Grace_Foster_Honors_Thesis.docx

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Lactation consultants, counselors, and supporters’ experiences providing care and services to

mothers in Appalachia

by

Grace Foster

Senior Honors Thesis

Department of Nutrition

University of North Carolina at Chapel Hill

2020

Approved:

Advisor: Stephanie Martin

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ACKNOWLEDGEMENTS

I first want to thank Dr. Stephanie Martin for her mentorship, encouragement, and guidance on this

project during these past two years in the Gillings School of Public Health. My academic experience at

UNC and passion for maternal and infant health is forever impacted because of the opportunity to work

with Dr. Martin. I would also like to thank Ruwaydah Sideek for her partnership and friendship

throughout this project. I am very grateful for the Appalachian Breastfeeding Network and Stephanie

Carroll for the support I have received during this project. I would also like to thank my parents, James

and Lisa, who got me to where I am today. I thank my parents and my siblings, Jay and Lauren, for being

my biggest fan club and my favorite hugs.

This project was supported by the Rodney F. Hood Undergraduate Research Fund administered by

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BACKGROUND

Although there are many known health benefits to breastfeeding for both the infant and

mother, several factors influence the decision or ability to breastfeed. Healthy People 2020 set goals to

reduce barriers to breastfeeding and increase the proportion of infants who are breastfed (Healthy

People, 2020). While there are improvements in breastfeeding rates nationwide, the Appalachian

Region continues to have lower breastfeeding rates compared to the rest of the United States (Machado

et al., 2014). The Appalachian Region spans across 13 states and 420 counties from southern New York

to northern Mississippi (Appalachian Regional Commission [ARC], 2020). This region is home to 25

million people and experiences a growing gap of incomes, poverty rates, unemployment rates, and

postsecondary education as compared to the national levels (ARC, 2020). Additionally, the Appalachian

Region performs poorly in health outcomes when compared to the rest of the United States (Marshall et

al., 2017).

The American Academy of Pediatrics recommends that infants should be fed breast milk

exclusively for the first six months after birth and then continue to breastfeed while introducing

complementary foods until the child is 12 months or older (2012). The CDC breastfeeding report card

shows that breastfeeding rates at 6 months for states in the Appalachia region are generally lower

compared to the rest of the United States (2015). Mississippi, Alabama, and West Virginia report

breastfeeding rates at 6 months to be 35.4%, 39.1%, and 40.1% respectively compared to the national

average of 57.6% (CDC, 2015).Suboptimal breastfeeding, defined as breastfeeding that does not meet

the minimum recommendations, is associated with an excess of premature maternal and child deaths

due to several diseases including childhood infections, obesity, breast cancer, and ovarian cancer

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identification and removal of barriers are needed for the benefit of mothers and infants in the

Appalachian region (Wiener & Wiener, 2011).

Breastfeeding behaviors can be improved through changes in hospital practices such as those

recommended by the Baby Friendly Hospital Initiative (Munn et al., 2018). There is also an improvement

in behaviors through counseling women about breastfeeding and lactation support provided by either

health care providers or peer counselors (Sinha et al., 2015). However, accessing skilled lactation

support is particularly challenging in Appalachia (Ray et al., 2018) and currently only 18 of the 518 Baby

Friendly Hospitals in the US are located in the Appalachian region (Baby Friendly, 2020). In order to

improve breastfeeding rates in Appalachia, it is important to understand the experiences of lactation

consultants, counselors, and supporters (LCCS) who provide lactation and breastfeeding information and

support to mothers and families. There is a lack of information in the literature about LCCS’ experiences

providing support to families in the United States in general, and a review of the literature did not reveal

any studies regarding the Appalachian region.Understanding LCCS’ experiences could improve

breastfeeding behaviors and quality of care families receive.

This research is being conducted in partnership with the Appalachian Breastfeeding Network

(ABN) and will help inform their programing. ABN is a non-profit organization that works towards the

transformation of breastfeeding culture in Appalachia by providing empowerment and education to

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STUDY OBECTIVES AND AIMS

This project employs quantitative and qualitative methods to address the following research objective

and aims:

Objective

The purpose of this study is to explore the sociocultural, community and family barriers that a diverse

range of people including lactation consultants, counselors, and supporters (LCCS) face when providing

support in the Appalachian Region.

Aims

1. Identify challenges LCCS face in the Appalachia region regarding breastfeeding and lactation support

through an online survey

2. Understand LCCS’ experiences providing breastfeeding and lactation support through conducting

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METHODS

Quantitative Methods

Design

A cross-sectional online survey was used to document ABN members’ challenges providing lactation

and breastfeeding support and information to mothers and families in their communities. The survey

was developed based on a review of the literature related to providers’ experiences of lactation support

and determinants of infant feeding practices in Appalachia. Questions were formulated as multiple

choice, ranking, and open-ended and were organized into three main sections: demographic

characteristics, experience providing breastfeeding and lactation support, and ABN initiatives (Appendix

1). The survey was developed using the Qualtrics Online Survey Software (Qualtrics, Provo, UT, USA).

Server space and access to the Qualtrics application was provided by UNC Chapel Hill. An invitation with

the survey link was sent out to ABN members through an email listserv and posted on ABN social media

platforms (Facebook, Instagram, and Twitter). Participants were asked to complete a one-time, online

survey. This study was approved by the Institutional Review Board at the University of North Carolina at

Chapel Hill. Participation was completely voluntary and survey responses were confidential. All

participants read and provided informed consent prior to the first survey question.

