Missed care and equitable breastfeeding support: An integrative review of exposure to in-hospital care by patient characteristics and breastfeeding outcomes

Aim: To synthesize the literature on breastfeeding outcomes associated with exposure to internationally recognized best practices, such as the Baby-Friendly Hospital Initiative, for patients in the United States during the postpartum period, contextualized within the Missed Care Model. Design: The authors employed Whittemore and Knafl's integrative review framework and the 2020 PRISMA guidelines for data extraction, synthesis, reporting and assessment. Methods: Five electronic databases were searched for articles published between 2007 and 2023. Eligible articles reported on exposure to breastfeeding best practices and outcomes or the experiences, views, perceptions and attitudes of parents, nurses or lactation consultants regarding hospital breastfeeding support. Extracted data were compared to identify in-hospital exposure to breastfeeding best practices and breastfeeding outcomes, and differences in exposure and outcomes based on patient and provider characteristics. Results: Twenty-one quantitative, qualitative and mixed methods articles met inclusion criteria. A higher reported adherence to best practices was associated with greater odds of breastfeeding; some practices demonstrated greater effects overall or for specific groups. Higher exposures to best practices and higher breastfeeding rates were found for non-Hispanic white patients, and those with more education, private insurance and who live in urban areas. Disparities in support and outcomes were related to patients' race/ethnicity, language, weight and age. Qualitative findings reflected missed care concepts, such as internal processes related to habits and group norms, relevant to breastfeeding support. Conclusion: Review findings also include an adapted Missed Care Model specific to breastfeeding support, which can inform future research related to providers' internal processes that may influence breastfeeding or equitable breastfeeding care. Implications for the Profession and/or Patient Care: Missed care can be influenced by a variety of factors, including providers' internal values and beliefs. Study findings suggest the existence of inequities in breastfeeding care and underscore the need to address and eliminate breastfeeding disparities. Impact: This study addressed how patient exposure to best practices in breastfeeding support relates to breastfeeding outcomes and whether exposure and outcomes differ by patient or provider characteristics, connecting this to the Missed Care in Breastfeeding Support Model. The main findings were that higher reported exposure to best practices in breastfeeding support related to improved breastfeeding outcomes; inequities exist in exposure to best practices; and patients and providers identify the importance of providers' internal processes in the delivery of breastfeeding support, which aligns with the Missed Care in Breastfeeding Support Model. Study findings will have the potential to impact how nurses, lactation consultants and other providers who deliver breastfeeding support in the postpartum hospital setting. Reporting Method: The authors adhered to relevant 2020 PRISMA reporting guidelines. Patient or Public Contribution: No patient or public contribution.