The National Breastfeeding Helpline Evaluation report

3.1 Access to Helpline breastfeeding information and support

Page last updated: 13 February 2013

Service implementation

Has the Helpline service been implemented as intended?

Trained volunteer counsellors are rostered on to shifts over the 24 hour period of the Breastfeeding Helpline service, on seven days of the week.The roster takes account of patterns of demand for the service, which fluctuates within the 24 hour period, between week days, weekends and on public holidays. There is a core of approximately 100 counsellors rostered in a week with additional capacity through unscheduled log in of counsellors during shifts.

Information about counsellors on roster and the number of calls to the Breastfeeding Helpline shows that the proportion of calls to counsellors has gradually increased over the period from July 2009 to March 2012 from approximately 15 to 17 calls per counsellor respectively. Over the same period, the proportion of counsellors to calls answered has remained relatively constant at around 13 calls per counsellor (see 0). Counsellor survey feedback, however, suggests that some shifts at least can be very busy with little time for pause. As volunteers are home based, a heavy caseload would reduce the flexibility for counsellors to attend to other matters over the period of the shift and potentially reduce their capacity to volunteer.

Figure 3.1 counsellor caseload by calls received and by calls answered

Graphical Presentation of counsellor caseload by calls received and by calls answered
Text version of Graphical Image of counsellor caseload by calls received and by calls answered

Source: ACG analysis of Helpline administrative data.

Promotion of the Breastfeeding Helpline as a toll free call is diminished by the increase in mobile phone users. Calls from mobiles to 1800 numbers are charged at standard rates. Mobile phone calls made up 27 per cent of calls received by the Breastfeeding Helpline since October 2008 to February 2012 and 32 per cent of unanswered calls for the same period. Stakeholder feedback including comments from focus group participants suggested that cost may have an impact on young mothers using the Breastfeeding Helpline.This potentially restricts their choice of support services rather than necessarily their access to alternative sources of information and support. However, professional associations and jurisdictions consulted expressed concerns about equity of access for mobile phone users.

In relation to service coordination and facilitating pathways to services, information about the Breastfeeding Helpline is provided by a wide range of service providers and in different settings. 02 shows that the hospital setting is the most likely place for callers responding to the evaluation survey to have first heard about the Breastfeeding Helpline. Friend or family member was the highest single source of information about the Breastfeeding Helpline followed by health professionals dispersed across the workforce and including midwife, maternal and child health nurse and to a lesser extent, doctor and lactation consultant. Information provided by the ABA featured in access to the website, brochure and most likely in information provided in hospital.

Figure 3.2 First source of information about the Breastfeeding helpline reported by callers (N = 97 callers)

Graphical presentation of First source of information about the Breastfeeding helpline reported by callers (N = 97 callers)
Text version of Graphical Image of First source of information about the Breastfeeding helpline reported by callers (N = 97 callers)
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Source: ACG National Breastfeeding Helpline Caller Survey, 2012.

The Breastfeeding Helpline support has also included active referrals to other services. Counsellor feedback through the evaluation survey showed that 85 per cent of respondents made a referral on their last shift (see 03). Fifteen per cent of respondents also indicated that a referral would have been made if they had been able to access information on the appropriate agency.

Counsellors also noted that where callers on their last shift indicated that they had been referred to the Breastfeeding Helpline, this referral was made by friends or family (77 callers) or health professionals (72 callers). Eight callers indicated a referral by another helpline.

counsellor referrals during last shift (n = 174 respondents)

Graphical presentation of counsellor referrals during last shift (n = 174 respondents)
Text version of counsellor referrals during last shift (n = 174 respondents)

Source: ACG National Breastfeeding Helpline Counsellor Survey, 2012.

Stakeholder feedback, however, suggests that there is not a systematic or integrated process for referrals to the Breastfeeding Helpline at jurisdictional level and through the related workforce.

It was also evident from consultations that other national and jurisdictional helplines attract breastfeeding calls (over 40,000 calls in a 12 month period to two helplines in one jurisdiction) reinforcing the view that callers may go to several sources for support. There was some concern about the need for clear differentiation between helplines to assist in minimising duplication of services, appropriate referrals and improving consumer choices.

