Addressing social inequality in breastfeeding through proactive support: A realist evaluation from Denmark

Background Breastfeeding is subject to social inequality with short-term education and young age being important risk factors of early breastfeeding cessation. Breastfeeding support can be offered reactively, with mothers reaching out, or proactively where a health professional or peer supporter contacts the mother. Reactive support alone may be inadequate for those with the greatest need for support as they are the least likely to ask for it. An evidence-based breastfeeding intervention was implemented in Denmark with the purpose of prolonging breastfeeding and reducing social inequality in breastfeeding. To address breastfeeding challenges timely, intervention elements were proactive telephone calls by a health visitor combined with home visits. Methods We applied a realist evaluation approach embedded in a cluster randomized trial carried out in 20 municipalities. In the intervention arm, we observed 35 home visits delivered by health visitors, interviewed 16 mothers and conducted six focus groups with a total of 34 health visitors to examine how the proactive telephone calls functioned, specifically among mothers at increased risk of early breastfeeding cessation. The theoretical concept of Candidacy was applied to unfold how access to breastfeeding support was negotiated and socially patterned. Results Mothers experienced various barriers for accessing breastfeeding support; one being to determine when a breastfeeding issue would be deemed relevant by the health visitor while fearing to be an annoyance, another related to the sensitive nature of breastfeeding. Proactive telephone calls improved access to breastfeeding support through three different mechanisms: 1) timely handling of breastfeeding issues, 2) bringing the health visitor and family closer together, and 3) increased rapport and trust. Conclusions Proactive telephone calls may function as a tool to mitigate social inequalities in breastfeeding if combined with home visits and if it is person-centered with attention to relationships rather than just practical assistance. Trial registration Clinical Trials: NCT05311631. First posted April 5, 2022.