Strengthening breastfeeding counseling through a scaled-up intervention implemented within Ecuador’s local healthcare system

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Its effectiveness relies on the quality of healthcare training, which remains highly variable. In Ecuador, however, public health services mainly rely on group-based strategies with limited access to individualized support. This gap reinforces existing inequalities as private counseling services remain costly. This article aims to document an intervention co-developed with the local health system to strengthen healthcare capacity and implement a model of individualized counseling in a rural area of the country. Methods: This practice-based case study was implemented in two phases between 2023 and 2024. In phase I, 32 primary-level healthcare professionals participated in a training consisting of 80 hours (40 theoretical, 40 practical), focused on technical content, affective communication, and supportive counseling strategies. Focus group discussions conducted at the beginning and end of the training informed the curriculum design and evaluated changes in knowledge and attitudes. In phase II, a breastfeeding counseling room was established at the Tabacundo Healthcare Center, staffed by ten certified counselors. Standardized digital records were used to document user profiles and counseling topics. Data were analyzed descriptively with Stata and thematically with MAXQDA. Results: Ten of 32 providers (31%) completed the full training and certification process. A total of 305 counseling sessions were conducted with 247 women, most of whom were lactating (74%), aged 18–29 (68%) and resided in the immediate catchment area (87.9%). Key consultation topics included latch difficulties, nipple pain, perceived low milk supply, and the need to express and store milk. Sessions averaged 36 minutes. Adolescents and primiparous women represented a significant proportion of users, reinforcing the need for differentiated approaches. The counseling model emphasized active listening, personalized support, and emotional containment. Conclusions: This study demonstrates the feasibility of designing and implementing a breastfeeding counseling model tailored to local healthcare system resources and user needs. The model proved technically sound, contextually appropriate, and responsive to maternal trajectories. The findings offer valuable insights for scaling similar interventions in other low-resource settings and support future research into their effects on breastfeeding outcomes and maternal–infant health. Breastfeeding training healthcare professionals breastfeeding counseling educational intervention Figures Figure 1 Figure 2 Background Breastfeeding counseling is one of the main interventions to promote both the early onset and exclusive practice of breastfeeding and one of the factors the healthcare system may have an impact on [ 1 , 2 ]. According to the guidelines proposed by UNICEF and the WHO’s Baby Friendly Hospital Initiative (BFHI), one of the critical management procedures is to make sure that healthcare professionals have sufficient knowledge, competency and skills to support breastfeeding [ 3 ]. In this regard, breastfeeding counseling, conceived as an individualized intervention combining communicational, educational and technical skills of healthcare providers to support informed decision-making by mothers, requires solid and specific training to be effective [ 4 – 6 ]. Apart from that, it has been reported that its impact is greater when, during the post-natal period, it is offered personally and adapted to each woman’s particular reality [ 1 , 2 , 5 ], since it favors the early resolution of problems and complications, besides clarifying doubts concerning infant feeding [ 7 ]. Hence, the quality of counseling is directly related to the training of the professionals offering it [ 4 , 8 , 9 ]. Despite the existence of international guidelines for healthcare staff training in breastfeeding counseling [ 6 ], there is evidence of great diversity in the way such trainings are applied [ 8 , 10 ]. Methodologies vary among in-person, virtual and mixed modes, with theoretical or practical focusses, and without any clear standards regarding contents or duration, which may range from 12 to 133 hours [ 8 , 10 – 12 ]. In addition, essential aspects, such as emphatic communication, active listening and respect for cultural diversity are not always treated in the necessary depth [ 1 , 4 ]. Evidence shows that those trainings that include both theory and practice, emphasizing the latter, are more effective in strengthening the self-efficacy of healthcare providers and have a significant impact on the promotion of breastfeeding counseling [ 4 , 11 – 13 ]. On the other hand, healthcare professionals possess unequal levels of knowledge and skills in regard of breastfeeding counseling, resulting from differences in university education and the lack of continuing updating programs, thus limiting their capacities to provide effective care, especially within the context of public healthcare systems [ 4 , 10 ]. The issue gains special relevance within the Ecuadorian context where recent figures reflect a setback in breastfeeding indicators and current promotion strategies keep facing important implementation challenges in the public healthcare system. Particularly, the prevalence of exclusive breastfeeding until six months of age went down sustainably from 62% in 2018 to 53% in 2024 [ 14 , 15 ]. In Ecuador’s national public healthcare system, the main promotion activities so far are based on community support groups, facilitated by primary care level professionals who mostly are trained theoretically and virtually. In these groups, pregnant women, lactating moms and other interested persons come together to share experiences and knowledge related to baby feeding and breastfeeding practices [ 16 ]. Although these initiatives allow for the exchange of experiences, their impact on exclusive breastfeeding is minor when compared to individual interventions focused on counseling within the context of healthcare systems [ 2 ]. Notwithstanding, when different types of interventions are combined, positive synergic effects may arise [ 1 , 2 ]. On the other hand, individual counseling services do exist in the country, offered by private sector professionals at an elevated cost for large parts of the population (between 40 and 60 USD per session, in a country with a minimum salary of 470 USD). This situation evidences a structural inequality in the access to basic maternal and child healthcare, something further stressed by the empirical evidence that women living in impoverished communities face significant bars to access breastfeeding counseling services [ 17 , 18 ]. In order to guarantee the equality of access to that service, other countries such as Chile [ 19 , 20 ] and Mexico [ 21 ] implemented breastfeeding clinics within their public health services, thus ensuring technical and professional support within breastfeeding counseling. In Mexico [ 22 ], the percentage of women receiving pre- or post-natal breastfeeding counseling was 91% in the public versus 80% in the private sector, reflecting the possibilities of including breastfeeding counseling within the public health institutions. In that light, we identified two large gaps in the provision of public services for the promotion of breastfeeding: 1) limited access to individualized counseling; and 2) lack of institutionalized spaces in the healthcare system for this kind of attention, in an affordable and continuing manner. This article aims to document and describe a form of intervention developed jointly with the local healthcare system, oriented toward the strengthening of capacities of healthcare professionals, and the implementation of an individualized breastfeeding counseling model in a predominantly rural area of Ecuador, to analyze its development, the lessons learned and its potential for replicability in similar contexts. To the best of our knowledge, this is the first initiative of its kind within the framework of the Ecuadorian local healthcare system. Methods Study Design This work takes place under the methodology of a practice-based case study , aimed to describe the development of an intervention scaled-up by two complementary phases. Phase I consisted of a theoretical-practical training process for primary-level care professionals, seeking to strengthen their capacities and skills, and train them as breastfeeding counselors. Phase II focused on the implementation of a specific room within a public healthcare unit destined exclusively to offer personalized breastfeeding counseling to women in their last third of pregnancy and mothers in their breastfeeding period, realized by previously trained professionals. The study documents this experience through a narrative approach, supported by implementation process monitoring in each phase, thus allowing to progressively strengthen, correct and adjust the intervention. To do so, we used qualitative (focal groups in phase I) and quantitative-descriptive methods (analysis of care records in phase II). We point out that this was not a formal assessment of the intervention but a documentation exercise meant to extract practices and learn lessons for similar contexts. The intervention was a part of the knowledge-transfer activities toward the SEMILLA birth cohort study community, implemented in the area of Cayambe-Pedro Moncayo, Ecuador [ 23 ]. This investigation evidenced low levels of confidence among the mothers to begin breastfeeding after delivery, as well as 63.6% of exclusive breastfeeding at three months of age. Additionally, we identified an alarming rate of childhood malnutrition reaching 27% during that same period, considerably surpassing the national average of 19.3% in children less than two years old [ 15 , 24 ]. The course of the intervention had the ethical approval of the Ethical Committee for Research in Humans of Universidad San Francisco de Quito (CEISH, ID 2017-177IN; approved February 8, 2018) within the framework of the SEMILLA study. Likewise, District Health Division 17D10 (Cayambe–Pedro Moncayo) authorized its implementation in the study area. All the focal groups participants gave their oral consent in advance. Study Area and Participants The intervention took place in Ecuadorian Cayambe-Pedro Moncayo Health District 17D10, a Ministry of Public Health basic entity for the deconcentrated management and operation of healthcare services. The district is geographically located in Ecuador’s Northwest, at 80 km from the country’s capital; it comprises the cantons Cayambe and Pedro Moncayo, is located in the Ecuadorian Sierra (at approximately 2,800 m above sea level). The area’s total population is 145,750; 50% of whom reside in rural areas. In ethnical terms, 60% identify themselves as mestizos, while another 30% regard themselves as indigenous [ 25 , 26 ]. The mean income per month and household in the region is 512 USD [ 23 ]. The Health District comprises a basic secondary-level hospital, located in canton Cayambe and 15 primary-level care centers distributed in the area. Among them is a “type C” 24/7 attending healthcare center in canton Pedro Moncayo. It includes a delivery room and shared early accommodation [ 27 ]. In the Ecuadorian healthcare system, “type C” centers represent the highest level of complexity in primary care, providing emergency services and basic obstetric care. The participants were primary-level healthcare professionals in charge of attending pregnant women and lactating mothers, and district managers. In phase I, a total of 30 professionals participated, among them obstetricians, general physicians and primary-level care technicians (TAPS) [ 27 ]. The district managers were two persons in charge of district health promotion and care quality; they are co-authors of this article (ACh and JM). Phase I: Breastfeeding counselor training (March through December 2023) The course was held by the authors of this article (FO, SM and MEHF). MEHF is a nutrition professional and breastfeeding counselor with over 18 years of experience. The other two are a medical and a public health professional. The two district managers (ACh and JM) had an active participation in the course of the intervention, not alone as collaborators in its realization, but also as group members. In addition, they assumed the responsibility of selecting the other persons forming part of the process, i. e. they assumed a twofold role in it. The course had a total duration of 80 hours, divided into 40 theoretical in-person and 40 hours guided by the facilitators. The hourly load was defined in accordance with the items treated [ 6 ] and staff availability so that it would not interfere with their institutional assistances and requirements [ 28 ]. The course lasted eight months, with 25 sessions of 2 to 3 hours each, in weekly or fortnightly intervals. This duration was partly due to staff vacation periods and interruptions resulting from countrywide manifestations and insecurity in the streets. We structured the curriculum around three core topics: empowerment-oriented healthcare education [ 29 , 30 ], communication in healthcare, and technical contents on breastfeeding. We developed these core topics within a pedagogical model comprising theory and practice [ 4 , 31 ], allowing for a coherent, reflexive and contextualized training. This model adopted a liberating education approach to breastfeeding, grounded in Paulo’s Freire critical pedagogy, which values mothers’ life experiences and promotes informed, autonomous decision through dialogue and mutual learning [ 29 ]. We maintained the articulation of the three curricular components throughout the entire course (see Table 1 ). Table 1 Core topics and themes treated in the breastfeeding counseling staff training. Cayambe-Pedro Moncayo Health District. Curricular axes Main topics Empowerment - Foundations of health education - Liberating education for breastfeeding support - Concept of power and empowerment in health promotion practice Health Communication - Active listening - Verbal and non-verbal communication - Assertiveness and empathy - Mother-centered care model - Comunication tailored to the morher’s profile (age, culture, educational level) - Use of plain and clear language - Building trust between the mother and the counselor - Facilitating the mother’s participation in decision making Specialized technical content - Anatomy and physiology of lactation - Infant nutrition - Milk production: barriers and facilitators - Breastfeeding techniques - Common breastfeeding challenges: pain, engorgement, poor weight gain, and swallowing difficulties - Breast milk expression techniques - Establishing a home-based milk bank - Breastfeeding in special situations: prematurity, low birthweight, HIV, tuberculosis, and other conditions - Kangaroo Mother Care for mothers and fathers The theoretical sessions took place in the health district headquarters’ auditorium, located in Cayambe. Depending on the themes, the sessions could be explicative or interactive. We used teaching instruments such as theoretical reviews, dramatizations, practical demonstrations, role plays, case simulations and guided exercises, together with structured analyses and feedbacks [ 4 , 30 , 32 , 33 ]. The practical sessions were held at the Tabacundo “type C” Healthcare Center and the Cayambe basic hospital, in the outpatient, shared accommodation and inpatient areas, depending on the establishment. It was our aim to strengthen the confidence of the participants in their role as breastfeeding counselors, exposing them to pregnant women and lactating mothers and to improve their decision-making techniques for an effective counseling. For this, each of the three facilitators led a small group of five to six participants. Initially, one participant facilitated a counseling session while the others were observing, and then successively the participants took turns in the following sessions. Prior to the practices, we obtained the mothers’ oral consent to speak about issues related to breastfeeding and receive breastfeeding counseling. Assessment of lessons learned The assessment included formative and summative evaluation components to evaluate both theoretical breastfeeding knowledge and practical competencies. In both modalities, we used the same form of assessment; however, the formative evaluations did not have grades but were used to identify the participants’ strengths and fields of improvement in performance. We applied the formative evaluations in 20 of the 25 sessions, while three sessions saw a summative evaluation. The course’s first two sessions did not include evaluations. Likewise, we rigorously controlled the facilitators’ attendance, registering the participation in each encounter. Two failed attendances in a row, or an attendance rate of under 70%, implied the exclusion from the course. Table 2 Integral assessment: Breastfeeding counseling and practice evaluation Criterion Description Observable indicators Success scale 1. Welcome and therapeutic bond Starts interaction showing respect, openness and creating trust. - Gives a warm welcome. - Explains the session’s purpose. - Shows respect for dignity and privacy. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 2. Active listening and context exploration Understands the mother, listening actively; acknowledges her personal, social and cultural circumstances. - Maintains eye contact and open posture. - Identifies bars and facilitators. - Considers age, culture and level of education. