Abstract
BACKGROUND: Breastfeeding is subject to social inequity with short-term education and young age being important risk factors of early breastfeeding cessation. Breastfeeding support can be offered reactively, with mothers reaching out, or proactively where a health professional or peer supporter contacts the mother. Reactive support alone may be inadequate and inequitable as individuals with the greatest needs are often less inclined to reach out. An evidence-based breastfeeding intervention, offering proactive telephone calls from a health visitor combined with home visits, was implemented in Denmark with the purpose of prolonging breastfeeding and reducing social inequity in breastfeeding. This study aims to illuminate the process of negotiating access to breastfeeding support from the perspectives of both mothers and health visitors and investigate how proactive telephone calls from a health visitor can address inequity in breastfeeding support. METHODS: We applied a realist evaluation approach embedded in a cluster randomized trial carried out in 20 municipalities. In the intervention arm, we observed 35 home visits delivered by health visitors, interviewed 16 mothers and conducted six focus groups with a total of 34 health visitors to examine how the proactive telephone calls functioned, specifically among mothers at increased risk of early breastfeeding cessation. The theoretical concept of Candidacy was applied to unfold how access to breastfeeding support was negotiated and socially patterned. RESULTS: Mothers encountered various barriers when seeking breastfeeding support; one being the fear of appearing bothersome, another stemming from the sensitive nature of breastfeeding itself. At times, their reluctance to reach out was interpreted by health visitors as a sign that breastfeeding was going smoothly, revealing a discrepancy between professional perceptions and the actual challenges mothers faced. Proactive telephone calls improved access to breastfeeding support through three different mechanisms: 1) timely handling of breastfeeding issues, 2) bringing the health visitor and family closer together, and 3) increased rapport and trust. CONCLUSIONS: Proactive telephone calls may function as a tool to mitigate social inequities in breastfeeding if combined with home visits and if it is person-centered with attention to relationships rather than just practical assistance. TRIAL REGISTRATION: Clinical Trials: NCT05311631. First posted April 5, 2022. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-026-26981-6.