Exploring Breastfeeding Mothers’ and Lactation Consultants’ Experiences of Lactation Consultancy Throughout the Restrictions Put in Place Due to the COVID-19 Pandemic

Anna Connolly; Anne Matthews

doi:10.12688/hrbopenres.13856.1

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Research Article

Exploring Breastfeeding Mothers’ and Lactation Consultants’ Experiences of Lactation Consultancy Throughout the Restrictions Put in Place Due to the COVID-19 Pandemic

[version 1; peer review: 1 approved, 1 approved with reservations]

Anna Connolly ¹, Anne Matthews¹

PUBLISHED 19 Feb 2024

Author details Author details

¹ Dublin City University, Dublin, Leinster, Ireland

Anna Connolly
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Anne Matthews
Roles: Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Breastfeeding rates in Ireland are among the lowest in the world. Lactation consultancy provides mothers with support and information on how to cope with any challenges they encounter. There is emerging evidence that COVID-19 restrictions impacted access to and the quality of breastfeeding support.

The aim of this study was to explore breastfeeding mothers’ and lactation consultants’ experiences of breastfeeding support throughout the COVID-19 restrictions in Ireland. It also aimed to explore what adaptations had to be made to the delivery of lactation consultancy and how these changes impacted mothers’ experiences of breastfeeding support.

Methods

A qualitative research design was chosen. Semi-structured interviews were conducted with eight participants, three breastfeeding mothers and five lactation consultants. Interviews were conducted online via Zoom, audio-recorded and transcribed. The data were analysed using thematic analysis.

Results

Five key themes were identified: ‘Lack of Support’, ‘Adapting to COVID-19 Restrictions’, Emotional Response to COVID-19 and Restrictions’, Vaccination as a Barrier to and Facilitator of Support’ and Inconsistency of Lactation Support Across Ireland’. Both lactation consultants and mothers identified similar issues however, slight variations within lactation consultants' perceptions of mothers’ and mothers’ attitudes towards online services were seen. An unanticipated finding was the lack of support in hospitals pre-COVID-19.

Conclusions

Both mothers’ and lactation consultants’ experiences of lactation consultancy were impacted by the COVID-19 restrictions. Although exacerbated by COVID-19, the lack of support in hospitals existed before COVID-19. Provision of better breastfeeding support is required.

Increased availability of lactation consultants and the implementation of breastfeeding rooms within hospitals is required in addition to debrief counselling sessions for lactation consultants. Further research is required to understand the unavailability of lactation consultants in hospital settings and to identify how to manage breastfeeding support in future emergency situations.

Keywords

Breastfeeding, COVID-19, Breastfeeding Support, Lactation

Corresponding author: Anna Connolly

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Connolly A and Matthews A. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Connolly A and Matthews A. Exploring Breastfeeding Mothers’ and Lactation Consultants’ Experiences of Lactation Consultancy Throughout the Restrictions Put in Place Due to the COVID-19 Pandemic [version 1; peer review: 1 approved, 1 approved with reservations]. HRB Open Res 2024, 7:9 (https://doi.org/10.12688/hrbopenres.13856.1) First published: 19 Feb 2024, 7:9 (https://doi.org/10.12688/hrbopenres.13856.1) Latest published: 16 Dec 2024, 7:9 (https://doi.org/10.12688/hrbopenres.13856.2)

List of abbreviations

WHO World Health Organisation

NWIHP National Women and Infants Health Programme

IBCLC International Board Certified Lactation Consultant

PHN Public Health Nurse

DoH Department of Health

ALCI Association of Lactation Consultants in Ireland

IT Information Technology

NICU Neonatal Intensive Care Unit

HSE Health Service Executive

PPE Personal Protective Equipment

Introduction

Breastfeeding rates globally do not meet the WHO targets (Global Breastfeeding Collective, 2021) and in Ireland they are among the lowest in Europe and the world (Leahy-Warren et al., 2017; NWIHP, 2021). According to most recent data available, only 15% of babies in Ireland are exclusively breastfed at six months old (WHO, 2014). This rate is extremely low in comparison to the global rate of 44% (Global Breastfeeding Collective, 2021). Breastfeeding is one of the most successful ways of ensuring child health and survival (WHO, 2022) with benefits such as protection against infections, diarrhoea and diabetes. Breastfeeding may protect mothers against breast cancer, ovarian cancer and type 2 diabetes and improve birth spacing (Victora et al., 2016; WHO, 2022). Breastfeeding’s immunological benefits are being recognised in the context of COVID-19 (Walker et al., 2022). Breastmilk of women who received two doses of SARS-CoV-2 vaccine was found to contain antibodies which may offer protection against COVID-19 for infants (Baird et al., 2021). One-on-one time with lactation consultants and other healthcare professionals who provide breastfeeding support is significantly beneficial to breastfeeding mothers by providing them with useful information on how to cope with breastfeeding challenges they face, and therefore prolonging breastfeeding duration (Alberdi et al., 2018; Giltenane et al., 2021; McFadden et al., 2017; McGuinness et al., 2020; Theurich et al., 2019; Whelan & Kearney, 2015). The COVID-19 restrictions hugely impacted access to breastfeeding support with many women feeling frustrated, stressed and dissatisfied with insufficient video consultations with lactation consultants (Panda et al., 2021). This qualitative research study aims to explore both breastfeeding mothers’ and lactation consultants’ experiences of receiving and giving breastfeeding support throughout the restrictions put in place in Ireland due to the COVID-19 pandemic. The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9% between 2019 and 2020 in Ireland. Only 58.5% of babies had received any type of breastfeeding on discharge from hospital in 2020 in comparison to 63.4% in 2019. It was suggested that this decline could be attributable to COVID-19 and the changes it caused in behaviour on post-natal hospital wards (NWIHP, 2021). Further research was warranted to explore both mothers’ and lactation consultants’ experiences of lactation consultancy throughout the COVID-19 restrictions in Ireland.

The term lactation consultant will be frequently referred to. A lactation consultant can be defined as a healthcare professional that has specific training to deliver breastfeeding support and assist with the prevention, recognition and provision of solutions to breastfeeding difficulties (Brooks et al., 2016)

Given the benefits of breastfeeding, facilitating and supporting women to breastfeed is vital. The importance of support from healthcare professionals such as International Board Certified Lactation Consultants (IBCLC) and public health nurses (PHN) (in the Irish context), health visitors, community health nurses/ midwives has been widely recognised given its association with positive breastfeeding outcomes such as increased initiation, duration and exclusivity rates (Alberdi et al., 2018; Leahy-Warren et al., 2017; McFadden et al., 2017; McGuinness et al., 2020; North et al., 2022; Whelan & Kearney, 2015). Women who attended consultations with IBCLCs and PHN led support groups felt that the support boosted their confidence and encouraged them to breastfeed (Alberdi et al., 2018; Giltenane et al., 2021; Leahy-Warren et al., 2017; McCarthy Quinn et al., 2019; McGuinness et al., 2020). Unfortunately, many women cease breastfeeding early due to the challenges they face however, support may help women overcome these issues and allow them to continue breastfeeding for longer (McFadden et al., 2017; McGuinness et al., 2020). Previous studies have shown how beneficial support from healthcare professionals and breastfeeding support groups can be in providing women with the right tools and techniques to overcome their challenges (Alberdi et al., 2018; McCarthy Quinn et al., 2019). Face-to-face support has been identified by mothers as important (Ingram et al., 2020) and shown to be more successful in encouraging women to continue and exclusively breastfeed (McFadden et al., 2017). Although the importance of breastfeeding support is well documented, women in Ireland have reported receiving inconsistent, contradictory and poor quality information on breastfeeding in addition to limited availability of support on post-natal wards with little or no access to lactation consultants (DOH, 2016).