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 3. Clear and adaptive communication Explains topics in simple language, adjusted to the mother’s profile. - Avoids unnecessary technicisms. - Relates information to previous experiences. - Checks understanding through questions or examples. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 4. Practical demonstration and application Demonstrates and practically guides the breastfeeding issue or technique. - Carries out demonstration step by step. - Allows mother to practice and seek feedback. - Uses practical resources from the environment. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 5. Breastfeeding technique Assesses key technical elements during feeding. - Comfortable posture of mother. - Alignment and closeness of baby. - Good mouth-breast latching. - Recognizes effective sucking and adequate feeding. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 6. Promotion of self-confidence and empowerment Reinforces mother’s security and furthers her decision-making autonomy. - Validates mother’s achievements and capacities. - Motivates to identify own solutions (liberating education). - Promotes protagonism and confidence (empowerment). 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 7. Proposed action and shared decision-making Provides recommendations, builds agreements with mother and family. - Presents practical alternatives. - Involves family/caretakers when adequate. - Furthers shared decision-making. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent 8. Motivating closure and continuity Ends consolidating the lessons learned and motivates for action. - Summarizes key points. - Reinforces confidence and motivation. - Offers future support and follow-up. 1 = Not achieved 2 = Partially achieved 3 = Adequate 4 = Excellent Finally, each curricular core topic was evaluated based on specific criteria, as detailed in Table 2 . The score of each evaluation was reached by summing the criteria, with a maximum of 32 points, which were subsequently converted into a scale from 1 to 10. In order to pass the course, we established a minimum of 7/10. Phase II Implementation of the breastfeeding counseling room (March through December 2023) The breastfeeding counseling room’s physical and functional design follows general guidelines from the region’s previous experiences [ 19 , 20 ], while the operative and normative aspects were adapted as a part of this intervention. The room’s implementation required the identification and adequation of a physical space within the local healthcare system, taking into account specific criteria: existence of ambulatory care for pregnant and lactating mothers, availability of an immediate post-partum care service favoring early user recruitment, and the disposition of a space with privacy, well-ventilated and functionally integrated with the other healthcare services. The Tabacundo “type C” Healthcare Center met these requirements, so we chose it as the idoneous place for implementation. We equipped the breastfeeding counseling room with a variety of didactic supplies and specialized materials, several of them adapted to the local cultural context to favor an effective and respectful care. The room implements are shown in image 1. Image 1. Breastfeeding counseling room implements. “type C” Healthcare Center Tabacundo. In parallel, we implemented several operative and normative processes to guarantee the room’s functionality. First of all, we established care flows that included the definition of operating hours, staff availability, user recruitment, and standardization of protocols. The district managers set operation hours for two days per week, in accordance with the number of certified counselors, who were to assist approximately twice a month. To ensure the availability of human resources, we cooperated with district authorities and healthcare service directors; as a result, the time dedicated to the room was recognized as part of the counselors’ institutional responsibilities. We designed specific user recruitment strategies. These included referrals from other healthcare services (gynecology, obstetrics, pediatrics, vaccination and healthy child programs), active searches in post-partum rooms and outpatient sections, as well as the direct inscription at the healthcare center. We also established a standardized care protocol to ensure service homogeneity. It began with taking the vital signs, followed by an interview to collect socio-demographic information, reproductive history and previous consultations. After that came the physical examination of mother (breasts and breastfeeding technique) and baby (position, latch, suction and possible clinical conditions affecting breastfeeding). The counseling ended with individualized recommendations, an invitation to further consultations and, if necessary, referral to psychological support. The protocol foresaw a minimum of 15 minutes per consultation, but it was flexible to be extended if necessary, to ensure an integral care. Sustainability of the intervention was guaranteed by formally incorporating the room into the district system, recognizing the counselors’ work as part of their institutional functions, and the existence of standardized care protocols and permanent resources. In December 2024, we transferred the supervision to the district’s technical team, acknowledging that the strategy had reached a sufficient level of maturity, with operative autonomy and an institutional recognition ensuring its continuity. Monitoring As part the intervention’s technical support, we implemented follow-up training strategies to document the process, identify necessary adjustments and obtain feedback on the implementation of the intervention, however without realizing an impact assessment or an effectivity study. During phase I, we realized three focal groups with the participants: two in course week 7, carried out by the facilitators, each with 15 persons simultaneously, aimed to explore main technical problems and limitations for effective breastfeeding, reported by lactating and pregnant mothers in their practices. At the end of the training, we realized a third focal with the persons who had completed the process, to understand the perceived relevance of the training experience and which elements the participants considered transformative of their practice. In all cases, we asked for oral consent to record their voices during the realization of the focal groups. The recordings were made with the iPad Voice Memos app. During phase II, we implemented institutional registering and monitoring processes aimed at integrating the room in the district’s official reports. In a first stage, the information was entered into a physical register by means of a clinical breastfeeding history with data regarding the number of women attended, their socio-demographic features y their reasons for attendance. Subsequently, these registers were migrated to a web application developed for the care service that allowed for information standardization and systematization. The systematic review of the digital forms from May to December 2024 enabled us to understand the room’s functionality and the care model’s relevance. Analysis The phase I focal group recordings were transcribed and analyzed with software MAXQDA 24 (VERBI Software GmbH, Berlin). We especially carried out a full initial transcript reading, to understand the overall content of the responses to the facilitators’ questions and identify preliminary patterns. Two of the authors (FO y FM) independently reviewed the material and realized a manual codification, tagging the most relevant text segments. These codes were grouped in categories or topics, based on conceptual similarities and relations. The topics were consensually reviewed by the said authors to ensure their internal coherence and that they were all clearly distinguishable. They chose representative extracts of the participants’ answers to illustrate each topic. In phase II, we organized the data of the digital forms in an Excel spreadsheet and then exported them to descriptive statistics in STATA/SE 18.0. The information appears in the form of frequencies and percentages. The variables registered in those forms comprise both the general features of the consultations, including their total number and duration in minutes and the mothers’ socio-demographic data. We specifically recorded if a mother was pregnant or in her breastfeeding period. The age was classified in three groups: 14–17 years, 18–30 years and over 30 years old. The mothers’ education levels were grouped as follows: incomplete primary, complete primary, incomplete secondary, complete secondary, incomplete higher and complete higher education. We also collected information as to the mothers’ formal employment (binary variable: “yes” or “no”) and their places of residence by canton (Cayambe or Pedro Moncayo). Finally, we collected the reasons for attendance in the form of an open text and subsequently coded that in analytical categories using MAXQDA 24. Results of the intervention The results of the intervention realized are described considering especially the main implementation aspects and the lessons learned along the process. Features of the participants Table 3 shows the participants’ occupations in the beginning and at the end of the training, thus identifying the professional profiles of those who entered and completed the process. Table 3 Professional profiles of the participants completing the breastfeeding counselor training. Profession/ working area Beginning (n, %) Approvals (n, %) Primary-level care technicians (TAPS) 15 (46.8%) 1 (10%) Obstetricians 12 (37.5%) 5 (50%) Physicians 3 (9.4%) 3 (30%) Nutritionists 2 (6.3) 1 (10%) TOTAL 32 (100%) 10 (100%) In accordance with the results shown in Table 3 , at the end of the training, one notes a marked decrease in the representation of primary-level healthcare technicians, while the share of obstetricians and physicians increased in respect of the total of participants. These changes reflect a variation in the group’s professional composition at the end of the course, suggesting that the profiles with university education tended to remain longer and show greater success along the training process. In total, 32 participants enrolled, 10 (31%) of whom satisfactorily completed the program and obtained the certification as breastfeeding counselors. Of the latter, eight bonded with the breastfeeding counseling room in phase II, seven of which were females. Reasons for failing the course Eight persons (25%) were discontinued for exceeding the non-attendance limit, while fourteen (44%) did not meet the minimum performance required. Overall, the results indicate that the greatest challenge was not the lack of attendance but the fulfilment of the course’s technical standards, showing that success depended on the capacity to complete the curriculum y show command of the contents. Results of the focal groups realized during week 7 of the course (phase I) 1. Bars for effective breastfeeding The first focal groups findings with healthcare providers, collected in phase I, evidence a variety of bars for breastfeeding, which may be grouped into two main directions: technical difficulties, and personal, social and contextual factors. At the technical level, we identified knowledge limitations both among the mothers and some healthcare professionals, as well as difficulties related to daily breastfeeding practice, especially regarding the application of adequate techniques and the handling of situations common in that process (see Table 4 ). On the other hand, the limitations of a personal, social and cultural order evidence the impact of deeply-rooted beliefs, prenatal support gaps, communicational difficulties during interventions and conditions of particular vulnerability in certain groups, like adolescent mothers (see Table 5 ). Overall, the findings show that the challenges for breastfeeding exceed the clinical scope, comprising social and relational dimensions directly impacting its practice. Table 4 Technical issues for breastfeeding identified by healthcare providers during the first focal group of phase I Technical issue Synthesis of findings Illustrative quote Lacking knowledge of breastfeeding techniques Many mothers (and some professionals) do not know how to position the baby or ensure an adequate latch. “(…) there is lack of knowledge as to how you breastfeed (…).” Reasons for consultation by mothers Three central worries: amount of milk, pain/discomfort in nipples, and sustainability returning to work “(…) of course, ‘cause they say, I mean, I’m going to work ( …) and how do I take ‘em out there (…)?” Lacking knowledge about milk extraction and conservation The mothers (and some professionals) do not know the right techniques of milk extraction and storage. “(…) there are many things, we as healthcare professionals do not know about milk extraction techniques (…).” Table 5 Limitations for breastfeeding identified by healthcare professionals during the first focal group of phase I Limitation Description Illustrative quote Belief breastfeeding is a natural and instinctive process Breastfeeding seen as something instinctive not needing preparation or support. “(...) the mothers think it is something very natural, something they will be able to do ‘normally’ (…).” False beliefs regarding the success of breastfeeding Idea the shape of the nipples decides over the success of breastfeeding. (…) they are worried: their nipples, ¿are they going to be right or not (…)” Insecurity about milk production Frequent fear of not producing enough mother milk. “(…) they always ask: am I going to have enough milk to satisfy the baby? (…).” Adequate time to receive breastfeeding counseling During pregnancy, there is little interest for issues related to breastfeeding. “(…) pregnant women show little interest, apparently. They do not ask about breastfeeding. Rather, they focus on growth, that is the baby’s food (…).” Communicational and relational bars Limited time for consultation, mothers’ low confidence to ask, healthcare provider’s gender. “(…) I think one of the problems there are in counseling is the ladies’ lack of confidence to ask. And, besides, the time we have is so limited (…). “(…) in breastfeeding counseling, we’ve had few consultations; the male staff would say they perceive a difference. Women shy away from asking (…).” Conditions of vulnerability in adolescent mothers This population requires a differentiated approach given their social, emotional and physical situation. “(…) many of them are alone, have no partners (…) so, imagine a raped, pregnant adolescent, what interest might she possibly have in breastfeeding? (…).” Early breastfeeding abandonment factors Lack of education of mother, work and/or household activities, reasons for not breastfeeding “ ( …) In my experience (...) the lack of education in pregnant women has an impact (…)” Curricular adjustments Based on the first focal group’s results, we adjusted the training curriculum both in regard of content and methodology, in order to deal with the technical and relational difficulties identified. Contentwise, we included new topics, such as mother milk extraction techniques and the creation of milk banks at home. Although no contents were excluded, some had to be reorganized in their sequence and approach, prioritizing their treatment in the early course stages, in order to strengthen their practical application, especially those related to the main reasons for maternal attendance and the resolution of common breastfeeding issues. Methodologically, we reinforced the curriculum’s practical component, putting special emphasis on teaching breastfeeding techniques. Likewise, we included strategies to develop communicational healthcare skills centered in the core topics of empowerment and emphatic behavior. These topics were addressed both in the practical and theoretical sessions, with interactive pedagogical tools. Healthcare staff perceptions of the formative experience following the training (phase I) In line with the study’s main objective, i. e. the strengthening of the healthcare professionals’ competencies in breastfeeding counseling, we realized a third focal group at the end of the training, in order to explore the participants’ perceptions of their training experience. Thus, we could receive assessments about different program aspects, especially those impacting their professional practice and way of interacting with the mothers (see Table 6 ). Table 6 Healthcare staff perceptions of the formative experience once the training was completed (phase I) Formative experience Relevance Theoretical-practical training methodology “The course enriched our knowledge in a practical manner, since we were not prepared to provide breastfeeding counseling” Counseling individualization in order to highlight specific situations “(…) this course took into account a lot of things, every… mother has different types of problems.” Horizontal exchange and active listening “(…) we abandoned the ‘we know and they know nothing’ attitude… we actually could learn from them (…) and empower them.” Addressing by name (avoiding diminutives and colloquial epithets) “…so, in order to address them as “mommy” instead of by their name, the mothers looked at us as if we were something bigger (…), but we understood that we must treat and address them by their names.” Practicing operational empathy to generate trust “(…) we got closer to the patient and they begin to relax, show more confidence, hence gratitude, security.” Reflecting about the changes in their personal approach, the participants mentioned that initially, they tended to employ a generic language and worried only about promoting breastfeeding as a generally desirable practice, without taking into account each woman’s individual context. As a result of the training process, they acknowledged the need for adapting the message, paying attention to the users’ concrete worries, and supporting them from a closer and respectful position. These elements, they said, strengthened their capacity to generate trust and improve the quality of counseling. Results of phase II. Implementation of the individualized breastfeeding counseling model The study’s second phase consisted of commissioning a breastfeeding counseling room and the application of the individualized breastfeeding counseling model based on the findings of phase I. Its operation was monitored with a systematic review of the digital forms registered between May and December 2024, thereby evaluating both the room’s operativity and the model’s pertinence and applicability in real context. The analysis focused on the dynamics of counseling, the profile of users, and the most frequent reasons of attendance. 