Discussion
milk insufficiency
Our findings reveal that the infant feeding support component of the The Lactation Specialist delivered the planned curriculum and was also able to personalize the sessions addressing a number of specific questions and concerns outside the curriculum during the sessions. Good rapport with the Lactation Specialist likely prompted women to inquire about a broad range of topics, some unrelated to infant feeding. As such, several distinct topic areas emerged during the sessions that may be considered for further development including infant skin care, the safety of traditional practices and maternal self-care. Regular calls from participants with concerns, especially early postpartum, further points to the trust and confidence women had in the Research Coordinator and Lactation Specialist as well as the need women had for support on-demand during times of high vulnerability. Despite unexpected topics emerging and the number of phone calls fielded between sessions, the Lactation Specialist delivered the planned curriculum at the planned timepoints with no significant modifications.We found the curriculum delivered aptly addressed women’s infant feeding challenges and concerns. Concerns regarding breastfeeding technique, milk insufficiency and the transmission of HIV through breastmilk as well as worries about “plastic teeth” decreased across time with support from the Lactation Specialist. The near perfect attendance by participants is noteworthy, especially considering several of the missed sessions occurred during the aftermath of Kenya’s presidential elections when civil unrest was feared. Furthermore, given the cash transfer was provided regardless of appointment attendance, the majority of women traveled 30 min or more to the clinic, and the frequency (every 2-weeks) of the early post-partum sessions, we believe this attendance record illustrates high acceptability of the intervention. Women benefited from the sessions and therefore willingly made an effort to attend even when they were not making a trip to the clinic for other patient visits.We also found that holding In addition to sessions being face to face, we found women needed regular support early postpartum to develop their breastfeeding technique, receive affirmation that their milk supply was adequate and ensure proper administration of their infant’s HIV prophylaxis medications. Early postpartum sessions allowed the Lactation Specialist to make timely referrals to medical providers for the few infants who were not thriving as expected. Interestingly, a common concern (especially at 2-weeks and 4-weeks postpartum) was the perception that infants were feeding “too much/ too frequently”. Given breastfeeding frequency early postpartum has been shown to directly impact the development of milk supply, [Frequent, personalized support for infant feeding through the early postpartum period was similarly part of the baby-friendly community initiative introduced in several counties in rural Kenya including, Kisumu County from 2014–2017 [While frequent early postpartum visits from 2 weeks on and the accessibility of our team were key strengths of our lactation sessions, we identified areas for improvement. First of all, while we were able to address many early postpartum needs by fielding participant’s phone calls, support provided immediately postpartum could ensure infants properly receive their first dose of HIV prophylaxis and facilitate the prompt initiation of breastfeeding. Secondly, due to project time constraints, our last support session occurred when women were about three months postpartum. Three months postpartum was an ideal time for breastfeeding support since many babies go through a growth spurt at this time with bouts of cluster feeding. However, we would have ideally held another session closer to six months postpartum and provided women with the information about introducing the baby’s first foods and complementary feeding at that time. Other sessions beyond 6-months could also support women to continue breastfeeding beyond 12-months as most women planned to stop breastfeeding at around 12-months, well short of the recommended period (24-months).