Caseworker Perceptions of the Implementation of Breastfeeding within Child Welfare: A Mixed Methods Study

Background and Purpose:

Infants make up almost a quarter of the 200,000 children placed in foster care annually in the United States. Mothers whose infants are removed are more likely to have mental health diagnoses, including postpartum depression, and have reduced opportunities to develop attachment with their infants. To address family mental health and relationships, family-centered interventions are increasingly offered to support parent-child attachment. One family-centered intervention is breastfeeding, which allows for the continuation of breastfeeding for infants placed in out-of-home care, which supports infant nutrition, parent-infant bonds, and parental mental health. However, breastfeeding is currently only supported by policy in two states. The objective of this study was to understand child welfare caseworker decision-making about the feasibility and acceptability of breastfeeding for parents of infants.

Methods:

This study used an explanatory mixed methods vignette design. Phase one quantitatively measured caseworkers’ perceptions of family-centered intervention feasibility and acceptability in the presence of postpartum depression using a sample of 136 child welfare caseworkers using cross-sectional surveys. Surveys were analyzed using ordinal probit regressions to determine the association between breastfeeding and presence of postpartum depression, on acceptability and feasibility. Phase two used a qualitative vignette design to understand how a nested sample of 23 caseworkers made decisions about breastfeeding feasibility and acceptability. Guided by the Consolidated Framework for Implementation Research, reflexive thematic analysis guided theme creation aimed at understanding factors impacting decision-making about implementation. Mixed methods analyses then integrated quantitative and qualitative phases, identified patterns of convergence and divergence, and generated meta-inferences.

Results:

In quantitative analyses, there was no significant difference in the level of acceptability between breastfeeding and all other family-centered interventions. Postpartum depression was similarly not associated with breastfeeding acceptability. Breastfeeding was perceived as significantly less feasible than other family-centered interventions, and postpartum depression marginally reduced intervention feasibility. Qualitatively, breastfeeding was perceived as beneficial for the parent-child bond, supporting its acceptability. However, caseworkers described liability concerns should there be safety risks from the parent such as substance use disorders or mental health conditions. These results supported quantitative findings that breastfeeding was not more or less acceptable than other interventions since most family-centered interventions support parent-infant bond, so caseworkers wished to identify the intervention that would maximize time together and infant safety. Caseworkers identified feasibility concerns related to breastfeeding, paralleling the quantitative results. Caseworkers attributed these concerns to the ability to facilitate increased visits between parent and child while ensuring the safety of the child.

Conclusions and Implications:

Overall, the study highlighted multiple areas of significance for child welfare practice, policy, and research. The study identified facilitators and barriers for breastfeeding that can be used to evaluate organizational capacity and needs to better implement breastfeeding. State policies should prioritize attachment through procedures allowing for increased visits and improved training on postpartum health. Future implementation research can specify implementation processes addressing facilitators and barriers to then evaluate impacts of interventions on families. This study ultimately elevates breastfeeding as a priority within child welfare.