To this extent, stakeholders articulated the key features of the Breastfeeding Helpline as including non - clinical, peer support, available at all times and anonymous.

Effectiveness of telephone helplines to support breastfeeding

Telephone helplines

Telephone based interventions are an increasingly common and legitimate method for the delivery of health services. They can provide a flexible and in home support for callers that bypasses barriers to healthcare such as accessibility, geography, transportation and cost. They are not without limitations however, relying on caller initiative and preclude face-to-face contact.

Table 3.11 provides a snapshot of selected helplines available to parents and other callers to provide information, advice and support about infant feeding and breastfeeding.

Table 1.1 helplines available to mothers, parents and caregivers

Helpline
Coverage
Staffing
Aim
National Breastfeeding Helpline
1800 686 268
National coverage
24 hours a day, 7 days a week
Volunteer counsellorsReassurance, support and counselling for breastfeeding mothers and other callers.
Pregnancy Birth and Baby Helpline
1800 882 436
National coverage.
24 hours a day, 7 days a week.
Registered nursesGeneral advice and counselling about pregnancy, childbirth and parenting issues during the first 12 months of a baby’s life.
Health Direct Australia (incorporating the after hours GP Helpline)
1800 022 222
Available in the Australian Capital Territory, New South Wales, Northern Territory, Western Australia, South Australia, Tasmania.
24 hours a day, 7 days a week
Registered nurses and General PractitionersHealth information and assistance about any health issue, with capacity for referral to a GP for diagnosis and medical advice.
Victorian Maternal and Child Health Helpline
13 22 29
Available in Victoria.
24 hours a day, 7 days a week.
Qualified maternal and child health nursesInformation, support and guidance regarding child health, nutrition, breast feeding, maternal and family health and parenting for Victorian families with children from birth to school age.
Nurse-on-Call
1300 60 60 24
Available in Victoria
24 hours a day, 7 days a week.
Registered nursesExpert health advice from a registered nurse, 24 hours a day, 7 days a week.
13Health
13 43 25 84
Available in Queensland
24 hours a day, 7 days a week.
Registered nursesHealth related information and advice including provision of a child health advice service that provides parenting support, education and advice to parents/carers and service providers of children aged 0-5 years.
Parenting lines
Various numbers across each jurisdiction
Operates in each jurisdiction – operating hours vary across each jurisdictionProfessional counsellors from a range of backgrounds including social work and psychologySupport, counselling and parent/carer education for children aged between 0–18 years of age.
Source: Helpline websites
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The rise of Web 2.0 technology and the proliferation of smart phones is driving change amongst service delivery models and the manner in which individuals source information.

Video conferencing and other interactive internet based interventions are an emerging (though at times problematic) field of healthcare, that have been shown to provide an important role in facilitating peer support and gathering information (Cowie et al 2008; and Hardyman et al 2005).

Table 3.2 provides an overview of selected websites, types of information available, and the level of user interaction available to users seeking breastfeeding information and support.

Table 3.2 websites available to mothers, parents and caregivers

Website
Information and education
User interaction
The Australian Breastfeeding Association
Australian Breastfeeding Association website
Comprehensive information about breastfeeding; information also available about weaning and other forms of infant feeding. Activities and promotion of membership to Australian Breastfeeding Association also provided.E-counselling provided.
Online forum hosted by the Australian Breastfeeding Association.
The Pregnancy, Birth and Baby web portal
The Pregnancy, Birth and Baby web portal
Fact sheets covering the first 12 months of a baby’s life, including breastfeeding, and other forms of infant feeding.Not applicable.
Raising Children Network
Raising Children Network website
Resources to assist parents raise children from birth to teens. A range of formats and methods used, including streaming video demonstrations.Online forums hosted by Raising Children Network.
The Bub Hub
The Bub Hub website
Independent pregnancy and parenting website, providing information from conception to the early years.Online forums hosted.
Babycenter
Babycenter website
Pregnancy and parenting website, providing information from conception to the early years.Online forums hosted.
Web Child
Web Child website
Parenting resource, from pregnancy to schooling.Online forums hosted.

