance suffer. Patients get lost, needed services fail to be delivered, or are delayed, quality and patient satisfaction decline, and the potential for cost-effectiveness diminishes” ([2], page 2).
-
Vertical integration defined across primary, hospital and tertiary care services
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Integration within one sector (e.g. within maternity care services)
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The use of system incentives, such as governance, guidance, funding and payment mechanisms, that seek to embed and reward integrated care
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Implementation of health promotion strategies
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The impact of integrated care in reducing health inequalities
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Horizontal integration between health services, social services and other care providers
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Delivery systems that bring together clinicians and managers, funders and deliverers, professionals and patients.
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Integration between care providers and patients that supports shared-decision making
Methods
Study design and setting
Questionnaire design
Data collection and analysis
Ethical approval
Results
Participants
Characteristic |
n (%)
|
---|---|
Continent of residence | |
Europe | 244 (81) |
North America | 28 (9.3) |
Oceania | 18 (6.0) |
Asia | 9 (3.0) |
Africa | 2 (0.7) |
Top twelve represented countries | |
Germany | 107 (35.5) |
Austria | 44 (14.6) |
Switzerland | 26 (8.6) |
USA | 21 (7.0) |
Australia | 16 (5.3) |
Netherlands | 15 (5.0) |
Italy | 8 (2.7) |
Canada | 7 (2.3) |
Belgium | 6 (2.0) |
Luxembourg | 4 (1.3) |
Norway | 4 (1.3) |
Sweden | 4 (1.3) |
Professiona
| |
Nurse | 146 (48.5) |
Pediatric | 52 (17.3) |
Maternity | 47 (15.6) |
Lactation Consultant | 26 (8.6) |
General | 21 (7.0) |
Midwife | 53 (17.6) |
Certified Doula | 1 (0.3) |
Physician | 44 (14.6) |
Pediatrician | 25 (8.3) |
Gynecologist | 11 (3.6) |
General Practitioner | 9 (3.0) |
Researcher (field of research as stated by respondents) | 19 (6.3) |
Medical | 7 (2.3) |
Public health | 7 (2.3) |
Othersb
| 5 (1.7) |
Public health official | 39 (13.0) |
Trainer of health care providers | 16 (5.3) |
Social and health service provider | 10 (3.3) |
Infant nutritionist | 7 (2.3) |
Baby-Friendly Hospital Initiative coordinator | 2 (0.7) |
Othersc
| 7 (2.3) |
Health policy maker | 8 (2.6) |
Advocator for breastfeeding | 3 (1.0) |
Government advisor | 2 (0.7) |
Othersd
| 3 (1.0) |
Professions outside the health care sectore
| 28 (9.3) |
Breastfeeding support qualificationsf
| 327 |
International Board Certified Lactation Consultant | 227 (75.4) |
Voluntaryg
| 73 (24.3) |
Other h
| 27 (9) |
Payment for breastfeeding support | |
Unpaid | 66 (22) |
Unpaid and paid | 23 (7.6) |
Paid | 194 (64.5) |
Integrated care in breastfeeding support
Univariate statistical evaluations | 4-point Likert scale | ||||
---|---|---|---|---|---|
Mean score | Measure for breastfeeding promotion | very important (4
a
)
n/% | important (3
a
)
n/% | less important
b
(2
a
)
n/% | not at all important
b
(1
a
)
n/% |
3.87 | Integrated care within breastfeeding support | 256/85.0 | 34/11.3 | 1/0.3 | 1/0.3 |
3.86 | Promotion of breastfeeding integrated into health policies | 252/83.7 | 37/12.3 | 2/0.7 | - |
3.75 | Education of the public on benefits of breastfeeding and risks of substitutes | 225/74.8 | 57/18.9 | 9/3.0 | - |
3.74 | Promotion of research independent of commercial sponsoring | 219/72.8 | 64/21.3 | 5/1.7 | - |
3.73 | Media campaigns for breastfeeding | 219/72.8 | 61/20.3 | 9/3.0 | - |
3.70 | Implementation of the International Code of Marketing of Breast-milk Substitutes into legislation | 220/73.1 | 56/18.6 | 9/3.0 | 4/1.3 |
3.61 | Implementation of Baby-Friendly standards as the norm | 201/66.8 | 65/21.6 | 22/7.3 | 1/0.3 |
3.59 | Upgrade the profession lactation consultant to create career possibilities | 188/62.5 | 83/27.6 | 18/6.0 | - |
3.58 | Implement the IBCLC credential as educational standard within healthcare | 193/64.1 | 78/25.9 | 17/5.6 | 3/1.0 |
3.57 | Governmental monitoring of and penalty for Code violations | 180/59.8 | 91/30.2 | 9/3.0 | 4/1.3 |
3.38 | Development of a human milk bank network | 133/44.2 | 110/36.5 | 25/8.3 | 3/1.0 |
Integrated care response groups according to categorization of open-ended responses (n) |
Total
n = 1,168
| ||||||
---|---|---|---|---|---|---|---|
