Original quantitative research – Lactation supports implemented within the Canada Prenatal Nutrition Program: findings from a national survey

Abstract

Introduction: Supporting breastfeeding is integral to the Canada Prenatal Nutrition Program (CPNP), although details on lactation support implementation are limited. This research aimed to assess lactation support delivery by CPNP sites across Canada, excluding Quebec, and how the COVID-19 pandemic affected services.

Methods: From May to July 2023, we conducted a cross-sectional survey; 207 sites were invited to participate. We investigated the types of lactation supports delivered; how and by whom; and the role of site characteristics (locality, Community Action Program for Children funding, breastfeeding clinic on-site, primary healthcare facility on-site) and funding sources (CPNP only, CPNP and other funds, other funds only) on lactation support provision.

Results: All respondents (n = 91 sites) reported providing at least one lactation support: 95% offered educational materials, 89% community referrals, 77% personalized support from a community-based provider, 69% live education sessions, 68% breast pumps, 51% peer support programming, 34% personalized support from a board-certified lactation professional, and 34% lactation-related supplies. Most sites continued to offer lactation supports during the COVID-19 pandemic but faced multiple service provision challenges. Availability of lactation supports that required additional resources beyond CPNP core funds varied by site characteristics. To provide lactation supports, particularly personalized support, most sites reported relying heavily on non-CPNP funds (e.g. donations, private funding).

Conclusion: Lactation support delivery varied widely across CPNP sites, with access differing by site characteristics and external resource availability. Increased programmatic guidance and support of core lactation resources holds potential to ensure consistent lactation support availability and reduce disparities in perinatal health and nutrition.

Keywords: lactation, breastfeeding, infant feeding, perinatal nutrition, vulnerable population, Canada Prenatal Nutrition Program, community programming

Introduction

Breastfeeding benefits maternal and child health in both the short- and long-term, with economic implications through reduced healthcare costs.^{Footnote 1Footnote 2Footnote 3Footnote 4} The World Health Organization (WHO) and Canadian guidelines recommend exclusive breastfeeding to six months.^{Footnote 5Footnote 6} In Canada, 91% of mothers start breastfeeding; however, only 69% continue and 36% exclusively breastfeed to six months.^{Footnote 7} Among those who stop breastfeeding early, 71% report a preventable or treatable reason (i.e. not enough breastmilk, difficulty with breastfeeding).^{Footnote 8} Furthermore, mothers with lower incomes or education are less likely to breastfeed in Canada.^{Footnote 9} The WHO highlights the importance of skilled lactation support, although access and socioeconomic barriers persist.^{Footnote 10}

The Canada Prenatal Nutrition Program (CPNP) is a federal program through the Public Health Agency of Canada (PHAC) that funds community groups to support the health of pregnant women and people, new parents, and their infants who face challenges that may put their health at risk.^{Footnote 11} Promoting and supporting breastfeeding is a stated goal of the CPNP,^{Footnote 12} although there is limited programmatic guidance and a lack of designated lactation support resources. Programming implemented at CPNP sites, including lactation support, is adaptive to the needs of communities and shaped by the availability of local partnerships (e.g. public health, community groups) and additional resources (e.g. donations, private funding).^{Footnote 13}

Understanding how CPNP sites deliver lactation supports can strengthen programming guidance, and there is a need to understand how the COVID-19 pandemic affected service delivery. This study is the first national survey to (1) assess what types of lactation supports are implemented by CPNP participants and how the pandemic affected service delivery; (2) explore how CPNP site characteristics relate to lactation supports availability; and (3) investigate types of funding used to provide lactation supports. To align with the terminology used by PHAC in reporting and publications, we have used the terminology “breastfeeding.” We acknowledge that there is great diversity among lactating CPNP participants and our definition of breastfeeding is intended to be inclusive of chest feeding.

Methods

Study design, eligibility and survey respondents

From May to July 2023, a cross-sectional survey of CPNP site characteristics, lactation supports, food supports, and coping during the COVID-19 pandemic was administered.^{Footnote 14} All CPNP sites across Canada were eligible to participate, excluding Quebec because CPNP administration differs compared to other provinces and territories.

