Can Telehealth Lactation Services Provide Effective Breastfeeding Support for Rural Areas?

In recent years, local and national organizations have emphasized the importance of exclusive breastfeeding and increasing access to lactation support. However, rural areas consistently have lower breastfeeding rates than urban areas and access to lactation consultants is limited. Telehealth lactation services is an emerging resource that can provide rural areas with access to a lactation specialist when one is not available for in-person consultations. In the rural central Utah hospital where this project was completed, only 45% of infants were exclusively breastfed on discharge from the hospital and lactation consultants were not available. The purpose of this project was to facilitate implementation of telehealth lactation services in a rural hospital to increase lactation support, with the eventual goal of increasing breastfeeding rates. This project also evaluated the patient, nurse, and lactation consultant experience with telehealth lactation services. This project took place in a rural, 20-bed hospital in central Utah. This hospital performs between 20-50 births per month and serves primarily white, low to middle income women. Prior to initiation of telehealth lactation services, nursing staff members were educated on how to assist patients during telehealth lactation consultations. To improve patient education, this training also included breastfeeding education considering most nurses had never received prior lactation education. Surveys were administered to nursing staff prior to and following this training session to evaluate their comprehension of the education and need for further training. Following this training, telehealth lactation services were implemented for 25 in-patient postpartum mothers. Following each consult, the patient, lactation consultant, and assisting nurse were asked to complete voluntary surveys on their experience. Exclusive breastfeeding rates were evaluated to analyze project impact. Descriptive and parametric statistics measured mean differences of survey responses. Following telehealth consultations, patients reported increased breastfeeding confidence (M= 3.8, SD= 0.9 vs. M= 4.5, SD= 0.7; Z= -2.809; p= 0.004) and 100% of mothers felt encouraged to continue breastfeeding after hospital discharge. Only 12% of nurses felt they had enough time to assist with consults and only 17% felt a bedside nurse was necessary during consults. Although a bedside nurse was present for 100% of consults, nurses reported providing hands-on assistance with only 29% of consultations. Contrarily, 95% of lactation consultant responses indicated a bedside nurse was essential. Lactation consultants felt the consults were comparable to in-person consultations (87%) and technology was adequate for the consults (90%). Of nurse and lactation consultant responses, 100% felt the service should be expanded to the outpatient setting. Exclusive breastfeeding rates during this project increased by 25% from an average of 45.4% to 70.8%. This project suggests telehealth lactation consultations can improve breastfeeding rates and are acceptable to patients and consultants. This technology may be a cost effective way to increase lactation support in rural areas. Future projects might evaluate consult effectiveness if a bedside nurse is not available for assistance. Strategies should also be discussed on how to expand this service to the outpatient setting to provide lactation support after hospital discharge.

Running head: LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Can Telehealth Lactation Services Provide Effective Breastfeeding Support for Rural Areas? Sadie Dahlsrud, RN, BSN, DNP Student Project Chair: Janice Morse Content Experts: Lory Maddox, Janis Sumsion, Dixie Rasmussen, Andrew Wilson University of Utah In Partial Fulfillment of the Requirements for the Doctorate of Nursing Practice 1 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 2 Abstract In recent years, local and national organizations have emphasized the importance of exclusive breastfeeding and increasing access to lactation support. However, rural areas consistently have lower breastfeeding rates than urban areas and access to lactation consultants is limited. Telehealth lactation services is an emerging resource that can provide rural areas with access to a lactation specialist when one is not available for in-person consultations. In the rural central Utah hospital where this project was completed, only 45% of infants were exclusively breastfed on discharge from the hospital and lactation consultants were not available. The purpose of this project was to facilitate implementation of telehealth lactation services in a rural hospital to increase lactation support, with the eventual goal of increasing breastfeeding rates. This project also evaluated the patient, nurse, and lactation consultant experience with telehealth lactation services. This project took place in a rural, 20-bed hospital in central Utah. This hospital performs between 20-50 births per month and serves primarily white, low to middle income women. Prior to initiation of telehealth lactation services, nursing staff members were educated on how to assist patients during telehealth lactation consultations. To improve patient education, this training also included breastfeeding education considering most nurses had never received prior lactation education. Surveys were administered to nursing staff prior to and following this training session to evaluate their comprehension of the education and need for further training. Following this training, telehealth lactation