Health care provider identified barriers and facilitators that impact Ten Steps to Successful Breastfeeding implementation: A multi-case study guided by organizational readiness to change

Introduction: The Joint Commission recently added exclusive breastfeeding as a perinatal care core measure. The Carolina Global Breastfeeding Institute (CGBI) developed the Breastfeeding Friendly Healthcare Initiative (BFHCI) to support hospitals in efforts to implement the Ten Steps and provide evidence-based breastfeeding support. This study presents the barriers and facilitators healthcare providers reported would impact their specific hospitals' efforts to implement the Ten Steps. Methods: The BFHCI is an operations-research project using a multi-case study design with eight cases (i.e., hospitals). CGBI developed a semi-structured interview guide to identify barriers and facilitating factors to implementing the Steps. The theory “Organizational Readiness to Change” directed guide development. Two CGBI staff conducted interviews at the eight hospitals. Informants were selected using purposeful sampling until achieving construct saturation. CGBI interviewed 34 providers and transcribed the interviews verbatim. Interview transcripts were coded using a codebook and analyzed in ATLAS.ti. The study used thematic and cross-case analyses. Results: Identified barriers included attitudes of experienced providers towards breastfeeding, staffing constraints, the need for more IBCLCs, and the fear of infringing on mothers' choices. Identified facilitators included having a breastfeeding advocate on staff, management support for the Steps, demonstrating the benefits of breastfeeding to nurses, including lactation support in evaluations, and hands-on training. Smaller hospitals' respondents identified more and different barriers than larger hospitals'. The number and type of barriers and facilitators differed by profession. Ability and commitment varied by profession and hospital size. Discussion: Interventions should address identified barriers and facilitators while considering hospital context and characteristics.