Survey tool development and distribution

The survey tool was developed following review of publicly available CPNP documentation.^{Footnote 12Footnote 15} There were three sections: site characteristics, service provision, and coping during the COVID-19 pandemic. Feedback on the survey tool was initially obtained from local CPNP coordinators in Toronto, and further review from an Advisory Group of CPNP coordinators (N = 16) from all five PHAC regions in Canada (BC and AB; SK and MB; the Territories [YT, NT, NU]; Central [ON and QC]; and Atlantic Canada [NB, NL, NS, PE]) to ensure relevance, clarity, and face validity. Advisory Group members self-identified from an open call to CPNP sites shared by PHAC regional leads on behalf of the researchers.^{Footnote 14} Both local CPNP coordinators and Advisory Group members represented racialized and diverse lived and professional perspectives. The Advisory Group included coordinators from CPNP sites that were community-based, Indigenous-led, and embedded within public health agencies. After incorporating feedback, the Advisory Group pilot tested the survey for their CPNP sites to confirm clarity and flow. Questions were found to be clear, and the finalized survey was professionally translated to French.^{Footnote 14} Post-survey, both local CPNP coordinators and the Advisory Group members were re-engaged to give feedback on the study findings and interpretation.

Lactation support questions appeared within the service provision section. Using a 5-year reference period (2018 to 2023), survey respondents were asked what types of lactation supports CPNP participants could access via their site from seven predefined categories (educational materials, live education sessions, community-based lactation referrals, board-certified lactation professional, another community-based lactation support provider [e.g. public health nurse, doula], breastfeeding peer support programming, breast pumps). If survey respondents reported offering a predefined lactation support, additional implementation questions were asked, including CPNP participant eligibility, frequency, location, personnel providing service, and funding. This was asked at each COVID-19 pandemic-related time period of interest: before the pandemic (2018 to March 2020), during the pandemic (March 2020 to late spring 2023), and/or in the upcoming 2024 fiscal year (starting in April 2024 [hereafter referred to as “post-pandemic”]). If participants were unsure about implementation details for a lactation support category, they could select an “unsure” response option. Across survey items, “unsure” and missing responses were generally infrequent (< 10%). In an open-ended category, survey respondents could list any additional lactation supports or supplies accessible to CPNP participants via their site; no further implementation questions were asked for these. As an optional question, survey respondents could describe additional lactation supports they would like their CPNP site to provide, if additional sustainable funds were available.

The survey was administered virtually, using Research Electronic Data Capture (REDCap; Vanderbilt University).^{Footnote 16Footnote 17} CPNP Regional Leads at PHAC, representing all PHAC regions in Canada, supported survey distribution by sharing a standardized invitation email to CPNP sites within their region.

Ethics

After completing an online consent form, survey respondents could access the survey in English or French. The University of Toronto Office of Research Ethics provided ethical approval of study procedures (Protocol: 00044170). Post-completion, survey respondents were offered their choice of a selection of $25 electronic gift cards as a token of appreciation. Contact information for gift card distribution was collected separately from survey responses to maintain confidentiality.

Data analysis

Data were exported from REDCap into Stata, version 15.0 (StataCorp LP, College Station, TX, US).^{Footnote 18} To describe the CPNP site and service delivery characteristics, proportions were presented. Data from all CPNP sites that reported providing one or more lactation supports were included, even if no further implementation details were provided. Across time periods, paired proportions were compared using McNemar’s test, given small cell counts.^{Footnote 19} In an exploratory analysis, lactation support provision was further examined by comparing proportions between four subgroups perceived to influence resource availability (hereafter referred to as “site characteristics of interest”): locality (urban/rural); whether an agency had Community Action Program for Children (CAPC) funding (a parallel PHAC-funded program for socially and/or economically vulnerable families to promote healthy development from birth to six-years);^{Footnote 13} offered a breastfeeding clinic on-site; or offered a primary healthcare facility on-site. Because this is the first study to assess lactation supports within the CPNP, and these data are not routinely collected by PHAC, the distribution of lactation supports across sites was unknown a priori. Since the study was not designed or sufficiently powered to support formal subgroup comparisons, and several site characteristics were anticipated to produce small cell counts, site-level analyses were intended to be exploratory and descriptive in nature. Accordingly, formal statistical comparisons were not performed. Additional lactation support data were reviewed by three researchers, categorized collaboratively by type of desired lactation support, and frequencies were calculated to identify priorities for additional lactation support.