Sample

A convenience sample was used and included people ages 18 to 65+. All participants in this study lived

or worked in the Appalachian region. The survey was used to identify challenges LCCS face when

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Data Analysis

All survey responses were collected using Qualtrics Online Survey Software and analyzed using Microsoft

Excel to generate descriptive statistics.

Qualitative Methods

In order to further understand the challenges that LCCS encounter when providing breastfeeding and

lactation support in the Appalachia region, semi-structured interviews were conducted.

Design

This qualitative study was conducted using semi-structured phone interviews with a subsample of the

Qualtrics survey participants that expressed interest in an interview. The interviews were conducted and

transcribed by two undergraduate BSPH students at UNC over the phone using Recordator. The goal was

to further understand the experiences of LCCS in the Appalachian region and their perceived challenges

to providing care. Participants were asked to identify what makes it difficult to provide lactation support

to families and what factors limit their ability to provide support to families. Additionally, participants

were asked what changes they would like to see related to providing lactation and breastfeeding

support.

Ethical Considerations

This study was approved by the Institutional Review Board at the University of North Carolina at Chapel

Hill. Participation in the semi-structured interviews was completely voluntary. At the end of the

Qualtrics survey, interested participants were directed to another survey that collected necessary

information (name and email address) in order to schedule an interview. Responses to this survey were

kept confidential. All participants provided verbal consent prior to participating in the interview. Only

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including interview transcripts, audio recordings, and electronic password-protected data files were

securely stored on UNC servers.

Sample

A convenience sample was used. All participants were age 18 years or older and lived and worked in the

Appalachian region. Interviews were conducted until data saturation was reached.

Data Collection

There were a total of 43 survey participants who indicated they were interested in an interview. All 43

participants in this subsample were contacted by email and asked if they would like to take part in the

interview. Participants were compensated for their time with a $15 online gift card to a location of their

choice. The semi-structured interview guide included a set of questions to explore the perspectives of

LCCS on the challenges to providing breastfeeding and lactation support in Appalachia (Appendix 2).

Similar questions were asked to each participant in order to compare experiences across the Appalachia

region and a range of lactation credentials. All interviews were audio recorded and transcribed using

Recordator automated transcription service.

Data Analysis

Interview transcripts were analyzed qualitatively using Atlas.ti. version 8.4. In order to investigate what

makes it difficult for LCCS to provide breastfeeding and lactation support to families in Appalachia, a

rapid, concept driven coding approach was used for analysis. The analysis team prepared a

predetermined coding scheme with eight main codes. The findings reported here are based on a rapid

analysis focused on the sociocultural, community and family factors that make it difficult for participants

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RESULTS

Quantitative Results

From March 2019 to July 2019, a total of 90 participants completed the survey. Demographic

characteristics of participants are summarized in Table 1. The professional backgrounds and range of

breastfeeding credentials of participants are also summarized in Table 1. Two-thirds of participants

indicated they worked as a health professional. Additionally, the area of work and states where

participants worked are summarized in Table 1. The Appalachian states where participants worked

included Georgia, Kentucky, Maryland, North Carolina, Ohio, Pennsylvania, Tennessee, Virginia, and

West Virginia. Almost half of participants ranged from 3 to 10 years of experiences providing

breastfeeding and lactation support, with almost a quarter of participants having 20+ years of

experience.

Participants were asked to choose challenges they encountered providing breastfeeding and

lactation support to families in Appalachia. The sociocultural, community and family barriers faced by

providers are summarized in Table 2. The top five challenges that LCCS face are clients’ partners,

families, or social networks are not supportive of breastfeeding; other health care providers are not

supportive of breastfeeding; breastfeeding is not viewed as the normal way to feed infants; challenges

connecting/reaching clients/participants to follow up; and counseling clients around issues related to

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Table 1. Qualtrics Participants

Participant Characteristics (N=90) Count %

Gender

Female 90 100

Age 18-24 25-34 35-44 45-54 55-64 65+ 6 32 21 19 10 2 6.7 35.6 23.3 21.1 11.1 2.2 Race (can select multiple)

American Indian/Alaskan Native Asian

Black/African American Hispanic, Latino or Spanish Middle Eastern/North Africa Native Hawaiian or Pacific Islander White Other 2 0 2 3 1 0 87 0 2.2 0 2.2 3.3 1.1 0 96.6 0 Education

Less than a high-school diploma

High school degree or equivalent (e.g. GED) Associate degree (e.g. AA, AS)

Bachelor’s degree (e.g. BA, BS)

Master’s degree ( e.g. MA, MS, MSN, MPH)

Doctoral degree (e.g. DNP, MD, DDS, JD, PhD, EdD, etc)

1 16 17 39 16 1 1.1 17.7 18.9 43.3 17.8 1.1 Profession Health professional Not a health professional

60 30

66.7 33.3 Breastfeeding Credential(can select multiple)

Breastfeeding USA Counselor CBC

CLC CLS IBCLC

La Leche League Leader

WIC Breastfeeding Peer Counselor Other 2 1 29 12 26 9 16 5 2.2 1.1 32.2 13.3 28.9 10.0 17.8 5.5 Area of Work(can select multiple)

