Exploring the concept of continuous midwifery-led care and its dimensions in the prenatal,perinatal, and postnatal periods in Iran (Kashan)

Aimto explore the concept of continuous care and its dimensions in the prenatal, perinatal, and postnatal periods based on the experiences of midwives, gynaecologists, obstetricians, pregnant women and their husbands.Designa qualitative study that was part of a large scale action research which aimed to develop, use and test a continuous midwifery-led care model. Data collection and analysis were performed concurrently through undertaking semi-structured interviews and using the conventional content analysis approach.Settinghealthcare centres and hospitals affiliated to Kashan University of Medical Sciences, Kashan, Iran.Participants21 women following a recent pregnancy, five husbands, 18 midwives, and five physicians who had different official positions.Findingsthe participants’ experiences revealed five concepts for continuous midwifery-led care which included continuity, the process of care, education and informing, management, and professionalism. Each of these five concepts consisted of several categories.Conclusion and implication for practiceaccording to the study participants, continuous midwifery-led prenatal, perinatal, and postnatal care is a multidimensional and important concept. Given the differences in the health infrastructures of different countries as well as the unique characteristics of pregnancy, higher priorities are recommended to be given to continuous midwifery-led care and its dimensions.     

Midwives’ perceptions and experiences of caring for women who experience perinatal mental health problems: An integrative review

Backgroundperinatal mental health is an important public health issue and consideration must be given to care provision for effective support and care of women in the perinatal period.Aimto synthesise primary research on midwives’ perceived role in Perinatal Mental Health (PMH).Designintegrative review.MethodsWhittemore and Knafl's (2005) framework was employed. A systematic search of the literature was completed. Studies were included if they met the following criteria: primary qualitative, quantitative and mixed methods research studies published in peer reviewed journals between January 2006 to February 2016, where the population of interest were midwives and the outcomes of interest were their perceived role in the management of women with PMH problems. The methodological quality of studies was assessed using the relevant CASP (Critical Appraisal Skills Programmes, 2014) criteria for quantitative and qualitative research studies. Data extraction, quality assessment and thematic analysis were conducted.Findingsa total of 3323 articles were retrieved and 22 papers were included in the review (15 quantitative, 6 qualitative and one mixed method study). The quality of the studies included was good overall. Two overarching themes emerged relating to personal and professional engagement. Within personal engagement four sub themes are presented: knowledge, skills, decision making and attitude. Within professional engagement four themes are presented: continuous professional development, organisation of care, referral, and support.Conclusions and implications for practicethe findings indicate midwives require continuous professional development opportunities that address knowledge, attitudes to PMH, communication and assessment skills. However educational and training support in the absence of appropriate referral pathways and support systems will have little benefit.     

Patient,provider, and system-level barriers and facilitators to addressing perinatal depression

Objective: To explore perinatal health care professionals’ perspectives on barriers and facilitators to addressing perinatal depression. Background: Perinatal depression is common and associated with deleterious effects on mother, foetus, child and family. Although the regular contact between mothers and perinatal health care professionals may make the obstetric setting ideal for addressing depression, barriers persist, and depression remains under-diagnosed and under-treated. Methods: Four 90-minute focus groups were conducted with perinatal health care professionals, including obstetric resident and attending physicians, licensed independent practitioners, nurses, patient care assistants, social workers and administrative support staff. Focus groups were transcribed, and resulting data were analysed using a grounded theory approach. Results: Participants identified patient-, provider- and system-level barriers and facilitators to addressing perinatal depression. Provider-level barriers included lack of resources, skills and confidence needed to diagnose, refer and treat perinatal depression. Limited access to mental health care and resources were identified as system-level barriers. Facilitators identified included targeted training for perinatal health care professionals’, structured screening and referral processes, and enhanced support and guidance from mental health providers. Conclusion: A complex set of interactions between women and perinatal health care professionals contributes to perinatal depression being untreated. Service gaps could be closed by addressing identified barriers through integrated obstetric and depression care and enhanced collaborations. Future intervention testing could include targeted training, improved access, and mental health provider support to empower perinatal health care professionals’ to address perinatal depression, and thereby improve delivery of depression treatment in obstetric settings.     