Results

Survey completion and CPNP site characteristics

Survey completion

Of the 207 CPNP sites invited to complete the survey, 98 consented, and 91 sites (44%) provided survey data. All invited Canadian provinces and territories were represented (Supplemental Table 1). Twenty-one percent of sites were identified as Indigenous-led. Most CPNP sites were operated by a lead agency that offered multiple services to the community (88%), and/or worked with partner agencies within the community to deliver CPNP programming (73%; Table 1). Most were based in an urban setting (75%) and 45% additionally offered CAPC; 23% percent and 19% offered a breastfeeding clinic or primary healthcare facility, respectively, with 7% offering both (Table 2).

General CPNP service provision and the effect of the COVID-19 pandemic

CPNP programming was most commonly offered weekly (Table 3). Among survey respondents that reported their CPNP site annual participation numbers (N = 77), most (81%) enrolled less than 110 CPNP participants per year (Supplemental Table 2). Urban CPNP sites tended to be larger than rural (average: 95 versus 41 participants/year, respectively). While a comparable number of rural and urban sites offered CAPC in addition to CPNP programming (43% versus 45%), fewer rural sites compared to urban sites were embedded within a lead agency that offered primary healthcare facility (9% versus 22%; Table 2).

Between 2019 and 2021, around one-quarter of CPNP sties indicated that their program was at maximum capacity and that they had to limit enrolment or service provision; this increased over time (2019: 24%, 2020: 26%, 2021: 29%). In 2021, CPNP sites more often reported being at maximum capacity if they also offered CAPC (41% versus 20%) or did not offer a breastfeeding clinic (32% versus 19%).

Following the onset of the COVID-19 pandemic, all CPNP sites reported remaining open for some duration of 2020 and 2021. However, there was an increase in virtual service provision within CPNP programming (Table 3). This did not differ by site characteristics of interest.

Lactation supports provided by CPNP sites and the effect of the COVID-19 pandemic

All survey respondents reported providing at least one type of lactation support in the past five years (Table 2). Providing lactation education was most common, with 95% offering educational materials and 69% live education sessions. Referrals to community services were also widely reported (89%). For personalized lactation support, 34% reported offering support from a board-certified lactation professional (i.e. International Board-Certified Lactation Consultant [IBCLC]); 77% from another community-based provider, and 51% peer support programming. Sixty-eight percent reported offering breast pumps. Provision of other lactation-related supplies (e.g. breast pads, nipple ointment, breastfeeding pillows, breast pump accessories, teas, supplementary nursing systems) was also reported by 34% of survey respondents.

While there was no disruption in offering educational materials during the COVID-19 pandemic, there was a decrease for all other lactation supports, although provision was largely expected to recover post-pandemic (Table 4). During the pandemic the greatest magnitudes of decrease in lactation support provision were observed for live education sessions (18%), followed by breastfeeding peer support (13%) and community referrals (12%; Table 4).

Understanding lactation support implementation, with reference to the characteristics of interest, across the three time periods of interest relative to the COVID-19 pandemic

Education about lactation

Both types of lactation education were typically available for all registered CPNP participants to access (Supplemental Table 3). Survey respondents reported offering educational materials (pamphlets, books, posters, YouTube clips, videos) nearly universally; these could be provided during group sessions, one-on-one sessions, or with other items. Offering educational materials was independent of the site characteristics considered (Table 2). However, live education sessions (workshops, webinars) were reported more often by urban CPNP sites (74% versus 57%) and when a lead agency offered a breastfeeding clinic (81% versus 66%). Live education sessions were typically led by CPNP program staff, public health partners, nurses, IBCLCs, and/or dietitians (Supplemental Table 3).

Regardless of the COVID-19 pandemic, educational materials continued to be provided to CPNP participants (Table 4). With the pandemic, there was an 18% decrease in sites that offered live education sessions, although this was anticipated to recover post-pandemic (Table 4). With the pandemic, live education sessions transitioned from mostly in-person (98%) to primarily virtual (79%), with in-person dropping to 30% (Supplemental Table 3). Notably, among survey respondents offering live education sessions during the pandemic, delivery by public health partners decreased and CPNP program staff increased, although public health engagement was expected to return post-pandemic (Supplemental Table 3).

