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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Breastfeeding.

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Strategy. Home Visitor Training and Education

Approach. Provide education, training, and coaching to home visiting staff to promote breastfeeding best practices during home visits

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Overview. Growing evidence shows that childhood home visiting programs for families experiencing socioeconomic challenges can have impacts in multiple areas, including maternal and child health.[1] Having someone regularly provide support to mothers, regardless of whether the home visitor is a nurse, a doula,[2] a social worker, or a paraprofessional worker, seems to improve breastfeeding outcomes.[3,4] Home visits in the first several weeks following birth may prolong the duration of exclusive breastfeeding. Postnatal support should focus on both psychosocial and practical aspects of breastfeeding.[5] Specialized home visitors can receive education, training, and coaching to provide home-based education and support to mothers and promote breastfeeding best practices during pregnancy and postpartum.

Evidence. Moderate Evidence. Strategies with this rating are likely to work. These strategies have been tested more than once and results trend positive overall; however, further research is needed to confirm effects, especially with multiple population groups. These strategies also trend positive in combination with other strategies. (Clarifying Note: The WWFH database calls this "some evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Environmental Health. This strategy improves the impact of physical, chemical, and biological factors in the environment on health.
  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Health Teaching (Education and Promotion) (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of home visiting staff who complete breastfeeding education and training. (Measures the capacity building reach of training efforts.)
  • Number of home visits where breastfeeding best practices are discussed with mothers. (Quantifies the frequency of breastfeeding support during visits.)
  • Number of hours of breastfeeding-related coaching and technical assistance provided to home visitors. (Tracks the intensity of staff development investments.)

OUTCOME MEASURES:

  • Number of mothers who receive breastfeeding education and support from trained home visitors. (Counts the mothers directly benefiting from the intervention.)
  • Number of home visitors who report increased knowledge and skills in breastfeeding best practices. (Assesses the learning outcomes of staff training.)
  • Number of mothers who initiate breastfeeding after receiving prenatal education from trained home visitors. (Links home visitor training to a key short-term outcome.)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of home visitor breastfeeding training that incorporates adult learning principles and interactive skill-building. (Evaluates the quality of training design and delivery.)
  • Percent of home visits where motivational interviewing techniques are used to encourage breastfeeding. (Measures adoption of evidence-based communication approaches.)
  • Percent of home visitor caseloads that include pregnant women and new mothers. (Assesses alignment of staff assignments with opportunities to impact breastfeeding.)

OUTCOME MEASURES:

  • Percent of mothers who report feeling more confident in their ability to breastfeed after home visits. (Measures the influence of home visiting on breastfeeding self-efficacy.)
  • Percent of home visitors who consistently provide breastfeeding education and support in line with best practices. (Tracks adherence to standards and quality improvement.)
  • Percent of mothers who receive breastfeeding support at multiple home visits during pregnancy and postpartum. (Assesses continuity and reinforcement of education.)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of community referral resources for breastfeeding support identified and utilized by home visitors. (Measures service linkages and care coordination by home visitors.)
  • Number of home visit program protocols and materials updated to incorporate breastfeeding best practices. (Captures systems-level changes and standardization.)
  • Number of joint visits conducted by home visitors and lactation consultants for high-need clients. (Tracks interprofessional collaboration and specialized support.)

OUTCOME MEASURES:

  • Number of mothers enrolled in home visiting who exclusively breastfeed for at least 6 months postpartum. (Measures impact on a key outcome and public health goal.)
  • Number of repeat pregnancies where mothers who received home visiting breastfeed their new baby. (Assesses behavioral maintenance across multiple births.)
  • Number of home visiting clients who access WIC breastfeeding peer counseling services. (Demonstrates linkages and utilization of supplemental community supports.)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • - Percent of home visitor breastfeeding training that addresses cultural beliefs and practices around infant feeding. (Assesses cultural responsiveness of staff preparation.)
  • - Percent of home visiting clients screened for social determinants of health that may impact breastfeeding. (Measures attention to contextual factors and health equity.)
  • - Percent of fathers and family members engaged by home visitors in breastfeeding education and support. (Captures a family-centered, multigenerational approach.)

OUTCOME MEASURES:

  • - Percent of low-income mothers in home visiting who initiate breastfeeding, compared to community baseline. (Assesses equity impact on a priority population.)
  • - Percent of infants in home visiting born preterm or low birthweight who receive breast milk. (Measures benefits for a group at high risk for breastfeeding challenges.)
  • - Percent increase in breastfeeding duration among home visiting clients, compared to similar families not enrolled. (Evaluates program impact on a key outcome metric.)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1Paulsell, D., Avellar, S., Martin, E. S., & Del Grosso, P. (2010). Home visiting evidence of effectiveness review: Executive summary (No. 5254a2ab30e146ce900220dbc4f41900). Mathematica Policy Research.

2 Hans, S. L., Edwards, R. C., & Zhang, Y. (2018). Randomized controlled trial of doula-home-visiting services: impact on maternal and infant health. Maternal and Child Health Journal, 22(1), 105-113.

3 McGinnis, S., Lee, E., Kirkland, K., Miranda-Julian, C., & Greene, R. (2018). Let’s talk about breastfeeding: The importance of delivering a message in a home visiting program. American Journal of Health Promotion, 32(4), 989-996.

4 Shah, M. K., & Austin, K. R. (2014). Do home visiting services received during pregnancy improve birth outcomes? Findings from Virginia PRAMS 2007–2008. Public Health Nursing, 31(5), 405-413.

5 Kronborg, H., Væth, M., Olsen, J., Iversen, L., & Harder, I. (2007). Effect of early postnatal breastfeeding support: a cluster‐randomized community based trial. Acta Paediatrica, 96(7), 1064-1070.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.