services were implemented for 25 in-patient postpartum mothers. Following each consult, the patient, lactation consultant, and assisting nurse were asked to complete voluntary surveys on their experience. Exclusive breastfeeding rates LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 3 were evaluated to analyze project impact. Descriptive and parametric statistics measured mean differences of survey responses. Following telehealth consultations, patients reported increased breastfeeding confidence (M= 3.8, SD= 0.9 vs. M= 4.5, SD= 0.7; Z= -2.809; p= 0.004) and 100% of mothers felt encouraged to continue breastfeeding after hospital discharge. Only 12% of nurses felt they had enough time to assist with consults and only 17% felt a bedside nurse was necessary during consults. Although a bedside nurse was present for 100% of consults, nurses reported providing hands-on assistance with only 29% of consultations. Contrarily, 95% of lactation consultant responses indicated a bedside nurse was essential. Lactation consultants felt the consults were comparable to in-person consultations (87%) and technology was adequate for the consults (90%). Of nurse and lactation consultant responses, 100% felt the service should be expanded to the outpatient setting. Exclusive breastfeeding rates during this project increased by 25% from an average of 45.4% to 70.8%. This project suggests telehealth lactation consultations can improve breastfeeding rates and are acceptable to patients and consultants. This technology may be a cost effective way to increase lactation support in rural areas. Future projects might evaluate consult effectiveness if a bedside nurse is not available for assistance. Strategies should also be discussed on how to expand this service to the outpatient setting to provide lactation support after hospital discharge. LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 4 Can Telehealth Lactation Services Provide Effective Breastfeeding Support for Rural Areas? Introduction Problem Description The World Health Organization and the U.S. Department of Health and Human Services state breastfeeding is the ideal form of nutrition for infants and also improves maternal health (World Health Organization, 2014; U.S. Department of Health and Human Services, 2011). These organizations recommend exclusive breastfeeding for at least the first 6 months of an infant's life. If all infants were exclusively breastfed for 6 months, numerous diseases would be prevented, the U.S. would save up to 3.6 billion dollars per year in medical costs, and nearly 1,000 infant deaths would be prevented (U.S. Department of Health and Human Services, 2011). In 2011, The U.S. Surgeon General issued a Call to Action to Support Breastfeeding. This document emphasized the importance of increasing breastfeeding rates, increasing support for breastfeeding, and increasing access to lactation specialists (U.S. Department of Health and Human Services, 2011). Yet despite this call to action and national goals to increase breastfeeding rates, rural areas continue to have lower rates of breastfeeding than urban areas (Harris, Aboueissa, Baugh, & Sarton, 2015; Allen, Perrine, & Scanlon, 2015; Sparks, 2010; Flower, Willoughby, Cadigan, Perrin, & Randolph, 2008). Research suggests one specific factor influencing this disparity in breastfeeding rates is the limited access to lactation specialists in rural areas (Patel & Patel, 2016; Sparks, 2010). In the county where this project was completed, only 67.7% of infants were ever breastfed, compared to 81.1% of infants nationwide (Public Health Indicator Based Information System (IBIS), 2016). This breastfeeding rate falls short of the national goal established by LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 5 Healthy People 2020 to increase the rate of infants who have ever breastfed to 81.9% (National Center for Chronic Disease Prevention and Health Promotion, 2016). In the rural central Utah hospital where this project was performed, lactation consultants were not available, likely contributing to the low rate of infants ever breastfed (Public Health Indicator Based Information System (IBIS), 2016; Intermountain Healthcare, 2018; Community Resources, n.d; Intermountain Healthcare, 2017). Lactation services delivered through telehealth technology is an emerging resource that can increase access to lactation specialists in rural areas, yet evidence on the effectiveness of telehealth lactation services remains limited (Rojjanasrirat, Nelson, & Wambach, 2012; Friesen, Hormuth, Petersen, & Babbitt, 2015). Available Knowledge Benefits of telehealth lactation services. In a review of existing telehealth lactation service programs, Uscher-Pines, Mehrotra, and Bogen (2017) evaluate the advantages and challenges of telehealth lactation consultations. In this review, the authors identify the decreased cost of telehealth lactation services compared to traditional in-person consultations ($25-130 vs. $80-175) as an advantage of this technology. These authors also recognize in-home telehealth lactation consultations as a more convenient service for new mothers and identify telehealth lactation consultations as a good triaging service for lactation concerns. Telehealth lactation services may also be beneficial since it is primarily "hands-off" assistance, thus assisting mothers to gain the confidence and skills necessary to breastfeed alone (Uscher-Pines et al., 2017). In a small pilot study, Rojjanasrirat et al. (2012) state that all of the 10 participants reported feeling comfortable discussing breastfeeding concerns through telehealth technology. In a study of 100 