We report a selection of recent experiences on the TSB made in Italy, according to the definition given by the SIN.

Health centers

During the pandemic, between year 2019 and 2021, the Health Centers of the Baby Friendly Community ASUGI in Trieste succeeded to give online assistance to a stable percentage (around 60%) of pregnant women, who would then give birth at the Maternal-infant Institute IRCCS Burlo Garofolo, the only Maternity Hospital of the Province of Trieste. In these settings, the TSB provided by midwives has proven effective to keep at around 51% the rate of exclusive breastfeeding at 4–5 months of life [22].

A qualitative study in the NICU

The SIN in collaboration with the Italian Society of Neonatal Nursing (SIN-INF) conducted a qualitative study with the methodology of Focus Group (FG) on the TSB.

FG implies a group discussion on a specific topic, allowing members to verbalize unaware, latent or otherwise difficult to emerge elements.

The study aimed to explore the TSB before, during and after the pandemic. It sought to identify strengths and weaknesses, strategies implemented, experiences of staff and families and suggestions for future improvements provided by the participants.

Two 90 min FGs, with 11 NICU nurses and 10 neonatologists respectively, were conducted by two facilitators in May 2022 (Table 2) [23]. A convenient sample of Italian NICUs was selected. Participants were individually recruited, homogeneous by profession, with varying levels of commitment to breastfeeding. To activate the discussion in the FGs, the facilitators proposed a semi-structured questionnaire to the participants (Table 3).

Table 2 Characteristics of nurses and neonatologists, who participated in the FGsTable 3 Questions asked to participants in the 2 FGs on TSB

The story telling of the 21 participants in the 2 FGs was audio-recorded, transcribed, anonymized and analyzed for predefined categories as well as for emerging categories. Participants described the different types of support applied in their work environments and with which they had experience/knowledge. The comments listed below emerged in one or both of the two FGs.

Main comments from both the nurses and the doctors’ FGs a.

A lack of sufficient breastfeeding support in some MHs was already reported before the COVID-19 pandemic. Consequently, providing TSB during an emergency situation with preexisting sub-optimal support was particularly challenging.

b.

The implementation of TSB had to deal with the chronic and economic shortage of human and material resources. This explains why during the initial phases of the pandemic, given the limitations of access to the hospital, in some cases the TSB was rather provided by local services or by peer volunteers.

c.

Understandably, it is more difficult to communicate, be empathetic, and provide relevant help to mothers during a remote contact, instead of an in-person visit.

Main comments from the nurses’ FG a.

The TSB has been usually included in the routine general care.

b.

The NICU nurses emphasized that even before the pandemic, the hospital used to care for newborns who had been discharged from the NICU and their mothers, at least through telephone consultations. A strong and continuous relationship is usually established between the hospital and the families as part of the follow-up service.

c.

For successful breastfeeding support, health staff must have a positive attitude towards the presence of parents in Postnatal Wards and NICUs. In fact, in settings where this is not the case, the TSB would paradoxically become a tool to perpetuate the separation between parents and their newborns. In many MHs, fathers were excluded from accessing rooming-in areas and NICUs for too long after the end of the pandemic. In some NICUs, the availability of video cameras in the unit, which allow parents to see their babies from a distance, appeared to influence the delay in parents being readmitted to the NICU.

d.

Midwives mostly dealt with the TSB, less often NICU nurses, and rarely doctors. Basically, the TSB was on a voluntary basis as institutional intervention was often lacking. Moreover, instead of receiving smartphones and/or tablets from the administration, most often the devices were personal or purchased from parents’ associations connected to the NICU (Table 4).

Table 4 Smartphones for the TSB e.

The staff in charge at the TSB did not receive appropriate training in telemedicine. Their selection was simply based on having attended a WHO Counseling Course on Breastfeeding. The need for health workers to acquire new skills to provide adequate online support through various and sometimes novel devices was not taken into account. Consequently, when the TSB was implemented, the staff had to familiarize themselves with the devices mostly independently. However, this was not considered entirely negative, as competence is an asset that will endure.

f.

At least for physiological newborns, the TSB should be organized by the community services, in the context of effective integration with the MH.

g.

Although healthcare personnel were sometimes worried by the new experience, the TSB as a whole was considered positively both for the novel mode of supporting mothers and for the rewarding prompt and generous response of the staff in organizing the service (Table 5).

Table 5 The individual initiative of health workers for the TSB Main comments from the doctors’ FG a.

Even in cases where the pre-pandemic breastfeeding support was inadequate, we must acknowledge that some important steps have been taken, particularly by dedicated midwives focused on postpartum care and breastfeeding.

b.

Given staff shortage, health workers engaged with the TSB did so adding this to other routine activities.

Summarizing, the FGs witnessed the great variability of the TSB in Italian MHs with regards to type of device (smartphone, tablet computer), owner of the device (property of the department/foundation rather than health professionals) and mode of access (e.g.: free access during a dedicated time window or following the request of the mother or as part of the NICU follow-up).

The experience with the TSB was challenging and, although it caused some confusion and discomfort among the staff, overall, it was satisfactory for both health workers and families (see Table 6). In particular, the nearly constant presence of fathers at the TSB activities during the lockdown was evaluated as positive by interviewees. On the contrary, the lack of a timely availability of cultural mediators represented an obstacle for the TSB, when directed to foreign people.

Table 6 Families and the TSB

Finally, the FG participants suggested that the TBS should be complementary to the in-person support, that still remains indispensable (Table 7), and that it should be organized as an integrated service between the community health services, voluntary associations and the MH. This is particularly needed when considering the current staff shortage.

Table 7 An obvious limitation of the TSB: lack of in presence contactThe Milan COD20 IT platform

The TSB was promoted during the COVID-19 pandemic by the corporate ASST Fatebenefratelli-Sacco in Milan, Lombardy. The COD20 IT platform (acronym for Hospital Care at Home; https://www.cod20.it/), originally dedicated to hospital care during the COVID-19 pandemic [24], has been adapted for 7 Health Centers that were enabled to provide support for the management of breastfeeding (e.g.: observation and assessment of latch and of breast diseases during lactation) as well as to inform groups of women during pregnancy and postpartum. Breastfeeding women with severe issues (e.g.: mammary abscess) were addressed to the hospital and on the contrary, women who were identified during the hospital stay to suffer from mental disease (such as postpartum depression) were referred for treatment to the community mental health services.

During the pilot phase the support of a project manager was crucial, helping the operators understand the system’s potential and address critical issues that arose from its use.

Finally, the platform was fully functional in February 2021. No Apps are used, nor registration on the portal is required: the system is accessible via browser from any device. Remote visits, consultations, clinical reports and medical prescriptions can be consulted in the medical dossier created by the patient or in the electronic health record. Following a remote assessment, the specialist can decide for an in person visit.

The TSB project via COD20, called Telelactation©, has achieved considerable appreciation both from mothers, particularly those who live far from services, and from operators, especially younger ones. In 2022, more than 500 mothers received remote support, in addition to over 1500 home visits.