Vertical integrationa (268) | Within one sector (52) | Incentives (87) | Health promotion strategiesb (454) | Health inequalities (19) | Horizontal integration (23) | Shared decision- making (265) | |
Lack of concerted action within healthcare to cooperate towards integrated care in breastfeeding support (88) | Lacking implementation of Baby-Friendly standards (26) | Lacking incentives of health insurance companies to motivate breastfeeding as disease prevention (35) | Lacking policies and their implementation to protect, promote and support breastfeeding (127) | Lacking research on policy implementation (26) | Differing breastfeeding rates among social classes contribute to exacerbate health inequalities (11) | Lacking education of kindergarten teachers and lacking normalization of breast-feeding in child education (13) | Lack of visible marketing strategies for breastfeeding to counter formula marketing (93) |
Lack of healthcare providers competent in breastfeeding support, lacking recognition of expertise within healthcare (64) | Lacking quality of breastfeeding support within hospitals (14) | Lack of healthcare system incentives to prevent unnecessary supplementation and interventions at birth (24) | Lacking impact of NBCs on policies and lacking coordination of policies and protagonists (76) | Lacking promotion of breastfeeding as a preventive measure (25) | Lacking access to adequate breastfeeding support, independent of socioeconomic factors (4) | Lacking competence of school teachers in the field of breastfeeding (5) | Lacking perception of breastfeeding as the norm, and lacking breastfeeding-friendliness in society (57) |
Lack of physicians’ cooperation towards integrated care in breastfeeding support (49) | Lacking integration of adequate breastfeeding support into routine hospital care (12) | Lack of adequate compensation from health insurance companies for receiving and providing breastfeeding support (16) | Lack of high-quality and ethically sound research and its funding, independent of commercial interests (68) | Lacking foundation of NBCs
c, d
as Delivery Systems in several countries (20) | Lacking access to breastfeeding support impairs patient satisfaction with healthcare (4) | Lack of family counselling services with competence in breastfeeding support (5) | Lack of consistent information on breastfeeding by healthcare professionals (35) |
Lack of researchers’ knowledge on breastfeeding, lack of practice-oriented research to improve breastfeeding support (34) | Lacking incentives for parents for breastfeeding and the donation of human milk (12) | Lacking support and funding for breastfeeding promotion from governments, health insurance companies, politicians (42) | Lacking legislation to protect and promote breastfeeding, including adequate maternal leave (20) | Lacking dissemination of relevant research to practitioners and the public (35) | |||
Lack of cooperation between voluntary and professional practitioners (19) | Lacking implementation and monitoring of the Code
d
(36) | Lack of health policies facilitating a patient-centered approach in providing breastfeeding support (8) | Lacking information and education of the public, including prenatal courses (34) | ||||
Lack of human milk bank networks to facilitate integrated care in breastfeeding support (14) | Lack of prioritizing breastfeeding protection and promotion towards “health before profit” (8) | Lacking control of sponsored media portrayal of infant feeding (11) |
Vertically integrated care
“Easy access to mother support groups”(Netherlands/General Practitioner/Healthcare Provider)
Integrated care within one sector
“ Currently the development on my ward towards improved breastfeeding support is stagnating” (Luxembourg/Pediatric Nurse at Maternity Ward/IBCLC)“
“The routines in my hospital prevent the application of my knowledge and skills as a lactation consultant.” (Germany/Midwife/IBCLC)
Incentives for breastfeeding support within the healthcare system
“Abolish financial incentives for birth interventions and the use of formula, such as formerly within the US Women, Infant and Children Program…”(USA/Maternity Nurse/IBCLC)
“ Provide regular remuneration from health insurance companies for breastfeeding support” (Poland/General Practitioner/IBCLC)
“There will be no increase in breastfeeding rates in the near future, as long as the current trend of obstetric interventions during childbirth continues.”(Austria/Maternity Nurse/IBCLC)
Health promotion strategies towards integrated care within breastfeeding support
“the slow and unsupported progress of a breastfeeding culture”(Australia/Midwife/IBCLC).