Hospital Private practice Midwifery practice Pediatric practice WIC

County health department

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Non-profit organization School/educational institution Other 27 3 10 30.0 3.3 11.1 States where participants work (can select multiple)

Georgia Kentucky Maryland North Carolina Ohio Pennsylvania Tennessee Virginia West Virginia 4 4 1 9 37 2 10 17 19 4.4 4.4 1.1 10 41.1 2.2 11.1 18.8 21.1 Years of Experiences

Less than 1 year 1-2 years 3-5 years 6-10 years 11-15 years 16-20 years 20 or more years

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Table 2. Main Challenges to Providing Breastfeeding/Lactation Support

Challenge providers face (n=79; can select multiple) Count %

Clients’ partners, families, or social networks are not supportive of breastfeeding 60 75.9

Other health care providers are not supportive of breastfeeding 57 72.2

Breastfeeding is not viewed as the normal way to feed infants 48 60.8

Challenges connecting/reaching clients/participants to follow up or retaining clients/participants in programs and services

45 57.0

Counseling clients around issues related to drug use and lactation/breastfeeding 45 57.0

Clients are not interested in breastfeeding/do not want to breastfeed 37 46.8

Supporting clients with concerns about milk supply issues 32 40.5

Challenges with cross-cultural communication/language barriers 29 36.7

Lactation and breastfeeding expertise is not valued 29 36.7

Supporting clients with multiples 23 29.1

Lack of confidence 18 22.8

Qualitative Results

From January 2020 to April 2020, a total of 20 interviews were conducted over the phone. The

lengths of the interviews ranged from 22 minutes to 50 minutes. Demographic information of in-depth

interview participants is summarized in Table 3. The range of participants’ breastfeeding credentials,

areas of work, and states of work are summarized in Table 3. Participants worked in a variety of

locations including the hospital, non-profit organizations, school/educational institutions, and support

groups. Half of participants worked locally with the Special Supplemental Nutrition Program for Women,

Infants, and Children (WIC) or the county health department. Participants represented the Appalachian

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Participants were asked to identify the main challenge or barrier that makes it difficult to provide

lactation support to families. Responses are summarized in Table 4. This analysis focused on the

sociocultural, community, and family barriers that make it challenging to provide lactation support to

families. Amongst the various responses across a range of barriers, the main challenges in order of

descending frequency were transportation issues, lack of family support, generational gap of

breastfeeding (grandmother/mother did not breastfeed), and the social stigma of breastfeeding in

Appalachia. Additional challenges with fewer frequency included lack of education in the community,

clients’ lack of confidence, clients do not have desire to breastfeed, communication issues/difficulty

following up with clients, and mental health. Challenges mentioned with the least frequency included

other providers are not supportive of breastfeeding, substance abuse, social media pressures, and

racism.

Participants were also asked about other factors that limited their ability to provide breastfeeding

and lactation support to families. Responses were categorized as either family factors or

sociocultural/community factors and are summarized in Tables 5 and 6 respectively. The common family

factors that limit the ability for LCCS to provide support in descending order of frequency were families

are not supportive of breastfeeding, generational gap of breastfeeding, families do not know how to

support breastfeeding, and mothers do not feel comfortable breastfeeding. The common sociocultural/

community factors that limit LCCS’ ability to provide support in descending order of frequency were

transportation issues/far distance to care, social stigma of breastfeeding, lack of information/

misinformation, lack of resources/hesitancy to use resources, lack of confidence/fear of being a burden,

and lack of cultural support.

Participants were asked to describe what changes they would like to see related to providing

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Common sociocultural/community changes that participants would like to see in descending order of

frequency were normalizing/increasing public support of breastfeeding, increased local lactation

support/support groups, increased community education, support from other providers, family

involvement, increased cultural support/changing perceptions, and improved transportation.

Table 3. Interview Participants

Participant Characteristics (n=20) Count %

Gender Gender flux Female 1 19 5 95 Age 18-24 25-34 35-44 45-54 55-64 Not provided 2 8 4 2 3 1 10 40 20 10 15 5 Education Some college

Associate degree (e.g. AA, AS) Bachelor’s degree (e.g. BA, BS)

Master’s degree ( e.g. MA, MS, MSN, MPH)

1 2 12 5 5 20 60 25 Race

American Indian/Alaskan Native Asian

Black/African American Hispanic, Latino or Spanish Middle Eastern/North Africa Native Hawaiian or Pacific Islander White Other 0 0 3 0 0 0 16 1 0 0 15 0 0 0 80 5 Breastfeeding Credential (can select multiple)

Breastfeeding USA Counselor CBC

Certified Childbirth Educator CLC

CLS IBCLC

La Leche League Leader La Leche Peer Counselor

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Area of Work (can select multiple) Hospital Private practice Midwifery practice Pediatric practice WIC

La Leche League

County health department Non-profit organization School/educational institution Volunteer (support groups) Other 4 2 0 0 8 1 2 2 2 1 20 10 0 0 40 5 10 10 10 5

States where participants work Alabama Georgia Kentucky North Carolina Ohio Virginia West Virginia 1 1 2 1 7 4 4 5 5 10 5 35 20 20 Years of Experiences

