Health interprofessional collaborative practice in exclusive breastfeeding: a scoping review

The World Health Organization reports the low coverage of exclusive breastfeeding. The need for collaborative practices of interprofessional has an effort to increase exclusive breastfeeding coverage. The purpose of this scoping review is to analyze the health interprofessional collaborative practice in exclusive breastfeeding. This scoping review used the Arksey and O'Malley framework. Search for articles published from 2009 to 2019 from 5 databases (PubMed, Wiley, Sciencedirect, EBSCO, and google scholar). Data were reviewed using the PRISMA flowchart. The results of the review found the role of health professionals and health interprofessional barriers in iexclusive breastfeeding.


INTRODUCTION
The World Health Organization (WHO) recommends exclusive breastfeeding as an important strategy to reduce child mortality (Thet et al., 2016). Research shows the benefit of exclusive breastfeeding in relation to reducing child morbidity and immortality, which are to optimize infant growth, foster children's intelligence, and assist in the development of children's mental health (Quigley et al., 2012). Based on data from the United Nations Children's Fund (UNICEF) in 2019, the number of exclusive breastfeeding in 2013-2018 is that only 43% of newborns start breastfeeding in the first 1 hour of birth and 41% of babies aged six month who receive exclusive breastfeeding (UNICEF, 2019). It still not in accordance with the target set by WHO, which is to increase the rate of exclusive breastfeeding in the first 6 month up to at least 50% (WHO, 2014).
The success of exclusive breastfeeding cannot be separated from the role of health professionals as the closest service unit to the community, especially breastfeeding mothers (Astutik, 2014). The health professionals in question are those who are influential in supporting exclusive breastfeeding, comprising of midwives, doctors, and nurses (Ware et al., 2018). Research conducted by Hussainy & Dermele (2011) about knowledge, attitudes and skills of health professionals influential in realizing the success of exclusive breastfeeding, because the education provided by health workers will affect the behavior of mother in giving exclusive breastfeeding to their babies. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics strongly encourages all health professionals who care for breastfeeding women, such as doctors, nurse practitioners, and registered nurses to use their knowledge and skills to encourage and support women to breastfeeding. Collaborative practice is not a new Two focus groups with midwives: 10 midwives. Two focus groups with mothers: 9 breastfeeding mothers The findings of the study were that midwives and mothers wanted the success of breastfeeding exclusively with Mother's milk. The direct approach is more often used by midwives in providing breastfeeding support, especially in hospital settings. This study also demonstrates the importance of providing breastfeeding support adjusted to the needs of the mother. The aim of this study was to explore the barriers that lactation consultants felt for managing problems with early breastfeeding.
Qualitative approach with grounded theory methodology.
In-depth interviews, data were digitally recorded, transcribed and analyzed in Atlas.ti.
30 International Council Certified Lactation Consultants.
The findings of the study found several obstacles that is, institutional constraints, lack of coordination in the health system, and give poor service which is not evidence-based. These factors are interrelated which have an impact on the management of breastfeeding problem management.

5.
The struggle for interprofessional teamwork and collaboration in maternity care: Austrian health professionals' perspectives on the implementation of the Baby-Friendly Hospital Initiative / (Wieczorek et al., 2016) / A

Austria
The study aimed to identify factors that could explain healthcare professionals' striving to promote and support collaborative breastfeeding in maternity units, based on previous research.
Qualitative. Semi-structured interviews and thematic analysis. Interviews used an interview guide provided with narratives and the topics to be discussed. 11 midwives, 11 nurses, 13 doctors (8 obstetricians, 3 pediatricians, 2 anesthetists), and one quality manager The research findings indicated several obstacles in the practice of interprofessional collaboration, especially in hospitals, such as differences in approaches and strategies in harmonizing professional approaches. Effective collaboration and good collaborative practice between midwives, nurses and doctors require extensive and continuous intervention in their skills and competencies.

6.
Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: a case study / (Behruzi et al., 2017) The aim of this study was to explore the barriers and facilitators of interprofessional and interorganizational collaboration between midwives in birth centers and other health care professionals.
Qualitative. Semi-structured interviews with direct observation, field notes, and various organizational and policy documents and files. Qualitative thematic analysis methods were used to analyze word-by-word transcripts. 4 administrators, 2 family doctors, 5 family doctors and obstetricians, 9 nurses, and 5 midwives.
The findings in the study show barriers to interprofessional health, including professional competition, differences in philosophy and work style, conflict of compensation issues, lack of time for interaction and communication between professionals, intervention versus nonintervention between interprofessionals and organizations, differences in rules and structures between organizations produce tension significantly.