Client satisfaction and transfers across care levels of women with uncomplicated pregnancies at the onset of labor

Objectiveto compare the client satisfaction of women with uncomplicated pregnancies at the onset of labor who were transferred across care levels during childbirth and women who were not transferred across care levels in the Dutch perinatal healthcare system, and–if there are differences–to identify the variables that may explain them.Methodsthe research entailed a population-based study of women with uncomplicated pregnancies at the onset of labor living in the catchment area of a Dutch Neonatal Intensive Care Unit (NICU) in the eastern part of the Netherlands who gave birth between April 2014 and September 2014. Respondents completed a validated questionnaire (n = 842; mean age 30.7 years). Client satisfaction, measured on a 10-point scale, was assessed within 12 weeks after childbirth.Findingsof the 842 respondents, 277 women experienced a transfer of care during childbirth, and 565 women were not transferred. The client satisfaction of women who were transferred across care levels (mean 8.04; SD 1.4) was significantly lower (p<0.001) than that of women who were not transferred across care levels (mean 8.78; SD 0.9). Seven variables together explained 93.2% of the difference in client satisfaction. Explanatory pregnancy and childbirth variables were perceived health problems for the mother and medical interventions during childbirth. Explanatory clients’ experiences with the care process variables were respect, prompt attention, quality of basic amenities, social consideration, and choice and continuity.Conclusionwomen were highly satisfied with the care they received, although transfers across care levels during childbirth were associated with substantially lower client satisfaction. The differences in client satisfaction between transferred and non-transferred women can largely be explained by pregnancy and childbirth characteristics, and by clients’ experiences with the care process.     

Antenatal and postnatal depression – Are Polish midwives really ready for them?

ObjectiveBefore January 2019, no established solutions regarding the screening, assessment, and treatment of patients suffering from perinatal depression existed in Poland. From 2019, a new standard of perinatal care has imposed the obligation to monitor the mental state of women during pregnancy and in the postpartum period on the healthcare providers (mainly on midwives). Thus, our study aimed to evaluate midwives’ knowledge about prenatal and postnatal mental health disorders in the first six months of implementing the new standard of perinatal care in Poland.DesignPolish midwives completed a survey consisting of the Test of Antenatal and Postpartum Depression Knowledge by Jones, Creedy, and Gamble (2001) and questions related to a hypothetical case study of a depressed woman named “Mary”, developed by Buist and colleagues (2006). The midwives also rated their perceived knowledge and skills in assessing women’ mental health condition.SettingThe study was conducted in four Polish cities: Gdansk, Olsztyn, Szczecin, Wroclaw, and the surrounding rural areas.Participants111 Polish midwives with varied professional experience and socio-demographic characteristics participated in the study.Measurements and findingsAmong all of their professional responsibilities, the midwives self-rated their knowledge and skills in assessing the mental state of patients as the lowest ones. A subsequent objective assessment revealed their insufficient knowledge about antenatal and postnatal depression and the ways of treatment of these disorders.Key conclusionsMidwives are not properly prepared for the new tasks resulting from the Polish standard of perinatal care: specifically, for the assessment of a woman's mental state.Implications for practiceFurther trainings are required to ensure midwives’ competency and knowledge about the assessment and dealing with mental disorders of patients who experience prenatal and postpartum depression.     

Relationship between Social Support and Quality of Life in Childbearing Women during the Perinatal Period

ObjectiveTo explore demographic and social support predictors of health‐related quality of life (HRQoL) (mental and physical) for childbearing women in the perinatal period.DesignLongitudinal.SampleThree public hospitals in metropolitan Brisbane, Australia.ParticipantsFour hundred seventy‐three (473) women recruited at 36 weeks of pregnancy, and 6 and 12 weeks following childbirth.MethodsThe Short Form‐12 (SF‐12) Version 2 Health Survey was used to measure the mental and physical domains of HRQoL. Social support was measured using the Maternal Social Support Scale (MSSS).ResultsMean scores for the mental and physical domains of HRQoL were lower than population norms. Social support was found to be a significant and consistent predictor of higher HRQoL scores, particularly in the physical domain at 12 weeks following child birth and mental domain during the perinatal period. The relationship between social support and HRQoL was found to be independent of other factors including education, length of relationship with partner, age, parity, and antenatal visit. The only other significant predictor was length of relationship with partner in the mental domain at 36 weeks of pregnancy.ConclusionSocial support is a significant and consistent predictor of a mother's HRQoL during the perinatal period. Nurses and midwives need to assess social support, rather than making assumptions based on demographic factors.     