mothers, Habibi, Springer, Spence, Hansen-Petrik, and Kavanagh (2017) report LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 6 women generally accept telehealth lactation services, with younger mothers demonstrating greater acceptance. Friesen et al. (2015) report on the experiences of 35 mothers involved in the TeleLactation Pilot Project. These authors suggest that telehealth lactation consultations can provide mothers with education on breastfeeding, increase confidence, and reduce anxiety about the birthing process and hospital experience. These authors recognize telehealth lactation services as a means of providing timely, accurate, expert breastfeeding advice while saving on the costs of time and travel (Friesen et al., 2015). Challenges/drawbacks of telehealth lactation services. In a review of the literature on telehealth lactation services, the challenges and drawbacks identified include limited evidence that telehealth consultations improve breastfeeding rates, possible variation in advice received from consultants, disparities in access to required technology, and lack of insurance coverage for telehealth lactation visits (Uscher-Pines et al.,2017; Rojjanasrirat et al., 2012). In an article reviewing the experience of lactation consultants' experiences with telehealth lactation services, Macnab, Rojjanasrirat, and Sanders (2012) report a challenge of this service lies with the clinician. During a telehealth lactation consultation, the lactation consultant must be confident in providing assistance without being able to physically connect with the patient. During a telehealth lactation visit, mothers must be able to independently hold, latch, and breastfeed their infant while receiving feedback. This limited contact also interferes with the personal connection and validation clinicians provide mothers during lactation consultations (Macnab et al., 2012). All of the lactation consultants in this article list technology as one of the greatest barriers to telehealth lactation services, explaining that it is difficult to visualize the patient's breast, the latch, assess suck, and the oral anatomy of the infant (Macnab et al., 2012). LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 7 Rationale The rationale for this project was based on Collerette's Organizational Change Theory (Kaminski, n.d.). This change theory acknowledges that change occurs on three dimensions: individual, collective, and organizational. This theory consists of three main stages and two sub stages: 1) awakening; 2) transitions; 2a) disintegration; 2b) reconstruction; 3) ritualization. For lactation telehealth services to be successful in the small, rural Utah hospital where this project was implemented, a culture change that supports breastfeeding and utilizes telehealth consults as needed, must occur in individual employees, department teams, and throughout the entire hospital. Utilizing Collerette's Organizational Change Theory as a model, in the awakening stage, these three groups must first recognize this hospital is consistently ranked as one of the lowest hospitals within the state for exclusive breastfeeding rates (Public Health Indicator Based Information System (IBIS), 2016). These groups must recognize that to alter these low ratings, exclusive breastfeeding must be supported, encouraged, and lactation services must be available (Kaminski, n.d.). Implementation of telehealth lactation services will be the initial step in initiating a culture change that supports and encourages exclusive breastfeeding. In the transitions stage, these groups must first "disintegrate" the current system of minimal breastfeeding support and then "reconstruct" a culture that encourages exclusive breastfeeding (Kaminski, n.d.). This encouragement will be fostered by the implementation of lactation telehealth services. Lastly, as breastfeeding becomes more widely supported with the aid of telehealth services, these groups must make breastfeeding support with consultations as needed a "ritual" in their daily work routine (Kaminski, n.d.). Specific Aims LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 8 The purposes of this project included the following: 1) Facilitate implementation of a pilot lactation telehealth services project at a small, rural hospital in the Southwestern United States. 2) Evaluate the patient, nurse, and lactation consultant experience with telehealth lactation services. 3) Initiate a culture change that encourages exclusive breastfeeding, with the eventual goal of increasing exclusive breastfeeding rates. 4) Understand how future telehealth lactation service programs can be improved, implemented, and expanded. 5) Determine if telehealth lactation services can increase exclusive breastfeeding rates. Methods Context This project took place in a small, rural hospital in central Utah. This hospital provides medical services for its local county, as well as five surrounding counties, thus serving approximately 60,000 people. This hospital has a 20-bed medical/surgical unit and 3-bed labor and delivery unit. This hospital is staffed by 35 registered nurses, 15 nursing assistants, 7 family practice physicians, 1 OB-GYN, and 1 certified nurse midwife. Nurses at this hospital are expected to provide care for patients in all units including the emergency room, medical/surgical, and labor and delivery. This hospital provides services for between 20-50 births per month. Patients served by this facility are primarily white and English speaking. Most patients are low to middle income and reside in rural areas. This hospital is located 120 miles from the nearest tertiary care center. Prior to project implementation, this hospital