7.
Breastfeeding Counselling can be a Matter of Interprofessional The aim of this study was to describe health professional care reflections on infant formulas given after birth and differences in how midwives understand their responsibilities.
Qualitative. Data were collected through a midwife's handwritten description of the care given to new mothers whose babies were fed formula milk.
The written text is interpreted through the study of the text structure and internal logic.

midwives
Breastfeeding presents a challenge for interprofessional cooperation and good communication between pediatricians and midwives, otherwise they will lose their holistic view of the mother-child relationship.

Descriptive summary and thematic analysis
The findings by systematic search resulted in 7 good quality articles. Of the 7 articles, all articles used qualitative research methods and most came from developed countries including New Zealand (n = 1), Belgium (n = 1), Sweden (n = 1), Canada (n = 1), Austria (n = 1), United States (n = 1), and one article came from a developing country, namely Bhutan (n = 1). The role of health professionals in exclusive breastfeeding 1. The role of the midwife a. Provide emotional support and self-efficacy to nursing mothers The views and attitudes of health professionals influence breastfeeding practice immediately after birth and during the post-partum period. Mothers need individual support from health professionals and need empowerment for themselves (Alianmoghaddam et al., 2017). This is in line with research Wieczorek et al (2016) that the attitude and education provided by health workers is very important to support or prevent the initiation and duration of breastfeeding and formula feeding. The importance of empowering and building mother's confidence in relation to breastfeeding is described as one of the main tasks of the midwife. In particular, midwives encourage on-demand breastfeeding or avoid formula feeding unless medically indicated. This is supported by research from Schafer et al (2017) which explained that health workers play a very important role in supporting mothers during difficult times in the breastfeeding process, building and maintaining intention to breastfeed, empowering them, increasing self-efficacy, and being able to continue to breastfeed their babies. b. Provide direct and indirect support Direct support provided by the midwife, which is the midwife physically touching the mother's breast with the excuse of helping to manually express milk from the breast, and repositioning the baby on the breast or attaching the baby to the breast manually. Meanwhile, indirect support means without physical intervention from the midwife. The mother independently attaches the baby to the breast. Midwives only observe, correct and train mothers to breastfeed (RM et al., 2019). It is in line with research by Swerts et al (2016) which explains that health professionals in providing breastfeeding support use direct and indirect approaches in providing support as a skilled companion. c. Provide Counseling, Information and Education Midwives are very instrumental in providing appropriate information and education in helping mothers to breastfeed their babies (Zwedberg, 2014). In line with the research of Doherty et al (2019) which explains the role of health professionals is divided into two, which are a positive role and a negative role. The positive role of health professionals is as an important and reliable source of information and education. As for the negative role, some health professionals only intervene without providing assistance and support. Counseling and information as well as support from health professionals are also positively associated with duration of breastfeeding. Conversely, lack of information and support from health professionals is negatively associated with exclusive breastfeeding (Ekström & Thorstensson, 2015;Grubesic & Durbin, 2017).

The role of pediatrician
The review results explain the role of pediatricians, which is providing interventions in exclusive breastfeeding. Pediatricians are more likely to measure breastfeeding success (mostly) on the basis of pediatric reference points for infant weight. They value the quantity rather than the quality of breast milk (Wieczorek et al., 2016). Pediatricians focus more on short-term solutions, so they often turn to formula milk as a quick fix rather than taking the time to solve breastfeeding problems (Anstey et al., 2018). Pediatricians consider breastfeeding nothing more than a means of feeding a baby. Other studies have also shown that the use of formula supplements is a quick fix that doctors and nurses give when they are unable to solve breastfeeding problems quickly and easily (Nelson et al., 2016). Pediatricians and obstetricians believe that they lack the skills needed to become breastfeeding educators and companions (Sigman-Grant & Kim, 2016;Sims et al., 2015). 3. The role of the nurse Specifically, the role of nurses in exclusive breastfeeding is to provide monitoring and care for mothers and babies so that breastfeeding problems are sometimes not resolved (Wieczorek et al., 2016). Mothers felt that the lack of inconsistent breastfeeding support and advice offered by nurses was one of the main causes for stopping breastfeeding (Attard Montalto et al., 2010).

