Health professionals, implementation and outcomes: reflections on a complex intervention to improve breastfeeding rates in primary care

Objectives. To understand why a complex breastfeeding coaching intervention, which offered health professional-facilitated breastfeeding groups for pregnant and breastfeeding mothers and personal peer coaches, was more effective at improving breastfeeding rates in some areas than others. Methods. This controlled intervention study was designed, implemented and evaluated using principles from action research methodology. We theoretically sampled 14 health professionals with varying levels of involvement and 12 consented to be interviewed. We analysed data from 266 group diaries kept by health professionals, 31 group observations, 10 audio-recorded steering group meetings and field notes. Women's perspectives were obtained by analysing qualitative data from one focus group, 21 semi-structured qualitative interviews and responses to open-survey questions. Results. The intervention was more effective at improving breastfeeding rates in areas where health visitors and midwives were committed to working together to implement the intervention, where health professionals shared group facilitation and where inter- and intra-professional relationships were strong. The area where the intervention was ineffective had continuity of a single group facilitator with breastfeeding expertise and problematic relationships within and between midwife and health visitor teams. No one style of group suited all women. Some preferred hearing different views, others valued continuity of help from a facilitator with breastfeeding expertise. Conclusions. We hypothesise that involving several local health professionals in implementing an intervention may be more effective than a breastfeeding expert approach. Inter- and intra-health professional relationships may be an important determinant of outcome in interventions that aim to influence population behaviours like breastfeeding