Referrals to community-based lactation services

Referrals to community-based lactation services were most often to public health clinics (84%), followed by hospital clinics (42%), and/or telehealth (42%; Supplemental Table 4). Referrals were reported more often by urban CPNP sites (96% versus 70%) and sites that did not offer CAPC (94% versus 83%; Table 2).

Among CPNP sites that reported providing referrals to community-based lactation services, referrals decreased during the COVID-19 pandemic (86% to 74%), but were anticipated to return to pre-pandemic levels (Table 4). This reduction occurred in urban sites (93% to 76%), but not rural sites (Supplemental Table 5), due to a notable decrease in referrals to public health clinics during the pandemic in urban settings (84% to 50%; Supplemental Table 6). Referrals decreased whether a site had CAPC or not (Supplemental Table 7). Referrals remained unchanged at sites with a breastfeeding clinic or primary healthcare facility, but decreased by 16% and 15%, respectively, at sites without them (Supplemental Tables 8 and 9).

Offering personalized lactation support

Among sites that offered personalized lactation support from IBCLCs, another community-based provider (public health nurse, dietitian, midwife, doula, elder), and/or peers, this was typically available to all registered CPNP participants (reported by > 70% of survey respondents), although some CPNP sites reported offering these services upon request (~20%; Supplemental Table 10). IBCLC support was more often offered in urban sites (38% versus 22%), and more common among lead agencies with a breastfeeding clinic (43% versus 31%) or primary healthcare facility (47% versus 31%; Table 2). Among sites that reported offering lactation support from another community-based provider, more were also urban-based (81% versus 65%; Table 2). Most respondents (75%) reported that community-based lactation support providers had some formal training (Supplemental Table 10). Sites that received CAPC funds were less likely to offer IBCLCs (29% versus 38%) or support from another community-based provider (66% versus 86%), but more likely to provide peer support programming (56% versus 46%; Table 2). Among sites that offered breastfeeding peer support programming, this was usually led by a CPNP staff member (> 80%) and could be in a group or one-on-one (Supplemental Table 10).

During the COVID-19 pandemic, fewer survey respondents reported being able to offer personalized lactation support compared to pre-pandemic, although coverage was expected to return to pre-pandemic levels (Table 4). Among CPNP sites that continued to offer personalized lactation support, providing support virtually increased (Supplemental Table 10). More virtual service integration was planned post-pandemic relative to pre-pandemic, although not to the same extent as during the pandemic. For breastfeeding peer support, there was also a loss of group sessions during the pandemic.

Among CPNP sites that provided personalized lactation support, there was a decrease in public health nurse and/or community member engagement reported during the pandemic (Supplemental Table 10). IBCLC access was the least offered lactation support overall, and among sites that reported offering IBCLCs, this continued more often during the pandemic at sites with CAPC or a breastfeeding clinic (Supplemental Tables 6 and 8). However, among sites that offered support from another community-based lactation support provider during the pandemic, this was less often offered at sites with CAPC, a breastfeeding clinic, or primary healthcare facility compared to pre-pandemic (Supplemental Tables 7, 8 and 9). Alternatively, among sites offering peer support programming, those with CAPC, a breastfeeding clinic, or a primary healthcare facility more often continued providing peer support programming during the pandemic (Supplemental Tables 7, 8 and 9).

Breast pumps

Among CPNP sites offering breast pumps, electric or manual models were most common, with 53% reporting that all registered CPNP participants could access pumps and 48% reporting that pumps were available upon request (Supplemental Table 11). Pumps were usually donated (53%) or loaned (43%) to CPNP participants, and most sites (81%) provided user guidance. Pumps were more often provided by rural sites (78% versus 65%) and lead agencies with a breastfeeding clinic (76% versus 66%), and less often provided by sites with CAPC funding (63% versus 72%) or an on-site primary healthcare facility (59% versus 70%; Table 2).