1.Characteristics of the counseling sessions The breastfeeding counseling room saw a total of 305 individual in-person sessions, with 247 women attending. For 275 of these sessions, we registered their duration, with a mean value of 36 minutes per consultation (DE = 12.2), more than twice the time established by the institutional regulations for any consultation in the public healthcare system (15 minutes). This suggests that the model requires a more ample timeframe to ensure an individualized and qualitatively acceptable attendance. Most users were women in their breastfeeding period (76.5%), vs. 23.5% of pregnant women, a ratio of 3.2 to 1. Such distribution indicates that the model was primarily used to address worries during the breastfeeding period, when the challenges usually are more concrete and urgent. The analysis of the attendance frequency showed that 81.8% of the women (n = 202) attended only one counseling session, while 18.2% (n = 45) did so twice or more often. Concretely, 13.8% assisted twice, 3.6% three and 0.8% even four times. Although the intervention allowed for multiple sessions, most women used the service in a pinpointed way. Socio-demographic profile of users The user profiles evidence a predominance of young women between ages 18 and 29, followed by adults of ages 30 or more. Nothing the less, we point out that 10.9% were adolescents between 14 and 17 years of age, an especially vulnerable part of the population, given their limited experience and little prior access to information on breastfeeding, hence underlining the need for differentiated counseling approaches (see Table 7 ). In respect of education levels, most users had attended secondary education, and a minor percentage higher education. In respect of their work situation, most did not have paid work at the time of attendance, reflecting a range of educational and work histories among the participants (see Table 7 ). Finally, 87,9% of the women attending lived in canton Pedro Moncayo, thus reinforcing the model’s territorial pertinence. Table 7 Socio-demographic characteristics of users attending the breastfeeding counseling room in May-December 2024 (n = 247) Characteristics Frequency Percentage Age in years -14–17 -18–29 − 30 or over - no data 27 168 51 1 10.9 68.0 20.7 0.4 Number of children - none − 1 − 2 − 3 − 4 − 5 - no data 24 108 64 25 12 2 12 9.7 43.7 26 10.1 4.9 0.8 4.8 Level of formal education - incomplete primary - complete primary - incomplete secondary - complete secondary - incomplete superior - complete superior - no data 2 28 43 113 1 58 2 0.8 11.3 17.4 45.8 0.40 23.5 0.8 Paid work - yes - no - no data 71 172 4 28.7 69.7 1.6 Canton of residence - Cayambe - Pedro Moncayo - no data 29 217 1 11.7 87.9 0.4 3. Reasons for attending the counseling sessions Most attendances were related to technical breastfeeding difficulties, primarily aspects such as breastfeeding technique, nipple-related problems and the sensation of low milk production. Overall, these issues represented the largest share of attendance (70%), highlighting the need for reinforcing the practical support at the early stages of the post-partum period (see graph 1). We also identified consultations about the planification of breastfeeding continuity in the light of a return to work or studies; these were mostly requests for information about mother milk extraction and conservation. A smaller number of women did not voice specific doubts at the moment of consultation, suggesting that some appreciate the counseling as a preventive space or an instance of emotional validation. These findings show the importance of combining technical issues and strategies of contention and orientation adapted to the different breastfeeding stages. Graph 1. Reasons of attending the breastfeeding counseling room at District Cayambe–Pedro Moncayo in May-December 2024. The findings obtained in both intervention phases provide a comprehensive vision of the healthcare professionals training process and the commissioning of an individualized breastfeeding counseling model within the local healthcare system. The information gathered allows to see how the service was set up, who took part in it, and what were the main reasons of consultation attended. These elements provide a relevant input for an in-depth analysis of the lessons learned, the challenges identified and the considerations needed to strengthen or adapt similar interventions; issues we address in the following section. Discussion The results of the intervention provide evidence on the feasibility and pertinence of integrating an individualized breastfeeding counseling model within the public healthcare system in Ecuador’s rural areas. In the following, we will discuss the primary findings as related to the existing literature, their practical implications, and possible future paths. The training model and its implications One of the study’s most striking findings was that only 31% of the participants satisfactorily completed the training process. This low completion rate occurred despite the employment of a carefully designed methodology, based on an integration of theory, roleplays, clinical simulations and field supervision [ 10 – 13 , 34 , 35 ]. The experience showed that although the approach was highly appreciated by those who managed to complete it, there were still bars related to work overload, lack of time and difficulties to harmonize the training processes and the institutional day-to-day demands, especially in primary-level care [ 36 , 37 ]. Besides, we observed changes in the group that completed the course, where profiles with university education dominated, such as obstetricians, physicians and nutritionists, in contrast to greater desertion among primary-level healthcare technicians (TAPS). This difference evidences the importance of adjusting the curricular design to each professional group’s training histories, specific functions and work realities, to favor the development of pertinent and sustainable competencies. Despite these tensions, a key factor along the process was the active participation of the district managers, who understood and supported the intervention’s strategic relevance from its very beginning. The institutional disposition made it possible to introduce a certain operative flexibility in the organization of operating hours, functions and work dynamics, thus favoring both the room’s implementation and progress along the training process. Such kind of institutional commitment, even in environments of limited resources, is a key facilitator to sustain innovations in healthcare promotion [ 38 – 40 ]. Thus, the experience not only provides evidence regarding the feasibility of applying more in-depth and contextualized healthcare training programs, but also emphasizes the relevance of an institutional leadership sensitive to maternal and infant healthcare priorities. As several authors state [ 8 , 41 ], when healthcare providers do not possess solid breastfeeding training, the counseling quality may be seriously limited, thus reinforcing the need for the development of well-trained technical references. Besides, the consolidation of a small group of professionals that completed the training process made it possible to strengthen a nucleus of professionals able to act as breastfeeding champions within the local healthcare system, promoting good practices, quality support and the counseling model’s continuity. These findings provide empirical evidence for the design of continuing maternal and infant healthcare training strategies, especially in public contexts where resources and time are limited. Future scaling processes should consider curricular adaptation, operative flexibility and the commitment of local key actors as determining factors to sustain and institutionalize breastfeeding support practices. Implementation of the breastfeeding counseling room and its contribution One of the study’s most tangible results was the breastfeeding counseling room’s implementation within the Tabacundo del healthcare center, conceived as an exclusive space for individual counseling to pregnant women and lactating mothers. Its commissioning required setting up a specific physical space, developing collaborative attendance protocols, organizing internal flows and articulating its operations within an institutional routine. This is particularly significative given the primary-level care’s rural context, where infrastructure, staff and resources limitations usually are obstacles to the implementation of specialized services. In countries like Chile, breastfeeding clinics are a part of the services covered by the National Health Fund (FONASA) and included in the program Chile Crece Contigo (Chile Grows with You), which facilitates their sustainability and institutional anchoring [ 20 ]. By contrast, this pilot experience in Ecuador represents the first documented attempt to establish such a room within the Ecuadorian local public healthcare system, without national regulative backing but strong district support. The fact of its implementation evidences that it is possible to institutionalize such spaces as part of maternal and infant healthcare services, even in environments of limited resources, provided that locally there is the will and a technical training strategy sustaining them. This experience aims to offer a concrete contribution to the scarce Latin American documentation on how to structure and include breastfeeding counseling rooms within the public healthcare systems of medium and low-income countries. Its systematization provides practical and strategic input for future scaling processes and the institutionalization of such interventions. Features of the counseling sessions and their impact for the attendance model The counseling model implemented was characterized by a more prolonged and personalized attendance time as compared to the public healthcare system’s usual standards, a kind of attendance highlighted by several authors as fundamental for the achievement of an effective breastfeeding support, notably when inclusion of active listening, resolution of doubts and emotional support are the objectives [ 9 , 10 , 42 ]. The findings emphasize the need for reviewing the timeframes assigned to maternal and infant attendance, if bond- and care experience-focused attendance models are the goal. In addition, the service’s usage profile suggests that counseling represents an especially heartfelt need in post-partum, where many mothers face practical and emotional difficulties requiring specific support [ 43 ]. Nonetheless, the fact that so few attended more than one session hints at obstacles for the continuity of assistance: Just as the literature states, factors like the load of reproductive and family care or time issues may limit their possibilities of coming back, although the service is available [ 18 ]. Therefore, future models should incorporate proactive follow-up strategies like reminders, scheduled appointments or home visits to reinforce the continuity and effectivity of counseling [ 3 , 44 ]. User profiles and vulnerability The profiles of the women attended evidence several factor of vulnerability to be considered in the design of contextualized interventions. 11% were adolescents, a portion in concordance with the 14% of liveborn babies in 2024 with mothers between ages 15 and 19 [ 45 ], thus underlining the importance of including the group in breastfeeding support services. The counseling model is a specific approach for these users, taking into account the worries expressed by the counselors during their training, where they identified bars like abandonment, violence or little family support. Such conditions, combined with social judgment and lacking contention networks, have been indicated as factors making the continuity of breastfeeding difficult. Within this scope, the findings reinforce the need for models including life trajectories as structuring elements of support. As for the levels of education, we observed a greater participation of women with secondary or higher education. This could make their bonding with the service easier, since several studies document that women with better education levels usually tend to more actively use healthcare services and sustain informed care practices like prolonged breastfeeding [ 45 ]. Notwithstanding, such a pattern runs the risk of leaving behind those with educational bars. Strengthening the articulation of counseling with institutional spaces, such as pre- or post-partum controls may achieve a more equal access and widen the model’s scope toward historically underattended groups [ 17 , 18 ]. We also observed differences depending on the number of children. Most users attended were primiparous, coinciding with previous findings suggesting the group’s greater disposition to sustain exclusive breastfeeding when they get technical support [ 46 ]. By contrast, multiparous women usually face greater challenges, like care overload, less social support or the early introduction of supplementary food [ 46 ]. In our study, the individual counseling mode facilitated a support adjusted to the mothers’ experiences, reinforcing the value of flexible and differentiated approaches. Lastly, geographic proximity influenced the access to the service, too: most users lived in Pedro Moncayo where counseling took place, whereas participation from Cayambe was limited, possibly due to transportation issues. The pattern reveals the importance of planning the service location, considering that not only criteria of territorial equality but also operative efficacy matter [ 18 ]. Demand for assistance and pertinence of the counseling model The reasons for consultation registered revealed a demand for assistance focused on practical issues such as holding the baby, nipple-related pains, sensation of low milk production or the need for milk extraction or conservation. This last issue was particularly frequent among mothers returning to work or school. Such situations, widely documented under diverse socio-economic contexts [ 36 , 47 – 50 ], are associated to the early interruption of breastfeeding, use of formulas or supplementary food [ 10 , 51 , 52 ]. During the first focal group, several counselors stated that initially they had underestimated those technical difficulties, influenced by the widely reigning social belief, sometimes shared by healthcare workers, that breastfeeding is a natural and instinctive process. Those perceptions hide the real challenges that many women, especially adolescents or primiparous, face shortly after childbirth, and they delegitimize their need for attendance [ 48 ]. The training process’s practical stage could re-signify those beliefs and reinforce the conviction of the need for a technical, affective and personalized approach to address counseling’s manifold dimensions. In this sense, the demand perceived validates the counseling model’s pertinence, particularly given its emphasis on active listening, prolonged healthcare attendance and support adapted to concrete situations. Contrarily to schemes focusing on the mere transfer of generalized and/or standardized information, our model enables to address questions marked by insecurity, physical discomfort or fear of not being able to breastfeed adequately; thereby evidencing a greater capacity to respond to the women’s concrete circumstances. Beyond the delivery of mere contents, these findings highlight the value of models that include a relational and contextual care dimension, focused on supporting breastfeeding processes a situated manner. Limitations Although this was not an impact study nor an effectivity trial, its implementation comprised a pre and post training assessment (phase I), which allowed us to identify preliminary improvements in the participants’ knowledge, skills and attitudes. And despite the fact that the absence of a control group forbids to attribute the changes stated exclusively to the intervention, our mixed approach including