Support is essential in facilitating breastfeeding and allowing its benefits to be experienced by both mothers and infants. However, the COVID-19 pandemic has presented challenges to breastfeeding and support services (Brown & Shenker, 2021; Panda et al., 2021). In December 2019, COVID-19, an infectious respiratory disease, emerged and resulted in significant restrictions on society. A new strain of coronavirus called SARS-CoV-2 is responsible for this disease which is transmitted through respiratory droplets (Chakraborty & Maity, 2020). In March 2020, the Irish government imposed a lockdown where people were asked to remain at home. Since then, Ireland experienced a continuous tightening and easing of restrictions that saw general practitioners move their services online and pre and post-natal appointments be postponed (Kennelly et al., 2020). During the pandemic, face-to-face contact with PHNs and IBCLCs was curtailed, support groups were suspended and family support was restricted (Kinoshita & Doolan, 2021; Lalor et al., 2021; Panda et al., 2021). Many mothers had difficulty accessing support and expressed their frustration over receiving ‘useless’ breastfeeding booklets and insufficient online consultations (Panda et al., 2021). A study conducted by Brown and Shenker (2021) in the UK found that 27% of mothers struggled to access support and ceased breastfeeding before they wanted to. Other challenges to breastfeeding and breastfeeding support included the separation of mothers from infants in hospitals due to fear of infection (Gribble et al., 2020) and personal protective equipment (PPE) such as masks that compromised communication between healthcare professionals and parents and parents and infants (Green et al., 2021).

In conclusion, breastfeeding rates in Ireland are low despite the clear benefits to both mothers and infants. Breastfeeding and breastfeeding supports have been challenged by COVID-19 and the restrictions. However, lactation support throughout the pandemic in an Irish context has not been previously explored from the perspective of both mothers and healthcare professionals. This provides clear rationale for research to be carried out combining both lactation consultants’ and breastfeeding mothers’ experiences of lactation consultancy in Ireland in the context of COVID-19.

Methods

This research was conducted as part of an undergraduate degree programme. The research including the interviews and data analysis were carried out by the final year undergraduate student whose research project was informed by this study.

Aim

Objectives

1. To explore the impact of COVID-19 restrictions on mothers’ access to lactation consultancy and breastfeeding support
2. To explore how the COVID-19 restrictions impacted the delivery of lactation consultancy
3. To investigate what adaptations have had to be made to the delivery of lactation consultancy due to COVID-19 restrictions
4. To explore how these changes have impacted mothers’ experiences of breastfeeding in Ireland during the COVID-19 pandemic.

Research design

A qualitative research design was used as it provided insight and understanding into individuals’ experiences and allowed the voices of participants to be included in the research (Denny & Weckesser, 2019). A quantitative research design places emphasis on numerical and statistical data (Liamputtong & Rice, 2021) and therefore, was deemed inappropriate for this study. The qualitative data collection method was semi-structured interviews as they are valuable for collecting rich data based on experiences and perceptions and because verbal communication is a valuable way of conveying emotions, feelings, experiences and views (Parahoo, 2014), which fits with the aim of this research study. Interviews were conducted with both lactation consultants and mothers to gain insight into the different perspectives that these groups have of lactation consultancy in Ireland throughout the COVID-19 restrictions.

Sample

Participants were selected from target populations of breastfeeding mothers and lactation consultants. Purposively selecting a sample from a target population is appropriate as the data collection, processing and analysis are cost and time efficient (Daniel, 2015). Sampling is a low-cost method that allows the researcher to collect the necessary data within the time constraints of the project. Purposive sampling was used to select participants who had first-hand experience of breastfeeding support who were able to provide rich and valuable data relevant to the topic being explored. A small sample size of eight participants (Figure 1) was used as this was large enough to generate original and high quality, rich data but also small enough to get an in-depth analysis (Vasileiou et al., 2018).

Figure 1. Flowchart of Participants Recruited.

A sample of three breastfeeding mothers was selected (Table 1). Inclusion criteria involved being over eighteen years old and having given birth throughout the time that the COVID-19 restrictions were in place as these participants would be able to provide insights on their experience of breastfeeding support during the COVID-19 pandemic. Although previous studies looked specifically at primiparous women (Alberdi et al., 2018), for this study participants could partake regardless of whether they were first-time or multiparous mothers, as the context of COVID-19 is the focus here.

A sample of five lactation consultants was also selected (Table 1). The inclusion criteria involved being a fully qualified lactation consultant (registered with ALCI) who provided breastfeeding support to mothers throughout the COVID-19 restrictions.

Instruments

Interview guides were developed by the researcher and used to conduct interviews.

Ethical issues

This is a low-risk study, however consideration was given to ethical issues in qualitative research such as informed consent, privacy and confidentiality. This study involved the use of Zoom and the digital recording of interviews, therefore consideration was given to the digital data protection of participants (Newman et al., 2021). Ethical approval was sought and obtained from the DCU Research Ethics Committee in November 2021.

Procedure

Upon receiving ethical approval, permission was sought from the Association of Lactation Consultants in Ireland (ALCI) for an email to be distributed to members on behalf of the researcher. The researcher negotiated access and complied with the ALCI’s student research policy which required the submission of an application to be reviewed by five ALCI council members. On approval, an email was distributed. Interested participants could then email the researcher for further information. Recruitment of breastfeeding mothers involved emails and phone calls with ae local PHN, breastfeeding support groups and community groups. Plain language statements and informed consent forms were distributed via email and the interviews were scheduled. Informed consent forms were completed and returned prior to interviews taking place. The interviews were conducted by one researcher (AC) via Zoom as it is easy to access, user-friendly, has robust privacy settings, is time and cost efficient and is beneficial for participants in maintaining rapport with investigators (Archibald et al., 2019). The interviews, which took place in February 2022, lasted 30-40 minutes and were recorded using the Zoom audio-recording option. The audio-recorded interviews were then transcribed by one researcher (AC).

Data analysis

Thematic analysis was chosen to analyse the collected data as it is used to identify, investigate and interpret patterns that emerge from datasets (Clarke & Braun, 2017). It is appropriate for this study given that it is used to understand thoughts, opinions, experiences and behaviours across data (Kiger & Varpio, 2020). The patterns that are identified through thematic analysis are referred to as themes. They are developed from the generation of codes that encapsulate intriguing aspects of the data that may be relevant to the research question. Themes are the outcomes of thematic analysis that provide a framework for presenting and reporting on the researcher’s findings (Clarke & Braun, 2017). Braun and Clarke’s (2006) six-step process for thematic analysis was used in this study to identify and interpret key aspects of the data that are relevant to the research question. The transcribed interviews were carefully read and codes were assigned to interesting features that were relevant to the research topic by one researcher (A.C). Patterns of similar codes emerged and from these patterns, common themes were generated. Each theme was then reviewed by both researchers and those that presented a strong pattern within the data were considered the most relevant. Any disagreements regarding the coding and theming were resolved by discussion between the two researchers. The themes were then assigned names based on the aspect of data that was covered and the insights it provided to the research topic. The themes were further developed to include sub-themes that provided a more detailed interpretation of the over-arching theme. Finally, a report was written up using themes to present the study’s findings. Extracts of data from the interviews that had been assigned codes and used to generate the themes were included in this write-up to put the themes into context and provide the reader with a raw illustration of the participants’ views, opinions and experiences.

Similar to the analysis approach used by Whelan and Kearney (2015), the categories that were developed from the coding of the transcripts were used to identify overarching themes from within both sets of interviews. The transcripts were considered separately and then combined as the overarching themes emerged from the thematic analysis. Given that staff and patient experiences are unequivocally intertwined in the delivery of good patient-centred care (Ocloo et al., 2020), it seemed appropriate to integrate data from the interviews with the mothers and the lactation consultants to gain an insight into both perspectives of the same phenomenon. This method of thematically analysing transcripts from interviews with both patients and healthcare professionals has previously been used by Maguire, Daffern and Martin (2014) to explore both patients’ and nurses’ perspectives of healthcare interventions.

Findings

The findings will be presented under themes that were identified through thematic analysis of the data collected. Both groups of participants who took part in this study identified lack of support as an integral part of their experience of lactation support throughout the COVID-19 restrictions. Both mothers and lactation consultants spoke of the adaptations that had to be made to the delivery of lactation consultancy throughout the pandemic. The mothers and lactation consultants also spoke about the emotions that they experienced in response to the COVID-19 restrictions during their own breastfeeding journeys or the journeys of mothers that they facilitated. Vaccination as both a barrier and an enabler of breastfeeding support was also highlighted throughout the interviews in addition to the inconsistency of lactation consultancy throughout the restrictions. These themes are presented in Figure 2.

Figure 2. Themes Generated through Thematic Analysis.

Table 1. Participant key.