consistently had low rates of LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 9 exclusive breastfeeding. In 2017, only 45.4% of infants were exclusively breastfed on discharge from the hospital (Intermountain Healthcare, 2018). Considering there are no lactation consultants in this hospital, registered nurses and nursing assistants are expected to provide lactation support and education. However, prior to this project, most nurses had never received formal lactation education beyond personal experience. A two-hour breastfeeding course for patients was offered by this hospital, but was taught in conjunction with a six-week long prenatal education class. In the community, there was a lactation consultant located at the local health department, however, only patients with Medicaid have access to this consultant. Prior to this project, access to telehealth technology was available at the project site, but for other specialties. Most nursing staff members had utilized telehealth services prior to this project and had received prior instruction on how to assist with telehealth consultations in other disciplines. Description of Intervention Prior to initiating telehealth lactation services at this hospital, obstetric providers were educated about the availability of telehealth lactation services in a department wide e-mail. In this correspondence, providers were asked to increase patient awareness of this service by informing patients of this service during prenatal appointments and on admission to labor and delivery. Internet and in-hospital poster advertisements were also utilized to inform patients about the availability of this service (See Appendix G). Also prior to initiation of telehealth lactation services, the project coordinator conducted an educational session for nursing staff on how to assist with telehealth lactation services. Since LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 10 most nurses had never received breastfeeding education, this training also reviewed basic breastfeeding information to ensure consistency in patient education. This education included topics such as how often infants should feed, how long to feed, how to recognize hunger cues versus satisfaction, when to supplement, when to pump, how to ensure a proper latch, common breastfeeding concerns, and how to assist patients with breastfeeding. Once telehealth lactation services were initiated, a nursing staff member or the project coordinator informed all patients of this service on hospital admission and again in the inpatient postpartum setting. Telehealth lactation consultations were offered daily from 11:00 A.M. to 12:00 P.M. on all weekdays. Consults were not available on weekends, nights, or holidays. Project enrollment included 25 inpatient postpartum mothers. During the project period, all women were offered a lactation consultation via telehealth, regardless of difficulty with breastfeeding, lactation concerns, LATCH score, or past experience with breastfeeding. After being informed of the service, patients who chose to have a lactation consultation were connected via telehealth to an International Board Certified Lactation Consultant (IBCLC) in a distant tertiary care center. During consultations, nurses were required to remain in the room to assist during the consultation as needed. Lastly, exclusive breastfeeding rates were evaluated during this project and one month after project completion to evaluate project effectiveness. Study of the Intervention During this project, surveys were administered on several occasions. First, prior to and following the nurse training session, nurses were asked to complete a voluntary survey on comfort with breastfeeding assistance, telehealth assistance, and information taught in the training. Then, to evaluate the nurse, patient, and lactation consultant experience with telehealth, LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 11 following each telehealth lactation consultation, the patient, assisting nurse, and lactation consultant were asked to complete a voluntary survey on their experience. Measures All survey questions administered during this project were based questions from the Centers for Disease Control's lactation questionnaires and the technology acceptance model. These surveys were reviewed and approved by faculty prior to administration. Questions on the pre- and post-nursing staff education session questionnaire contained demographic information and questions on the nurse's attitude toward breastfeeding, lactation knowledge, ability to assist with breastfeeding, and comfort in assisting with telehealth lactation services. This training session and these surveys were administered one day prior to implementation of telehealth lactation services. Surveys administered to patients, nurses, and lactation consultants following each telehealth lactation consultation contained demographic questions and questions on why the consult was requested, perceived benefits, and drawbacks of telehealth lactation services. To protect patient anonymity, the project coordinator did not distribute or collect surveys to patients or employees during the project period. Patient surveys were placed in the Living and Learning packet received by every mother who delivered at the project site. On admission, nursing staff members educated patients about the availability of telehealth lactation services and the associated surveys. Then in the postpartum setting, patients were again reminded of this service. Nursing staff and lactation consultant surveys were available at the nursing station and in the lactation consultant office, respectively. Nursing staff members were