Monitoring of the Implementation of a Breastfeeding Guideline for 6 Years: A Mixed-Methods Study Using an Interrupted Time Series Approach

Abstract

Background: Current literature provides poor information about the implementation of health-promoting clinical practice guidelines (CPGs) and their longitudinal monitoring.

Purpose: The aim of this study was to evaluate the longitudinal impact of a CPG implementation program that promotes breastfeeding, its associated quantitative and qualitative indicators, and direct costs.

Design: A mixed-methods design with a longitudinal approach was utilized, with an interrupted time series design and the analysis of reports from the implementation program as the qualitative approach.

Methods: The study setting was maternity and pediatric units of a health area in the Spanish health system. The implementation of a CPG for the promotion of breastfeeding was evaluated, which included a pre-implementation year (2011), 3 years of implementation (2012-2014), and 2 years of post-implementation (2015-2016). The sample was composed of mother-infant dyads. A segmented logistic regression analysis was utilized to evaluate the changes in the most important breastfeeding indicators. A deductive thematic content analysis was performed starting with quality indicators and a descriptive economic analysis.

Findings: In the 6 years of monitoring, 7,842 mother-infant dyads were recorded. The results of the quantitative indicators showed the presence of four stages: baseline, gain, adjustment, and sustainability or saturation. The breast milk at the first feeding had an increasing slope in the gain stage (24% per quarter; odds ratio [OR] = 1.24, 95% confidence interval [CI] 1.12-1.37). The exclusive breastfeeding at hospital discharge showed significant changes in the period of gain (OR = 2.45, 95% CI 1.95-3.08), which was maintained in the adjustment period, with an increase of 18% in the slope of the gain stage (OR = 1.18, 95% CI 1.06-1.32). The longitudinal distribution of the qualitative indicators showed a greater concentration of indicators towards the first half of each phase. The total cost was 209,575€ ($248,670.17).

Conclusions: The implementation of the breastfeeding CPG showed early, positive, and sustained results in the exclusive breastfeeding rates. The implementation implied the application of a complex intervention, with its qualitative indicators showing a wave-shaped dynamic.

Clinical relevance: Our findings contribute to the understanding and evolution of the main indicators of the implementation of a breastfeeding CPG, providing details on the magnitude of the effect, the process of change, and the associated costs.

Keywords: Breastfeeding; complex interventions; guidelines; implementation; implementation planning; implementation science; implementation strategies; time series.