training follow-up, focal groups, and the review of the attendance records, enabled a wider understanding of the model’s implementation and value. Likewise, the close support to the training team facilitated a curriculum adjustment in accordance with the needs arising, strengthening a qualitative analysis despite not having applied a direct systematized observation. On the other hand, the facilitators’ twofold role as investigators alike may have introduced a social desirability bias, affecting the spontaneity or depth of some answers. However, the triangulation of qualitative and quantitative sources helped mitigate this risk, producing consistent patterns. For future investigations, it would be advisable, though, to include comparison groups, longer-term evaluations and external observers, in order to increase the model’s methodological solidity and assess its sustainability. Still, with these limitations, the study provides relevant findings about the feasibility of counseling and its perceived benefits in rural contexts, emphasizing its capacity to adapt to local conditions, such as institutional flexibility and the infrastructure minimally necessary for its implementation. Conclusion This study describes the implementation of a breastfeeding counseling model developed in, and adapted to, a primary-level healthcare center within a rural context of Ecuador. Based on a practical approach, it was structured into two phases: initially, the training of healthcare professionals and subsequently, the establishment of a counseling room. This way, we evidenced that it is possible to install a technically sound service, empathetic and sensitive to the users’ life histories, using already existing institutional resources. Our findings, among them the improvement of the counselors’ knowledge and attitudes, as well as a demand in assistance focused on technical difficulties and other needs in accordance with the profiles of users, underline the importance of models combining technical information and personalized support. The experience sheds light on how an integral approach may respond better to the challenges of early post-partum women, especially those in conditions of greater vulnerability like adolescent or primiparous mothers. The model’s scalable nature, its low infrastructure requirements and its compatibility with local healthcare systems make it a proposal with potential for adaptation in other rural environments or ones with similar structural limitations, both in Ecuador and countries with comparable characteristics. Future studies might include quasi-experimental designs, such as the measurement of results in infant healthcare and a sustainability analysis over time, which would allow to delve into the effects and conditions for the expansion of this kind of intervention at a larger scale. Declarations Ethics approval and consent to participate The course of the intervention had the ethical approval of the Ethical Committee for Research in Humans of Universidad San Francisco de Quito (CEISH, ID 2017-177IN; approved February 8, 2018) within the framework of the SEMILLA study. Likewise, District Health Division 17D10 (Cayambe–Pedro Moncayo) authorized its implementation in the study area. All the focal groups participants gave their oral consent in advance. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding The realization of the intervention was made possible thanks to the funding granted as part of the Outreach Grant USFQ 2023; also, funded (in part) by the University of Michigan Office of Global Public Health, School of Public Health. Author Contribution F.O., M.E.H.F., and S.M. jointly contributed to the conceptualization of the study, with F.O. leading the overall project design and formulating the research idea, M.E.H.F. strengthening the breastfeeding-related methodological components, and S.M. leading fieldwork implementation and contributing to key methodological decisions that guided the study. F.O. and S.M. jointly prepared the original manuscript draft, contributed to the development of visualizations, and supported project administration throughout implementation. M.E.H.F. also provided supervisory guidance during the project. F.M. was responsible for software development. F.O. and F.M. jointly conducted the formal analysis and were responsible for data infrastructure maintenance and data curation. A.Ch. and J.M. provided institutional resources for project implementation and contributed supervisory input. F.O. and A.J.H. secured funding and contributed to overall project support. All authors contributed to reviewing and editing the manuscript and approved the final version. Acknowledgement We thank Dr. William Perugachi, who at the time served as the District Director of Health for Cayambe–Pedro Moncayo, for his institutional commitment and support. We also extend our gratitude to Diana Coello Baquero, Coordinator of Social Engagement at Universidad San Francisco de Quito, for her unwavering support, enthusiasm, and trust in our work. To Dr. Alena Clark from Colorado State University, for her support during the training of breastfeeding counselors and her guidance in the implementation of the breastfeeding counseling room, as well as for her strategic review of the draft of this manuscript. And, special thanks to Graciela García and Amílcar Chingal for their logistical support during the study implementation. Data Availability The datasets generated and/or analyzed during this study include transcripts of focus group discussions and anonymized counseling records collected through standardized clinical forms. Due to privacy and ethical considerations, these data are not publicly available but may be available from the corresponding author upon reasonable request. References Blanco S, Aboul-Enein BH, Benajiba N, Dodge E. A Scoping Review of Breastfeeding Interventions and Programs Conducted Across Spanish-Speaking Countries. Health Promotion Pract [Internet]. 2025;26(1):168–91. Available from: [15,24] Accessed: 25 Jun 2025. Sinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S et al. Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatrica [Internet]. 2015;104(S467):114–34. Available from: https://onlinelibrary.wiley.com/doi/ 10.1111/apa.13127 Accessed: 25 Jun 2025. World Health Organization, United Nations Children’s Fund (UNICEF). 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Available from: https://dx.plos.org/10.1371/journal.pone.0275477 Accessed: 26 Jun 2025. Bergmann RL, Bergmann KE, Von Weizsäcker K, Berns M, Henrich W, Dudenhausen JW. Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers – a review of the scientific evidence. Journal of Perinatal Medicine [Internet]. 2014;42(1):9–18. Available from: https://www.degruyter.com/document/doi/ 10.1515/jpm-2013-0095 /html Accessed: 26 Jun 2025. Martinez NG, Strohbach A, Hu F, Yee LM. Real-world effect of a peer counselor on breastfeeding outcomes in an urban prenatal clinic in the United States. BMC Pregnancy Childbirth [Internet]. 2020;20(1):671. Available from: https://bmcpregnancychildbirth.biomedcentral.com/articles/ 10.1186/s12884-020-03360-6 Accessed: 20 Aug 2025. Wagner EA, Chantry CJ, Dewey KG, Nommsen-Rivers LA. Breastfeeding Concerns at 3 and 7 Days Postpartum and Feeding Status at 2 Months. Pediatrics [Internet]. 2013;132(4):e865–75. Available from: https://doi.org/10.1542/peds.2013-0724 Accessed: 20 Aug 2025. Dueñas-Espín I, León Cáceres Á, Álava A, Ayala J, Figueroa K, Loor V et al. Breastfeeding education, early skin-to-skin contact and other strong determinants of exclusive breastfeeding in an urban population: a prospective study. BMJ Open [Internet]. 2021;11(3):e041625. Available from: https://bmjopen.bmj.com/lookup/doi/ 10.1136/bmjopen-2020-041625 Accessed: 26 Jun 2025. Owais A, Suchdev PS, Schwartz B, Kleinbaum DG, Faruque ASG, Das SK et al. Maternal knowledge and attitudes towards complementary feeding in relation to timing of its initiation in rural Bangladesh. BMC Nutr [Internet]. 2019; 5(1):7. Available from: https://bmcnutr.biomedcentral.com/articles/ 10.1186/s40795-019-0272-0 Accessed: 2 Jul 2025. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Apr, 2026 Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 07 Mar, 2026 Reviewers invited by journal 15 Dec, 2025 Editor assigned by journal 13 Dec, 2025 Submission checks completed at journal 13 Dec, 2025 First submitted to journal 12 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8347342","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561248175,"identity":"427ae956-3721-489d-bb1c-a2656c910834","order_by":0,"name":"Fadya Orozco","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYPACOQaGAwyMD4AsHj4itRiDtDAbgLSwkaKFTQLEJKiFX/rw4Q8/Kgzk+W4kP6v8mmMnw8bA/PDRDTxaJPvSEgx7zhgYzryRZnZbdlsy0GFsxsY5eLQYnOExSGZs+8O44UaC2W3JbcxALTxs0oS0HGZsM7DfcCP9W7HktnqitBg2A7UkbriRY8b4cdthwloke9iSGYF+SZ555k2xNOO24zxszAT8ws/DDA4x277j6Rs//txWbc/P3vzwMT4tCCCQwMDMA2IwE6UcbB8wxfwgWvUoGAWjYBSMJAAAajNGpUqTtX0AAAAASUVORK5CYII=","orcid":"","institution":"Universidad San Francisco de Quito","correspondingAuthor":true,"prefix":"","firstName":"Fadya","middleName":"","lastName":"Orozco","suffix":""},{"id":561248176,"identity":"01be63c9-c489-46e3-8ed6-c9a7a3be67fc","order_by":1,"name":"María Elisa Herrera-Fontana","email":"","orcid":"","institution":"Universidad San Francisco de Quito","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Elisa","lastName":"Herrera-Fontana","suffix":""},{"id":561248177,"identity":"4fb26a77-95bc-40c6-b636-49fed753e271","order_by":2,"name":"Stephanie Montenegro","email":"","orcid":"","institution":"Universidad San Francisco de Quito","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Montenegro","suffix":""},{"id":561248178,"identity":"a7d95648-b52a-42d0-a2c5-f0dea9eedeee","order_by":3,"name":"Fabián Muñoz","email":"","orcid":"","institution":"Visor Análisis Estadístico Cia. Ltda","correspondingAuthor":false,"prefix":"","firstName":"Fabián","middleName":"","lastName":"Muñoz","suffix":""},{"id":561248179,"identity":"b56cee2f-d17e-4cc1-8a60-6f522c3d2727","order_by":4,"name":"Johanna Molina","email":"","orcid":"","institution":"Distrito 17D10 Cayambe Pedro Moncayo, Ministerio de Salud Pública del Ecuador","correspondingAuthor":false,"prefix":"","firstName":"Johanna","middleName":"","lastName":"Molina","suffix":""},{"id":561248180,"identity":"451e7e64-ec8a-4de3-9040-bc841f5bae71","order_by":5,"name":"Alicia Chicaiza","email":"","orcid":"","institution":"Distrito 17D10 Cayambe Pedro Moncayo, Ministerio de Salud Pública del Ecuador","correspondingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Chicaiza","suffix":""},{"id":561248181,"identity":"506720af-6d54-490f-85b6-678254b45718","order_by":6,"name":"Alexis J. 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12:30:39","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165266,"visible":true,"origin":"","legend":"","description":"","filename":"af8558fce2004df291be18aecebde8fd1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8347342/v1/18ee46311ebfeda7257a781c.xml"},{"id":98756542,"identity":"24cd3e46-0baa-46b4-a9cd-76e44f5323ad","added_by":"auto","created_at":"2025-12-22 09:33:01","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":185271,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8347342/v1/d1e42d573c24c24ae22916c5.html"},{"id":98756536,"identity":"c9779ec9-5c01-406f-a6e6-2903585a236e","added_by":"auto","created_at":"2025-12-22 09:33:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1314582,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImage 1. \u003c/strong\u003eBreastfeeding counseling room implements. “type C” Healthcare Center Tabacundo.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8347342/v1/6113305c5df959ebc505c352.png"},{"id":98756535,"identity":"bab7c2e1-93d6-4114-8b4c-e1ac59d73f26","added_by":"auto","created_at":"2025-12-22 09:33:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39048,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraph 1.\u003c/strong\u003e Reasons of attending the breastfeeding counseling room at District Cayambe–Pedro Moncayo in May-December 2024.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8347342/v1/5141ba673e13027e90ec07f1.png"},{"id":98783434,"identity":"7e3d488a-8c51-4c68-b695-f2cb075beb60","added_by":"auto","created_at":"2025-12-22 12:41:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2717657,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8347342/v1/c18a85a5-4d33-4948-ad8e-1853650b824a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strengthening breastfeeding counseling through a scaled-up intervention implemented within Ecuador’s local healthcare system","fulltext":[{"header":"Background","content":"\u003cp\u003eBreastfeeding counseling is one of the main interventions to promote both the early onset and exclusive practice of breastfeeding and one of the factors the healthcare system may have an impact on [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the guidelines proposed by UNICEF and the WHO\u0026rsquo;s Baby Friendly Hospital Initiative (BFHI), one of the critical management procedures is to make sure that healthcare professionals have sufficient knowledge, competency and skills to support breastfeeding [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this regard, breastfeeding counseling, conceived as an individualized intervention combining communicational, educational and technical skills of healthcare providers to support informed decision-making by mothers, requires solid and specific training to be effective [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Apart from that, it has been reported that its impact is greater when, during the post-natal period, it is offered personally and adapted to each woman\u0026rsquo;s particular reality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], since it favors the early resolution of problems and complications, besides clarifying doubts concerning infant feeding [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Hence, the quality of counseling is directly related to the training of the professionals offering it [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the existence of international guidelines for healthcare staff training in breastfeeding counseling [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], there is evidence of great diversity in the way such trainings are applied [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Methodologies vary among in-person, virtual and mixed modes, with theoretical or practical focusses, and without any clear standards regarding contents or duration, which may range from 12 to 133 hours [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In addition, essential aspects, such as emphatic communication, active listening and respect for cultural diversity are not always treated in the necessary depth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Evidence shows that those trainings that include both theory and practice, emphasizing the latter, are more effective in strengthening the self-efficacy of healthcare providers and have a significant impact on the promotion of breastfeeding counseling [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, healthcare professionals possess unequal levels of knowledge and skills in regard of breastfeeding counseling, resulting from differences in university education and the lack of continuing updating programs, thus limiting their capacities to provide effective care, especially within the context of public healthcare systems [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe issue gains special relevance within the Ecuadorian context where recent figures reflect a setback in breastfeeding indicators and current promotion strategies keep facing important implementation challenges in the public healthcare system. Particularly, the prevalence of exclusive breastfeeding until six months of age went down sustainably from 62% in 2018 to 53% in 2024 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Ecuador\u0026rsquo;s national public healthcare system, the main promotion activities so far are based on community support groups, facilitated by primary care level professionals who mostly are trained theoretically and virtually. In these groups, pregnant women, lactating moms and other interested persons come together to share experiences and knowledge related to baby feeding and breastfeeding practices [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although these initiatives allow for the exchange of experiences, their impact on exclusive breastfeeding is minor when compared to individual interventions focused on counseling within the context of healthcare systems [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Notwithstanding, when different types of interventions are combined, positive synergic effects may arise [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, individual counseling services do exist in the country, offered by private sector professionals at an elevated cost for large parts of the population (between 40 and 60 USD per session, in a country with a minimum salary of 470 USD). This situation evidences a structural inequality in the access to basic maternal and child healthcare, something further stressed by the empirical evidence that women living in impoverished communities face significant bars to access breastfeeding counseling services [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn order to guarantee the equality of access to that service, other countries such as Chile [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and Mexico [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] implemented breastfeeding clinics within their public health services, thus ensuring technical and professional support within breastfeeding counseling. In Mexico [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], the percentage of women receiving pre- or post-natal breastfeeding counseling was 91% in the public versus 80% in the private sector, reflecting the possibilities of including breastfeeding counseling within the public health institutions.