Participant Key
Lactation Consultant 1 (LC 1)	Health Service Executive (HSE) Lactation Consultant
Lactation Consultant 2 (LC 2)	Lactation Consultant in Private Practice
Lactation Consultant 3 (LC 3)	Lactation Consultant in Private Practice
Lactation Consultant 4 (LC 4)	Lactation Consultant in Private Practice
Lactation Consultant 5 (LC 5)	Hospital Lactation Consultant
Mother 1 (M 1)	Multiparous Mother
Mother 2 (M 2)	First-time Mother
Mother 3 (M 3)	First-time Mother

Lack of support

The lack of support for both mothers and lactation consultants was highlighted by the participants throughout their interviews. A lack of support was particularly relevant amongst breastfeeding mothers in relation to the lack of access to lactation consultants in hospital settings and in the lack of face-to-face support groups. Although lack of support was a key feature of breastfeeding mothers’ experiences of lactation consultancy throughout the pandemic, lactation consultants within the HSE also felt they did not receive enough help in relation to Information Technology (IT) related support for moving their services to online platforms. Another interesting and unanticipated finding was the lack of supervision and support provided to lactation consultants, specifically in private practice where they do not work amongst a team of health professionals, to discuss the sometimes traumatic and distressing nature of their work.

Lack of lactation consultancy and breastfeeding support in hospital settings. All the participants in this study identified the lack of breastfeeding support from lactation consultants within the hospital setting as a key feature of their experience of lactation consultancy throughout the pandemic:

“in those early stages they had no support, they were delivered and everybody kept away from each other” (LC 1)
“I had no support from a lactation consultant or anything like that on the post-natal ward and again I found it quite unsupportive” (M 1)
“I firmly believe, if my babies weren’t in NICU, they, I would not be breastfeeding … there was one hundred percent not adequate support on the post-natal ward” (M 1)

An unanticipated finding was the suggestion from both mothers and lactation consultants that the issue of the unavailability of lactation consultants within hospital settings, although exacerbated by COVID-19, was an issue that existed pre-COVID-19:

“I mean you know this was even going back pre-COVID you know, the lack of support is shocking in hospitals like it really, really is” (LC 3)

Another unexpected finding was the suggestion that there has been an increase in mothers signaling their intention to breastfeed however, due to the lack of support available, many of these mothers will not have been able to fulfil that intention:

“the number of people signaling an intention to breastfeed will have gone up… but sadly too many of them will not have because of just the lack of available… it’s been fairly grim you know so people are not getting as much hands on support as they could do with” (LC 4)

The mothers who participated in this study spoke from their own experience of the lack of support they were offered in hospital and emphasised the importance of lactation consultancy by expressing their wishes to have had more support and time with a lactation consultant:

“I’d love if there was more support in the hospitals for new mums from professional lactation consultants… instead of a fleeting moment from a midwife who is under pressure you know and is trying her best (M 2)

The lactation consultants held the same view as the mothers about this topic and spoke of their experience of hearing stories from mothers that they have provided support to who were denied appointment from hospital lactation consultants as:

“she only comes to mothers with mastitis” (LC 3).

Frustration was also expressed by both lactation consultants and mothers at the limited hours that lactation consultants within hospitals are available for and the impact this has on the support given to and received by mothers.

“the lactation consultant at the time… was only there like two or three days a week” (M 1)
“the lack of support is awful, I mean in any of the maternity hospitals the lactation consultant is nine to five Monday to Friday” (LC 3)

Lack of support for lactation consultants. The lactation consultants in this study identified the lack of support available to them during their transition from face-to-face to online platforms as a key feature of their experience of delivering lactation consultancy throughout the COVID-19 restrictions. One HSE lactation consultant described the lack of IT support as a challenge they faced and another in public service spoke of having to work it out for themselves:

“IT support was very limited… I could have done with an awful lot more IT support” (LC 1)
“[you] kind of work it out yourself” (LC 5)

An unanticipated finding in relation to support was the suggestion that lactation consultants, specifically those in private practice, do not have adequate support to help them cope with the sometimes-distressing nature of their work. The restrictions may have exacerbated the lack of support for lactation consultants by further limiting their contact with others. The need for a counsellor to facilitate debriefings and offer care to lactation consultants was identified:

“I just feel from the professional side of things we do need some kind of a minder or counsellor or debriefer” (LC 3)

Adapting to COVID-19 restrictions

The COVID-19 restrictions forced lactation consultants to quickly adapt and alter the ways in which they delivered their support. Both mothers and lactation consultants had to turn to online platforms to continue support. These adaptations came easy to some, however others struggled and had difficulty getting used to them. PPE was worn to protect both mothers and babies and lactation consultants however, it didn’t come without its own issues.

Reduction in face-to-face support and delivery of support via online platforms. All the participants in this study spoke of the reduction of face-to-face support due to the COVID-19 restrictions. Both mothers and lactation consultants had to adapt to the restrictions in order to continue delivering and receiving support. The lactation consultants adapted to the restrictions by offering their support through online platforms:

“I did an awful lot of, of Zoom or WhatsApp videos so we could see each… you know I had my knitted boob, I had my doll baby” (LC 3)

The mothers’ experiences of lactation consultancy via online platforms were varied. Several lactation consultants perceived that the mothers were satisfied with online support:

“Yeah, they love it and they stay in their bed” (LC 4)

The mothers themselves had varying experiences with online support. Some adapted well and were happy and grateful for it:

“I actually found doing it online really good like you know you kind of, you were in the comfort of your own home, you were in your own environment… we both found that really good” (M 2)

Others had difficulty adapting to the online world and didn’t place much value on online support:

“There was no local groups of that around, it all seemed to be online based…I didn’t really get much value from it” (M 3)
“so many people… just wanted you face-to-face, they didn’t want zoom (LC 2)

Most lactation consultants adapted quickly to the online world and worked out ways to deliver their support through a screen:

“I would ask the mother to get a partner to video the baby coming to the breast or a close up of the baby latching or a video of the baby’s mouth when the baby is crying” (LC 3)

An interesting and unexpected adaptation that mothers discussed was their reliance on social media for lactation consultancy and breastfeeding support throughout the Pandemic:

“I was always looking at lactation consultants on Instagram and like honest to God I learned more from them than anything else” (M 2)

PPE and its limitations. The wearing of PPE was another adaptation that both lactation consultants and mothers had to make in order to continue face-to-face support, where that was done. Lactation consultants spoke about their experience of wearing gloves, aprons and masks and adapting to a new procedure regarding infection control practices that had to be carried out in between consultations:

“it was mask, gloves, apron and then as soon as you got home you got changed in an area of your home that wasn’t inside so either in the porch or you took off your clothes anyway and put them in the washing machine and changed and if you were going on to see a second client you had a full change of clothes and a shower” (LC 4)

Both mothers’ and lactation consultants’ experiences of lactation consultancy were impacted by communication issues due to wearing of PPE. Although all were grateful that the wearing of PPE facilitated the delivery of face-to-face support, they acknowledge that the wearing of masks had a huge impact on communication:

“wearing PPE, FFP2 masks… it’s difficult to communicate, difficult showing empathy” (LC 5)

Physical contact is an integral part of lactation consultancy however, adhering to social distancing rules had a huge impact on the personal relationship and interactions between mothers and lactation consultants which undoubtedly had a negative impact on both parties’ experience of lactation consultancy:

“not being able to hug somebody, place a hand on their shoulder, shake hands with them, all the things as human beings that we do to interact and build up a relationship in a very short period of time” (LC 5)

Emotional response to covid-19 and restrictions

The COVID-19 restrictions appear to have had a huge impact on the emotions that women felt throughout their experience of lactation consultancy. Social distancing and travel restrictions saw then unable to see family, friends and other mothers and limited their access to lactation consultancy. These restrictions resulted in feelings of loneliness, isolation and anxiety.