Less than 1 year 1-2 years 3-5 years 6-10 years 11-15 years 16-20 years 20 or more years

1 0 5 4 2 4 4 5 0 25 20 10 20 20

Table 4. Themes with Illustrative Quotations for Main Challenges to Providing Support

Theme Definition Quotation example

Transportation issues

Lack of transportation resources; far

distance to receive care

I think because not being in a city we do have people who do travel a long way for their care and either they might not be able to come for follow up appointments or they're less likely to come to a prenatal class because you drive an hour or something like that” –IBCLC, Virginia

Lack of family support

Family not supportive of breastfeeding

“It’s very difficult when you don’t have a positive

support system so you know husbands aren't supportive of it but the mother really wants to do it or the

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should I do?” –WIC Peer Counselor, Virginia Generational gap

of breastfeeding

Mother or

grandmother did not breastfeed

“Just the generational gap. I live in a place where people have very strong family connections, that sense of community, and there's just a real gap where their mother or grandmother didn’t breastfeed.” –Birth and postpartum doula, Kentucky

Social stigma Breastfeeding not perceived as the norm

“There isn't necessarily a culture of breastfeeding or my mom's (clients) might not have seen women

breastfeeding. The culture of it; there are no current people in the community who have done it so I'm uncomfortable with it.” –IBCLC, Ohio

Lack of education Clients or community not knowledgeable about breastfeeding

“I think the most difficult part is probably ignorance because people don't know what they don't know and though I guess that it becomes the fear of the unknown so you're talking about a subject that they might know anything about, they can't really engage in the

conversation. I think that the ignorance comes from all levels whether it’s the mom, the poor people in that community, their school, health care setting.” –WIC Project Coordinator, Ohio

Clients’ lack of confidence

Clients do not feel confident in ability to breastfeed

“I have heard one speaker describe it as the temple of doom like they've got to get through the temple of doom to actually be able to successfully breastfeed. That’s so true they just have zero confidence in themselves that they can do it they have zero confidence their bodies that they can breastfeed.” – IBCLC, Kentucky

Clients do not desire to breastfeed

Clients do not express interest in continuing to breastfeed

“Everybody's different so it's just kind of really

frustrating whenever you know you give all these people the information and then they're all well you know I didn't like it so I'm just going to switch to formula or they just feel like formula is easier.” –WIC Breastfeeding Counselor, Virginia

Communication issues

Difficulty getting in touch with or following up with clients

“Also communication issues a lot of these moms don't have cell phones that have enough minutes on it to be on the phone long enough to do a phone assessment… like I said it's a very poor community.” –CLC, Virginia Mental Health Clients experience

challenges with mental health

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Table 5. Themes with Illustrative Quotations for Family Factors that Limit Ability to Provide Support

Themes Definition Quotation Example

Families not supportive of breastfeeding

Lack of support of breastfeeding; do not approve of breastfeeding

“Sometimes we have families that are not supportive of the mom so she’s not doing it or using formula because her family said that she needed to and she really didn’t, so that makes it kind of difficult when the family doesn't quite listen to the professionals.” –IBCLC, Virginia

“Every case of family that I work with that experience domestic violence that has been a huge barrier. Some moms really have a desire to breast feed and their partner shut that down that's definitely a common theme I see.” –CLC, West Virginia Generational gap of breastfeeding Mother or grandmother did not breastfeed

“It's whatever mamaw says goes you're not going to go against the matriarch of the family. Yep, like mamaw raised ten kids she knows what she’s doing she fed them all gravy at two months old.” –IBCLC, Kentucky

“Mom thinks maybe it’s because her whole family couldn’t do it and it’s systematic.” –Birth and postpartum doula, Kentucky Families do not

know how to support breastfeeding

Not against breastfeeding, but do not know how to help with breastfeeding

“When they (partners) see their wife struggling and they fear her crying, instead of patting her back and you know

reminding her of the things that they have learned

throughout the process they just want to make everything better and so they're like just give the baby bottles.” –IBCLC, Ohio

Clients feel uncomfortable breastfeeding

Clients do not feel comfortable breastfeeding in front of family members

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Table 6. Themes with Illustrative Quotations for Sociocultural/Community Factors that Limit Ability to Provide Support

Theme Explanation Quotation Example

Transportation issues/far distance to care

Lack of

transportation or far distances to health care resources

“Access is a big problem in our area just because we are very rural. Yeah we don't have great public transportation; we don't have a lot of ways for families to access services so I definitely think that’s big.” –CLC, West Virginia

“They're coming from an hour and a half two hours away a lot of the time and then in the more rural community sometimes they don't have a lot of patient support available there.” – IBCLC, North Carolina

Social stigma Breastfeeding not socially accepted

“You know you see a woman on a magazine in a bikini and she's breastfeeding her child in public and that’s an automatic sin among lot of Appalachian individuals.” –Home visitor lactation consultant, West Virginia

“Some places you know breastfeeding in public is okay if that mom covers up with a blanket but it's okay and that's much less accepted in rural Appalachia.” –IBCLC, Ohio

Lack

of/deterrence to local resources

General lack of local

breastfeeding support groups or hesitation to attend available support groups

“Community wise I've noticed people have been shifting to social media. They're getting all their information out of a mom's group or you know out of a YouTube video because asking for help can be embarrassing. Maybe they feel embarrassed about not knowing the answer. Access of like social media and information in general kind of deters people from coming out in public.”-CLC, Alabama

