Exploring the Implementation of Two Breastfeeding Interventions in Six LGAs in Victoria in the Supporting Breastfeeding In Local Communities (SILC) Cluster Randomised Controlled Trial

Submission note: A thesis submitted in total fulfilment of the requirements for the degree of Doctor of Philosophy to the Judith Lumley Centre, School of Nursing and Midwifery, College of Science, Health and Engineering, La Trobe University, Victoria, Australia.

Thesis with publications.

The majority of Australian women initiate breastfeeding, however rates decline quickly in the early weeks post-birth. The Supporting breastfeeding In Local Communities (SILC) trial was implemented in 10 Local Government Areas in Victoria, Australia. The trial aimed to improve breastfeeding rates by introducing two new innovations: proactive home-based breastfeeding support, and proactive support plus access to a community-based breastfeeding drop-in centre. The SILC trial did not demonstrate improvement in breastfeeding rates at three, four or six months, so a process evaluation was critical to gain an understanding of intervention implementation. This thesis explored the implementation of the two interventions aimed at increasing breastfeeding. The process evaluation, which formed the basis of the thesis, explored four elements considered likely to have an impact on SILC implementation: uptake and content of home-based support by Maternal and Child Health Nurses (SILC-MCHNs); drop-in centre establishment and uptake; views and experiences of staff providing the interventions; and women’s experiences of infant feeding support. The overall thesis aim was to explore what factors impacted on the implementation of SILC. Implementation barriers were experienced at each LGA, and as a result the home visits and drop-in centre attendance were significantly less than expected. Despite this, the SILC-MCHNs and the women reported very positive experiences of the SILC interventions. Women appreciated the early support, and SILC-MCHNs reported the interventions enabled them to spend time with women in their homes and individualise breastfeeding support. This process evaluation demonstrated that, despite the positive response to SILC from all stakeholders, the interventions were not delivered as planned. Given this, it is not possible determine if proactive, home-based breastfeeding support, with or without access to community-based drop-in centres, is or is not effective. Increasing breastfeeding is inherently complex, particularly when considering the equally complex community-based health care system. This thesis provides important knowledge that helps to explain the SILC primary outcome and inform future research aimed at improving breastfeeding outcomes.