Loneliness and isolation. Both mothers themselves and lactation consultants spoke about the experience of loneliness and isolation throughout the restrictions. The mothers spoke about their experience of feeling isolated by not having support groups where they could meet other mothers and be shown breastfeeding techniques in-person. The COVID-19 restrictions isolated them by taking away their opportunity to ask questions, share stories and have their feelings and experiences normalized by conversations with other mothers:

“I think the isolation of not having support group to just pop in on a weekly basis and say hi, I’m a new mum, I’m struggling” (M 3)

Lactation consultants spoke from their experience of meeting women who felt abandoned by the lack of support available, resulting in them feeling very alone, abandoned and vulnerable:

“they were very vulnerable, they were very, very alone” (LC 3)

Anxiety. Most lactation consultants spoke about the increased levels of anxiety in women who have had babies throughout the pandemic. Mothers also reported feeling anxious and scared due to COVID-19 and the restrictions:

“I’ve seen a general level of anxiety… around birth and some fear for COVID as well” (LC 4)
“it was all on you and you were a first-time mam on your own and you know that was scary” (Mum 2)

Vaccination as a barrier to and facilitator of support

An unexpected finding identified through this research was the impact that vaccination status had on access to support in certain areas. Several lactation consultants discussed vaccination as both a barrier to and facilitator of support.

Vaccination as a barrier. One lactation consultant spoke about her experience of delivering lactation consultant led support groups. Once the support group had resumed in-person, there were, and still are, certain guidelines that must be adhered to. She spoke about vaccination status as an indicator of ability to access the breastfeeding support group. Only mothers who were fully vaccinated could attend the support groups:

“people who weren’t vaccinated weren’t allowed to come to breastfeeding support group and still aren’t” (LC 1)

Although those who were not vaccinated against the SARS-CoV-2 virus were not allowed to attend the support groups, they were not denied access to a lactation consultant. The lactation consultant would contact the unvaccinated person and offer them a one-on-one consultation to discuss any issues and provide them with support:

“I couldn’t have her at the breastfeeding support group, what I did do was tell her I’d see her on a one-to-one” (LC 1)

Vaccination as a facilitator. Several lactation consultants described their experience of returning to face-to-face lactation consultancy once they had been vaccinated against the SARS-Cov-2 virus. Vaccination, in this case, acted as an enabler to resuming face-to-face support. Those who were at high-risk due to underlying health conditions who did not feel comfortable offering support face-to-face were able to remain online until they received their vaccination, at which stage they could then decide if they felt comfortable to return to face-to-face support:

“…because I’m diabetic I chose not to do any face-to-face until we were vaccinated so I did all my client calls by Zoom… once I’d had both my vaccines I started going back out” (LC 4)

Inconsistency of lactation support across Ireland

Lack of clear guidelines. There did not appear to be a standardised protocol in relation to the delivery of lactation consultancy throughout the COVID-19 restrictions. There appear to have been geographical discrepancies in relation to what lactation consultants were authorised to do. Lactation consultancy was deemed an essential service in some areas and therefore in-person, face-to-face support continued, however in other areas face-to-face support was paused and only online support could be delivered. This variation suggests that there was no single cohesive or standardised approach to breastfeeding support throughout the pandemic:

“in some parts of the country the support was non-existent… they weren’t allowed see people” (LC 1)

Luck. Both mothers and lactation consultants discussed the lack of consistency within support for breastfeeding mothers, particularly in hospital. Mothers described their experiences of getting support by chance or because they were lucky that a midwife with a specific interest in breastfeeding was on that shift:

“it would have depended on the day they had their baby, the day they were discharged and whether or not the staff were overrun… if they happened to find the right person on the right day, absolutely they’ll have had lots of help and support but if they didn’t then they mightn’t have had what they needed” (LC 4)

It is evident that both mothers’ and lactation consultants’ experiences of lactation consultancy have been hugely impacted by the restrictions put in place due to COVID-19, however it is clear that these services were already limited before the pandemic. These findings have highlighted the considerable impact COVID-19 had on mothers’ access to support and how the restrictions impacted the way in which breastfeeding support was delivered. The findings have also demonstrated the various adaptations which had to be made to the delivery of lactation consultancy and how these changes impacted mothers’ experiences of lactation consultancy.

Discussion and conclusions

The provision of high quality, timely and effective breastfeeding support remains a challenge, which has been exacerbated by COVID-19, in Ireland and globally. The findings of this research suggest that mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants. The DoH (2016) previously identified this issue, therefore suggesting that although exacerbated by COVID-19, it pre-existed. Both lactation consultants and mothers in this study expressed their views that these issues existed pre-COVID-19. Similar views on this topic have been expressed previously (Whelan & Kearney, 2015), which strengthens the evidence that this is not a novel issue. This research presented an interesting finding on the varied experiences that women had of online lactation consultancy. Whilst some mothers struggled with insufficient online consultations, similar to those in a study conducted by Panda et al. (2021), an unanticipated finding was that others enjoyed and were satisfied with the online support.

Another important and unexpected finding was the lack of support available to lactation consultants. Healthcare professionals who worked throughout COVID-19 are at a higher risk of mental health problems, therefore it seems necessary to provide better psychosocial support for them (Stuijfzand et al., 2020). Previous research suggests that clinical debriefing for healthcare workers who experience trauma at work can be useful in reducing post-traumatic stress symptoms (Scott et al., 2022). These findings provide rationale for the implementation of clinical debriefings into lactation consultants’ routines.

Adaptations have evidently had to be made to the delivery of lactation consultancy throughout the COVID-19 restrictions. The transition from in-person to virtual support is a significant adaptation that has been previously identified (Brown & Shenker, 2021; Panda et al., 2021). Both mothers and lactation consultants have had to adapt to reduced face-to-face support (Kinoshita & Doolan, 2021; Panda et al., 2021), an aspect of breastfeeding support shown to be valuable to mothers (Ingram et al., 2020) and successful in encouraging women to continue and exclusively breastfeed (McFadden et al., 2017). Another significant adaptation to the delivery of lactation consultancy was the wearing of PPE. Both mothers and lactation consultants had difficulty adapting to this change due to issues communicating with masks. This difficulty has been previously mentioned by Green et al. (2021) and raises an interesting concern going forward as to whether in-person support with the use of masks is more beneficial than virtual consultations.

Lactation consultants discussed the loneliness, isolation and anxiety experienced by breastfeeding mothers in response to COVID-19. The mothers themselves agreed that due to the lack of support from healthcare professionals, family and friends and the unavailability of support groups, they felt alone and isolated. Some mothers expressed their anxiety about contracting COVID-19 and their babies becoming ill. Feelings of loneliness, isolation and anxiety, as expressed by both lactation consultants’ perceptions of mothers’ emotions and mothers’ descriptions of their own emotions, has been previously identified (Jackson et al., 2021; Kotlar et al., 2021; Pacheco et al., 2021; Sakalidis et al., 2021). This highlights the necessity of providing support to mothers to protect their well-being.

Vaccination as a barrier and facilitator to accessing and providing support was an unanticipated finding. Healthcare workers, who work in close proximity to people, are at an increased risk of exposure to COVID-19 (Dooling et al., 2020) and group gatherings are a risk factor for contracting COVID-19 (Rashedi et al., 2020). This provides rationale for compulsory vaccination in order to attend support groups for the protection of others and those unvaccinated. Although compulsory vaccination can worsen inequities in access to resources (Omer et al., 2019) such as support, that is not the case here as support was offered on a one-to-one basis regardless of vaccination status. Some lactation consultants felt safe and protected once they had received their vaccinations and this enabled them to resume face-to-face support. Previous studies show that other healthcare professionals also felt that the COVID-19 vaccines would protect them and their families from contracting the infection (Al-Metwali et al., 2021) therefore, suggesting that vaccination facilitated them to feel safe and protected whilst at work.

Inconsistency of lactation support across Ireland due to the lack of standardised protocol for all lactation consultants has resulted in women having varying experiences of accessing support. Inconsistency in the application of restrictions has previously been identified on a European level, with guidelines from authoritative bodies such as the WHO being adhered to at varying degrees by individual countries and specific areas within countries (Lalor et al., 2021). The lack of a cohesive approach to lactation consultancy in Ireland throughout the pandemic has resulted in unequal distribution of support which may have subsequently led some women to cease breastfeeding early or be unable to fulfil their wish to breastfeed.

