Background
The COVID-19 pandemic has introduced unforeseen challenges in the delivery of lactation
training, education, and skilled support worldwide. The World Health Organization
(WHO) has developed global recommendations for the protection, promotion, and support
of breastfeeding when COVID-19 is suspected or confirmed (World Health Organization,
2020). This interim guidance, which is grounded in the best available clinical evidence
and epidemiology, brings attention to the importance of integrating breastfeeding
education and skilled lactation support into the COVID-19 pandemic response (Gribble,
2018; UNICEF, 2020).
Prenatal breastfeeding education is a critical, yet often overlooked, emergency nutrition
intervention for COVID-19. It provides expectant parents with essential information
and anticipatory guidance they will need as they prepare to care for a newborn and
themselves. Because emergency response must be adapted to fit different situations
and contexts, it is important that parents and other infant caregivers are supported
to make informed decisions regarding the relative costs, benefits, and risks of available
infant feeding alternatives (Angood, 2017). Anticipatory guidance during pregnancy
on infant feeding in emergencies is integral to coordinated holistic response for
maternal, child, and family health during COVID-19. However, social distancing measures
that mitigate the transmission of SARS-CoV-2 have disrupted families’ access to perinatal
care services around the world, including breastfeeding education, skilled lactation
support immediately postpartum, and continuity of lactation counseling throughout
the period of lactation. They have also created practical challenges for competency-based
training of professional and peer lactation support persons, who might be deployed
during the COVID-19 response.
Timely delivery of high quality, scientifically sound, and evidence-based prenatal
breastfeeding education during the COVID-19 pandemic is a critical infant and young
child feeding in emergencies (IYCF-E) intervention. It also is a component of care
that is readily adaptable to virtual platforms compatible with social distancing measures.
In this paper we describe our experience of leveraging lactation education, training,
and technical assistance programs at the Carolina Global Breastfeeding Institute (CGBI)
to provide virtual prenatal breastfeeding education during the COVID-19 pandemic.
Ready, Set, BABY Live: An Interactive Online Format for Prenatal Breastfeeding Education
During the COVID-19 Pandemic
Ready, Set, BABY (RSB) is an open-access prenatal breastfeeding curriculum that was
created by CGBI in 2012 (Figure 1). RSB content reflects best practices outlined for
Step 3 (Figure 2) in the Ten Steps to Successful Breastfeeding and the Baby Friendly
Hospital Initiative (BFHI). The RSB toolkit consists of a 24-page patient booklet
along with a complementary facilitator flipchart that offers suggested scripting to
support an interactive experience as the facilitator guides the learner through the
content in the booklet. The use of RSB in face-to-face group prenatal counseling classes
and individual sessions has been found to improve breastfeeding outcomes among participants
(Parry et al., 2019). Since its initial release, the content has been continually
updated to align with changes in BFHI global guidance, and RSB materials have been
translated into Arabic, Chinese, French, Spanish, and Mongolian. In 2020, the English
version of RSB was launched as a self-directed, online interactive experience for
families in collaboration with the Connecticut Department of Public Health (http://www.readysetbabyonline.com).
Figure 1
Ready, Set, BABY facilitation guide cover page.
Figure 2
Ready, Set, BABY education topics.
Adaptation of RSB During the COVID-19 Pandemic
The opportunity to adapt RSB with content related to COVID-19 presented itself in
March 2020, when the governor of the state of North Carolina (NC) announced an executive
Stay at Home Order (NCDHHS, 2020). As a result, health care facilities across the
state were required to limit on-site personnel to essential workers. This change meant
that all clinical placements of lactation students enrolled in the CGBI Mary Rose
Tully-Training Initiative (MRT-TI), a lactation education and training program for
participants interested in becoming an International Board Certified Lactation Consultant
(IBCLC), were suspended while the order was in effect.
Key Messages
Anticipatory breastfeeding guidance for expectant parents is a critically important
aspect of emergency response.
There are few examples of technology-based prenatal breastfeeding education adapted
to specific public health emergencies, like COVID-19.
It is possible to design a virtual prenatal breastfeeding education course that enables
students to acquire clinical competencies required of a CAAHEP/LEAARC approved pathway
2 lactation training program.
