Abstract Background The National Health and Medical Research Council and the Royal Australian College of General Practitioners recommend exclusive breastfeeding for the first six months of an infant’s life and continued breastfeeding with the addition of appropriate complementary food until at least 12 months. While most Australian women initiate breastfeeding, many wean earlier than recommended due to breastfeeding difficulties. As most women consult their GP frequently in the first six months postpartum, GPs are in an ideal position to provide encouragement, evidence-based information and advice that breastfeeding women need. In addition, women are more likely to initiate and continue to breastfeed if their doctor supports and encourages them to do so. The limited Australian data available question whether GPs have the skills to be able to effectively assist breastfeeding women, although no research has specifically addressed the breastfeeding knowledge or attitudes of Australian GPs. Additionally, there are no data detailing the breastfeeding training available to medical students, GP registrars or GPs. Aim This study aimed to identify the breastfeeding educational needs of Australian GP registrars and to develop a relevant and applicable breastfeeding educational resource within the context of these identified needs. Research design Triangulation methodology, using more than one data source and qualitative and quantitative data-collection methods, was chosen for this study to give a richer, more inclusive and wider reaching understanding of the issues involved than could be obtained by using one method alone. Therefore, to meet the aims of the study, a three phase mixed-method project with triangulation of data was designed. Phase 1 had three distinct data-collection arms: a quantitative survey of medical school curricula; focus groups with medical students from two Queensland medical schools; and interviews with eight GP registrars. Data from Phase 1 provided information about breastfeeding attitudes, knowledge needs and learning opportunities, and informed the development of a questionnaire sent to final-year GP registrars Australia-wide (Phase 2). The aim of this phase was to ascertain the GP registrars’ breastfeeding attitudes and knowledge gaps. Phase 3 used the outcomes of Phases 1 and 2 to design an educational resource that would meet the needs of GP registrars. Results Breastfeeding was included in the curricula of most of the Australian medical schools surveyed (n = 10). Many medical schools relied on contact between the student and patients to provide clinical experience and practical knowledge. Medical students and GP registrars reported marked variability in breastfeeding learning opportunities. Although both groups had positive breastfeeding attitudes, participants had differing opinions regarding doctors’ involvement in infant feeding decisions and the type of support and information offered to women. Overall, the breastfeeding attitudes of the 161 GP registrars who returned the questionnaire were positive (mean 3.99, 1 = least positive, 5 = most positive). However, while the mean breastfeeding knowledge score was 3.40, (1 = minimum score, 5 = maximum score) 40 percent of the knowledge items were incorrectly answered by more than half the cohort. Approximately 40 percent of the registrars were confident and thought they were effective assisting breastfeeding women. Nevertheless, only 23 percent thought they had had sufficient breastfeeding training. Registrars who thought their previous training was inadequate had lower knowledge scores, were less confident and perceived that they were less effective than the remainder of the cohort. A new finding from this study was that Australian-born registrars had more positive breastfeeding attitudes and higher knowledge scores than their overseas-born counterparts. In addition, while parents with more than 26 weeks’ personal breastfeeding experience (self or partner) had more positive breastfeeding attitudes and higher breastfeeding knowledge, confidence and perceived effectiveness scores, parents with less experience had less positive attitudes and poorer knowledge than non-parent participants. Similar to previous studies, gender had no effect on breastfeeding knowledge or attitudes. Using adult learning principles, a five-session, case-based breastfeeding educational resource addressing the knowledge deficits identified in the previous phases of the study was developed. Evaluation activities before and after each session, as well as exercises designed for reflection and critical thinking, were an integral part of the resource. Conclusion This study found that the breastfeeding training of Australian medical students and GP registrars was inadequate and, regardless of their positive breastfeeding attitudes, resulted in registrars being ill-prepared to assist breastfeeding women. Based on the training needs identified in the study and in the literature, an educational resource was developed that presented information within real-life case-based scenarios. Additional background information provided logic and rationale for diagnosis, management and treatment. While the implementation of the resource is outside the scope of this thesis (but will be the focus of post-doctoral work), it is believed that the resource has the potential to provide GP registrars with training opportunities to improve their breastfeeding knowledge and skills, thus better meeting the needs of breastfeeding women.

Disparities in breastfeeding are increasing for Black women in the United States despite initiatives aimed at improving breastfeeding outcomes. As a result, Black communities are not being protected, which is reflected in the disproportionate rates of mortality and morbidity for the Black dyad. Much of the qualitative studies in the literature have focused on the patient experience through focus groups or interviews. However, this information typically is not communicated to the same physicians providing the care in a study. This study aims to change that by obtaining the breastfeeding experiences and perspectives of patients and medical providers in a low-risk prenatal clinic in urban North Philadelphia. The secondary aim is to disseminate patient feedback to providers to develop a realistic call to action specific to that community. Work obligations and perceived necessary lifestyle changes were the patients' most significant barriers to breastfeeding. Patients desire more education from the medical community, but at the same time, providers lack the knowledge, comfort, and time to counsel. What is clear is that the medical system contributes to these poor outcomes; institutionalized barriers add to existing disparities and ultimately worsen the crisis for everyone, with long-term effects on the economy and productivity of the surrounding community and the population. Providers cannot create change by themselves, as breastfeeding disparities have roots in much larger policies and systems, but providers must examine what is in their scope of influence. Future research is needed to explore the effects of empowering Black communities with education regarding workplace laws and addressing myths that reinforce breastfeeding barriers. Medical education must incorporate breastfeeding into its curriculum as the consequences are dire and intersect with many areas of medicine. This research offers hope for change and has led to providers developing proposals for timely and realistic interventions based on community feedback and narratives. / Urban Bioethics