“There's also a real sense of being private in rural Appalachia. In some places it might be appropriate to suggest peer support groups or breastfeeding support groups, on one on one care support and it’s not necessarily the method that works in rural Appalachia.”-IBCLC, Ohio Lack of information/ education about breastfeeding Breastfeeding information/ education not widely known in community

“It's just no one really talks about breastfeeding or educates about breastfeeding. It's just kind of not really talked about… no education about it or signs supporting it you know.” – Volunteer in support group, Ohio

Clients’ lack of confidence

Clients do not believe in their ability to breastfeed

“Some of them just that they don't have much confidence in themselves. That confidence factor is really really limiting, they don't believe in themselves enough to say yeah I can breast feed and and go back to high school or yeah I can breast feed and work at my job.” –IBCLC & La Leche Leader, West Virginia Lack of cultural

support

Lack of

representation or support

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groups for women of color

see in the community say, ‘There's no point for me to even try.’ Yeah I feel like there is really a lack of cultural support.” – CLC, Georgia

Table 7. Themes with Illustrative Quotations for Sociocultural/Community Changes

Theme Explanation Quotation Example

Normalizing/ increasing public support of breastfeeding Local organizations publicly supporting breastfeeding

“Just being supportive you know. Our agency is talking about getting little cards that that might say thank you for

breastfeeding your baby to hand out to people that we see who are breastfeeding in public places to that let them know that we think it's awesome. Any little thing like that so if we just have a little just a little card that says thank you for doing that.” –IBCLC, La Leche Leader, West Virginia

“I really wish there were more businesses that supported breastfeeding that publicly stated breastfeeding is welcome here. It makes a huge difference when you see a mom and say ‘oh by the way its breastfeeding friendly here you can nurse’ and it’s like ‘oh my gosh I don’t need to go to the bathroom, I don't have to go back to the car.’ Community wise people really need to stick up for people.” –CLC, Alabama Increased local lactation support/support groups Local community lacks lactation professionals and support groups for mothers

“I would love to see a La Leche League or a Breastfeeding USA or some type of peer support group where women may be felt more comfortable approaching this well-known breastfeeding organization as opposed to just sending a stranger a message on Facebook Hey I heard you're into breastfeeding, can I ask you something? I think if moms knew that this organization existed in our area maybe they would be more likely to access support.” –CLC, West Virginia

“Having the available support for moms because like I said in our area there's not a lot of people that they can turn to get that help. I think I looked it up and there were only three CLCs within thirty to forty miles.” –CLC, Virginia

“So if there was a way that we could kind of get a support group once a week or have a hotline number for them to call saying Hey you know I really need some support and if we can get four to five participants that would participate in that I feel like that would help.” –WIC Breastfeeding Counselor, Virginia Increased community education More community education about breastfeeding

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Support from doctors/other providers

Other providers supporting breastfeeding

“They need to look at patients like a mother baby dyad. However, like you know the OBGYN only treats mom and so she's not thinking about the baby and then pediatrician only thinking of baby and not thinking about the mom and so you get mismatched care.” –CLC, Ohio

Increased family involvement

Increasing family support of breastfeeding

“Finding ways for getting dad's involved and seeing dad and grandparents feeling out where or how do they fit in to this breastfeeding journey because it does require everyone and I think people just assume if you’re going to breastfeed, then you don't need help.” –CLC, Alabama

Increased cultural support/ changing perceptions

Representation of women of color and changing false perceptions

“I think it's also great to have just all inclusive of all races you know support each other like to kind of just let go of that perception that okay black women don't breastfeed so we won't be having breastfeeding conversations with them so I would like to see like the perception of people in the community or conversation of perceptions.” –CLC, Georgia Improved

transportation

Increased access to care

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DISCUSSION

This study provides quantitative and qualitative insight into the sociocultural, community, and family

barriers that LCCS face providing breastfeeding and lactation support in Appalachia. These findings

speak to the various challenges LCCS encounter and suggestions for improving breastfeeding practices in

Appalachia.

Main Challenges/Barriers

The main challenges that LCCS believe impact care across quantitative and qualitative methods

include families who are not supportive of breastfeeding, social stigma of breastfeeding in Appalachia,

and transportation issues/challenges connecting with or reaching clients for follow up. Survey

participants believe that the main sociocultural, community and family challenges that they face when

providing breastfeeding and lactation support include clients’ partners, families, or social networks are

not supportive of breastfeeding; other health care providers are not supportive of breastfeeding;

breastfeeding is not viewed as the normal way to feed infants; challenges connecting/reaching clients/

participants to follow up; and counseling clients around issues related to drug use and

lactation/breastfeeding. In comparison, interview participants identify their main challenges to providing

care to be transportation issues, lack of family support, generational gap of breastfeeding, and the social

stigma of breastfeeding in Appalachia. Interview participants identify lack of education in the

community, clients’ lack of confidence, clients not desiring to breastfeed, communication

issues/difficulty following up with clients, and mental health to also influence their ability to provide

support.