Health inequalities in providing breastfeeding support
“the gap between well-educated families of higher socioeconomic status with higher breastfeeding rates, and lower breastfeeding rates of disadvantaged families, will worsen in the future” (Germany/Bank clerk/LLL).
while several respondents feared that a two-class society will develop, mentioning“the increasing rate of teenage mothers problematic”(USA/Maternity Nurse/IBCLC);
“the challenge to support the vulnerable” (Croatia/General practitioner/IBCLC).
and guarantee“Integrate lactation consulting into the national healthcare system”(China/Obstetrician-Gynecologist/IBCLC + LLL)
“lactation consulting for everyone”(Germany/Pediatric nurse/IBCLC).
Horizontally integrated care
“The Lactational Amenorrhea Method should be included in family planning counseling” (USA/Pediatrician, Preventive Medicine, Epidemiology, Maternal and Child Health, State and National and International Health Policies/FABM + IBCLC + LLL)
Teach breastfeeding as normal from kindergarten age”(USA/Lactation Consultant/IBCLC + LLL)
“Educate the importance of breastfeeding at school”(Japan/Pediatrician/IBCLC)
Delivery system for integrated care in breastfeeding support
“We have a new Committee of Breastfeeding in Finland, I’m sure something will happen…” (Finland/Public Health Nurse, Head Nurse/Healthcare Provider)
“A strong policy that is supported by appropriate legislation to give adequate maternity leave and breastfeeding breaks.” (UAE/Midwife/IBCLC)“NBC should advise government on legislation to support breastfeeding.” (UK/Midwife/IBCLC)
“The NBC should plan and coordinate a national policy to be implemented with political support” (Italy/Pediatrician/Healthcare Provider)“What can I expect from a committee without funds, power and influence?”(Germany/Midwife/IBCLC)
“Progress is only possible with broad campaigns and large investments.”(Germany/Pediatric Nurse/IBCLC)“Create an image of breastfeeding as smart, cool and career-right.”(Norway/Gynecologist, Government Advisor/Healthcare Provider)
Decision making on infant feeding
“Breastfeeding myths from healthcare providers and aged people”(Taiwan R.O.C./Obstetrician,Gynecologist/IBCLC + LLL)“Too many different opinions” (Switzerland/Nurse/IBCLC)
“Antenatal classes which include family members (father, aunts, grandparents)”(New Zealand/Maternity Nurse/IBCLC)
“Ads of breast milk substitutes are rampant on mass media”(South Korea/Pediatrician/Healthcare provider)
“There is a cultural and educational ignorance of the natural breast function.”(USA/Maternity Nurse/IBCLC)
“Without consistent breastfeeding support from healthcare providers, the promotion of breastfeeding might be understood as a moral sermon that cannot be put into practice; therefore the education of healthcare professionals should be considered the first priority before the education of the public.” (Germany/Gynecologist/IBCLC)