instructed about these surveys and their voluntary nature in the training session prior to implementation of LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 12 telehealth lactation services. Lactation consultants were educated about the surveys by the project coordinator and lead lactation consultant. Once surveys were complete, patients, nurses, and lactation consultants were asked to deposit the completed survey in a locked drop box located in a central location. Considering that nurses and lactation consultants were asked to fill out surveys on multiple occasions, it was possible during this project to have multiple surveys from the same individual. Therefore, in an effort to identify surveys completed by the same staff member and evaluate individual trends in data while maintaining confidentiality and anonymity, staff members were asked to place a self-selected, anonymous "code name" on every survey completed throughout the project. Through the use of this code name, the project coordinator was able to identify trends in data based on individual staff response. To ensure surveys were easily accessible and understandable, for the first two weeks of the project, the project coordinator contacted nursing staff and lactation consultants for feedback on any project or survey concerns. Patients were also instructed to inform their nurse or the project coordinator if they had any concerns about the surveys. Throughout the project, the telehealth lactation team held several meetings to evaluate project progress and address any issues. To ensure ongoing validity of the survey questions, halfway through project completion, surveys were reviewed for completeness. Surveys were also counted to determine how often surveys were being completed and returned. At this time, nursing staff members and lactation consultants were again reminded of the project and associated surveys. Exclusive breastfeeding rates at the project site were evaluated halfway through the project, at project completion, and one month later to determine the longer-term impact of this project. LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 13 Analysis Prior to project initiation, statisticians from the University of Utah were consulted on appropriate statistical analysis processes for this project. Demographic data collected from surveys in this project were analyzed using frequency tables. Continuous variables were summarized by studies of central tendency. From this data, descriptive and parametric statistics measured mean differences. Open-ended questions were transcribed, inductively coded, and categorized by frequency of comments. For surveys with the possibility of multiple staff responses, unconditional means modeling was utilized for analysis. Conditional means modeling was used to analyze relationships between variables. On the surveys, a 1-5 Likert scale was used. Unless otherwise noted, the Likert scale was as follows: 1 being strongly disagree, 2 being disagree, 3 being neutral, 4 being agree, and 5 being strongly agree. Ethical Considerations This project was reviewed by the Intermountain Healthcare Institutional Review Board (IRB), found to be of minimal human risk, and then approved by the IRB. Once Intermountain Healthcare IRB approval was received, reciprocal approval from the University of Utah was also obtained. Results Prior to analysis, commonly themed questions were grouped on each survey in an effort to understand key findings from this project. Therefore, not all questions will be discussed, but key ideas will be highlighted. LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 14 Nursing Staff Training Session On review of the nurse training session, of 50 possible nurses who could have attended this training session, 41 nurses were in attendance. See Figure 1 for demographic data of the nursing staff in attendance. As depicted in the table, 73% of nurses in attendance were registered nurses, while 26% were nursing assistants. Nursing experience of the staff is well varied, with the majority of the staff, 34%, having 1-5 years of experience. As previously discussed, one primary factor affecting breastfeeding rates is the limited formal breastfeeding education of the nursing staff. As seen in Figure 1, only 27% of the staff had attended the lactation essentials course, while 71% of nursing staff had personal experience with breastfeeding. On analysis of the pre and post-surveys collected at the nurse training session, two primary themes emerged. First, the training session improved breastfeeding knowledge (M= 3.4, SD=0.9) vs. (M= 3.8; SD: 0.6) t(69) = -2.368; p = 0.01. Second, the training improved nurse's perception of telehealth services (M=3.6, SD=1.2) vs. (M = 4.1, SD = 0.63) t(60)= -2.362; p = 0.01. Patient Experience As discussed, following the nursing staff training session, telehealth lactation services were implemented for 25 in-patient postpartum mothers. See Figure 2 for patient demographic information. Of 25 consults completed, 25 patients provided survey responses, thus equaling a 100% response rate from patients. From these surveys, two principal findings surfaced. First, on the patient survey, patients were asked to rate their comfort with breastfeeding before the consult and following the consult. On analysis, patient breastfeeding confidence increased following the telehealth lactation consult (M = 3.8; SD = 0.9) vs. (M = 4.5, SD = 0.7) t(44) = -3.07, p = 0.001. Second, 100% of patients reported the consult encouraged them to continue breastfeeding after hospital LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 15 discharge. Although patients were receptive to this technology, 56% of