Sociocultural, community, and family factors

Consistent factors that make it difficult for LCCS to provide care are unsupportive families of clients,

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breastfeeding. Interview participants believe specific family factors that limit their ability to provide

support include families not being supportive of breastfeeding, generational gaps in breastfeeding

experience, families do not know how to support breastfeeding, and mothers do not feel comfortable

breastfeeding. Previous research suggests it is important for providers to acknowledge and understand

the family dynamic to determine strategies they will use in their provision of care (Anstey et al., 2018).

Additionally, the influence of families has been shown to be important in the US and globally for

improving health outcomes, specifically increasing maternal social support for the enactment of healthy

infant feeding (Britton et al., 2007; Khandpur et al., 2014; Meedya et al., 2010; Mitchell-Box & Braun,

2013). Because of fathers, grandmothers and other family members’ influence on infant feeding and

care decisions, it is essential to involve them in breastfeeding programs.

The specific sociocultural/community factors that interview participants identify as affecting their

ability to support include transportation issues/far distance to care, social stigma of breastfeeding, lack

of information/misinformation, lack of resources/hesitancy to use resources, lack of confidence/fear of

being a burden, and lack of cultural support. Although the lack of cultural support is not as frequently

suggested among all interview participants, it is an important finding when each African American/Black

participant identified this barrier in their interview. Participants believe other women of color in their

communities are not receiving sufficient support. Prior research highlights the importance of

family-based and personal breastfeeding support and experience as important factors for successful

breastfeeding, particularly for disadvantaged and African American mothers (Johnson et al., 2015).

Additionally, this systematic review found that the influence of psychosocial interventions, including

peer support groups of women with similar social experiences, could affect the decision for women of

color to breastfeed (Johnson et al., 2015). This is an important finding for consideration of sociocultural

interventions and further research regarding barriers to breastfeeding that women of color experience

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The most frequently mentioned factors (unsupportive families of clients, transportation issues/far

distance to care, social stigma of breastfeeding, and generational gap of breastfeeding) are consistent

with the main challenges/barriers identified in both the survey and interviews. These findings agree with

prior research that indicate family/partner support and geographic isolation/limited access to health

care impact the decision of rural mothers to breastfeed (Wiener & Wiener, 2011).

Implications for Practice

Interview participants suggest that there are sociocultural, community, and family changes that

could improve breastfeeding practices in Appalachia. Participants believe normalizing/increasing public

support of breastfeeding; increased local lactation support/support groups; increased community

education; support from other providers; family involvement; increased cultural support/changing

perceptions; and improved transportation could have a positive impact. Efforts to normalize

breastfeeding and increase public support of breastfeeding is an implication for practice in order to

improve breastfeeding practices in Appalachia. Practically, participants suggest local businesses should

publically advertise they are breastfeeding friendly. Additionally, participants suggest the recruitment of

LCCS to tangibly encourage mothers who are breastfeeding in public by handing out supportive thank

you cards. These suggested changes speak to the commonly reported barrier of the social stigma of

breastfeeding in Appalachia. Increasing local lactation support/support groups is an implication for

practice in the Appalachia region. Practically, participants suggest peer support groups that are more

accessible and include a smaller number of participants. This suggested change addresses the commonly

reported barrier of transportation issues/communication issues that many providers find difficult when

caring for their clients. Family involvement is also an implication for practice. Participants suggest finding

ways to incorporate family members in the breastfeeding journey of the mother would be beneficial.

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unsupportive of breastfeeding or a lack of family support for a client. There were many practical

suggestions to improving breastfeeding practices in Appalachia. These three suggestions in particular

(efforts to normalize breastfeeding and increase public support of breastfeeding, increasing local

lactation support/support groups, and increasing family involvement) were most frequently discussed.

The hope of this research project is to inform ABN, ARC, and potential future Appalachian-specific

funding about the primary challenges LCCS face when providing care and suggested changes to

improved breastfeeding practices in Appalachia. Future research is needed to determine the appropriate

intervention methods for these reported challenges and suggestions.

STRENGTHS AND LIMITATIONS

The current study had several strengths, including the use of quantitative and qualitative data to

determine emerging themes. Additionally, the collection and analysis of data was performed by the

same two undergraduate students. The diversity in areas of work, breastfeeding credentials, age, and

work experience provided the researchers with a broad range of experiences to identify emerging

themes. However, the research also presented some limitations. Researcher bias is a concern with

qualitative and quantitative research. Similar coding techniques were used between the two

undergraduate students; however, a rapid analysis was used and therefore may not have been as robust

or comprehensive as a more in-depth, traditional analysis. Although methods sought to capture a wide

range of experiences, the perceptions of LCCS of color were not well represented in this study and

efforts should be made to ensure they are included in future research. Additionally, other areas of work

such as pediatric offices and midwifery practices were not represented by participants and likely would

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CONCLUSION

Lactation consultants, counselors, and supporters (LCCS) are the key informants in

understanding the challenges/barriers to providing breastfeeding and lactation support. Particularly in

the Appalachian region, it is important to know and understand the challenges that providers face when

breastfeeding practices are considerably lower in this region compared to the rest of the United States.

The interrelated sociocultural, community, and family factors that make it more difficult for LCCS to

provide care are indicative of the need of socially-adapted, community-based approaches to improve

breastfeeding support for mothers and their families in the Appalachian region. Normalizing

breastfeeding/increasing local support of breastfeeding, increasing local lactation resources/support

groups, and increasing family involvement in breastfeeding practices could lead to an increased ability

for mothers to breastfeed in Appalachia.