Among CPNP sites offering breast pumps, access decreased slightly during the COVID-19 pandemic (pre-pandemic: 64%, during pandemic: 58%; Table 4). This decrease was observed among urban sites, sites without CAPC, and sites with a breastfeeding clinic (Supplemental Table 5, 7, and 8). Similar to other lactation support modalities, there was an increase in virtual guidance on how to use a pump (Supplemental Table 11).

Funding of lactation supports

To provide lactation supports, most survey respondents reported requiring resources beyond CPNP core funds (Table 5). While more non-CPNP funding was required to offer IBCLCs, another community-based provider, or breast pumps, more CPNP sites reported funding breastfeeding peer support programming using CPNP funds only. Urban sites more often reported using funds outside of CPNP core funds for all supports except education (Supplemental Table 12). Compared to sites with CAPC, sites without CAPC more often reported using non-CPNP funds only to offer live education sessions, IBCLCs, another lactation support provider, or breast pumps (Supplemental Table 12). Sites that offered a breastfeeding clinic more often reported using non-CPNP funds to offer these four types of lactation support.

Additional desired lactation support

Eighty-three CPNP sites (91%) responded to optional questions about additional desired lactation supports. If sustainable funds were available, 81% wanted to offer additional lactation supports, including skilled lactation support (indicated by 54%; e.g. specialized lactation or IBCLC training for staff, improved accessibility to existing supports) and support for breastmilk expression (indicated by 42%; e.g. breast pumps and hand expression kits), lactation education for staff (14%), other lactation supplies (12%; e.g. breast pads, nipple cream, milk storage bags), lactation education for CPNP participants (11%; e.g. guest speakers, teaching tools, community elders), and peer support programming (8%).

Discussion

Promoting and supporting lactation is a stated goal of CPNP programming. Offered in both official languages, this survey is the first to document what and how lactation supports are implemented within CPNP programming. While lactation educational materials and community referrals were offered universally, providing lactation supports that required additional human resource capacity or additional materials varied. With the onset of the COVID-19 pandemic, sites continued to deliver lactation supports; however, they faced challenges in adapting service provision (e.g. shift to virtual programming, loss of personalized lactation support, loss of public health support). To provide lactation supports to CPNP participants, most sites relied heavily on resources beyond CPNP core funds.

The variation in lactation supports and delivery methods across CPNP sites reflects the intended flexibility of the CPNP delivery model. This allows for programming adaptation to reflect community preferences and best meet participants’ needs, in contrast with other countries’ more structured, entitlement-based programming, such as Women, Infants, and Children (WIC) in the United States.^{Footnote 13Footnote 20} Within WIC, increasing the number of lactation supports available has been associated with increased breastfeeding likelihood.^{Footnote 21} However, access to lactation supports and supplies could differ by CPNP site characteristics: urban sites offered more types of lactation supports than rural; sites within a lead agency with an on-site breastfeeding clinic or primary healthcare facility more often offered support from an IBCLC; and sites that received both CPNP and CAPC funding continued to provide multiple types of lactation support (live educational sessions, breastfeeding peer support programming, trained lactation support, and breast pumps) during the pandemic more often than those without CAPC, potentially because CAPC funds could be leveraged to offer protective benefits. Collectively, this demonstrates that without adequate, designated core resources, there is precarity in lactation support availability for CPNP participants. This leads to disparities between CPNP sites.

CPNP sites were resilient during the COVID-19 pandemic. CPNP programming was affected by the pandemic and resulting public health restrictions, including changes in social interactions, disruptions to service delivery, and public health redeployment. Despite restrictions and shutdowns to core public services and healthcare, CPNP sites adapted (e.g. virtual program integration) and continued to offer perinatal services. There was a noted drop in public health-led lactation supports, particularly affecting urban CPNP sites. However, lactation support delivery continued at most sites, often with CPNP personnel assuming the additional workload where possible. The needs and challenges CPNP participants face had become increasingly complex before the pandemic, and the pandemic amplified these challenges.^{Footnote 13Footnote 14} For example, Canadian mothers of young children, especially those socially and/or economically vulnerable, increased their use of mental health services during the pandemic, indicating heightened exposure to stressors.^{Footnote 22} The increase in workload and complexity of factors experienced by CPNP participants created additional stress on personnel implementing the already constrained CPNP model.^{Footnote 13Footnote 23}