Limitations

The small sample size of this study, appropriate for a qualitative study, means that the findings are not generalisable. Linked interviews conducted with patients and healthcare professionals can potentially provide a deeper understanding of needs and experiences than interviews that explore single perspectives. These types of multi-perspective interviews provide opportunities for exploring similarities and differences in the perceptions of and integrating service improvement suggestions from both patients and healthcare professionals (Kendall et al., 2009). In this study, it was not possible to recruit participant matches in terms of lactation consultant and the mothers they supported. Due to this limitation, similar to findings from Whelan and Kearney (2015), the findings from both groups cannot be directly correlated to each other. Despite this limitation, this study may contribute important information in relation to breastfeeding support by placing mothers’ views about support in the context of their experiences and integrating them with the views of those delivering support to provide practical recommendations for the improvement of such services. Although both private and public lactation consultants were interviewed, it was not possible to get an equal representation from each sector. Fewer mothers than lactation consultants participated in this study, nevertheless including both perspectives in this small study was seen to be of value.

Implications of the research

The findings of this study suggest that although the COVID-19 restrictions played a role in the limitation of services available to mothers, it is evident that the issue regarding the lack of lactation consultants in hospital settings existed before COVID-19. More research should be undertaken to investigate why there are so few lactation consultants available in hospitals. Research investigating attitudes to breastfeeding in medical settings could be beneficial in identifying why breastfeeding does not appear to be sufficiently encouraged in hospital settings. Further research may also be warranted to identify how lactation consultancy should be managed in future emergency situations. This research suggests a need for support for lactation consultants, specifically in private practice given that they often work alone, to allow them to discuss and share the burden of the sometimes-distressing nature of their work, through clinical supervision or peer-support or other mechanisms. In the context of future emergency situations, this research supports an approach that would deem lactation consultancy and breastfeeding support an essential service. Any new policy should be accompanied by a monitoring framework setting out clear actions and indicators to effectively monitor implementation and progress in this area.

Data availability

The data used to inform this research was collected via interviews with participants who provided their informed consent. The interviews were recorded and transcribed however, these datasets are not publicly available due to participants being informed at the time of giving consent that the data collected would not be accessed by others and would be destroyed after one year.

Acknowledgements

We would like to thank all of the participants who took part in this study for their contribution to this research.

Faculty Opinions recommended

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Version 2

VERSION 2 PUBLISHED 19 Feb 2024

Author details Author details

¹ Dublin City University, Dublin, Leinster, Ireland

Anne Matthews
Roles: Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

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Published: 16 Dec 2024, 7:9

https://doi.org/10.12688/hrbopenres.13856.2

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Published: 19 Feb 2024, 7:9

https://doi.org/10.12688/hrbopenres.13856.1

© 2024 Connolly A and Matthews A. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Connolly A and Matthews A. Exploring Breastfeeding Mothers’ and Lactation Consultants’ Experiences of Lactation Consultancy Throughout the Restrictions Put in Place Due to the COVID-19 Pandemic [version 1; peer review: 1 approved, 1 approved with reservations]. HRB Open Res 2024, 7:9 (https://doi.org/10.12688/hrbopenres.13856.1)

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Open Peer Review

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Reviewer Report 11 Jun 2024

Jane Francis, Acadia University, Wolfville, NS, Canada

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15184.r39463

Thank you for the opportunity to review the manuscript “Exploring breastfeeding mothers’ and lactation consultants’ experiences of lactation consultancy throughout the restrictions put in place due to the COVID-19 pandemic”. Using semi-structured interviews, the aim of the study was to explore breastfeeding mothers’ and lactation consultants’ experiences of breastfeeding support throughout COVID-19 pandemic restrictions in Ireland. It is important to speak to those receiving and providing breastfeeding support services in order to better understand how support can be implemented within specific contexts. This is a well-written manuscript which could be strengthened by addressing the comments below.

Abstract

The conclusion states “Increased availability of lactation consultants and the implementation of breastfeeding rooms within hospitals is required”, but the main body of the text does not mention or discuss “breastfeeding rooms” in hospital. I would recommend removing this statement so that conclusions align with the presented findings.

Introduction

The McFadden et al 2017 Cochrane review has been updated, therefore, the following reference should be included throughout the paper: (Gavine A, et al., 2022 [Ref 1]). Another reference which would be important to include in the paper would be the WHO guidelines entitled “Counselling of Women to Improve Breastfeeding Practices" (https://www.who.int/publications/i/item/9789241550468) to highlight that global best practice guidelines do exist but may not be implemented (as noted by the participants in this study). This reference may fit well into the discussion.

The sentence “The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9% between 2019 and 2020 in Ireland. Only 58.5% of babies had received any type of breastfeeding on discharge from hospital in 2020 in comparison to 63.4% in 2019” should be revised to indicate “…from hospital dropped 4.9 percentage points” instead of 4.9 percent.

In the introduction, the sentence “This qualitative research study aims to explore both breastfeeding mothers’ and lactation consultants’ experiences of receiving and giving breastfeeding support throughout the restrictions put in place in Ireland due to the COVID-19 pandemic” can be removed since it’s in the middle of the introduction, or it can be moved to the last paragraph of the introduction (although the high-level aim is already noted at the end of the introduction and specific aims and objectives are in the methods section).

In the introduction, the sentence “The term lactation consultant will be frequently referred to. A lactation consultant can be defined as a healthcare professional that has specific training to deliver breastfeeding support and assist with the prevention, recognition and provision of solutions to breastfeeding difficulties (Brooks et al., 2016)” seems a bit out of place. It may fit better in the methods when describing IBCLCs, which was the specific profession of focus for this study.

Methods

Instruments/interview guide: was the interview guide developed by both authors or just one of the authors? It would be helpful to indicate who was involved in instrument development and consider including a sample of interview questions in a table or the complete set of questions as an appendix.

Sample: were there any exclusion criteria?

Ethical issues: it would be helpful to spell out the DCU acronym.

Under Procedure, the sentence states “Recruitment of breastfeeding mothers involved emails and phone calls with ae local PHN, breastfeeding support groups and community groups”. More information is needed on the recruitment process. For example, how were these relationships established/how were the PHN, breastfeeding support groups and community groups chosen? Did the PHN and/or group staff and/or researcher approach specific women who might be interested or were all women/clients in a specific time period provided with the study information? Were women provided with information on the study and then required to follow up with the researcher if they were interested in participating?

Under data analysis, the sentence states “This method of thematically analysing transcripts from interviews with both patients and healthcare professionals has previously been used by to explore both patients’ and nurses’ perspectives of healthcare interventions.” It would be helpful in the procedure section for sample size justification that the intent was to analyze perspectives of mothers and IBCLCs together.

Under data analysis, the sentence states “Thematic analysis was chosen to analyse the collected data as it is used to identify, investigate and interpret patterns that emerge from datasets.” Braun and Clarke argue that themes do not emerge from data (Braun V, et al., 2022 [Ref 2]). Given Braun and Clarke’s thematic analysis process was used, different wording could be used here.

Findings

Some clarity on the sample could be included. For example, were the 8 participants only those who responded to researchers or were there others who were approached/expressed interest who did not end up participating (e.g., an extension of figure 1 could be done to indicate if anyone was approached and indicated interest, but was lost to follow up). Was there any attempt to recruit more mothers or lactation consultants for the study?

Confirm demographic characteristics were not collected from participants beyond parity among the mothers. This could be stated in the methods.

Was the theme ‘vaccination as a barrier to and facilitator of support’ only discussed amongst LCs and not mothers? If so, it would be a good idea to make a note of this explicitly in the findings since the interviews from both mothers and IBCLCs were analyzed together.

Discussion

In the discussion, it states “Although compulsory vaccination can worsen inequities in access to resources (Omer et al., 2019) such as support, that is not the case here as support was offered on a one-to-one basis regardless of vaccination status.” However, unvaccinated mothers could not attend group sessions, which may be important for informal peer support and socialization.

Implication of findings

Under implication of findings, the sentence “Research investigating attitudes to breastfeeding in medical settings could be beneficial in identifying why breastfeeding does not appear to be sufficiently encouraged in hospital settings” does not appear to be supported from the findings of this study. The word “encouraged” could be changed to “support” to better align with the study findings.