\u003c/p\u003e \u003cp\u003eIn that light, we identified two large gaps in the provision of public services for the promotion of breastfeeding: 1) limited access to individualized counseling; and 2) lack of institutionalized spaces in the healthcare system for this kind of attention, in an affordable and continuing manner.\u003c/p\u003e \u003cp\u003eThis article aims to document and describe a form of intervention developed jointly with the local healthcare system, oriented toward the strengthening of capacities of healthcare professionals, and the implementation of an individualized breastfeeding counseling model in a predominantly rural area of Ecuador, to analyze its development, the lessons learned and its potential for replicability in similar contexts.\u003c/p\u003e \u003cp\u003e To the best of our knowledge, this is the first initiative of its kind within the framework of the Ecuadorian local healthcare system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis work takes place under the methodology of a \u003cem\u003epractice-based case study\u003c/em\u003e, aimed to describe the development of an intervention scaled-up by two complementary phases.\u003c/p\u003e \u003cp\u003ePhase I consisted of a theoretical-practical training process for primary-level care professionals, seeking to strengthen their capacities and skills, and train them as breastfeeding counselors. Phase II focused on the implementation of a specific room within a public healthcare unit destined exclusively to offer personalized breastfeeding counseling to women in their last third of pregnancy and mothers in their breastfeeding period, realized by previously trained professionals.\u003c/p\u003e \u003cp\u003eThe study documents this experience through a narrative approach, supported by implementation process monitoring in each phase, thus allowing to progressively strengthen, correct and adjust the intervention. To do so, we used qualitative (focal groups in phase I) and quantitative-descriptive methods (analysis of care records in phase II). We point out that this was not a formal assessment of the intervention but a documentation exercise meant to extract practices and learn lessons for similar contexts.\u003c/p\u003e \u003cp\u003eThe intervention was a part of the knowledge-transfer activities toward the SEMILLA birth cohort study community, implemented in the area of Cayambe-Pedro Moncayo, Ecuador [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This investigation evidenced low levels of confidence among the mothers to begin breastfeeding after delivery, as well as 63.6% of exclusive breastfeeding at three months of age. Additionally, we identified an alarming rate of childhood malnutrition reaching 27% during that same period, considerably surpassing the national average of 19.3% in children less than two years old [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The course of the intervention had the ethical approval of the Ethical Committee for Research in Humans of Universidad San Francisco de Quito (CEISH, ID 2017-177IN; approved February 8, 2018) within the framework of the SEMILLA study. Likewise, District Health Division 17D10 (Cayambe\u0026ndash;Pedro Moncayo) authorized its implementation in the study area. All the focal groups participants gave their oral consent in advance.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Area and Participants\u003c/h3\u003e\n\u003cp\u003eThe intervention took place in Ecuadorian Cayambe-Pedro Moncayo Health District 17D10, a Ministry of Public Health basic entity for the deconcentrated management and operation of healthcare services. The district is geographically located in Ecuador\u0026rsquo;s Northwest, at 80 km from the country\u0026rsquo;s capital; it comprises the cantons Cayambe and Pedro Moncayo, is located in the Ecuadorian Sierra (at approximately 2,800 m above sea level).\u003c/p\u003e \u003cp\u003eThe area\u0026rsquo;s total population is 145,750; 50% of whom reside in rural areas. In ethnical terms, 60% identify themselves as mestizos, while another 30% regard themselves as indigenous [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The mean income per month and household in the region is 512 USD [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Health District comprises a basic secondary-level hospital, located in canton Cayambe and 15 primary-level care centers distributed in the area. Among them is a \u0026ldquo;type C\u0026rdquo; 24/7 attending healthcare center in canton Pedro Moncayo. It includes a delivery room and shared early accommodation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the Ecuadorian healthcare system, \u0026ldquo;type C\u0026rdquo; centers represent the highest level of complexity in primary care, providing emergency services and basic obstetric care.\u003c/p\u003e \u003cp\u003eThe participants were primary-level healthcare professionals in charge of attending pregnant women and lactating mothers, and district managers. In phase I, a total of 30 professionals participated, among them obstetricians, general physicians and primary-level care technicians (TAPS) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The district managers were two persons in charge of district health promotion and care quality; they are co-authors of this article (ACh and JM).\u003c/p\u003e\n\u003ch3\u003ePhase I: Breastfeeding counselor training (March through December 2023)\u003c/h3\u003e\n\u003cp\u003eThe course was held by the authors of this article (FO, SM and MEHF). MEHF is a nutrition professional and breastfeeding counselor with over 18 years of experience. The other two are a medical and a public health professional.\u003c/p\u003e \u003cp\u003eThe two district managers (ACh and JM) had an active participation in the course of the intervention, not alone as collaborators in its realization, but also as group members. In addition, they assumed the responsibility of selecting the other persons forming part of the process, i. e. they assumed a twofold role in it.\u003c/p\u003e \u003cp\u003eThe course had a total duration of 80 hours, divided into 40 theoretical in-person and 40 hours guided by the facilitators. The hourly load was defined in accordance with the items treated [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and staff availability so that it would not interfere with their institutional assistances and requirements [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The course lasted eight months, with 25 sessions of 2 to 3 hours each, in weekly or fortnightly intervals. This duration was partly due to staff vacation periods and interruptions resulting from countrywide manifestations and insecurity in the streets.\u003c/p\u003e \u003cp\u003eWe structured the curriculum around three core topics: empowerment-oriented healthcare education [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], communication in healthcare, and technical contents on breastfeeding. We developed these core topics within a pedagogical model comprising theory and practice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], allowing for a coherent, reflexive and contextualized training. This model adopted a liberating education approach to breastfeeding, grounded in Paulo\u0026rsquo;s Freire critical pedagogy, which values mothers\u0026rsquo; life experiences and promotes informed, autonomous decision through dialogue and mutual learning [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. We maintained the articulation of the three curricular components throughout the entire course (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCore topics and themes treated in the breastfeeding counseling staff training. Cayambe-Pedro Moncayo Health District.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurricular axes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMain topics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmpowerment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Foundations of health education \u003c/p\u003e \u003cp\u003e- Liberating education for breastfeeding support\u003c/p\u003e \u003cp\u003e- Concept of power and empowerment in health promotion practice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth Communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Active listening\u003c/p\u003e \u003cp\u003e- Verbal and non-verbal communication\u003c/p\u003e \u003cp\u003e- Assertiveness and empathy\u003c/p\u003e \u003cp\u003e- Mother-centered care model\u003c/p\u003e \u003cp\u003e- Comunication tailored to the morher\u0026rsquo;s profile (age, culture, educational level)\u003c/p\u003e \u003cp\u003e- Use of plain and clear language \u003c/p\u003e \u003cp\u003e- Building trust between the mother and the counselor\u003c/p\u003e \u003cp\u003e- Facilitating the mother\u0026rsquo;s participation in decision making\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecialized technical content\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- Anatomy and physiology of lactation \u003c/p\u003e \u003cp\u003e- Infant nutrition\u003c/p\u003e \u003cp\u003e- Milk production: barriers and facilitators\u003c/p\u003e \u003cp\u003e- Breastfeeding techniques\u003c/p\u003e \u003cp\u003e- Common breastfeeding challenges: pain, engorgement, poor weight gain, and swallowing difficulties\u003c/p\u003e \u003cp\u003e- Breast milk expression techniques\u003c/p\u003e \u003cp\u003e- Establishing a home-based milk bank\u003c/p\u003e \u003cp\u003e- Breastfeeding in special situations: prematurity, low birthweight, HIV, tuberculosis, and other conditions\u003c/p\u003e \u003cp\u003e- Kangaroo Mother Care for mothers and fathers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe theoretical sessions took place in the health district headquarters\u0026rsquo; auditorium, located in Cayambe. Depending on the themes, the sessions could be explicative or interactive. We used teaching instruments such as theoretical reviews, dramatizations, practical demonstrations, role plays, case simulations and guided exercises, together with structured analyses and feedbacks [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe practical sessions were held at the Tabacundo \u0026ldquo;type C\u0026rdquo; Healthcare Center and the Cayambe basic hospital, in the outpatient, shared accommodation and inpatient areas, depending on the establishment. It was our aim to strengthen the confidence of the participants in their role as breastfeeding counselors, exposing them to pregnant women and lactating mothers and to improve their decision-making techniques for an effective counseling. For this, each of the three facilitators led a small group of five to six participants. Initially, one participant facilitated a counseling session while the others were observing, and then successively the participants took turns in the following sessions. Prior to the practices, we obtained the mothers\u0026rsquo; oral consent to speak about issues related to breastfeeding and receive breastfeeding counseling.\u003c/p\u003e\n\u003ch3\u003eAssessment of lessons learned\u003c/h3\u003e\n\u003cp\u003eThe assessment included formative and summative evaluation components to evaluate both theoretical breastfeeding knowledge and practical competencies. In both modalities, we used the same form of assessment; however, the formative evaluations did not have grades but were used to identify the participants\u0026rsquo; strengths and fields of improvement in performance.\u003c/p\u003e \u003cp\u003eWe applied the formative evaluations in 20 of the 25 sessions, while three sessions saw a summative evaluation. The course\u0026rsquo;s first two sessions did not include evaluations. Likewise, we rigorously controlled the facilitators\u0026rsquo; attendance, registering the participation in each encounter. Two failed attendances in a row, or an attendance rate of under 70%, implied the exclusion from the course.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegral assessment: Breastfeeding counseling and practice evaluation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriterion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObservable indicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuccess scale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Welcome and therapeutic bond\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStarts interaction showing respect, openness and creating trust.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Gives a warm welcome.\u003c/p\u003e \u003cp\u003e- Explains the session\u0026rsquo;s purpose.\u003c/p\u003e \u003cp\u003e- Shows respect for dignity and privacy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Active listening and context exploration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands the mother, listening actively; acknowledges her personal, social and cultural circumstances.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Maintains eye contact and open posture.\u003c/p\u003e \u003cp\u003e- Identifies bars and facilitators.\u003c/p\u003e \u003cp\u003e- Considers age, culture and level of education.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3. Clear and adaptive communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplains topics in simple language, adjusted to the mother\u0026rsquo;s profile.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Avoids unnecessary technicisms.\u003c/p\u003e \u003cp\u003e- Relates information to previous experiences.\u003c/p\u003e \u003cp\u003e- Checks understanding through questions or examples.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4. Practical demonstration and application\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDemonstrates and practically guides the breastfeeding issue or technique.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Carries out demonstration step by step.\u003c/p\u003e \u003cp\u003e- Allows mother to practice and seek feedback.\u003c/p\u003e \u003cp\u003e- Uses practical resources from the environment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5. Breastfeeding technique\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssesses key technical elements during feeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Comfortable posture of mother.\u003c/p\u003e \u003cp\u003e- Alignment and closeness of baby.\u003c/p\u003e \u003cp\u003e- Good mouth-breast latching.\u003c/p\u003e \u003cp\u003e- Recognizes effective sucking and adequate feeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6. Promotion of self-confidence and empowerment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReinforces mother\u0026rsquo;s security and furthers her decision-making autonomy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Validates mother\u0026rsquo;s achievements and capacities.\u003c/p\u003e \u003cp\u003e- Motivates to identify own solutions (liberating education).\u003c/p\u003e \u003cp\u003e- Promotes protagonism and confidence (empowerment).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7. Proposed action and shared decision-making\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides recommendations, builds agreements with mother and family.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Presents practical alternatives.\u003c/p\u003e \u003cp\u003e- Involves family/caretakers when adequate.\u003c/p\u003e \u003cp\u003e- Furthers shared decision-making.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8. Motivating closure and continuity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnds consolidating the lessons learned and motivates for action.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Summarizes key points.\u003c/p\u003e \u003cp\u003e- Reinforces confidence and motivation.\u003c/p\u003e \u003cp\u003e- Offers future support and follow-up.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;Not achieved\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially achieved\u003c/p\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Adequate\u003c/p\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Excellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFinally, each curricular core topic was evaluated based on specific criteria, as detailed in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The score of each evaluation was reached by summing the criteria, with a maximum of 32 points, which were subsequently converted into a scale from 1 to 10. In order to pass the course, we established a minimum of 7/10.\u003c/p\u003e\n\u003ch3\u003ePhase II Implementation of the breastfeeding counseling room (March through December 2023)\u003c/h3\u003e\n\u003cp\u003eThe breastfeeding counseling room\u0026rsquo;s physical and functional design follows general guidelines from the region\u0026rsquo;s previous experiences [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], while the operative and normative aspects were adapted as a part of this intervention.