Good practice in the delivery of telephone information and support

Noting these features, a systematic review of different telephone support services for women during pregnancy and early post partum, provided inconclusive findings on services such as smoking cessation advice, but did find that telephone support can positively impact on breastfeeding duration and exclusivity (Dennis & Kingston 2008). Significant features of these studies on the effectiveness of telephone helplines, includes:
  • the capacity for mothers to call when they need to, rather than relying on set times; and
  • the greater relevance of peer support and counselling support, rather than professional or clinical advice, in contributing to improved breastfeeding outcomes, noting that peer support and counselling is highly dependent on the quality of training provided and accordingly more susceptible to service variability (Dennis & Kingston 2008).
The importance of providing a service that ensures continuity of care is borne out by an evaluation of a service operating from a local government authority in Melbourne that incorporated both a telephone support line and in home visits. The evaluation found that mothers were breastfeeding longer and were better educated about the benefits of breastfeeding (Coffield 2008). In this instance, the staffing of the telephone helpline is undertaken by a Maternal and Child Health Nurse Lactation Consultant and is integrated into a broader service system response.

Key features of approaches to telephone helplines in other countries includes:
  • findings that quality rather than the quantity of peer support contact appeared to be the most important factor in a peer telephone support and assistance service established in Canada for first time mothers (Dennis et al 2002);
  • establishment of a language-specific newborn feeding telephone helpline serviced a hard to reach culturally and linguistically diverse population and appeared to contribute to improved breastfeeding exclusivity and duration (Janssen et al 2009); and
  • Breastfeeding helplines in Taiwan and Lebanon found that use of the service was highest by mothers calling during the first month after birth (Wang & Chen 2008; and Osman et al 2010).
Drawing on the review of services currently available, the selected literature, and consultations undertaken during the project, identified good practices associated with the delivery of a breastfeeding support helpline have been summarised in Box 3.1.
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Box 3.1 Good practice relevant to a Breastfeeding Support Helpline

Availability and responsiveness
  • The provision of 24 hour, 7 day a week access is required of a breastfeeding support line if it is to service the demands and potential stresses associated with breastfeeding.
  • The flexibility and responsiveness to accommodate different types of calls, ranging from simple information requests through to the counselling of distraught mothers, is another indicator of an effective service. Significant wait times are an inhibitor to ongoing engagement of mothers.
Quality and consistency of information and support
  • A staffing profile of well trained and supported counsellors or practitioners is required to ensure a quality service, retention of the workforce and to sustain confidence within the service population.
  • Variability in breastfeeding information and support can confuse mothers and impact decisions they make about breastfeeding their child. Accordingly, the presence of a: trained and competent telephone staffing workforce; consistent and up to date organisational resources and guidelines; linkages with other services and research organisations; and ongoing quality assurance measures, are essential to ensuring a consistency of information and advice provided to callers.
Integration of services, and continuity between professional and peer support
  • Mothers trust and rely on quality health and clinical advice to assist them in promoting their child's health and wellbeing. They also value their own informal social networks, and peer support provided by other mothers who have real life experience of the issues they are facing. An effective breastfeeding support helpline needs to sit within a broader service system with appropriate linkages and referral pathways that assist mothers access the particular form of advice, information or support they require and when they most need it.
Capacity to meet diverse needs of callers
  • The strength of a peer support model of service provision is in having the trust and recognition of the different population groups that need to access it. This requires a staffing profile with an appropriate mix of training, skills and lived experience that aligns with potential callers. An associated promotional requirement involves appropriate marketing of the service amongst particular populations, and partnering with existing services or platforms.
Source: The Allen Consulting Group based on a targeted literature review.

Service cost effectiveness

As part of considering the efficiency of the National Breastfeeding Helpline, a cost effectiveness analysis (CEA) was undertaken, which compared the Breastfeeding Helpline with two alternative models. The methodology of the CEA is outlined, with the results and limitations of the analysis discussed. The results suggest that for all modelled scenarios, the National Breastfeeding Helpline was more cost effective than the alternatives.