MRT-TI is the first pathway 2 (P2) lactation consultant training program in the US
to be accredited by the Commission on the Accreditation of Allied Health Education
Programs (CAAHEP) fulfilling requirements set by the IBLCE. MRT-TI operates within
the University of North Carolina (UNC) Chapel Hill system, and the program is completed
in two academic semesters. It provides students with 90 hours of didactic education
and over 300 hours of clinical practice under the supervision of an IBCLC. Participants
enrolled in the MRT-TI program earn their required clinical hours through supervised,
in-person practice across diverse settings, including several different hospitals,
a free-standing birth center, outpatient pediatric offices, and external sites.
When the NC Stay at Home Order was executed, it was not clear how to provide MRT-TI
students with directly supervised clinical hours so that they would remain eligible
to register for the 2020 International Board of Lactation Consultant Examiners (IBLCE)
examination. IBLCE did release interim guidance during the COVID-19 pandemic for P2
programs that allowed candidates to earn up to 100% of the 300 total required hours
of directly supervised lactation practice using technology (e.g., via telehealth platforms).
Based on this guidance, CGBI faculty and staff designed a solution that would provide
MRT-TI students with an opportunity to earn the remaining 1/3 of their clinical practice
hours, while simultaneously addressing the urgent need to deliver breastfeeding education
for COVID-19.
CGBI team members convened to review the standard RSB content and update it to reflect
the WHO (2020) interim guidance for breastfeeding and COVID-19. COVID-19-related content
was integrated throughout the facilitation guide wherever birthing practices were
mentioned, along with other places where information about returning home after birth,
visitors, and other caregivers are discussed. Other adaptations in content included
incorporation of WHO (2020) guidance and infographics for pregnancy, birth, and breastfeeding
when COVID-19 is suspected or confirmed, new open-ended questions and discussion points
to enhance online interactive facilitation, and scripting to enable the facilitator
to more effectively assess any counseling needs of pregnant attendees (see Table 1).
Table 1
Examples of Scripted Questions Adapted from the Traditional Curriculum.
Ready, Set, Baby Scripted Questions to Assess Needed Counseling (these examples are
included in the traditional curriculum)
What are some things you do to stay healthy?
Do you have concerns about your current lifestyle?
What have you heard about infant feeding?
Have you or anyone that you’ve known breastfed before?
What plans have you made for help after delivery?
Ready, Set, Baby Scripting Additions to Assess Needed Counseling (these examples were
added to the adapted curriculum)
What have you heard about breastfeeding and COVID-19?
Has your OB office discussed any changes in your planned care due to COVID-19?
How are you feeling about what is going to happen?
What additional questions do you have?
All content for RSB Live was evaluated to ensure that it fulfilled competency standards
for P2 lactation consultant training programs that are accredited by CAAHEP through
the recommendation of the Lactation Education Accreditation and Approval Committee
(LEAARC). The assessment identified that RSB Live mapped to 33 of the 124 required
competencies in the following content areas: communication and counseling; history
taking and assessment; prenatal and perinatal breastfeeding support; extended breastfeeding
support; professional responsibilities and practice; and leadership and teaching.
Three MRT-TI students were involved in piloting RSB Live and contributed to further
adaptions and improvements in the facilitation scripting. Once the content was finalized,
all MRT-TI students were trained by CGBI faculty/staff IBCLC preceptors to ensure
that they had an accurate and thorough understanding of the content, its adaptation
to COVID-19, and that they were able to demonstrate the required competencies for
assessment and education.
Implementation
RSB Live for COVID-19 is hosted on a secure virtual teleconferencing platform at the
UNC Gillings School of Global Public Health that is compliant with the US Health Insurance
Portability and Accountability Act (HIPAA), which protects personal information. RSB
Live is offered in English and Spanish languages. The virtual conferencing platform
supports both verbal and written interaction via the video conferencing feature and
the interactive chat pod.
RSB Live was launched on April 15, 2020. The sessions were facilitated by two MRT-TI
students and directly supervised by a CGBI faculty/staff IBCLC clinical preceptor,
who provided technical assistance and facilitation support as needed. The primary
student facilitator is responsible for presenting key content using video, voice,
and visual aids. The secondary student facilitator is responsible for interactively
monitoring the chat pod, responding to questions and comments from participants, and
sharing appropriate resources and referrals. The standard RSB toolkit was designed
for participants to have individual booklets to use throughout the facilitated session.