DECLARATION OF CONFLICTING INTERESTS

The authors declared no potential conflicts of interest with respect to the research, data collection, data

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REFERENCES

Anstey et al. (2018). Lactation Consultants’ Perceived Barriers to Providing Professional Breastfeeding Support. Journal of Human Lactation, 34(1), 51-67. doi: 10.1177/0890334417726305

American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), 827-841. doi:10.1542/peds.2011-3552

Appalachian Breastfeeding Network. (2020). Available: https://www.appalachianbreastfeedingnetwork.org/

Appalachian Regional Commission. (2020). “The Appalachian Region.” Available: https://www.arc.gov/appalachian_region/TheAppalachianRegion.asp

Baby Friendly USA. (2020). Available: https://www.babyfriendlyusa.org/for-parents/find-a-baby-friendly-facility

Bartick et al. (2016). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal and Child Nutrition, 13(1). doi: 10.111/mcn.12366

Britton et al. (2007). Support for breastfeeding mothers. Cochrane Database of Systematic Reviews, 1. doi: 10.1002/14651858.CD001141.pub3.

Centers for Disease Control and Prevention. (2015). Breastfeeding Report Card. Available: https://www.cdc.gov/breastfeeding/data/reportcard.htm

Johnson et al. (2015). Enhancing Breastfeeding Rates Among African American Women: A Systematic Review of Current Psychosocial Interventions. Breastfeeding Medicine, 10(1). doi:

10.1089/bfm.2014.0023

Khandpur et al. (2014). Fathers’ child feeding practices: a review of the evidence. Appetite, 78, 110-121. doi: 10.1016/j.appet.2014.03.015

Machado, Ana & Coleman, Caroline & Linares (Quelopana), Ana. (2014). Appalachia Breastfeeding Disparities: A Literature Review. doi: 10.13140/2.1.1420.7689

Marshall et al. (2017). Health Disparities in Appalachia. PDA, Inc.; Cecil G. Sheps Center for Health Services Research; Appalachian Regional Commission. Available:

https://www.arc.gov/assets/research_reports/Health_Disparities_in_Appalachia_August_2017. pdf

Meedya et al. (2010). Factors that positively influence to breastfeeding duration to 6 months: a literature review. Women Birth: Journal of the Australian College of Midwives, 23(4), 135-145. doi: 10.1016/j.wombi.2010.02.002

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Munn et al. (2018). Factors Influencing Southeastern U.S. Mothers’ Participation in Baby-Friendly Practices: A Mixed-Methods Study. Journal of Human Lactation, 34(4), 821-834. doi: 0.1177/0890334417750143

Ray et al. (2018). Geographic Access to International Board-Certified Lactation Consultants in Pennsylvania. Journal of Human Lactation, 35(1),1-10. doi: 10.1177/0890334418768458 Sinha et al. (2015). Interventions to improve breastfeeding outcomes: a systematic review and

meta-analysis. Acta Paediatrica, 104(S467), 114-134. doi: 10.1111/apa.13127

US Government. Maternal, infant, and child health. Objective MICH-21, Increase the proportion of infants who are breastfed. In: Healthy People 2020. (Online) 2010. Available:

https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives

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APPENDIX

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4/22/2020 Qualtrics Survey Software

Supporting families in Appalachia with breastfeeding and lactation

Thank you for your interest in completing this survey!

The purpose of this research study is to learn about the experiences of people who support families in Appalachia with breastfeeding and lactation, and to explore some of the challenges they experience. You are being asked to take part in this research study because you support breastfeeding and lactation in the Appalachian Region.

Being in a research study is completely voluntary. You can choose not to be in this

research study. You can also say yes now and change your mind later.

If you agree to take part in this research, you will be asked to complete an online survey. Your participation in this study will take about 15-20 minutes. We expect that 200-300 people will take part in this research study.

You can choose not to answer any question you do not wish to answer. You can also choose to stop taking the survey at any time. You must be at least 18 years old to participate. If you are younger than 18 years old, please stop now.

The possible risks to you in taking part in this research are: Feeling uncomfortable

when thinking about challenges you face in your work or your experiences with

infant feeding.

To protect your identity as a research subject no identifiable information will be collected.

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have questions or concerns about your rights as a research subject, you may

contact the UNC Institutional Review Board at 919-966-3113 or by email to

IRB_subjects@unc.edu.

I consent

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Demographic Characteristics

What is your age?

Less than 18 years old

18-24 years old

25-34 years old

35-44 years old

45-54 years old

55-64 years old

65 years old or older

What is your gender?

Where do you live?

What is the highest degree or level of school you have completed? (If you're currently enrolled in school, please indicate the highest degree you have received)

Less than a high school diploma

High school degree or equivalent (e.g. GED)

Associate degree (e.g. AA, AS)

Bachelor's degree (e.g. BA, BS)

Master's degree (e.g. MA, MS, MSN, MPH)

Doctoral degree (e.g. DNP, MD, DDS JD, PhD, EdD, etc)

Which categories describe you? Select all boxes that apply. Note: You may select more than one group

American Indian or Alaska Native

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Black or African American

Hispanic, Latino, or Spanish

Middle Eastern or North Africa

Native Hawaiian or Pacific Islander

White

Another race, ethnicity, or origin (please specify)

What is your current employment status?