Editorial errors:

Quotation marks missing for some themes in abstract
“ae” under procedure on page 5 should be “a”
(A.C) on page 5 should be “A.C.”
“saw then” should be “saw them” on page 8

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Gavine A, Shinwell SC, Buchanan P, Farre A, et al.: Support for healthy breastfeeding mothers with healthy term babies.Cochrane Database Syst Rev. 2022; 10 (10): CD001141 PubMed Abstract | Publisher Full Text
2. Braun V, Clarke V: Toward good practice in thematic analysis: Avoiding common problems and be(com)ing aknowing researcher. International Journal of Transgender Health. 2023; 24 (1): 1-6 Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: infant and maternal nutrition, breastfeeding support, food insecurity, community nutrition

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 16 Dec 2024

Anna Connolly, Dublin City University, Dublin, Ireland

16 Dec 2024

Author Response

We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions ... Continue reading We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions align with the presented findings and the statement in relation to breastfeeding rooms has been removed. The full interview guides have now been included in the appendix of the paper.

In light of the update to the McFadden et al 2017 Cochrane review, the reference Gavine A, et al., 2022 has been included throughout the manuscript. Reference to the WHO guidelines entitled “Counselling of Women to Improve Breastfeeding Practices" has also been made in the discussion section of the manuscript to acknowledge that guidelines in relation to best practices exist but may not be implemented. Furthermore, the sentence in relation to the rates of breastfeeding has been amended to state that “The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9 percentage points between 2019 and 2020 in Ireland”. On review of the manuscript, the sentence stating the aim of the research in the middle of the introduction section was deemed superfluous and has been removed. The sentence defining the role of the IBCLC has been removed from the introduction section of the manuscript and inserted into the methods section.

The interview guides were developed from the literature by the first author and with input from the second author.

The manuscript has been amended to include any exclusion criteria in relation to the sample of mothers and lactation consultants in this study. In relation to the ethical issues, Dublin City University has been included in the manuscript to spell of the DCU acronym. Under the procedure section, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study. All potential participants were provided with information on the study and were then required to follow up with the researcher via email to express their interest in participating. Under the data analysis section, it has been clarified for sample size justification that the intent was to analyse the perspectives of mothers and IBCLCs together. Furthermore, this section has also been amended to correctly reflect Braun and Clarke’s thematic analysis process and clarify that the themes were generated or constructed through the analysis of the qualitative data collected through the interviews.

Further clarity has been provided in relation to the sample. Figure 1 has been updated to demonstrate the additional participants that expressed interested but were lost to follow up. Given the time constraints due to this research being conducted as part of an undergraduate degree, there were no further attempts to recruit additional mothers or lactation consultants for participation in this research. The methods section has been amended to provide confirmation that demographic characteristics beyond parity were not collected among the mother participants. Furthermore, the findings section has been amended to clarify that the theme ‘vaccination as a barrier to and facilitator of support’ was only discussed amongst LCs.

In the discussion section, the impact of not being able to attend breastfeeding support groups on informal peer support and socialisation has been acknowledged. Under the implication section, the word “encouraged” has been changed to “supported” in order to ensure that the implications align with the study findings.

Finally, the editorial errors outlined in the review have been corrected in the manuscript.

Thank you again for your comments, feedback and support of this research.
We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions align with the presented findings and the statement in relation to breastfeeding rooms has been removed. The full interview guides have now been included in the appendix of the paper.

In light of the update to the McFadden et al 2017 Cochrane review, the reference Gavine A, et al., 2022 has been included throughout the manuscript. Reference to the WHO guidelines entitled “Counselling of Women to Improve Breastfeeding Practices" has also been made in the discussion section of the manuscript to acknowledge that guidelines in relation to best practices exist but may not be implemented. Furthermore, the sentence in relation to the rates of breastfeeding has been amended to state that “The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9 percentage points between 2019 and 2020 in Ireland”. On review of the manuscript, the sentence stating the aim of the research in the middle of the introduction section was deemed superfluous and has been removed. The sentence defining the role of the IBCLC has been removed from the introduction section of the manuscript and inserted into the methods section.

The interview guides were developed from the literature by the first author and with input from the second author.

The manuscript has been amended to include any exclusion criteria in relation to the sample of mothers and lactation consultants in this study. In relation to the ethical issues, Dublin City University has been included in the manuscript to spell of the DCU acronym. Under the procedure section, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study. All potential participants were provided with information on the study and were then required to follow up with the researcher via email to express their interest in participating. Under the data analysis section, it has been clarified for sample size justification that the intent was to analyse the perspectives of mothers and IBCLCs together. Furthermore, this section has also been amended to correctly reflect Braun and Clarke’s thematic analysis process and clarify that the themes were generated or constructed through the analysis of the qualitative data collected through the interviews.

Further clarity has been provided in relation to the sample. Figure 1 has been updated to demonstrate the additional participants that expressed interested but were lost to follow up. Given the time constraints due to this research being conducted as part of an undergraduate degree, there were no further attempts to recruit additional mothers or lactation consultants for participation in this research. The methods section has been amended to provide confirmation that demographic characteristics beyond parity were not collected among the mother participants. Furthermore, the findings section has been amended to clarify that the theme ‘vaccination as a barrier to and facilitator of support’ was only discussed amongst LCs.

In the discussion section, the impact of not being able to attend breastfeeding support groups on informal peer support and socialisation has been acknowledged. Under the implication section, the word “encouraged” has been changed to “supported” in order to ensure that the implications align with the study findings.

Finally, the editorial errors outlined in the review have been corrected in the manuscript.

Thank you again for your comments, feedback and support of this research.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 16 Dec 2024

Anna Connolly, Dublin City University, Dublin, Ireland

16 Dec 2024

Author Response

We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions ... Continue reading We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions align with the presented findings and the statement in relation to breastfeeding rooms has been removed. The full interview guides have now been included in the appendix of the paper.

In light of the update to the McFadden et al 2017 Cochrane review, the reference Gavine A, et al., 2022 has been included throughout the manuscript. Reference to the WHO guidelines entitled “Counselling of Women to Improve Breastfeeding Practices" has also been made in the discussion section of the manuscript to acknowledge that guidelines in relation to best practices exist but may not be implemented. Furthermore, the sentence in relation to the rates of breastfeeding has been amended to state that “The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9 percentage points between 2019 and 2020 in Ireland”. On review of the manuscript, the sentence stating the aim of the research in the middle of the introduction section was deemed superfluous and has been removed. The sentence defining the role of the IBCLC has been removed from the introduction section of the manuscript and inserted into the methods section.

The interview guides were developed from the literature by the first author and with input from the second author.

The manuscript has been amended to include any exclusion criteria in relation to the sample of mothers and lactation consultants in this study. In relation to the ethical issues, Dublin City University has been included in the manuscript to spell of the DCU acronym. Under the procedure section, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study. All potential participants were provided with information on the study and were then required to follow up with the researcher via email to express their interest in participating. Under the data analysis section, it has been clarified for sample size justification that the intent was to analyse the perspectives of mothers and IBCLCs together. Furthermore, this section has also been amended to correctly reflect Braun and Clarke’s thematic analysis process and clarify that the themes were generated or constructed through the analysis of the qualitative data collected through the interviews.

Further clarity has been provided in relation to the sample. Figure 1 has been updated to demonstrate the additional participants that expressed interested but were lost to follow up. Given the time constraints due to this research being conducted as part of an undergraduate degree, there were no further attempts to recruit additional mothers or lactation consultants for participation in this research. The methods section has been amended to provide confirmation that demographic characteristics beyond parity were not collected among the mother participants. Furthermore, the findings section has been amended to clarify that the theme ‘vaccination as a barrier to and facilitator of support’ was only discussed amongst LCs.

In the discussion section, the impact of not being able to attend breastfeeding support groups on informal peer support and socialisation has been acknowledged. Under the implication section, the word “encouraged” has been changed to “supported” in order to ensure that the implications align with the study findings.

Finally, the editorial errors outlined in the review have been corrected in the manuscript.

Thank you again for your comments, feedback and support of this research.
We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions align with the presented findings and the statement in relation to breastfeeding rooms has been removed. The full interview guides have now been included in the appendix of the paper.

In light of the update to the McFadden et al 2017 Cochrane review, the reference Gavine A, et al., 2022 has been included throughout the manuscript. Reference to the WHO guidelines entitled “Counselling of Women to Improve Breastfeeding Practices" has also been made in the discussion section of the manuscript to acknowledge that guidelines in relation to best practices exist but may not be implemented. Furthermore, the sentence in relation to the rates of breastfeeding has been amended to state that “The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9 percentage points between 2019 and 2020 in Ireland”. On review of the manuscript, the sentence stating the aim of the research in the middle of the introduction section was deemed superfluous and has been removed. The sentence defining the role of the IBCLC has been removed from the introduction section of the manuscript and inserted into the methods section.