Guideline-based quality indicators for early pregnancy assessment units

Research questionWhat valid guideline-based quality indicators can measure quality of care in early pregnancy assessment units (EPAU)?DesignThe systematic RAND-modified Delphi method was used to develop an indicator set from four evidence-based guidelines. An international expert panel was assembled to extract recommendations from these guidelines to establish quality indicators.ResultsA total of 119 recommendations were extracted. Eleven recommendations received a high median score and top five score above the 75th percentile and were selected as key recommendations. The expert panel reassessed 15 high score recommendations and top five score between the 50th and 75th percentile as well as one high score recommendation without consensus. Eight of these 16 recommendations were selected in the second round as key recommendations. The key recommendations were formulated into a set of 19 quality indicators, summarized as follows: women referred to an EPAU could be seen within 24 h and receive a clear explanation on treatment options; designated senior staff members could be responsible for the unit and staff could have had ultrasound training; protocols could be available for daily practice covering all treatment options for miscarriage and ectopic pregnancy; and an EPAU could have access to urine pregnancy testing and serum HCG assays.ConclusionsNineteen quality indicators to measure early pregnancy care provided by EPAU were identified.     

Perspectives of Family Physicians on the Care of Uninsured Pregnant Women

ObjectiveNo official provisions are made for the medically uninsured under provincial public health programs in Canada. Studies have shown that uninsured pregnant women have inadequate access to prenatal and obstetrical services that favour healthy maternal and child outcomes. This qualitative study aimed to explore the perspectives of family physicians who provided care to uninsured pregnant women.MethodsEight family physicians affiliated with two Montreal-based primary-care clinics and one tertiary care hospital between 2004 and 2007 were interviewed using a semi-structured interview guide. Data were assessed using thematic analysis.ResultsUninsured pregnant patients were characterized by physicians as socially vulnerable, with precarious immigration status that limited their access to health services. Uninsured patients were thought not to benefit from the same standard of perinatal care as their insured counterparts. Care of uninsured women was generally thought to be a professional obligation, regardless of the woman’s ability to pay. Caring for this population was considered by family physicians to be challenging, engendering psychological stress, increased workload, and occasional tensions with other health care providers.ConclusionIn the present context, family physicians are left to negotiate the health care system in an attempt to provide adequate perinatal care for uninsured pregnant patients. This situation has repercussions for physicians, for patients and, ultimately, for infants. Leadership is required to ensure that all pregnant women in Canada have access to appropriate health care during the perinatal period.     

Assessing women’s perinatal psychological health: exploring the experiences of health visitors

Objective: This study aimed to explore health visitors’ (HVs) experiences of the assessment of women with psychological distress and mental health problems across the perinatal period in clinical practice. Background: In international contexts, there is now a firm policy remit for the assessment of psychological and mental health disorder across the perinatal period. Women are in regular contact with health professionals across this time and consultations intuitively create an ideal and appropriate context in which to assess women’s psychological health. National reports and academic literature highlight that to prevent the escalation of perinatal mental illness, significant change is needed to support health professionals in detecting, discussing and dealing with mental illnesses. Methods: In a qualitative aspect of a larger mixed-method study, data were collected from two Focus Group Discussions with HVs pre and post a training session related to assessing and managing perinatal mental health problems in practice. For the purposes of this paper, the data were explicitly examined for references to recognition and assessment. Results: Four themes emerged from the data: recognising the problem; questioning and identification; so what do I do now; the importance of support to promote effective identification and assessment. Conclusion: Findings elucidate the complexities that practitioners face in assessing women’s psychological health in real world settings. HVs’ experiences highlight that the implementation of measures into practice needs to be workable and accompanied by contemporary and appropriately contextualised knowledge, adequate service provision and clear referral pathways to ensure effective assessment of women’s psychological health.     

Mothers’ views of caseload midwifery and the value of continuity of care at an Australian regional hospital