Employed full time (40 or more hours per week)

Employed part time (up to 39 hours per week)

Unemployed and currently looking for work

Unemployed and not currently looking for work Student Retired Self-employed

Unable to work

Are you a health professional? (for example, work in medicine, nursing, or allied health)

Yes

No

If yes, are you a:

Advanced practice nurse (APN) such as a nurse practitioner or nurse midwife

Certified professional midwife (CPM)

Chiropractor

Community health worker CranioSacral therapist Doula Dentist Health educator

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Occupational therapist

Physical therapist

Physician (MD, DO)

Physician Assistant (PA)

Registered Dietitian (RD)/Registered Dietitian Nutritionist (RDN)

Registered Nurse (RN)

Speech language pathologist

Other (list)

What is your profession?

Do you do work (paid or volunteer) related to breastfeeding and lactation?

Yes, currently employed related to breastfeeding and lactation Yes, currently volunteer related to breastfeeding and lactation

Yes, in the past have been employed related to breastfeeding and lactation Yes, in the past have volunteered related to breastfeeding and lactation No, have not worked or volunteered related to breastfeeding and lactation

How many years have you been working or volunteering related to breastfeeding and lactation?

Less than 1 year

1-2 years

3-5 years

6-10 years

11-15 years

16-20 years

20 or more years

Is the work that you do related to lactation and breastfeeding based in Appalachia?

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No

Where do you work on breastfeeding and lactation?

Where in Appalachia do you work? (can select more than one)

Alabama

Georgia Kentucky

Maryland

Mississippi New York

North Carolina Ohio

Pennsylvania South Carolina

Tennessee Virginia

West Virginia

Other

Do you:

Select all boxes that apply.

Provide direct lactation consulting, counseling, or support to individual clients/patients

Offer breastfeeding or lactation education, information, and promotion to

patients, clients, or families

Manage or implement programs related to breastfeeding and lactation

Conduct research related to breastfeeding and lactation

Train other providers, program staff, or students in

lactation and breastfeeding

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Breastfeeding/lactation credential

Do you have any of the following certifications or experiences related to breastfeeding and

lactation? Select all boxes that apply.

Currently have Had previously Breastfeeding USA

Counselor

CBC

CLC ‘

CLE

CLS

IBCLC

LEC

La Leche League

Leader

WIC Breastfeeding Peer

Counselor

Other (please specify)

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Now, please choose the biggest challenge that you personally

experience when providing breastfeeding/lactation information or support

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Do clients/participants/families in your community experience any of the following

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In the future, would you be willing to be contacted about participating in a longer interview either over the phone or in person? (Note you will be re-directed to a new webpage and your personal information will not be connected to your responses here).

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Appendix 2. Semi-Structured Phone Interview Guide

Hi is this _____?

My name is Grace and I am 4th year undergraduate student at UNC that worked on the survey you

completed last semester. I have been working on a project with Stephanie Martin who is interested in barriers to breastfeeding in the Appalachia region. This past semester I got the chance to attend the ABN annual conference, were you able to attend? My research partner and I had the opportunity to present on our findings with the survey results so this is the second phase of that same project. Thank you for agreeing to talk with me today. We are interested in hearing about the experiences of people who support families in Appalachia with breastfeeding and lactation, and to explore some of the challenges they experience.

Before we get started, these interviews will be kept confidential and anonymous. I wanted to ask if it is okay if I record our conversation? If you do not feel comfortable answering a certain question, please feel free to tell me. Do you have any questions?

So to start off how long have you worked or volunteered related to breastfeeding?

Do you have any breastfeeding or lactation credentials? Which ones?

Have you had more than one position related to breastfeeding and lactation? If so, what are the different kinds of positions that you have had related to breastfeeding and lactation?

Can you tell me about your professional or volunteer work that you currently do related to breastfeeding lactation?

Where do you work?

How long have you worked/volunteered there?

Who are your clients or program participants?

What is your role/position?

What do you do related to breastfeeding and lactation?

Where and when do you see family members (pregnancy, birth, in hospital, after discharge, WIC clinic, etc)

What do you like most about providing lactation support to families?

What makes it difficult to provide lactation support to families?

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Organization/institute Other providers

Community/social factors Families

Are these different in different situations? Can you give me some examples?

What are some things that make it more difficult provide to support families?

Organization/institute Other providers

Community/social factors Families

Are these different in different situations? Can you give me some examples?

Has your ability to provide support and management of breastfeeding problems changed over time and if so, how and why?

Are there are any breastfeeding or lactation issues that you do not feel comfortable supporting/managing? Which? Why?

What are changes you would like to see related to providing breastfeeding and lactation support?

Organization/institute Other providers

Community/social factors Families

What do you see as the biggest barriers to breastfeeding in your community?

Are these different among different groups? How?

Can you give me examples of how these barriers impact breastfeeding?

What do you think could be done to address these barriers?

Are families in your community identifying breastfeeding problems and seeking help?

Why or why not?

What prevents them from seeking support?

Are you a parent?

How does your own experience with infant feeding influence your interactions with families?

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So then our last questions are for collecting demographic data:

What is your age?

What is the highest level of education you have completed?

What is your gender?

What is your race/ethnicity?

Figure

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Related subjects :