The interview guides were developed from the literature by the first author and with input from the second author.

The manuscript has been amended to include any exclusion criteria in relation to the sample of mothers and lactation consultants in this study. In relation to the ethical issues, Dublin City University has been included in the manuscript to spell of the DCU acronym. Under the procedure section, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study. All potential participants were provided with information on the study and were then required to follow up with the researcher via email to express their interest in participating. Under the data analysis section, it has been clarified for sample size justification that the intent was to analyse the perspectives of mothers and IBCLCs together. Furthermore, this section has also been amended to correctly reflect Braun and Clarke’s thematic analysis process and clarify that the themes were generated or constructed through the analysis of the qualitative data collected through the interviews.

Further clarity has been provided in relation to the sample. Figure 1 has been updated to demonstrate the additional participants that expressed interested but were lost to follow up. Given the time constraints due to this research being conducted as part of an undergraduate degree, there were no further attempts to recruit additional mothers or lactation consultants for participation in this research. The methods section has been amended to provide confirmation that demographic characteristics beyond parity were not collected among the mother participants. Furthermore, the findings section has been amended to clarify that the theme ‘vaccination as a barrier to and facilitator of support’ was only discussed amongst LCs.

In the discussion section, the impact of not being able to attend breastfeeding support groups on informal peer support and socialisation has been acknowledged. Under the implication section, the word “encouraged” has been changed to “supported” in order to ensure that the implications align with the study findings.

Finally, the editorial errors outlined in the review have been corrected in the manuscript.

Thank you again for your comments, feedback and support of this research.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 07 May 2024

Louise Gallagher, Trinity College Dublin, Dublin, Ireland

Approved

https://doi.org/10.21956/hrbopenres.15184.r39009

Review:

The aim of this study was to explore breastfeeding mothers’ and lactation consultants’ experiences of breastfeeding support throughout the COVID-19 restrictions in Ireland. support.

This was overall a well written piece of work and I commend the student for this important and rigorously conducted study.

On page 4 it states that LC’s should be fully qualified and registered with ALCI. This needs to be reworded as ALCI is not a registration body for IBCLC’s and has both affiliate (certified) and non-affiliate (uncertified or lay) members.

Although the sample is identified as ‘purposive’ there is a lack of clarity on how participants were sourced. It’s unclear if this has any impact or introduces any inherent biases but this requires further detail.

The use of the term ‘unanticipated’ throughout the findings suggests some degree of bias that many of the findings were expected. While this may indeed be the case it comes across as somewhat biased in parts, and I would suggest rephrasing in relation to some of the findings.

The ‘Vaccination as a barrier’ should include SARS- CoV-2 as part of the title as I read this earlier in the paper to be related infant vaccination.

The findings (line 2) should clarify that ‘some mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants’. The current statement presents some overreach given the small sample size of mothers and LC’s.

Typos:

Page 5 line 10 has a redundant e before ‘a local PHN’.

Review initials for consistency (sometimes AC and also A.C)

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Breastfeeding, mixed methods, maternity care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

CITE

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Author Response 16 Dec 2024

Anna Connolly, Dublin City University, Dublin, Ireland

16 Dec 2024

Author Response

We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify ... Continue reading We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify that the inclusion criteria for participating in the interviews involved being an International Board Certified Lactation Consultant rather than registered with the ALCI.

Furthermore, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study.

The sections of the manuscript that referred to unanticipated findings have been rephrased to reduce any suggestions of bias.

The manuscript has also been amended to include SARS-CoV-2 as part of the title for the findings related to vaccination.

In light of the comments in relation to the overreach of the statement in line 2 of the discussion section given the small sample size, the manuscript has been amended to clarify that ‘some mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants.
Finally, the typos on page 5 and the inconsistencies in relation to the authors initials throughout the manuscript have been corrected.

Thank you again for your comments, feedback and support of this research.
We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify that the inclusion criteria for participating in the interviews involved being an International Board Certified Lactation Consultant rather than registered with the ALCI.

Furthermore, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study.

The sections of the manuscript that referred to unanticipated findings have been rephrased to reduce any suggestions of bias.

The manuscript has also been amended to include SARS-CoV-2 as part of the title for the findings related to vaccination.

In light of the comments in relation to the overreach of the statement in line 2 of the discussion section given the small sample size, the manuscript has been amended to clarify that ‘some mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants.
Finally, the typos on page 5 and the inconsistencies in relation to the authors initials throughout the manuscript have been corrected.

Thank you again for your comments, feedback and support of this research.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 16 Dec 2024

Anna Connolly, Dublin City University, Dublin, Ireland

16 Dec 2024

Author Response

We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify ... Continue reading We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify that the inclusion criteria for participating in the interviews involved being an International Board Certified Lactation Consultant rather than registered with the ALCI.

Furthermore, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study.

The sections of the manuscript that referred to unanticipated findings have been rephrased to reduce any suggestions of bias.

The manuscript has also been amended to include SARS-CoV-2 as part of the title for the findings related to vaccination.

In light of the comments in relation to the overreach of the statement in line 2 of the discussion section given the small sample size, the manuscript has been amended to clarify that ‘some mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants.
Finally, the typos on page 5 and the inconsistencies in relation to the authors initials throughout the manuscript have been corrected.

Thank you again for your comments, feedback and support of this research.
We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify that the inclusion criteria for participating in the interviews involved being an International Board Certified Lactation Consultant rather than registered with the ALCI.

Furthermore, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study.

The sections of the manuscript that referred to unanticipated findings have been rephrased to reduce any suggestions of bias.

The manuscript has also been amended to include SARS-CoV-2 as part of the title for the findings related to vaccination.

In light of the comments in relation to the overreach of the statement in line 2 of the discussion section given the small sample size, the manuscript has been amended to clarify that ‘some mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants.
Finally, the typos on page 5 and the inconsistencies in relation to the authors initials throughout the manuscript have been corrected.

Thank you again for your comments, feedback and support of this research.
Competing Interests: No competing interests were disclosed. Close
Report a concern

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Version 2

VERSION 2 PUBLISHED 19 Feb 2024

Open Peer Review

Reviewer Status

Reviewer Reports

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	1	2	3	4
Version 2 (revision) 16 Dec 24		read	read	read
Version 1 19 Feb 24	read	read

Louise Gallagher, Trinity College Dublin, Dublin, Ireland
Jane Francis, Acadia University, Wolfville, NS, Canada
Kathleen Kendall-Tackett, Texas Tech University Health Sciences Center, Amarillo, USA
Charlotte M Wright, University of Glasgow, Glasgow, UK

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Reviewer Report

15 Views

13 Feb 2025 | for Version 2

Charlotte M Wright, University of Glasgow, Glasgow, UK

15 Views Cite this report Responses(0)

Approved

This modest qualitative study has already been extensively reviewed and amendments made. The question addressed was fairly limited and the numbers studied small, but it seems to be appropriately written up and i have no substantive comments to make apart from a minor issue in the introduction, where the authors refer to only 15% Irish babies being exclusively breast feed at age 6 months. This is not a helpful age to work with, as mothers are advised to start solids at around 6 months. Are they sure that this figure doesn't in fact reflect the proportion of all children aged <6m who are exclusively breastfed?

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Infant and child nutrition

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

16 Views

03 Feb 2025 | for Version 2

Kathleen Kendall-Tackett, Texas Tech University Health Sciences Center, Amarillo, USA

16 Views Cite this report Responses(0)

Approved With Reservations

This article considers the subject of COVID restrictions on breastfeeding in Ireland, noting that Ireland has one of the lowest exclusive breastfeeding rates in Europe prior to COVID.

I note that this is a revised article, but this is my first time seeing it.

Introduction
Overall, the writing is clear. However, I found the structure of the introduction confusing. The focus is on the impact of COVID on breastfeeding rates. Yet that topic is only in the third paragraph.