Objectiveto evaluate mothers’ satisfaction with a caseload-midwifery scheme, and whether this varied according to the extent of continuity of care provided.Designmothers’ satisfaction with care was assessed using a postal survey, which was linked with their clinical outcomes data.Settingthe Wollongong Hospital, the major public hospital in the Illawarra region, New South Wales, Australia.Participants174 women gave birth during the evaluation period of a pilot midwifery group practice (MGP) programme at the Wollongong Hospital between 5 July 2004 and 30 April 2005. This group included 87 primiparous and 87 multiparous women, all of whom met the Australian College of Midwives’ criteria for low-risk pregnancies.Interventionthe MGP was staffed by six midwives working in two groups of three. Each midwife took on a primary caseload of 40 women per year, and provided support as a secondary midwife to women cared for by colleagues.Measurementsmothers’ satisfaction with care and adjustment to motherhood were assessed with self-completed questionnaires. Survey responses were linked with clinical data, allowing examination of the relationship between maternal satisfaction and continuity of care.Findingsthe MGP achieved high levels of continuity of care, both objectively (based on birth records) and from mothers’ perspectives. Overall, mothers’ evaluations of their care were very positive. Women indicated that their relationships with their midwives were genuinely caring and a valued source of reassurance and comfort during pregnancy, labour and early motherhood. Although continuity of care did not predict summary scores for maternal satisfaction, it was related to some individual items on the satisfaction scales. Satisfaction with control and communication was predicted by parity and the level of intervention during labour and birth.Key conclusionscontinuous care appears to facilitate the development of supportive relationships between women and their midwives. Women's perceptions about continuous and respectful treatment were related to objectively measured continuity of care. The qualitative data confirm the importance of less tangible benefits, such as the quality of relationships between women and their caregivers.Implications for practicethe viability of caseload-midwifery-led care for low-risk pregnancies depends, in part, on the model's acceptability to consumers. This study demonstrated that the caseload model is associated with high levels of maternal satisfaction. Supportive relationships with midwives in a caseload scheme are highly valued by women.     

A systematic approach towards the development of quality indicators for postnatal care after discharge in Flanders,Belgium

Objectiveto develop a set of quality indicators for postnatal care after discharge from the hospital, using a systematic approach.Designkey elements of qualitative postnatal care were defined by performing a systematic review and the literature was searched for potential indicators (step 1). The potential indicators were evaluated by five criteria (validity, reliability, sensitivity, feasibility and acceptability) and by making use of the ‘Appraisal of Guidelines for Research and Evaluation’, the AIRE-instrument (step 2). In a modified Delphi-survey, the quality indicators were presented to a panel of experts in the field of postnatal care using an online tool (step 3). The final results led to a Flemish model of postnatal care (step 4).SettingFlanders, BelgiumParticipantshealth care professionals, representatives of health care organisations and policy makers with expertise in the field of postnatal care.Findingsafter analysis 57 research articles, 10 reviews, one book and eight other documents resulted in 150 potential quality indicators in seven critical care domains. Quality assessment of the indicators resulted in 58 concept quality indicators which were presented to an expert-panel of health care professionals. After two Delphi-rounds, 30 quality indicators (six structure, 17 process, and seven outcome indicators) were found appropriate to monitor and improve the quality of postnatal care after discharge from the hospital.Key conclusions and implications for clinical practicethe quality indicators resulted in a Flemish model of qualitative postnatal care that was implemented by health authorities as a minimum standard in the context of shortened length of stay. Postnatal care should be adjusted to a flexible length of stay and start in pregnancy with an individualised care plan that follows mother and new-born throughout pregnancy, childbirth and postnatal period. Criteria for discharge and local protocols about the organisation and content of care are essential to facilitate continuity of care.     

Development and internal validation of a multivariable model to predict perinatal death in pregnancy hypertension

ObjectiveTo develop and internally validate a prognostic model for perinatal death that could guide community-based antenatal care of women with a hypertensive disorder of pregnancy (HDP) in low-resourced settings as part of a mobile health application.Study designUsing data from 1688 women (110 (6.5%) perinatal deaths) admitted to hospital after 32 weeks gestation with a HDP from five low-resourced countries in the miniPIERS prospective cohort, a logistic regression model to predict perinatal death was developed and internally validated. Model discrimination, calibration, and classification accuracy were assessed and compared with use of gestational age alone to determine prognosis.Main outcome measuresStillbirth or neonatal death before hospital discharge.ResultsThe final model included maternal age; a count of symptoms (0, 1 or ⩾2); and dipstick proteinuria. The area under the receiver operating characteristic curve was 0.75 [95% CI 0.71–0.80]. The model correctly identified 42/110 (38.2%) additional cases as high-risk (probability >15%) of perinatal death compared with use of only gestational age <34 weeks at assessment with increased sensitivity (48.6% vs. 23.8%) and similar specificity (86.6% vs. 90.0%).ConclusionUsing simple, routinely collected measures during antenatal care, we can identify women with a HDP who are at increased risk of perinatal death and who would benefit from transfer to facility-based care. This model requires external validation and assessment in an implementation study to confirm performance.     