patients stated they would have preferred an in-person lactation consultation. On analysis of the reasons patients desired a telehealth consult, the most common reason for a consult was due to concerns about milk supply (mean: 3.92; SD: 1.07), followed by a desire for breastfeeding education (mean: 3.6; SD: 1.04), then for issues with latch (mean: 3.12; SD: 1.33), and lastly, for concerns with nipple pain (mean: 2.8; SD: 1.35). Patients also reported feeling technology was adequate for the consults (mean: 4.3; SD: 0.85) and the lactation consultants communicated well (mean: 4.8; SD: 0.41). Patients felt the primary drawback of this service was the lack of hands-on support they received. Also of note, a relationship comparison was performed evaluating women's comfort with breast exposure on camera in relation to their age versus the number of previous children. On analysis, there was no statistical significance between age and comfort with exposure (p>0.05), however, women with more children reported less discomfort with breast exposure (p = 0.0116). See Figure 3 for a graph of this relationship. Nurse Experience On analysis of the nursing staff post-consult surveys, of the 25 possible surveys that could have been completed, 17 surveys were collected, equaling a 68% response rate. A contextual element contributing to this response rate was the timing of the consults. Although 41 nurses attended the training session, many of these nurses did not have the opportunity to participate in telehealth consults since consults were only offered on weekdays from 11:00 A.M. - 12:00 P.M. Therefore, night nurses and weekend staff were unable to participate in these LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 16 consults or complete surveys. Considering the timing of the consults, only 7 nurses completed the 17 surveys. On review of the nursing staff surveys, the primary theme that emerged from nurses' surveys was their concerns of time limitations and the ability to assist with consults. On review of surveys, only 12% of nurses reported having enough time to assist with consults. Further, only 17% of nurses felt a bedside nurse was essential during consults. Although a bedside nurse was present during every consult, nurses reported providing direct hands-on assistance with only 29% of consults. Lactation Consultant Experience On review of the lactation consultant's surveys completed following consultations, 23 out of 25 possible surveys were returned, equaling a response rate of 92%. Interestingly, unlike the nursing staff, lactation consultants continued to complete surveys despite possible survey fatigue. On review of the lactation consultant surveys, 87% of responses either "agree" (score of 4) or "strongly agree" (score of 5) that telehealth consults are comparable in quality to in person consultations. Also, 90% of consultant responses report the technology is adequate for the consults. Interestingly, although nursing staff does not believe a bedside nurse is essential, 95% of lactation consultant responses indicate a bedside nurse is essential during consults. Lactation consultants felt the primary drawback of this service was the stationary nature of the camera. Lactation consultants stated they would have liked to been able to move the camera as needed, particularly to an overhead view to better assess the infant's latch. Breastfeeding Rates LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 17 One month following project completion, a final analysis of exclusive breastfeeding rates at the project site was performed. See Figure 6 for a complete graph of exclusive breastfeeding rates at the project site from February 2017 - February 2018. As depicted in this chart, breastfeeding rates were between 22-58% prior to project implementation. Following implementation of this project, exclusive breastfeeding rates in November 2017 increased to 68.2%. Then in December 2017, during the heart of the project period, exclusive breastfeeding rates increased to 90.5%. In January of 2018, breastfeeding rates decreased to 57.9%, however, this rate still far surpassed the average breastfeeding rate prior to project initiation. Further, in February 2018, breastfeeding rates again increased demonstrating the longer-term impact of this project. On comparison of breastfeeding rates prior to and following project initiation, the average breastfeeding rate increased from 45.4% to 70.8%; an average 25.4% higher than the 10 months prior to project initiation. Further, after this initial project period, the project site decided to continue offering telehealth lactation consultations considering the benefits demonstrated by this project. Discussion Summary In summary, from this project, it appears telehealth lactation services are feasible, can improve breastfeeding rates, and are acceptable to patients and consultants. Nurses, however, express concerns over time constraints affecting their ability to assist with consults. Although this service increased patient breastfeeding confidence and rates, lactation consults are time intensive, which impacts daily nursing routines. Future projects might assess the effectiveness of telehealth lactation consultations when a bedside nurse is not available for assistance. Also for LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 18 future project success, hospitals must provide a designated person or team available on-site to promote this service, assist with education, and support nurses as needed. Interpretation Results of this project align with several findings from previous studies on telehealth lactation services. Findings of this project agree with Friesen et al. (2015) that