Regardless of the lactation support considered, most survey respondents reported that resources beyond CPNP core funds were required to offer services. Furthermore, accessing more personalized lactation supports (e.g. IBCLC, another community-based lactation support provider) was largely financed using non-CPNP funds. Although the CPNP is meant to build on community-based partnerships, no increase in core funds since the 1990s presents a clear challenge in service level continuity. Compared to the 1990s, CPNP sites are estimated to have 33% less purchasing power in 2019, after adjusting for inflation.^{Footnote 13} Service provision has continued without increased financial support, suggesting additional costs are shouldered by the lead agencies implementing CPNP programming. This highlights the strain on the current CPNP service delivery model. Providing CPNP-based lactation supports is considered a programmatic strength, and CPNP participants widely report increased breastfeeding knowledge and skills because of programming.^{Footnote 13} Evidence from Ontario indicates that increasing exclusive breastfeeding would yield substantial short- and long-term healthcare and economic benefits,^{Footnote 24} which supports scale-up of existing evidence-based interventions.^{Footnote 25} Our research with one CPNP site offering enhanced lactation support through external funding showed high value and uptake of this service, and high breastfeeding rates.^{Footnote 26Footnote 27} Strengthening CPNP funding could bolster program capacity to improve breastfeeding, thereby advancing maternal and child health and contributing to healthcare and economic gains.^{Footnote 4}

With sustainable funding, expanding access to skilled lactation providers was identified as a desired way to strengthen CPNP lactation supports. This included supporting CPNP personnel to receive formal lactation training. This highlights the importance of lactation support within the CPNP and aligns with global recommendations for universal access to skilled, personalized lactation support.^{Footnote 28} However, IBCLCs were the least provided lactation support, and, along with other skilled providers, depended heavily on non-CPNP funding and were less available at rural sites.

Strengths and limitations

This study was strengthened by CPNP site participation across all invited Canadian provinces and territories, and the availability of the survey in both national languages. Advisory Group guidance was a strength of the study, although it was based on an open call and sites with greater capacity or institutional support may have been over-represented. Participating sites’ general characteristics reflected those of CPNP sites in Canada (e.g. proportion urban/rural, receive CAPC funding, Indigenous-led), although the response rate may limit generalizability and subgroup analyses were exploratory due to power limitations.^{Footnote 13} Data were not collected on survey non-respondents, including why the survey was not completed; sites with fewer resources (e.g. time, capacity, Internet access) may not have participated. Despite aligning survey questions with PHAC documentation wherever possible, findings should be interpreted in the context of potential recall bias and self-reported data.

Conclusion

This national survey found that lactation education and community referrals were commonly offered at CPNP sites, but that availability of other lactation supports requiring more resources and/or non-CPNP funds varied. This led to inequities between CPNP sites. These findings suggest a need for PHAC to identify and support a core package of lactation supports that should be universally available across CPNP sites, alongside relevant monitoring and evaluation measures, while maintaining flexibility for local adaptation. Increased and sustained investment in core lactation supports within the CPNP may help reduce inequities in availability across Canada. To contextualize findings on lactation supports, future research should assess the fidelity and nuances of CPNP lactation support programming and examine participants’ breastfeeding outcomes and experiences regarding service quality, adequacy, and appropriateness.

Acknowledgements

Funding to conduct this research was provided by The Sprott Foundation. JABB received a Fellowship Award from the Canadian Institutes of Health Research. DLO is a Canada Research Chair in Human Milk and Infant Nutrition. The authors gratefully acknowledge all the CPNP sites which took part in the survey, members of the Advisory Group of CPNP coordinators, and national and regional Public Health Agency of Canada personnel who shared the survey with CPNP sites.

Conflicts of interest

The authors declare no conflicts of interest.

Authors’ contributions and statement

• JABB: Conceptualization, methodology, data curation, formal analysis, project administration, writing—original draft, writing—review and editing.
• AM: Conceptualization, methodology, formal analysis, project administration, writing—review and editing.
• JF: Conceptualization, methodology, formal analysis, project administration, writing—review and editing.
• DWS: Conceptualization, methodology, supervision, writing—review and editing.
• DLO: Conceptualization, methodology, supervision, writing—review and editing.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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