Obstetric Risks and Outcomes of Refugee Women at a Single Centre in Toronto

ObjectivesWomen who are refugees during pregnancy may be exposed to homelessness, poor nutrition, and limited access to health care, yet the pregnancy outcomes of this vulnerable population have not been systematically evaluated. We undertook a study to determine the risk of adverse obstetric and perinatal outcomes among refugee women in Toronto.MethodsUsing a retrospective cohort design, we examined pregnancy outcomes for refugee and non-refugee women delivering at St. Michael’s Hospital in Toronto, between January 1, 2008, and December 31, 2010. The primary outcome measures were preterm delivery (< 37 weeks’ gestational age), low birth weight (< 2500 g), and delivery by Caesarean section.ResultsMultiparous refugee women had a significantly higher rate of delivery by Caesarean section (36.4%), and a 1.5-fold increase in rate of low birth weight infants when compared with non-refugee women. In subgroup analysis by region of origin, women from Sub-Saharan Africa had significantly higher rates of low birth weight infants and Caesarean section than non-refugee control subjects. Further, compared with non-refugee control subjects, refugee women had significantly increased rates of prior Caesarean section, HIV-positive status, homelessness, social isolation, and delays in accessing prenatal care.ConclusionsRefugee women constitute a higher-risk population with increased rates of adverse obstetric and perinatal outcomes. These findings provide preliminary data to guide targeted public health interventions towards meeting the needs for obstetric care of this vulnerable population. Recent changes to the Interim Federal Health Program have highlighted the importance of identifying and diminishing disparities in health outcomes between refugee and non-refugee populations.     

Somali women's experiences of antenatal care: A qualitative interview study

ObjectiveTo explore Somali women's experiences of antenatal care in Norway.DesignA qualitative study based on individual semi-structured interviews conducted either face-to-face or over the phone.SettingNorway.ParticipantsEight Somali-born women living in Norway.Key findingsFour themes were generated from the analysis. From their experiences of antenatal care in Norway, the Somali women described: 1) when care was provided in a way that gained their trust, they made better use of the available health services, 2) the importance of continuity of care and of sharing commonalities with the caregiver, 3) a need for accessible information, specifically tailored to the needs of Somali women and 4) how culturally insensitive caregivers had a negative impact on the quality of care.Conclusion and implications for practiceThe Somali women in this study were grateful for the care provided, although the quality of antenatal care did not always meet their needs. This study should serve as a reminder of the importance of establishing trust between the pregnant woman and the caregiver, strengthening interpretation services and assuring tailored information is available to Somali women at an early stage. The findings further suggest that antenatal care for Somali women may be improved by offering continuity of care and improving clinical and cultural skills in clinicians. Suggestions for practice, and future research, include initiating group antenatal care especially tailored to Somali women.     

Women’s experience of care when undergoing termination of pregnancy for fetal anomaly in England

Objective: This study investigated women’s experience of care when undergoing termination of pregnancy for fetal anomaly (TOPFA) with a view to assisting healthcare professionals in providing optimum care to women. Background: Technological developments in antenatal screening and testing mean more women are given a prenatal diagnosis of fetal anomaly and confront the possibility of terminating the pregnancy. TOPFA is a psychologically significant life event, but there is limited evidence on how women perceive their termination care. Methods: A cross-sectional online survey was used to elicit qualitative data as part of a study examining women’s experience of the TOPFA procedure, in particular the choice of method. Women were asked to comment on what they had found helpful and unhelpful in their termination care. Participants were recruited from a national support organisation. A total of 361 women offered qualitative comments, which were analysed using thematic analysis. Results: Women’s experience of termination care varied. Five themes were identified as underpinning what women considered ‘good care’: being cared for in a timeframe and environment that feels right; receiving the right level of care; the role of healthcare professionals and support organisations; acknowledging women’s particular circumstances; and enabling women to make choices. Regarding the last theme, women particularly valued being offered a choice of termination method. Conclusions: The findings suggest that many women undergoing TOPFA perceived their care as lacking in some way. Recommendations on improving practice are made and areas of further research are suggested, which may deepen knowledge on how best to care for these women.     

