In this study, a novel educational toolkit that teaches BMHE was developed in consultation with healthcare providers, lactation consultants, and individuals with recent breastfeeding experience, and evaluated by the obstetrical population. Our results suggest that this toolkit was easy to understand, well laid-out, clear, and visually appealing. Participants indicated a preference for online resources and for breastfeeding resources that were provided by healthcare providers.
A key finding in this study was that the majority of participants had heard of hand expression before (95.1%) and had hand expressed their own breastmilk (80.5%). This is a high prevalence of BMHE when compared to other studies that have reported approximately 60% of surveyed participants had experience with hand expression [30]. Our findings may be explained by the fact that the survey was distributed in Facebook groups and shared on Twitter accounts that are frequented by healthcare practitioners who have likely been exposed to BMHE during their training or through personal experience. Furthermore, the number of participants who had exclusively breastfed their infant until six months of age (45.8%) and who had discontinued breastfeeding within the infant’s first month of life (14.6%) were higher and lower, respectively, when compared to what has been previously reported [14, 15]. The higher rates of exclusive breastfeeding and the lower rates of early discontinuation may be explained the fact that our sample was highly educated and overwhelmingly English-speaking. It is likely that these participants were able to seek out timely breastfeeding support and utilize the many breastfeeding resources that are readily available in English to overcome their challenges [31].
Our novel BMHE toolkit will be revised based on participant feedback and the anticipated revisions are outlined here. In Sect. 1 (What is hand expression? ), participants indicated that they were confused as to why they needed approval from a healthcare provider before performing hand expression in the antenatal period. As such, the second part of the second bullet point in Sect. 1 that encourages BMHE in the antenatal period will be removed from the toolkit. This is an important revision to highlight as the goal of the toolkit is not to provide education about when to perform BHME, but instead to provide education to individuals on how to effectively perform BMHE. When the toolkit is recommended, whether in the antenatal or post-natal period, will be determined on a case-by-case basis between individuals and their healthcare providers. Next, the language in Sect. 2 (Why hand express?) that certain participants felt was discouraging the use of human milk supplements, will be completely eliminated. Third, the order of the step-by-step instructions in Sect. 4 (How do I hand express?) will be reorganized to allow readers to read the images from top to bottom, (i.e., step two will be placed directly beneath step one, instead of to the right of step one). The instructions to describe BMHE in Sect. 4 will also be rephrased to match the technique outlined in the Global Health Media video [29]. Finally, changes will be made to all sections of the toolkit to ensure that consistent terminology is employed (i.e., any mention of ‘nipple’ will be changed to ‘areola’), instructions are clear and concise (i.e., ‘sit up and learn forward’ will be changed to ‘lean forward’), and established hand expression terminology that is in keeping with the video is utilized (i.e., ‘squeeze’ will be changed to ‘compress’).
Ultimately, the data collected in this survey will be used to create a revised toolkit and to develop and implement tailored strategies to optimize its use. An important consideration prior to widespread distribution of the toolkit is that 78.1% of participants indicated they would find it helpful to have a healthcare practitioner go through the toolkit when learning how to hand express. This finding is important as it suggests that the toolkit on its own may not replace the time requirement that healthcare providers need to spend teaching BMHE in clinical settings, but will facilitate this discussion Accordingly, it may be important to provide healthcare providers with BMHE training, through an online module for example, to ensure that they are correctly teaching their patients this skill. Implementing baby-friendly initiatives (BFI) at local and national hospitals, birthing centres, and community health centres that aim to "protect, promote and support breastfeeding in Canada” will also encourage uptake of the BMHE toolkit [13, 32]. This study is not without limitations. First, the survey response rate of 41% was somewhat lower than the reported response rate for similar electronic surveys of healthcare providers [33]. This may be attributed to the surge in digital technologies that has manifested as a result of the COVID-19 pandemic [34]. Second, the respondents of the survey were not representative of the population in that the majority of participants were Caucasian, English-speaking and highly educated. Therefore, our results are likely biased as we are missing important feedback from Black, Indigenous and people of colour, non-English speakers, and individuals from vulnerable populations. To overcome this, additional focused feedback will be sought from consenting individuals when the toolkit is distributed in local clinical care settings or utilized in future trials where BMHE is being taught. Despite this limitation, when developing patient-facing materials, it is important to continuously seek feedback from the target audience and modify the information accordingly to ensure it is up-to-date, accessible, and informative [35]. Finally, the survey did not evaluate the toolkit’s ability to correctly teach participants how to hand express breastmilk. As such, to improve the quality of this educational tool, it would be important to collect additional feedback and determine whether the steps included in the BMHE toolkit are effective at teaching individuals how to correctly hand express.