1.4 Talk Back

This concern is quite common and understandable. For a long time this approach has been expected of those doing education about safe sleep and breastfeeding. It doesn’t take into account the fact that families will decide what they want to do—we cannot control that, we can only provide as much information as possible about how they can implement their decisions and, if they decide not to implement all of our recommendations, what factors may create the risks so they can address them. This approach is now included in the new American Academy of Pediatrics (AAP) safe sleep guidelines, which also urge open and honest conversations with families. So in effect, not talking about accommodating families’ decisions may actually put babies at risk and undermine the many benefits of breastfeeding.

If we are going to increase breastfeeding and safe sleep behaviors, it will take more than one person at one point in time “educating” families about these issues. The change in mind-set and approach can be implemented within any role, even if you are not able to work through all the steps. Promoting safe sleep and breastfeeding is actually a team effort. Studies have repeatedly shown that hearing messages about safe sleep, for example, from multiple sources, multiple times increases likely acceptance and implementation of safe sleep behaviors. The Conversations Approach will work best within an accessible and integrated system of supports that ensures that families have multiple opportunities to explore their decisions about optimal breastfeeding and safe sleep—before the baby is born, at the time of delivery, throughout the neonatal period, and beyond. So it is not all on your shoulders! Learn who else in your community can be part of the team and who else may be on the family’s support team who can continue the conversation and deepen it.

You can still document your interaction. It will just be done as a two-way communication, where you anticipate and elicit questions and concerns and help with problem solving. Part of your interaction may be connecting families with ongoing support for their decisions about how to feed and sleep their babies.

These modules will provide you with the knowledge you will need to have conversations with families about both topics. As already noted, the Conversations Approach is a team sport and you may need to identify others with more expertise to guide families through implementing safe sleep and breastfeeding at home with their infants. But you can raise both issues and provide the basic information families need to decide to embrace them. If they raise technical questions, then you can rely on other experts and connect them to those resources. But for the family, these two issues are the biggest challenges they face when they get a new baby home—they are not separate at all—and to effectively support families, we need to break down the silos!

While a Conversations Approach is primarily based on face-to-face contact, it can be used to craft complementary brochures, videos and other media communications. Those materials need to reflect the person receiving the information as an active participant in the communication by anticipating potential reactions and addressing refusal, reluctance, and problem solving. Many such communications model safe sleep or optimal breastfeeding behavior in pictures or video. It may be equally important to model caregivers grappling with the information and being able to move from rejection of recommendations to imagining how they might implement them within their own situation, potentially through vignettes. This approach needs to be based on local populations’ beliefs, values, and environments. Information shared should include the rationale for a recommendation and address possible challenges (attitudinal or environmental) to implementing the recommended behavior as well as actions to address those challenges. For example, the recommendation that there be no loose blankets in a baby’s sleep location could include the explanation of airway occlusion and address concerns in geographic areas where winters are cold and families with limited resources may have poor or no central heating with ideas of how to keep the baby warm without loose blankets and how to get help with heating costs along with safety information about use of space heaters.

While the Conversations Approach has much in common with motivational interviewing (and those skilled in implementing motivational interviewing will be very effective), it is not the same. Motivational interviewing is a specific clinical intervention that takes a high level of skill and specific training to implement effectively. The Conversations Approach also requires skill and training and reflects the mind-set of motivational interviewing—a dialogue in which an individual can share and address their reluctance (resistance) to behavior change and work towards making some steps to change. It is different in that the goal is not moving the infant caregiver to a predetermined set of behaviors but to work with them to make the best decisions for their child within their parameters and supporting them to meet the challenges to maintain those behaviors. The hope is, over the course of the conversations, that caregivers will choose to implement the recommended safe sleep and optimal breastfeeding behaviors in total. However, the Conversations Approach recognizes the reality that families make other decisions and supports them to minimize risk and maximize benefits within their chosen approaches.

The Conversations Approach works extremely well in group settings. While some caregivers may be hesitant to share their refusal or reluctance to implementing recommended behaviors, a group conversation may allow others in the group to voice concerns that may be shared across several members or embolden other group members to speak. In addition, the group can help brainstorm ways of meeting challenges, share past successes, and create a network of support for addressing unanticipated challenges in the future.