The role of a lactation consultant
A lactation consultant is a consultant who has been licensed by the International Board Certified Lactation Consultants (IBCLC). The role of a lactation consultant is to provide information and help overcome breastfeeding problems. However, lactation consultants often face problems in the early postpartum period. Some problems are handled with counseling, but some mothers eventually stop breastfeeding because of unresolved lactation problems (Alianmoghaddam et al., 2017). Lactation consultants must also continue to refer for diagnosis and treatment (Anstey et al., 2018). Lactation support and education from lactation consultants have a positive impact on breastfeeding initiation, duration, and levels of exclusivity (Andaya et al., 2012;Patel & Patel, 2016;Teich et al., 2014). One study found that the integration of breastfeeding evaluations scheduled by a lactation consultant into pediatric practice increased maternal satisfaction and duration of breastfeeding (Witt et al., 2012).

Barriers to institutions
Barriers to institutions in interprofessional collaboration are institutional constraints and lack of coordination in the health system. Institutional constraints relate to hospital policy and practice. Lack of coordination between health professionals can illustrate the continuity of intermittent care and inconsistencies in treatment plans and recommendations between lactation consultants, nurses, pediatricians and obstetricians. Institutional practices, policies and coordination can influence care services. Hospitals that are designated as hospitals that implement the Baby-Friendly Hospital Initiative (BFHI) have implemented evidence-based practices and policies that support breastfeeding and lead to coordination and lead to better care for families. However, many hospital protocols encourage practices that hinder breastfeeding. Including non-medically complement or formula feeding in the hospital (Anstey et al., 2018).

Barriers between professions
Profession barriers include different approaches between midwives, nurses and doctors regarding childbirth and breastfeeding. In particular nurses and doctors, they define labor and breastfeeding as processes that require medical control. Meanwhile, midwives refer to the natural processes of childbirth and breastfeeding such as breastfeeding on demand. Another obstacle is the strategy to harmonize the interprofessional approach. These different strategies seem to hinder collaborative practice. Nurses and doctors share bio-medical approaches and interventions regarding childbirth and breastfeeding that differ from interpretations of midwives. Nurses and doctors interpret in medical terms, but midwives emphasize more philosophical attitudes and practices. Meanwhile, the relevance of effective interprofessional collaboration is largely determined by the same approaches and strategies among health professionals (Wieczorek et al., 2016). 4. Barriers to work culture and communication Barriers to work culture are largely due to the health professional philosophy and different working styles between obstetricians and midwives in hospitals and midwives at birth centers. Midwives prioritize the importance of continuous care, women's empowerment and one-on-one care. Meanwhile, obstetricians mostly see pregnancy, childbirth, and breastfeeding as risky conditions that require intervention. Furthermore, the lack of time for interaction and communication between health professionals also hinders the practice of interprofessional health collaboration. They do not have time together once a week to do formal teaching on a topic, review cases or discuss different issues (Behruzi et al., 2017). Indirect communication can also make it difficult to develop a holistic view of the mother-child relationship. Where health professionals focus on different parts (Zwedberg, 2014). In line with the research of Soemantri et al (2019) that the most significant factor that hinders interprofessional collaboration in health is poor communication. Communication barriers such as, misinterpretation of messages and slow response after receiving messages cause significant problems in teamwork. The mode and frequency of communication in a team occupies an important place in interprofessional collaboration. Garner et al (2016) also conducted interviews with obstetricians, midwives, pediatricians, nurses and lactation consultants who found that discontinuity in breastfeeding care was a major barrier to providing breastfeeding support. This discontinuity is caused by lack of time and skills of health professionals, inconsistent messages, poor communication between providers which leads to continuity of care.

Barriers to the organization
The factors that hinder the implementation of interprofessional collaboration felt by all health professionals are the nature of the organization as well as differences and organizational structure. Another obstacle is the difference in rules and structure between the Hospital and the Birth Center. Health professionals revealed that the hierarchical nature of doctors in hospitals who consider midwives as subordinates has an influence on inter-professional and inter-organizational collaboration. The obstetrician has the power to decide the last word. So that midwives feel that they cannot provide the same care as in a birth center if it is under the control of a doctor at the hospital (Behruzi et al., 2017).

CONCLUSION
The current scoping review highlights the role of health professionals and the importance of health interprofessional collaboration in maintaining and enhancing exclusive breastfeeding by minimizing barriers to interprofessional health collaborative practice.
Health professionals have a very significant role in maintaining and increasing exclusive breastfeeding. Every health professional has a different role. Midwives have a role in providing emotional support and self-efficacy to breastfeeding mothers, providing direct and indirect support and providing counseling, information and education. Pediatricians have a role in providing interventions in exclusive breastfeeding. Lactation consultants have a role to provide information and help solve breastfeeding problems, as well as the role of nurses in providing monitoring and care for mothers and babies.
In the practice of interprofessional health collaboration, there are also several obstacles, including barriers to health professional resources, barriers to institutions, barriers between professions, barriers to work culture and communication, and barriers to the organization.