\u003c/p\u003e \u003cp\u003eThe room\u0026rsquo;s implementation required the identification and adequation of a physical space within the local healthcare system, taking into account specific criteria: existence of ambulatory care for pregnant and lactating mothers, availability of an immediate post-partum care service favoring early user recruitment, and the disposition of a space with privacy, well-ventilated and functionally integrated with the other healthcare services. The Tabacundo \u0026ldquo;type C\u0026rdquo; Healthcare Center met these requirements, so we chose it as the idoneous place for implementation.\u003c/p\u003e \u003cp\u003eWe equipped the breastfeeding counseling room with a variety of didactic supplies and specialized materials, several of them adapted to the local cultural context to favor an effective and respectful care. The room implements are shown in image 1.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImage 1.\u003c/b\u003e Breastfeeding counseling room implements. \u0026ldquo;type C\u0026rdquo; Healthcare Center Tabacundo.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn parallel, we implemented several operative and normative processes to guarantee the room\u0026rsquo;s functionality. First of all, we established care flows that included the definition of operating hours, staff availability, user recruitment, and standardization of protocols. The district managers set operation hours for two days per week, in accordance with the number of certified counselors, who were to assist approximately twice a month. To ensure the availability of human resources, we cooperated with district authorities and healthcare service directors; as a result, the time dedicated to the room was recognized as part of the counselors\u0026rsquo; institutional responsibilities.\u003c/p\u003e \u003cp\u003eWe designed specific user recruitment strategies. These included referrals from other healthcare services (gynecology, obstetrics, pediatrics, vaccination and healthy child programs), active searches in post-partum rooms and outpatient sections, as well as the direct inscription at the healthcare center.\u003c/p\u003e \u003cp\u003eWe also established a standardized care protocol to ensure service homogeneity. It began with taking the vital signs, followed by an interview to collect socio-demographic information, reproductive history and previous consultations. After that came the physical examination of mother (breasts and breastfeeding technique) and baby (position, latch, suction and possible clinical conditions affecting breastfeeding). The counseling ended with individualized recommendations, an invitation to further consultations and, if necessary, referral to psychological support. The protocol foresaw a minimum of 15 minutes per consultation, but it was flexible to be extended if necessary, to ensure an integral care.\u003c/p\u003e \u003cp\u003eSustainability of the intervention was guaranteed by formally incorporating the room into the district system, recognizing the counselors\u0026rsquo; work as part of their institutional functions, and the existence of standardized care protocols and permanent resources. In December 2024, we transferred the supervision to the district\u0026rsquo;s technical team, acknowledging that the strategy had reached a sufficient level of maturity, with operative autonomy and an institutional recognition ensuring its continuity.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMonitoring\u003c/h2\u003e \u003cp\u003eAs part the intervention\u0026rsquo;s technical support, we implemented follow-up training strategies to document the process, identify necessary adjustments and obtain feedback on the implementation of the intervention, however without realizing an impact assessment or an effectivity study.\u003c/p\u003e \u003cp\u003eDuring phase I, we realized three focal groups with the participants: two in course week 7, carried out by the facilitators, each with 15 persons simultaneously, aimed to explore main technical problems and limitations for effective breastfeeding, reported by lactating and pregnant mothers in their practices. At the end of the training, we realized a third focal with the persons who had completed the process, to understand the perceived relevance of the training experience and which elements the participants considered transformative of their practice. In all cases, we asked for oral consent to record their voices during the realization of the focal groups. The recordings were made with the iPad \u003cem\u003eVoice Memos\u003c/em\u003e app.\u003c/p\u003e \u003cp\u003eDuring phase II, we implemented institutional registering and monitoring processes aimed at integrating the room in the district\u0026rsquo;s official reports. In a first stage, the information was entered into a physical register by means of a clinical breastfeeding history with data regarding the number of women attended, their socio-demographic features y their reasons for attendance. Subsequently, these registers were migrated to a web application developed for the care service that allowed for information standardization and systematization. The systematic review of the digital forms from May to December 2024 enabled us to understand the room\u0026rsquo;s functionality and the care model\u0026rsquo;s relevance.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eThe phase I focal group recordings were transcribed and analyzed with software MAXQDA 24 (VERBI Software GmbH, Berlin). We especially carried out a full initial transcript reading, to understand the overall content of the responses to the facilitators\u0026rsquo; questions and identify preliminary patterns. Two of the authors (FO y FM) independently reviewed the material and realized a manual codification, tagging the most relevant text segments. These codes were grouped in categories or topics, based on conceptual similarities and relations. The topics were consensually reviewed by the said authors to ensure their internal coherence and that they were all clearly distinguishable. They chose representative extracts of the participants\u0026rsquo; answers to illustrate each topic. In phase II, we organized the data of the digital forms in an Excel spreadsheet and then exported them to descriptive statistics in STATA/SE 18.0. The information appears in the form of frequencies and percentages.\u003c/p\u003e \u003cp\u003eThe variables registered in those forms comprise both the general features of the consultations, including their total number and duration in minutes and the mothers\u0026rsquo; socio-demographic data. We specifically recorded if a mother was pregnant or in her breastfeeding period. The age was classified in three groups: 14\u0026ndash;17 years, 18\u0026ndash;30 years and over 30 years old. The mothers\u0026rsquo; education levels were grouped as follows: incomplete primary, complete primary, incomplete secondary, complete secondary, incomplete higher and complete higher education. We also collected information as to the mothers\u0026rsquo; formal employment (binary variable: \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;) and their places of residence by canton (Cayambe or Pedro Moncayo).\u003c/p\u003e \u003cp\u003eFinally, we collected the reasons for attendance in the form of an open text and subsequently coded that in analytical categories using MAXQDA 24.\u003c/p\u003e"},{"header":"Results of the intervention","content":"\u003cp\u003eThe results of the intervention realized are described considering especially the main implementation aspects and the lessons learned along the process.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFeatures of the participants\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the participants\u0026rsquo; occupations in the beginning and at the end of the training, thus identifying the professional profiles of those who entered and completed the process.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProfessional profiles of the participants completing the breastfeeding counselor training.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession/ working area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeginning (n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eApprovals \u003c/p\u003e \u003cp\u003e(n, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary-level care technicians (TAPS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (46.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetricians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNutritionists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn accordance with the results shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, at the end of the training, one notes a marked decrease in the representation of primary-level healthcare technicians, while the share of obstetricians and physicians increased in respect of the total of participants. These changes reflect a variation in the group\u0026rsquo;s professional composition at the end of the course, suggesting that the profiles with university education tended to remain longer and show greater success along the training process.\u003c/p\u003e \u003cp\u003eIn total, 32 participants enrolled, 10 (31%) of whom satisfactorily completed the program and obtained the certification as breastfeeding counselors. Of the latter, eight bonded with the breastfeeding counseling room in phase II, seven of which were females.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReasons for failing the course\u003c/h2\u003e \u003cp\u003eEight persons (25%) were discontinued for exceeding the non-attendance limit, while fourteen (44%) did not meet the minimum performance required. Overall, the results indicate that the greatest challenge was not the lack of attendance but the fulfilment of the course\u0026rsquo;s technical standards, showing that success depended on the capacity to complete the curriculum y show command of the contents.\u003c/p\u003e \u003cp\u003e \u003cem\u003eResults of the focal groups realized during week 7 of the course (phase I)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e1. Bars for effective breastfeeding\u003c/h2\u003e \u003cp\u003eThe first focal groups findings with healthcare providers, collected in phase I, evidence a variety of bars for breastfeeding, which may be grouped into two main directions: technical difficulties, and personal, social and contextual factors.\u003c/p\u003e \u003cp\u003eAt the technical level, we identified knowledge limitations both among the mothers and some healthcare professionals, as well as difficulties related to daily breastfeeding practice, especially regarding the application of adequate techniques and the handling of situations common in that process (see Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, the limitations of a personal, social and cultural order evidence the impact of deeply-rooted beliefs, prenatal support gaps, communicational difficulties during interventions and conditions of particular vulnerability in certain groups, like adolescent mothers (see Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, the findings show that the challenges for breastfeeding exceed the clinical scope, comprising social and relational dimensions directly impacting its practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTechnical issues for breastfeeding identified by healthcare providers during the first focal group of phase I\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnical issue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSynthesis of findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLacking knowledge of breastfeeding techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMany mothers (and some professionals) do not know how to position the baby or ensure an adequate latch.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) there is lack of knowledge as to how you breastfeed (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReasons for consultation by mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree central worries: amount of milk, pain/discomfort in nipples, and sustainability returning to work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) of course, \u0026lsquo;cause they say, I mean, I\u0026rsquo;m going to work (\u003c/em\u003e\u0026hellip;) \u003cem\u003eand how do I take \u0026lsquo;em out there (\u0026hellip;)?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLacking knowledge about milk extraction and conservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe mothers (and some professionals) do not know the right techniques of milk extraction and storage.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) there are many things, we as healthcare professionals do not know about milk extraction techniques (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLimitations for breastfeeding identified by healthcare professionals during the first focal group of phase I\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimitation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief breastfeeding is a natural and instinctive process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreastfeeding seen as something instinctive not needing preparation or support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(...) the mothers think it is something very natural, something they will be able to do \u0026lsquo;normally\u0026rsquo; (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFalse beliefs regarding the success of breastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdea the shape of the nipples decides over the success of breastfeeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e(\u0026hellip;) they are worried: their nipples, \u0026iquest;are they going to be right or not (\u0026hellip;)\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsecurity about milk production\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequent fear of not producing enough mother milk.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) they always ask: am I going to have enough milk to satisfy the baby? (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate time to receive breastfeeding counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuring pregnancy, there is little interest for issues related to breastfeeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) pregnant women show little interest, apparently. They do not ask about breastfeeding. Rather, they focus on growth, that is the baby\u0026rsquo;s food (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunicational and relational bars\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited time for consultation, mothers\u0026rsquo; low confidence to ask, healthcare provider\u0026rsquo;s gender.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) I think one of the problems there are in counseling is the ladies\u0026rsquo; lack of confidence to ask. And, besides, the time we have is so limited (\u0026hellip;).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) in breastfeeding counseling, we\u0026rsquo;ve had few consultations; the male staff would say they perceive a difference. Women shy away from asking (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConditions of vulnerability in adolescent mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis population requires a differentiated approach given their social, emotional and physical situation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;(\u0026hellip;) \u003cem\u003emany of them are alone, have no partners (\u0026hellip;) so, imagine a raped, pregnant adolescent, what interest might she possibly have in breastfeeding? (\u0026hellip;).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly breastfeeding abandonment factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of education of mother, work and/or household activities, reasons for not breastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003e(\u003c/em\u003e\u0026hellip;) \u003cem\u003eIn my experience (...) the lack of education in pregnant women has an impact (\u0026hellip;)\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eCurricular adjustments\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eBased on the first focal group\u0026rsquo;s results, we adjusted the training curriculum both in regard of content and methodology, in order to deal with the technical and relational difficulties identified.\u003c/p\u003e \u003cp\u003eContentwise, we included new topics, such as mother milk extraction techniques and the creation of milk banks at home. Although no contents were excluded, some had to be reorganized in their sequence and approach, prioritizing their treatment in the early course stages, in order to strengthen their practical application, especially those related to the main reasons for maternal attendance and the resolution of common breastfeeding issues.\u003c/p\u003e \u003cp\u003eMethodologically, we reinforced the curriculum\u0026rsquo;s practical component, putting special emphasis on teaching breastfeeding techniques. Likewise, we included strategies to develop communicational healthcare skills centered in the core topics of empowerment and emphatic behavior. These topics were addressed both in the practical and theoretical sessions, with interactive pedagogical tools.