Assessing the validity of maternal report on breastfeeding counselling in Kosovo’s primary health facilities

Abstract

Abstract Background: Improving the quality of breastfeeding counselling delivered by primary care providers can improve breastfeeding outcomes and ultimately reduce mortality and morbidity of children and mothers. Accurate data on coverage and quality of primary care breastfeeding counselling is essential for monitoring progress, however global and national indicators are limited. To help address this gap, this study validated indicators of receipt and quality of breastfeeding counselling during routine consultations for infant care at seven primary health facilities across Kosovo. Methods:Using a structured checklist, mother’s reports of breastfeeding counselling received during routine consultations for their infants (0-12 months of age) were collected by exit interview in 2019 and 2021 (n=609). Responses were compared against direct observation of their consultation (reference standard) by a trained third-party observer at the primary care facility. We assessed 13 indicators; ten were related to the receipt and content of breastfeeding counselling, and three were specific to the provider’s interpersonal skills. We calculated sensitivity, specificity, and area under the receiver operating curve (AUC) to determine individual-level reporting accuracy. Results: Ten indicators had an agreement rate above 70% and seven indicators had high overall validity (AUC≥0.7). High prevalence indicators recorded high sensitivity and low specificity, and the inverse for low prevalence indicators. In line with other studies, more subjective indicators were less reliable e.g., mothers over-reported the prevalence of all three interpersonal indicators. Conclusions: This study offers an original perspective on breastfeeding counselling quality by validating whether a provider discussed breastfeeding, the clinical content of that counselling and how it was delivered i.e., interpersonal behaviors. It is also situated in a primary care setting within a fragile state of which there is limited evidence. We observed that asking mothers directly to recall breastfeeding counselling services received provided an accurate reflection on what was delivered. Capturing mothers’ experience of care, the subjective aspects of counseling quality, is important. As this study and others show, as a community we need to further validate subjective questions and discuss accurate standard measures for the ‘experience of care’ quality dimension.