telehealth lactation services can provide education on breastfeeding and increase confidence. Feedback from the lactation consultants in this project also corroborated findings reported by Macnab et al. (2012) that one primary drawback of this service is the stationary nature of the camera and the limited ability to assess the patient's breast, the latch, assess suck, and the oral anatomy of the infant. Uscher-Pines et al. (2017) recognize the hands-off nature of telehealth lactation services as a benefit of telehealth lactation services. In this project, however, a majority of mothers identified the lack of hands-on support as a primary drawback of this service. In this project, most mothers state they would have preferred an in-person consultation for additional hands-on assistance. This project did not coincide with the findings published by Habibi et al. (2017) that younger mothers were more accepting of this service. Results of this project did not find a statistically significant relationship between maternal age and acceptance with this service, but did find a relationship between the number of previous children and a woman's comfort with telehealth lactation services. In relation to adequacy of technology, unlike other studies, this project did not find technology limitations as a drawback of this service. Limitations LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 19 The primary limitation to the generalizability of this project was the limited sample size. Also, the homogenous white population of the project site also limited the ability of this project to assess women's acceptance of this service who are not English speaking, of other cultures, or of another race. For this service to be more inclusive, technology advancements must be made that can provide interpretation services during a telehealth consult. Lastly, this project is also limited in availability as it was only available on weekdays, therefore, this project excluded women who birthed their infant on weekends or holidays. Limitations possibly influencing data results for this project include possible survey fatigue from survey repetition. This project was also affected by the timing of the telehealth lactation consultations. As described above, these consults were only conducted during weekdays, thus excluding nurses who work only at night or on weekends. Consults were also not available on any holidays. These factors also limited the number of patients who were able to receive telehealth lactation consults. Data on patient's race and ethnicity are missing from this discussion since this information was not included on surveys. This project was designed only for English speaking patients due to limitations with technology and translation; therefore, race and ethnicity were not identified. On retrospect, this data could have contributed to analysis and should have been included in this project. Conclusions In conclusion, it appears promising that telehealth lactation services can effectively provide rural areas with breastfeeding education, support, access to lactation consultants, and can influence breastfeeding rates. Telehealth lactation services benefit women as it provides local LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 20 access to lactation consultants without the expense, inconvenience, or cost associated with travel. Telehealth lactation services can also increase maternal confidence with breastfeeding, provide effective education, and encourage mothers to continue breastfeeding after hospital discharge. However, for this service to be successful, hospitals must provide daily on-site staff to promote breastfeeding and encourage telehealth consults as needed. Without on-site assistance, nursing staff becomes responsible for support of this service, yet nurses do not believe they have the time necessary to assist with telehealth lactation consults. If nurses are required to provide support for this service, the necessity of a nurse remaining at bedside throughout the consult must be further evaluated. After completion of this project, it is recommended that if this service is to be expanded, hospitals must consider the cost effectiveness of staffing an on-site support person for this service versus the feasibility of providing an on-site lactation consultant. To effectively connect with all women, this service must also be expanded to include weekend and holiday services. Ideally, this service will be expanded to the outpatient setting since breastfeeding issues are more common after discharge from the hospital. Considering the high frequency of breastfeeding issues after hospital discharge, women need continued access to lactation consultants in the outpatient setting in their home community. In summary, telehealth lactation services can effectively provide rural hospitals with increased lactation support and can improve breastfeeding rates. However, for long-term success, hospitals must make breastfeeding and lactation support a priority. To create a long-term impact on breastfeeding rates, hospitals and communities must embrace a culture change that recognizes the importance of breastfeeding, promotes exclusive breastfeeding, and supports women with breastfeeding challenges in their home community. LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 21 Acknowledgements I would like to acknowledge my project chair and course professors, Dr. Janice Morse, Dr. Andrea Wallace, and Dr. Nancy Allen, for their assistance and guidance in this project. I would also like to thank Dr. Andrew Wilson, statistician, for his statistics advice on this project. I would like to thank the lactation