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare staff perceptions of the formative experience following the training (phase I)\u003c/h2\u003e \u003cp\u003eIn line with the study\u0026rsquo;s main objective, i. e. the strengthening of the healthcare professionals\u0026rsquo; competencies in breastfeeding counseling, we realized a third focal group at the end of the training, in order to explore the participants\u0026rsquo; perceptions of their training experience. Thus, we could receive assessments about different program aspects, especially those impacting their professional practice and way of interacting with the mothers (see Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealthcare staff perceptions of the formative experience once the training was completed (phase I)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormative experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelevance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheoretical-practical training methodology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The course enriched our knowledge in a practical manner, since we were not prepared to provide breastfeeding counseling\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCounseling individualization in order to highlight specific situations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) this course took into account a lot of things, every\u0026hellip; mother has different types of problems.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHorizontal exchange and active listening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) we abandoned the \u0026lsquo;we know and they know nothing\u0026rsquo; attitude\u0026hellip; we actually could learn from them (\u0026hellip;) and empower them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAddressing by name (avoiding diminutives and colloquial epithets)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;so, in order to address them as \u0026ldquo;mommy\u0026rdquo; instead of by their name, the mothers looked at us as if we were something bigger (\u0026hellip;), but we understood that we must treat and address them by their names.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePracticing operational empathy to generate trust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(\u0026hellip;) we got closer to the patient and they begin to relax, show more confidence, hence gratitude, security.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eReflecting about the changes in their personal approach, the participants mentioned that initially, they tended to employ a generic language and worried only about promoting breastfeeding as a generally desirable practice, without taking into account each woman\u0026rsquo;s individual context. As a result of the training process, they acknowledged the need for adapting the message, paying attention to the users\u0026rsquo; concrete worries, and supporting them from a closer and respectful position. These elements, they said, strengthened their capacity to generate trust and improve the quality of counseling.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eResults of phase II. Implementation of the individualized breastfeeding counseling model\u003c/h2\u003e \u003cp\u003eThe study\u0026rsquo;s second phase consisted of commissioning a breastfeeding counseling room and the application of the individualized breastfeeding counseling model based on the findings of phase I. Its operation was monitored with a systematic review of the digital forms registered between May and December 2024, thereby evaluating both the room\u0026rsquo;s operativity and the model\u0026rsquo;s pertinence and applicability in real context. The analysis focused on the dynamics of counseling, the profile of users, and the most frequent reasons of attendance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e1.Characteristics of the counseling sessions\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe breastfeeding counseling room saw a total of 305 individual in-person sessions, with 247 women attending. For 275 of these sessions, we registered their duration, with a mean value of 36 minutes per consultation (DE\u0026thinsp;=\u0026thinsp;12.2), more than twice the time established by the institutional regulations for any consultation in the public healthcare system (15 minutes). This suggests that the model requires a more ample timeframe to ensure an individualized and qualitatively acceptable attendance.\u003c/p\u003e \u003cp\u003eMost users were women in their breastfeeding period (76.5%), vs. 23.5% of pregnant women, a ratio of 3.2 to 1. Such distribution indicates that the model was primarily used to address worries during the breastfeeding period, when the challenges usually are more concrete and urgent.\u003c/p\u003e \u003cp\u003eThe analysis of the attendance frequency showed that 81.8% of the women (n\u0026thinsp;=\u0026thinsp;202) attended only one counseling session, while 18.2% (n\u0026thinsp;=\u0026thinsp;45) did so twice or more often. Concretely, 13.8% assisted twice, 3.6% three and 0.8% even four times. Although the intervention allowed for multiple sessions, most women used the service in a pinpointed way.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSocio-demographic profile of users\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe user profiles evidence a predominance of young women between ages 18 and 29, followed by adults of ages 30 or more. Nothing the less, we point out that 10.9% were adolescents between 14 and 17 years of age, an especially vulnerable part of the population, given their limited experience and little prior access to information on breastfeeding, hence underlining the need for differentiated counseling approaches (see Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn respect of education levels, most users had attended secondary education, and a minor percentage higher education. In respect of their work situation, most did not have paid work at the time of attendance, reflecting a range of educational and work histories among the participants (see Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, 87,9% of the women attending lived in canton Pedro Moncayo, thus reinforcing the model\u0026rsquo;s territorial pertinence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of users attending the breastfeeding counseling room in May-December 2024 (n\u0026thinsp;=\u0026thinsp;247)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003cp\u003e-14\u0026ndash;17\u003c/p\u003e \u003cp\u003e-18\u0026ndash;29\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;30 or over\u003c/p\u003e\u003cp\u003e- no data\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003cp\u003e168\u003c/p\u003e \u003cp\u003e51\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003cp\u003e68.0\u003c/p\u003e \u003cp\u003e20.7\u003c/p\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003cp\u003e- none\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;1\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;2\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;3\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;4\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;5\u003c/p\u003e \u003cp\u003e- no data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e108\u003c/p\u003e \u003cp\u003e64\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003cp\u003e43.7\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e10.1\u003c/p\u003e \u003cp\u003e4.9\u003c/p\u003e \u003cp\u003e0.8\u003c/p\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of formal education\u003c/p\u003e \u003cp\u003e- incomplete primary\u003c/p\u003e \u003cp\u003e- complete primary\u003c/p\u003e \u003cp\u003e- incomplete secondary\u003c/p\u003e \u003cp\u003e- complete secondary\u003c/p\u003e \u003cp\u003e- incomplete superior\u003c/p\u003e \u003cp\u003e- complete superior\u003c/p\u003e \u003cp\u003e- no data\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e43\u003c/p\u003e \u003cp\u003e113\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e58\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003cp\u003e11.3\u003c/p\u003e \u003cp\u003e17.4\u003c/p\u003e \u003cp\u003e45.8\u003c/p\u003e \u003cp\u003e0.40\u003c/p\u003e \u003cp\u003e23.5\u003c/p\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaid work\u003c/p\u003e \u003cp\u003e- yes\u003c/p\u003e \u003cp\u003e- no\u003c/p\u003e \u003cp\u003e- no data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003cp\u003e172\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003cp\u003e69.7\u003c/p\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCanton of residence\u003c/p\u003e \u003cp\u003e- Cayambe\u003c/p\u003e \u003cp\u003e- Pedro Moncayo\u003c/p\u003e \u003cp\u003e- no data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e217\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003cp\u003e87.9\u003c/p\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e3. Reasons for attending the counseling sessions\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMost attendances were related to technical breastfeeding difficulties, primarily aspects such as breastfeeding technique, nipple-related problems and the sensation of low milk production. Overall, these issues represented the largest share of attendance (70%), highlighting the need for reinforcing the practical support at the early stages of the post-partum period (see graph 1).\u003c/p\u003e \u003cp\u003eWe also identified consultations about the planification of breastfeeding continuity in the light of a return to work or studies; these were mostly requests for information about mother milk extraction and conservation. A smaller number of women did not voice specific doubts at the moment of consultation, suggesting that some appreciate the counseling as a preventive space or an instance of emotional validation. These findings show the importance of combining technical issues and strategies of contention and orientation adapted to the different breastfeeding stages.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGraph 1.\u003c/b\u003e Reasons of attending the breastfeeding counseling room at District Cayambe\u0026ndash;Pedro Moncayo in May-December 2024.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe findings obtained in both intervention phases provide a comprehensive vision of the healthcare professionals training process and the commissioning of an individualized breastfeeding counseling model within the local healthcare system. The information gathered allows to see how the service was set up, who took part in it, and what were the main reasons of consultation attended. These elements provide a relevant input for an in-depth analysis of the lessons learned, the challenges identified and the considerations needed to strengthen or adapt similar interventions; issues we address in the following section.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of the intervention provide evidence on the feasibility and pertinence of integrating an individualized breastfeeding counseling model within the public healthcare system in Ecuador\u0026rsquo;s rural areas. In the following, we will discuss the primary findings as related to the existing literature, their practical implications, and possible future paths.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe training model and its implications\u003c/h2\u003e \u003cp\u003eOne of the study\u0026rsquo;s most striking findings was that only 31% of the participants satisfactorily completed the training process. This low completion rate occurred despite the employment of a carefully designed methodology, based on an integration of theory, roleplays, clinical simulations and field supervision [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The experience showed that although the approach was highly appreciated by those who managed to complete it, there were still bars related to work overload, lack of time and difficulties to harmonize the training processes and the institutional day-to-day demands, especially in primary-level care [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Besides, we observed changes in the group that completed the course, where profiles with university education dominated, such as obstetricians, physicians and nutritionists, in contrast to greater desertion among primary-level healthcare technicians (TAPS). This difference evidences the importance of adjusting the curricular design to each professional group\u0026rsquo;s training histories, specific functions and work realities, to favor the development of pertinent and sustainable competencies.\u003c/p\u003e \u003cp\u003e Despite these tensions, a key factor along the process was the active participation of the district managers, who understood and supported the intervention\u0026rsquo;s strategic relevance from its very beginning. The institutional disposition made it possible to introduce a certain operative flexibility in the organization of operating hours, functions and work dynamics, thus favoring both the room\u0026rsquo;s implementation and progress along the training process. Such kind of institutional commitment, even in environments of limited resources, is a key facilitator to sustain innovations in healthcare promotion [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Thus, the experience not only provides evidence regarding the feasibility of applying more in-depth and contextualized healthcare training programs, but also emphasizes the relevance of an institutional leadership sensitive to maternal and infant healthcare priorities. As several authors state [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], when healthcare providers do not possess solid breastfeeding training, the counseling quality may be seriously limited, thus reinforcing the need for the development of well-trained technical references. Besides, the consolidation of a small group of professionals that completed the training process made it possible to strengthen a nucleus of professionals able to act as breastfeeding \u003cem\u003echampions\u003c/em\u003e within the local healthcare system, promoting good practices, quality support and the counseling model\u0026rsquo;s continuity.\u003c/p\u003e \u003cp\u003eThese findings provide empirical evidence for the design of continuing maternal and infant healthcare training strategies, especially in public contexts where resources and time are limited. Future scaling processes should consider curricular adaptation, operative flexibility and the commitment of local key actors as determining factors to sustain and institutionalize breastfeeding support practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of the breastfeeding counseling room and its contribution\u003c/h2\u003e \u003cp\u003eOne of the study\u0026rsquo;s most tangible results was the breastfeeding counseling room\u0026rsquo;s implementation within the Tabacundo del healthcare center, conceived as an exclusive space for individual counseling to pregnant women and lactating mothers. Its commissioning required setting up a specific physical space, developing collaborative attendance protocols, organizing internal flows and articulating its operations within an institutional routine. This is particularly significative given the primary-level care\u0026rsquo;s rural context, where infrastructure, staff and resources limitations usually are obstacles to the implementation of specialized services.\u003c/p\u003e \u003cp\u003eIn countries like Chile, breastfeeding clinics are a part of the services covered by the National Health Fund (FONASA) and included in the program Chile Crece Contigo (Chile Grows with You), which facilitates their sustainability and institutional anchoring [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. By contrast, this pilot experience in Ecuador represents the first documented attempt to establish such a room within the Ecuadorian local public healthcare system, without national regulative backing but strong district support. The fact of its implementation evidences that it is possible to institutionalize such spaces as part of maternal and infant healthcare services, even in environments of limited resources, provided that locally there is the will and a technical training strategy sustaining them.\u003c/p\u003e \u003cp\u003eThis experience aims to offer a concrete contribution to the scarce Latin American documentation on how to structure and include breastfeeding counseling rooms within the public healthcare systems of medium and low-income countries. Its systematization provides practical and strategic input for future scaling processes and the institutionalization of such interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFeatures of the counseling sessions and their impact for the attendance model\u003c/h2\u003e \u003cp\u003eThe counseling model implemented was characterized by a more prolonged and personalized attendance time as compared to the public healthcare system\u0026rsquo;s usual standards, a kind of attendance highlighted by several authors as fundamental for the achievement of an effective breastfeeding support, notably when inclusion of active listening, resolution of doubts and emotional support are the objectives [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The findings emphasize the need for reviewing the timeframes assigned to maternal and infant attendance, if bond- and care experience-focused attendance models are the goal.