Cost Effectiveness Analysis of the National Breastfeeding Helpline

A CEA compares the relative costs and outcomes of two or more interventions. In many instances, outcomes are difficult to measure, so outputs are used instead as a measure of effectiveness. When comparing the relative costs and effects of two or more interventions, an incremental analysis is performed. An incremental analysis seeks to determine how much more should be invested in a new intervention to derive an additional benefit or outcome, relative to the status quo.

From a breastfeeding helpline perspective, this will assist in identifying whether the Commonwealth Government should invest additional funds, and if so what quantity of funds, to secure additional benefits in improving current helpline arrangements.

The methodology adopted for the analysis is described in Box 3.2.

Box 3.2 Cost effectiveness analysis methodology


For this review, we have undertaken a CEA, which compares the current arrangements — the National Breastfeeding Helpline — with two alternative models. The models that have been considered in this review are:
  • Model 1: the National Breastfeeding Helpline (NBH) (status quo arrangements), with the volunteer workforce working approximately 172 hours per week which equates to 4.6 Full-Time Equivalent (FTE) workers (May 2012);
  • Model 2: a Breastfeeding Helpline with Paid Staff, which is based on the experience of the NBH with a paid workforce. Similar to the NBH, this paid workforce is estimated at 4.6 FTE workers, with wage estimates derived for a low and high salary band, for relevant classifications in the Social and Community Services (SACs) Modern Award; and
  • Model 3: an Existing Comparator Helpline, which provides advice on a range of issues, including breastfeeding. This model is fully funded and employs nurses to operate the helpline.
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The cost effectiveness of Model 1 was compared to Model 2 and Model 3 for the 2010-11, and 2011-12 financial years. Analysis was completed for total and variable (operational costs) for each of the helplines, with the measures assessed including:
  • the cost per call received, which provide a measure of demand and access for the service;
  • the cost per call answered, which measures the actual use of the service;
  • the cost per call from callers who believed support was relevant. This provides a measure of overall effectiveness and performance of the telephone helpline.
Analysis was also completed on the cost per call for priority groups, focusing on calls from Aboriginal and Torres Strait Islanders. However the sample size was too small for this cohort to provide meaningful results.
Source: The Allen Consulting Group

Results

A CEA was completed assessing the relative merits of the models for 2010-11 and 2011-12 financial years. This evaluation focused on calculating the CEA using the operational costs. This provided a more realistic representation of the variable labour costs associated with running a helpline, and removed some of the fixed costs, which were not measured consistently across the models.

Note : The individual model details inclusive of Table 3.3 have been removed from this document as they contain Commercial in Confidence data.

Findings

The results of the analysis suggest that Model 1 (the National Breastfeeding Helpline) is more cost effective than the alternatives.

However these results may be impacted by the fact that the costs of Model 3 may be significantly higher than Model 1, given that services other than feeding advice are provided. In addition, it may be the case, that Model 3 is still in an early establishment phase, and this may account for its lower volume of calls when compared to Model 1.

It may also be suggested that the performance of the National Breastfeeding Helpline may improve if staff are paid and this results in an increased number of call takers being available, given that the number of calls answered have declined over time, whereas the number of calls received have remained roughly constant over time (ABA Helpline Data 2012). These trends are in line with an increase in average call waiting time and an increase in calls lost (due to hang-ups), which correspond to a decline in the number of available volunteers. This analysis suggests that the supply of active volunteers to staff the National Breastfeeding Helpline is at a critical point with any reduction in volunteers having a direct impact on capacity to respond to demand.

In addition, 95 per cent of the callers believe that the support provided by the National Breastfeeding Helpline is relevant (StrategyCo 2011). This high rating of customer satisfaction may suggest that the room for further quality of service improvements are limited if volunteers are paid. There is also evidence to suggest there is no significant difference in service delivery performance (including productivity improvements) between paid and volunteer workers staffing the helplines (Campos 2008).