I'm not sure that the authors need to describe the benefits of breastfeeding (para 1) and the importance of lactation consultants (para 2) before they describe what they are actually studying (para 3). I recommend that they narrow the focus to COVID and bring in the already low rates in Ireland and how COVID made it worse for both LCs and mothers. That's the focus. The other information takes away from that but can be briefly summarized once the authors make clear that their focus is breastfeeding during COVID.

Methods
I recommend moving the objectives to the Introduction. The purpose of the intro is to justify the study: tell us why it is necessary. That section should end with laying out the objectives of the study.

Why is the impact of COVID on LCs important? Yes, they were definitely affected, but how does that impact the breastfeeding rates? Try to make that connection clearer while focusing on rates during COVID.

When describing the qualitative portion, the authors really do not need to describe why qualitative studies are necessary. People pretty much get that. I would like to see how they plan to collect and analyze their data instead. What method will/did they apply?

What is the "target population"? That is very vague. Are they local? Are they online? Are they all Irish? We need to know that so we can understand where you selected your participants from.

The authors do not need to editorialize about the "rich data" the participants will provide. We assume that. Just tell us more about who they are and how they were selected.

We need much more information about the interview guides. How were the questions selected? What was asked? The idea is to provide enough info that someone could replicate the study.

The authors can cut the explanation about Zoom. Most of us are familiar with it. We don't need to justification for it.

Results
It's confusing to have the LC comments mixed with the mothers' comments. I recommend separating them but noting their similarity with a transition sentence.

I'm not clear about why LCs felt unsupported beyond not knowing how to use Zoom. And it sounds like many LCs were pleased during this time. It isn't very clear through this section.

As for the other effects, they are what others in the very large lit on COVID are saying. Loneliness and isolation are definitely not unique. Please make it clear why this is important and unique for breastfeeding mothers and their helpers.

There have been numerous studies on the effects of COVID on healthcare providers. It would strengthen this article if the authors included some of those and then noted why their sample was unique. It's been so bad here that some LCs have started special support groups for mothers who gave birth during COVID. It took a wrecking ball through maternal mental health that has been well-documented. Therefore, the authors' task is the show why their study is necessary and unique. In its current form, I am not getting much of that from this article, but it could be improved.

Discussion
I also would not call a small sample for a qualitative study a limitation. It's expected that the sample is small.

When discussing the implications, the authors have not made the case that COVID made things more difficult. It sounds as if they are already bad. How did COVID make it worse? I know it's challenging in Ireland; I have several Irish LC colleagues.

I am happy that you have done this study, but we need a lot more information from the authors.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Maternjal mental health, psychology, lactation, IBCLC, psychological trauma

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Reviewer Report

17 Views

23 Jan 2025 | for Version 2

Jane Francis, Acadia University, Wolfville, NS, Canada

17 Views Cite this report Responses(0)

Approved

I have reviewed the revised manuscript and amend my previous status of Approved with Reservations to Approved. However, there are two corrections needed in the abstract and introduction:

It appears the conclusion still states “Increased availability of lactation consultants and the implementation of breastfeeding rooms within hospitals is required”, but the main body of the text does not mention or discuss “breastfeeding rooms” in hospital. I would recommend removing this statement so that conclusions align with the presented findings.
The sentence defining the role of the IBCLC remains in the introduction section of the manuscript and should be removed.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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40 Views

11 Jun 2024 | for Version 1

Jane Francis, Acadia University, Wolfville, NS, Canada

40 Views Cite this report Responses(1)

Approved With Reservations

Quotation marks missing for some themes in abstract
“ae” under procedure on page 5 should be “a”
(A.C) on page 5 should be “A.C.”
“saw then” should be “saw them” on page 8

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

No
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

infant and maternal nutrition, breastfeeding support, food insecurity, community nutrition

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Responses (1)

Author Response

16 Dec 2024

Anna Connolly, Dublin City University, Dublin, Ireland

We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The abstract has been amended to ensure that the conclusions align with the presented findings and the statement in relation to breastfeeding rooms has been removed. The full interview guides have now been included in the appendix of the paper.

In light of the update to the McFadden et al 2017 Cochrane review, the reference Gavine A, et al., 2022 has been included throughout the manuscript. Reference to the WHO guidelines entitled “Counselling of Women to Improve Breastfeeding Practices" has also been made in the discussion section of the manuscript to acknowledge that guidelines in relation to best practices exist but may not be implemented. Furthermore, the sentence in relation to the rates of breastfeeding has been amended to state that “The rate of babies that had received any breastfeeding on discharge from hospital dropped 4.9 percentage points between 2019 and 2020 in Ireland”. On review of the manuscript, the sentence stating the aim of the research in the middle of the introduction section was deemed superfluous and has been removed. The sentence defining the role of the IBCLC has been removed from the introduction section of the manuscript and inserted into the methods section.

The interview guides were developed from the literature by the first author and with input from the second author.

The manuscript has been amended to include any exclusion criteria in relation to the sample of mothers and lactation consultants in this study. In relation to the ethical issues, Dublin City University has been included in the manuscript to spell of the DCU acronym. Under the procedure section, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study. All potential participants were provided with information on the study and were then required to follow up with the researcher via email to express their interest in participating. Under the data analysis section, it has been clarified for sample size justification that the intent was to analyse the perspectives of mothers and IBCLCs together. Furthermore, this section has also been amended to correctly reflect Braun and Clarke’s thematic analysis process and clarify that the themes were generated or constructed through the analysis of the qualitative data collected through the interviews.

Further clarity has been provided in relation to the sample. Figure 1 has been updated to demonstrate the additional participants that expressed interested but were lost to follow up. Given the time constraints due to this research being conducted as part of an undergraduate degree, there were no further attempts to recruit additional mothers or lactation consultants for participation in this research. The methods section has been amended to provide confirmation that demographic characteristics beyond parity were not collected among the mother participants. Furthermore, the findings section has been amended to clarify that the theme ‘vaccination as a barrier to and facilitator of support’ was only discussed amongst LCs.

In the discussion section, the impact of not being able to attend breastfeeding support groups on informal peer support and socialisation has been acknowledged. Under the implication section, the word “encouraged” has been changed to “supported” in order to ensure that the implications align with the study findings.

Finally, the editorial errors outlined in the review have been corrected in the manuscript.

Thank you again for your comments, feedback and support of this research.

View more View less

Competing Interests

No competing interests were disclosed.

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Reviewer Report

37 Views

07 May 2024 | for Version 1

Louise Gallagher, Trinity College Dublin, Dublin, Ireland

37 Views Cite this report Responses(1)

Approved

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Breastfeeding, mixed methods, maternity care

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (1)

Author Response

16 Dec 2024

Anna Connolly, Dublin City University, Dublin, Ireland

We would like to thank the reviewer for their support of our work and constructive feedback on our manuscript.

The manuscript has been amended on page four to clarify that the inclusion criteria for participating in the interviews involved being an International Board Certified Lactation Consultant rather than registered with the ALCI.

Furthermore, the sampling strategy and recruitment process has been amended to provide further clarity on how the participants were sourced for this study.

The sections of the manuscript that referred to unanticipated findings have been rephrased to reduce any suggestions of bias.

The manuscript has also been amended to include SARS-CoV-2 as part of the title for the findings related to vaccination.

In light of the comments in relation to the overreach of the statement in line 2 of the discussion section given the small sample size, the manuscript has been amended to clarify that ‘some mothers have inadequate breastfeeding support in hospitals with little or no access to lactation consultants.
Finally, the typos on page 5 and the inconsistencies in relation to the authors initials throughout the manuscript have been corrected.

Thank you again for your comments, feedback and support of this research.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Exploring Breastfeeding Mothers’ and Lactation Consultants’ Experiences of Lactation Consultancy Throughout the Restrictions Put in Place Due to the COVID-19 Pandemic

Abstract

Background

Methods

Results

Conclusions

Keywords

List of abbreviations

Introduction

Methods

Aim

Objectives

Research design

Sample

Figure 1. Flowchart of Participants Recruited.

Instruments

Ethical issues

Procedure

Data analysis

Findings

Figure 2. Themes Generated through Thematic Analysis.

Table 1. Participant key.

Lack of support

Adapting to COVID-19 restrictions

Emotional response to covid-19 and restrictions

Vaccination as a barrier to and facilitator of support

Inconsistency of lactation support across Ireland

Discussion and conclusions

Limitations

Implications of the research

Data availability

Acknowledgements

References

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