‘It's a good thing…’: Women's views on their continuity experiences with midwifery students from one Australian region

Backgroundmidwifery relationships, especially ones developed over time, are viewed and valued as practical and political health interventions that increase the likelihood of good health for women and infants and assist with health challenges. Thus the continuity relationships with women required for each Bachelor of Midwifery student are used, not only to expand students' learning but also, in a fragmented maternity care system, to provide opportunities for women to experience the care of a known person through their pregnancy, labour and early parenting time.Aim of the studywe sought understandings of women's experiences of their continuity relationships with midwifery students.Methoda survey was posted to all women (n=1008) who had agreed to continuity in the first years of our undergraduate program 2009–2011. We analysed 354 completed surveys (34% response rate). SPSS was used for quantitative data and content analysis identified themes expressed in the qualitative responses from a selected sub-set of 27 participants. Ethical approval was obtained from the authors' institution and research funding from the local registration board.Findingswomen's satisfaction of being with a student in a continuity relationship was high. On a scale from one (not at all satisfied) to 10 (extremely satisfied), the mean score was 8.88. The women, more than half of whom received standard maternity care, stated they valued the opportunity for a constant presence across their childbearing experience and will recommend student continuity to their friends.Conclusions and implicationsthis study shows that our curriculum emphasis on continuity is valued by women. Pairing a woman and a student gives women a relationship with a named person in the maternity health field that provides valued extras: care, time, patience, effort, information, advocacy, support and kindness. It raises the profile of midwifery in the community, especially the profile of continuity of midwifery care for women in standard models of care. It increases communication for and with women in a variety of useful and desirable ways and it allows an opportunity for women to contribute to students' learning. It also provides the university sector a chance to value and privilege the continuity of midwifery relationship.     

Assessment acting as intervention: findings from a study of perinatal psychosocial assessment

Objective: To consider how psychosocial assessment in the perinatal period may act as an intervention. Background: Psychosocial assessment has been introduced into routine antenatal care in several countries but there has been no consideration of ‘measurement reactivity’, the effects of such processes on those being measured. Methods: Psychosocial assessment as part of routine antenatal booking and by self-completion of a research questionnaire, followed by interview of a purposive sample of 22 women who scored above threshold on maternal stress measures. Interviews were conducted up to three times during pregnancy and the early postnatal period, to explore women’s experiences and understandings of maternal stress and to obtain their views on antenatal psychosocial assessment and social support. Transcribed data and field notes were analysed using Framework Analysis. Results: The potential for assessment to act as an intervention varied across different settings (clinical practice and assessment in a research context), with different methods (self-completion and assessment as part of a consultation or interview), and across individuals. Measurement effects were pronounced through longitudinal involvement, interviewer style and concurrently assessing the origins of psychological health and coping strategies. Conclusion: The analysis illustrates how reflexivity can enable new and often unexpected findings to emerge. The findings raise important questions about how the role of the research(er) is constructed, particularly when evaluating interventions. Clinically, the findings have implications for how we view psychosocial assessment within care pathways.     

Perspectives of Hospital‐Based Nurses on Breastfeeding Initiation Best Practices

ObjectiveTo assess the variation in breastfeeding knowledge and practices of registered nurses in hospital women and family‐care units and the informal and formal hospital policies related to the initiation and support of breastfeeding.DesignThis qualitative study employed a focus group approach to solicit perceptions of hospital‐based nurses regarding breastfeeding best practices.SettingEight state hospitals stratified by socioeconomic status (SES) and size served as settings to recruit participants for this study.ParticipantsForty female registered nurses from labor and delivery (n=9), postpartum (n=13), labor and delivery/recovery/postpartum care (LDRP) (n=12) and neonatal intensive care unit (NICU) (n=6) constituted eight focus groups.ResultsThe majority of nurses reported being knowledgeable of evidence‐based best practices related to breastfeeding initiation. However, in non‐Baby Friendly/Baby Friendly Intent (non‐BF/BFI) settings, nurses' knowledge often was not in accordance with current best practices in breastfeeding initiation, and reported hospital policies were not based upon evidence‐based practices. Barriers to best practices in breastfeeding initiation included hospital lactation policies (formal and informal), nurses' limited education in breastfeeding initiation best practices, high rates of surgical delivery, and lack of continuity of care with the transition of responsibility from one nurse to another from labor and delivery to transition care to postpartum care.ConclusionsA significant disparity between nurses' intention to support breastfeeding and their knowledge suggests a need for education based on the World Health Organization Baby Friendly standards for nurses at non‐BF/BFI hospitals. A significant barrier to supporting breastfeeding is lack of hospital policy and inappropriate or outdated policy.