Both the high consumer satisfaction rate of the National Breastfeeding Helpline, combined with the conclusion that paid and volunteer workers perform equally (Campos 2008) also weakens the possibility that the gap between calls received and calls answered is due to a productivity issue rather than a labour shortage.

Sensitivity analysis was undertaken which adjusted the existing comparator model (Model 3) to better align with the focus of the Breastfeeding Helpline model (Model 1) and to allow for growth in calls in out years. Model 1 remained dominant for both options.

CEA discussion

The results of the CEA analysis suggest that Model 1 (the National Breastfeeding Helpline) is more cost effective than Model 2 (the Breastfeeding Helpline with paid staff) and is dominant compared to Model 3 (the Existing Comparator Helpline). These results did not change for Model 3, when sensitivity analysis was completed.

Given that volunteers staff the National Breastfeeding Helpline, these results are not unexpected. The other comparator helplines face an additional cost impost through payments for staff. In addition, the National Breastfeeding Helpline could be viewed as a more ‘mature’ helpline as it has been in operation for a number of years, compared to Model 3, which is only in its second year of operation. This may account for the differential between these helplines in terms of calls received.

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These results should be interpreted with these factors in mind. In addition, there are a number of assumptions used in the modelling, which may not hold up in practice:

  • all the outputs used in the CEA are based on ‘annualised’ estimates for the 2011-12 financial year, as data were only available for three-quarters of this year. While past trends can be used to indicate future trends, there is no reason to pre-suppose that the existing trends may apply to the last quarter of the 2011-12 financial year;
  • for the National Breastfeeding Helpline (Model 1), we have not been able to provide representative results for calls for Aboriginal and Torres Strait Islanders, given that their assumed participation rate in calling the helpline is very low at 0.58 per cent of the total (ABS 2006);
  • for the Breastfeeding Paid Staff Model (Model 2), the costs and output data have been assumed from Model 1, with the addition of the total annual wage costs. These costs are conservative estimates and may be higher if labour on-costs are included (representing an additional 10 per cent of estimated costs). However, the incorporation of these extra costs would not impact on any conclusions from the analysis; and
  • the Existing Comparator Helpline Model (Model 3) can be considered not as ‘mature’ as Model 1, given that it only started taking calls in the financial year 2010-11. Even though the calls have increased in the current financial year, the data suggests that this helpline has not reached a ‘stable state’ where calls are consistent over the years. Furthermore, the cost data are almost five times higher than those for Model 2, given that this helpline provides advice on more topics than breastfeeding alone. In addition, the costing breakdown for this model compared to the breakdown in Model 1 and Model 2, may not be strictly comparable as insufficient information was available to allow this analysis.

In terms of the sensitivity analyses, the two modelled options did not impact the results significantly, as Model 1 (the National Breastfeeding Helpline) remained dominant throughout. The first sensitivity analysis proved to be even less cost effective than the original Model 3 (Existing Comparator Helpline) since all costs ratios were roughly 20 per cent higher when compared to Model 3. However, the results of the second sensitivity analysis were improved compared to the original Model 3. This was largely due to the high assumed growth of 88 per cent and 85 per cent in calls received and calls answered respectively. However these results could be questioned, as it is not likely that the same level of growth can be sustained over time.

This analysis confirms that the National Breastfeeding Helpline is the most cost-effective option, which has been considered in this review.

This estimate is based on the number of females aged 15 to 44 years in the Aboriginal and Torres Strait Islander population.


Service utilisation

To what extent have mothers and their families utilised the services of the Helpline?
The number of calls to the Breastfeeding Helpline totalled 86,214 in 2010-2011. This represented a small increase of approximately 6 per cent over the previous year. 0 draws from the evaluation survey sample to provide a snapshot of the profile of callers. While the majority of calls were from metropolitan areas, almost one quarter were from regional Australia. A very small proportion of calls were from remote areas of some states. Over the survey period, calls were received from all states and the ACT with the majority coming from NSW and Victoria. This accords with ABA data that show the highest number of calls to the Breastfeeding Helpline since its inception originated in NSW and Victoria.