consultants, Janis Sumsion and Bernadette Fish, who so willingly provided lactation consultations during this project. Lastly, I would like to thank all staff members at this project site for supporting this project and initiating a culture change that encourages exclusive breastfeeding. Funding This project did not receive any funding contributing to its completion. LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 22 References Allen, J. A., Perrine, C. G., & Scanlon, K. S. (2015). Breastfeeding supportive hospital practices in the US differ by county urbanization level. Journal of Human Lactation, 31(3), 440- 443. http://doi.org/10.1177/0890334415578440 Community resources. (n.d.). Retrieved from http://choosehealth.utah.gov/documents/pdfs/For%20Parents.pdf Flower, K. B., Willoughby, M., Cadigan, R. J., Perrin, E. M., Randolph, G., & Family Life Project Investigative Team. (2008). Understanding breastfeeding initiation and continuation in rural communities: A combined qualitative/quantitative approach. Maternal and Child Health Journal, 12(3), 402-414. https://doi.org/10.1007/s10995-0070248-6 Friesen, C. A., Hormuth, L. J., Petersen, D., & Babbitt, T. (2015). Using videoconferencing technology to provide breastfeeding support to low-income women: Connecting hospitalbased lactation consultants with clients receiving care at a community health center. Journal of Human Lactation, 31(4), 595-599. https://doi.org/10.1177/0890334415601088 Habibi, M. F., Springer, C. M., Spence, M. L., Hansen-Petrik, M. B., & Kavanagh, K. F. (2017). Use of videoconferencing for lactation consultation: An online cross-sectional survey of mothers' acceptance in the United States. Journal of Human Lactation, 089033441771138. https://doi.org/10.1177/0890334417711385 Harris, D. E., Aboueissa, A.-M., Baugh, N., & Sarton, C. (2015). Impact of rurality on maternal and infant health indicators and outcomes in Maine. Rural and Remote Health, 15(3), 3278. LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 23 Intermountain Healthcare. (2018). Exclusive breast milk feeding (iCentra sites). Intermountain Healthcare. (2017). Intermountain moms. Retrieved from https://intermountainhealthcare.org/blogs/2015/01/where-can-new-moms-find-help/ Kaminski, J. (n.d.). Learning activity 3: Adapting to change and selected theories. Retrieved June 28, 2017, from http://nursing-informatics.com/N4111/LA3.html Macnab, I., Rojjanasrirat, W., & Sanders, A. (2012). Breastfeeding and telehealth. Journal of Human Lactation, 28(4), 446-449. https://doi.org/10.1177/0890334412460512 National Center for Chronic Disease Prevention and Health Promotion. (2016). Breastfeeding report card: Progressing toward national breastfeeding goals. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdf Patel, S., & Patel, S. (2016). The effectiveness of lactation consultants and lactation counselors on breastfeeding outcomes. Journal of Human Lactation, 32(3), 530-541. https://doi.org/10.1177/0890334415618668 Public Health Indicator Based Information System (IBIS). (2016). Complete health indicator report of breastfeeding (ever). Utah Department of Health: Women, Infants, and Children Bureau of Maternal and Child Health. Retrieved from https://ibis.health.utah.gov/indicator/complete_profile/BrstFeed.html Rojjanasrirat, W., Nelson, E.-L., & Wambach, K. A. (2012). A pilot study of home-based videoconferencing for breastfeeding support. Journal of Human Lactation, 28(4), 464- 467. https://doi.org/10.1177/0890334412449071 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES 24 Sparks, P. J. (2010). Rural-urban differences in breastfeeding initiation in the United States. Journal of Human Lactation, 26(2), 118-129. https://doi.org/10.1177/0890334409352854 Uscher-Pines, L., Mehrotra, A., & Bogen, D. L. (2017). The emergence and promise of telelactation. 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LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix A Figure 1: Nurse Training Session Demographic Information 25 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix B Figure 2: Patient Demographic Information 26 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix C Figure 3: Relationship Between Number of Children and Comfort with Breast Exposure 27 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix D Figure 4: Nursing Demographics of Post-Consult Surveys 28 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix E Figure 5: Project Site Exclusive Breastfeeding Rates 29 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix F Poster 1: Patient Advertisement of Telehealth Lactation Services 30 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix G Survey 1: Nurse Education Session Pre- and Post-Survey 31 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 1 (continued) 32 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 1 (continued) 33 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix H Survey 2: Patient Post-Consult Survey 34 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 2 (continued) 35 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 2 (continued) 36 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 2 (continued) 37 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix I Survey 3: Nurse Post-Consult Survey 38 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 3 (continued) 39 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 3 (continued) 40 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Appendix J Survey 4: Lactation Consultant Post-Consult Survey 41 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 4 (continued) 42 LACTATION SUPPORT FOR RURAL AREAS THROUGH TELEHEALTH SERVICES Survey 4 (continued) 43