\u003c/p\u003e \u003cp\u003eIn addition, the service\u0026rsquo;s usage profile suggests that counseling represents an especially heartfelt need in post-partum, where many mothers face practical and emotional difficulties requiring specific support [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Nonetheless, the fact that so few attended more than one session hints at obstacles for the continuity of assistance: Just as the literature states, factors like the load of reproductive and family care or time issues may limit their possibilities of coming back, although the service is available [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, future models should incorporate proactive follow-up strategies like reminders, scheduled appointments or home visits to reinforce the continuity and effectivity of counseling [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eUser profiles and vulnerability\u003c/h2\u003e \u003cp\u003eThe profiles of the women attended evidence several factor of vulnerability to be considered in the design of contextualized interventions. 11% were adolescents, a portion in concordance with the 14% of liveborn babies in 2024 with mothers between ages 15 and 19 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], thus underlining the importance of including the group in breastfeeding support services. The counseling model is a specific approach for these users, taking into account the worries expressed by the counselors during their training, where they identified bars like abandonment, violence or little family support. Such conditions, combined with social judgment and lacking contention networks, have been indicated as factors making the continuity of breastfeeding difficult. Within this scope, the findings reinforce the need for models including life trajectories as structuring elements of support.\u003c/p\u003e \u003cp\u003eAs for the levels of education, we observed a greater participation of women with secondary or higher education. This could make their bonding with the service easier, since several studies document that women with better education levels usually tend to more actively use healthcare services and sustain informed care practices like prolonged breastfeeding [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Notwithstanding, such a pattern runs the risk of leaving behind those with educational bars. Strengthening the articulation of counseling with institutional spaces, such as pre- or post-partum controls may achieve a more equal access and widen the model\u0026rsquo;s scope toward historically underattended groups [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe also observed differences depending on the number of children. Most users attended were primiparous, coinciding with previous findings suggesting the group\u0026rsquo;s greater disposition to sustain exclusive breastfeeding when they get technical support [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. By contrast, multiparous women usually face greater challenges, like care overload, less social support or the early introduction of supplementary food [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In our study, the individual counseling mode facilitated a support adjusted to the mothers\u0026rsquo; experiences, reinforcing the value of flexible and differentiated approaches.\u003c/p\u003e \u003cp\u003eLastly, geographic proximity influenced the access to the service, too: most users lived in Pedro Moncayo where counseling took place, whereas participation from Cayambe was limited, possibly due to transportation issues. The pattern reveals the importance of planning the service location, considering that not only criteria of territorial equality but also operative efficacy matter [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eDemand for assistance and pertinence of the counseling model\u003c/h2\u003e \u003cp\u003eThe reasons for consultation registered revealed a demand for assistance focused on practical issues such as holding the baby, nipple-related pains, sensation of low milk production or the need for milk extraction or conservation. This last issue was particularly frequent among mothers returning to work or school. Such situations, widely documented under diverse socio-economic contexts [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan additionalcitationids=\"CR48 CR49\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], are associated to the early interruption of breastfeeding, use of formulas or supplementary food [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring the first focal group, several counselors stated that initially they had underestimated those technical difficulties, influenced by the widely reigning social belief, sometimes shared by healthcare workers, that breastfeeding is a natural and instinctive process. Those perceptions hide the real challenges that many women, especially adolescents or primiparous, face shortly after childbirth, and they delegitimize their need for attendance [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The training process\u0026rsquo;s practical stage could re-signify those beliefs and reinforce the conviction of the need for a technical, affective and personalized approach to address counseling\u0026rsquo;s manifold dimensions.\u003c/p\u003e \u003cp\u003eIn this sense, the demand perceived validates the counseling model\u0026rsquo;s pertinence, particularly given its emphasis on active listening, prolonged healthcare attendance and support adapted to concrete situations. Contrarily to schemes focusing on the mere transfer of generalized and/or standardized information, our model enables to address questions marked by insecurity, physical discomfort or fear of not being able to breastfeed adequately; thereby evidencing a greater capacity to respond to the women\u0026rsquo;s concrete circumstances. Beyond the delivery of mere contents, these findings highlight the value of models that include a relational and contextual care dimension, focused on supporting breastfeeding processes a situated manner.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAlthough this was not an impact study nor an effectivity trial, its implementation comprised a pre and post training assessment (phase I), which allowed us to identify preliminary improvements in the participants\u0026rsquo; knowledge, skills and attitudes. And despite the fact that the absence of a control group forbids to attribute the changes stated exclusively to the intervention, our mixed approach including training follow-up, focal groups, and the review of the attendance records, enabled a wider understanding of the model\u0026rsquo;s implementation and value. Likewise, the close support to the training team facilitated a curriculum adjustment in accordance with the needs arising, strengthening a qualitative analysis despite not having applied a direct systematized observation.\u003c/p\u003e \u003cp\u003eOn the other hand, the facilitators\u0026rsquo; twofold role as investigators alike may have introduced a social desirability bias, affecting the spontaneity or depth of some answers. However, the triangulation of qualitative and quantitative sources helped mitigate this risk, producing consistent patterns. For future investigations, it would be advisable, though, to include comparison groups, longer-term evaluations and external observers, in order to increase the model\u0026rsquo;s methodological solidity and assess its sustainability. Still, with these limitations, the study provides relevant findings about the feasibility of counseling and its perceived benefits in rural contexts, emphasizing its capacity to adapt to local conditions, such as institutional flexibility and the infrastructure minimally necessary for its implementation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study describes the implementation of a breastfeeding counseling model developed in, and adapted to, a primary-level healthcare center within a rural context of Ecuador. Based on a practical approach, it was structured into two phases: initially, the training of healthcare professionals and subsequently, the establishment of a counseling room. This way, we evidenced that it is possible to install a technically sound service, empathetic and sensitive to the users\u0026rsquo; life histories, using already existing institutional resources.\u003c/p\u003e \u003cp\u003e Our findings, among them the improvement of the counselors\u0026rsquo; knowledge and attitudes, as well as a demand in assistance focused on technical difficulties and other needs in accordance with the profiles of users, underline the importance of models combining technical information and personalized support. The experience sheds light on how an integral approach may respond better to the challenges of early post-partum women, especially those in conditions of greater vulnerability like adolescent or primiparous mothers.\u003c/p\u003e \u003cp\u003eThe model\u0026rsquo;s scalable nature, its low infrastructure requirements and its compatibility with local healthcare systems make it a proposal with potential for adaptation in other rural environments or ones with similar structural limitations, both in Ecuador and countries with comparable characteristics.\u003c/p\u003e \u003cp\u003eFuture studies might include quasi-experimental designs, such as the measurement of results in infant healthcare and a sustainability analysis over time, which would allow to delve into the effects and conditions for the expansion of this kind of intervention at a larger scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe course of the intervention had the ethical approval of the Ethical Committee for Research in Humans of Universidad San Francisco de Quito (CEISH, ID 2017-177IN; approved February 8, 2018) within the framework of the SEMILLA study. Likewise, District Health Division 17D10 (Cayambe\u0026ndash;Pedro Moncayo) authorized its implementation in the study area. All the focal groups participants gave their oral consent in advance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe realization of the intervention was made possible thanks to the funding granted as part of the Outreach Grant USFQ 2023; also, funded (in part) by the University of Michigan Office of Global Public Health, School of Public Health.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eF.O., M.E.H.F., and S.M. jointly contributed to the conceptualization of the study, with F.O. leading the overall project design and formulating the research idea, M.E.H.F. strengthening the breastfeeding-related methodological components, and S.M. leading fieldwork implementation and contributing to key methodological decisions that guided the study. F.O. and S.M. jointly prepared the original manuscript draft, contributed to the development of visualizations, and supported project administration throughout implementation. M.E.H.F. also provided supervisory guidance during the project. F.M. was responsible for software development. F.O. and F.M. jointly conducted the formal analysis and were responsible for data infrastructure maintenance and data curation. A.Ch. and J.M. provided institutional resources for project implementation and contributed supervisory input. F.O. and A.J.H. secured funding and contributed to overall project support. All authors contributed to reviewing and editing the manuscript and approved the final version.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe thank Dr. William Perugachi, who at the time served as the District Director of Health for Cayambe\u0026ndash;Pedro Moncayo, for his institutional commitment and support. We also extend our gratitude to Diana Coello Baquero, Coordinator of Social Engagement at Universidad San Francisco de Quito, for her unwavering support, enthusiasm, and trust in our work. To Dr. Alena Clark from Colorado State University, for her support during the training of breastfeeding counselors and her guidance in the implementation of the breastfeeding counseling room, as well as for her strategic review of the draft of this manuscript. And, special thanks to Graciela Garc\u0026iacute;a and Am\u0026iacute;lcar Chingal for their logistical support during the study implementation.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during this study include transcripts of focus group discussions and anonymized counseling records collected through standardized clinical forms. Due to privacy and ethical considerations, these data are not publicly available but may be available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBlanco S, Aboul-Enein BH, Benajiba N, Dodge E. A Scoping Review of Breastfeeding Interventions and Programs Conducted Across Spanish-Speaking Countries. Health Promotion Pract [Internet]. 2025;26(1):168\u0026ndash;91. Available from: [15,24] Accessed: 25 Jun 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S et al. Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatrica [Internet]. 2015;104(S467):114\u0026ndash;34. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bmcnutr.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"https://bmcnutr.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40795-019-0272-0\u003c/span\u003e\u003cspan address=\"10.1186/s40795-019-0272-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed: 2 Jul 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breastfeeding, training, healthcare professionals, breastfeeding counseling, educational intervention","lastPublishedDoi":"10.21203/rs.3.rs-8347342/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8347342/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eBreastfeeding counseling plays a key role in promoting optimal infant feeding, particularly when delivered individually and in person. Its effectiveness relies on the quality of healthcare training, which remains highly variable. In Ecuador, however, public health services mainly rely on group-based strategies with limited access to individualized support. This gap reinforces existing inequalities as private counseling services remain costly. This article aims to document an intervention co-developed with the local health system to strengthen healthcare capacity and implement a model of individualized counseling in a rural area of the country.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis practice-based case study was implemented in two phases between 2023 and 2024. In phase I, 32 primary-level healthcare professionals participated in a training consisting of 80 hours (40 theoretical, 40 practical), focused on technical content, affective communication, and supportive counseling strategies. Focus group discussions conducted at the beginning and end of the training informed the curriculum design and evaluated changes in knowledge and attitudes. In phase II, a breastfeeding counseling room was established at the Tabacundo Healthcare Center, staffed by ten certified counselors. Standardized digital records were used to document user profiles and counseling topics. Data were analyzed descriptively with Stata and thematically with MAXQDA.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eTen of 32 providers (31%) completed the full training and certification process. A total of 305 counseling sessions were conducted with 247 women, most of whom were lactating (74%), aged 18\u0026ndash;29 (68%) and resided in the immediate catchment area (87.9%). Key consultation topics included latch difficulties, nipple pain, perceived low milk supply, and the need to express and store milk. Sessions averaged 36 minutes. Adolescents and primiparous women represented a significant proportion of users, reinforcing the need for differentiated approaches. The counseling model emphasized active listening, personalized support, and emotional containment.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThis study demonstrates the feasibility of designing and implementing a breastfeeding counseling model tailored to local healthcare system resources and user needs. The model proved technically sound, contextually appropriate, and responsive to maternal trajectories. The findings offer valuable insights for scaling similar interventions in other low-resource settings and support future research into their effects on breastfeeding outcomes and maternal\u0026ndash;infant health.\u003c/p\u003e","manuscriptTitle":"Strengthening breastfeeding counseling through a scaled-up intervention implemented within Ecuador’s local healthcare system","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:32:56","doi":"10.21203/rs.3.rs-8347342/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-01T04:32:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T20:48:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223952283794775092392306763063233018588","date":"2026-03-07T07:55:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-15T14:40:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-13T19:31:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-13T19:30:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Breastfeeding Journal","date":"2025-12-12T15:42:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cbb85ffe-81f1-40ed-85cb-e23c9fa50c71","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T03:23:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 09:32:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8347342","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8347342","identity":"rs-8347342","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}