Caller Location (N = 94 Respondents)

Graphical presentation of Callers Location

Text version of Graphical Image of Caller Location (N = 94 Respondents)

Source: The Allen Consulting Group National Breastfeeding
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Based on ABA data, the NT is the lowest user of the Breastfeeding Helpline accounting for 0.8 per cent of all calls received since implementation of the service in October 2008 up to May 2012, followed by Tasmania (0.95 per cent) and the ACT (1.7 per cent). The demand for the Breastfeeding Helpline continues to be lowest for the NT when adjustment is made for the relevant jurisdiction populations as shown in 0. The figure provides an overview of the number of calls received by the number of births for each jurisdiction and Australia as a whole mapped for the period July 2009 to October 2010. The figure shows that the demand for Breastfeeding Helpline services varies across jurisdictions, with the highest demand in the ACT and the lowest in the NT. This could be explained in part by lower breastfeeding rates amongst disadvantaged population groups, including Aboriginal and Torres Strait Islander mothers, less educated women and younger mothers (ABS 2011b, 2007). For comparison purposes, calls to the Pregnancy, Birth and Baby Helpline indicate that in the first quarter of 2012, calls from the NT accounted for 0.6 per cent of all calls to the helpline (National Health Direct 2012) suggesting that low usage may be more widely applicable to telephone helplines.

Number of Calls received per Birth July 2009 to October 2010
Graphical presentation of Number of Calls received per Birth July 2009 to October 2010

Source: ABA Helpline data; ABS 2011a.

Counsellors surveyed reported that the calls taken in their last shift were largely from callers about their infants who were under the age of 12 months (see 0). Of these infants, 45 per cent were four weeks old or younger and 40 per cent were between one and six months old. The single highest age category was two to four weeks old making up18 per cent of infants under the age of 12 months.

Age of baby & number of callers reported by Counsellors during last shift (N = 172 respondents)

Graphical presentation of Age of baby & number of callers reported by Counsellors during last shift (N = 172 respondents)
Text version of Graphical Image of Age of baby & number of callers reported by Counsellors during last shift (N = 172 respondents)

Source: The Allen Consulting Group National Breastfeeding Helpline Counsellor Survey, 2012.
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As shown in 0, a large proportion (almost 48 per cent) of caller survey respondents were aged between 30 and 34 years. The age of the majority of callers ranged from 26 to 39 years (around 95 per cent). A small proportion of callers were born overseas.
The significance of this population group amongst callers to the Breastfeeding Helpline is broadly consistent with two other sources of data, specifically:
ABS data on the age of mothers giving birth, with 74 per cent of all births in 2010 occurring to mothers aged between 26 and 39 and those aged between 30 and 34 being the dominant group (32 per cent) (ABS 2011a); and
Quarterly data from the Pregnancy, Birth and Baby Helpline with 70 per cent of female callers aged 25 to 39 and those aged between 30 and 34 being the dominant group (30 per cent) (National Health Direct 2012).

Age and Place of birth of callers (N = 94 respondents)
Graphical presentation of Age and Place of birth of callers (N = 94 respondents)

Text version of Graphical Image of Age and Place of birth of callers (N = 94 respondents)

Source: The Allen Consulting group National Breastfeeding Helpline Caller Survey, 2012.

Callers to the Breastfeeding Helpline indicated that they considered a telephone helpline to be a very important source of information and advice in supporting decisions they made about breastfeeding (see 0). This was followed by maternal and child health nurse and family. A majority of respondents considered social media sources were not important.

Caller Perceptions of the importance of Information and Advice sources (N = 96 respondents)

Graphical presentation of Caller perceptions of the importance of information and advice sources (n = 96 respondents)

Text version of Graphical Image of Caller Perceptions of the importance of Information and Advice sources (N = 96 respondents)

Source: The Allen Consulting Group National Breastfeeding Helpline Caller Survey, 2012.

Consistent with previous research on callers to the Breastfeeding Helpline, 0 shows that the majority (60 per cent) of survey respondents were feeding their child exclusively on breastmilk with a further one quarter (26 per cent) partly breastfeeding and providing solids.
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