All facilitation notes for RSB Live were updated so that key content would be covered
verbally even if participants did not have access to a booklet. An electronic hyperlink
is shared with all participants during the RSB Live presentation so that they might
access the booklet online.
A single session length is just over an hour, depending on participant chat activity
and questions. MRT-TI students earn their competency hours by facilitating an online
session every 90 minutes between 9am and 5pm. This equates to 5 sessions per day Monday
through Friday, and an additional 2 per day on Saturdays.
Broader Impact
RSB Live serves a dual-purpose during the COVID-19 pandemic; it is a clinical lactation
training opportunity for MRT-TI students, and it is a quality, prenatal breastfeeding
education resource for expectant parents. The rapid development, implementation, and
dissemination of RSB Live was made possible by the strength of existing programs,
resources, and faculty and staff expertise at CGBI.
CGBI has provided support to maternity care facilities for nearly a decade (Labbok
et al., 2013; Taylor et al., 2012). Funded by The Duke Endowment, the ENRICH Carolinas
community currently includes over 40 maternity care facilities, and additional enrollment
is planned throughout 2021. Project coaches notified participating ENRICH Carolinas
facilities of the opportunity for their prenatal community and encouraged them to
share flyers with detailed information about the live online sessions with the prenatal
clinics that send patients for delivery. Flyers were also shared with contacts from
maternity care facilities from previous projects, posted on social media, and shared
via the United States Breastfeeding Committee’s member news sharing resources. Between
April and May 2020, 173 sessions were held in English and 65 in Spanish.
Participating ENRICH Carolinas facilities also have access to technical assistance
for IYCF-E through the Lactation and Infant Feeding in Emergencies (L.I.F.E.™) Initiative.
The L.I.F.E.™ Initiative has added value to multiple CGBI programs by providing technical
assistance during the COVID-19 pandemic. The technical assistance has been instrumental
to ensuring that RSB content stays up to date with any revisions to the interim guidance
for COVID-19 and breastfeeding and is supported by the best available science and
evidence.
Broad dissemination of RSB Live was made possible through engagement with stakeholders
from the NC Division of Public Health. RSB Live offers a valuable solution to providing
prenatal breastfeeding education in a time of social distancing. Stakeholders have
been enthusiastic and grateful, and agreed to promote the RSB Live in public clinics
providing Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
and prenatal care services across NC. Flyers for the sessions were shared with 84
NC local agencies that house the NC WIC Program. The NC WIC program, after vetting
the background and training of the CGBI preceptors for the class and the class content,
has allowed WIC participants to use RSB Live as the second required prenatal nutrition
education contact or as a supplemental breastfeeding education session. Although RSB
Live was designed primarily for a US-based audience, participants from other countries
have joined RSB Live sessions.
Conclusion
The rapid onset of a global pandemic (i.e., COVID-19) can quickly change the landscape
of maternity care practices and policies along with the ability to give and complete
lactation training. In response to the lack of face-to-face supervised clinical opportunities
for lactation training students, alongside the probable need for digital solutions
for offering breastfeeding education in prenatal clinics and communities served by
maternity care facilities and public health, the CGBI team opted to adapt the RSB
curriculum as a digital COVID-19-specific resource. We focused on rapid implementation
of live delivery of the RSB curriculum in a HIPPA-compliant online classroom supervised
by IBCLCs, allowing students to continue to meet the rigorous demands of a P2 accredited
lactation training program by providing interactive, assessment-informed counseling.
By the end of May 2020, health care facilities in NC began relaxing staffing restrictions.
However, most still do not have adequate personal protective equipment (PPE) for employees
or students completing clinical rotations. A lack of required PPE remains a barrier
to clinical placement for most MRT-TI students, despite the availability of potential
clinical training placements currently. There continues to be strong interest and
participation in RSB Live.
CGBI has put into place a survey to assess the effectiveness and acceptability of
the COVID-19 digital adaptation of RSB through a recently IRB approved patient experience
survey. The findings of the assessment will be disseminated in peer-reviewed publications,
professional conference presentations, and in CGBI programmatic reports. CGBI developed
RSB Live to ensure that prenatal breastfeeding education is made available to families
during emergencies and to maintain continuity of quality clinical lactation training
during the COVID-19 pandemic. There is potential for other clinical lactation training
programs and breastfeeding support organizations to adopt similar strategies to meet
the breastfeeding education needs of expectant parents when remote learning and telehealth
services are available.