Of the 49 interviewees the mean age of participant was 38.7±10.1. A majority of participants identified as Caucasian (85.7%) followed by African American (8.2%), Caucasian/Asian American (4.1%) and Hispanic (2.0%). Further, 75.5% of the population resided in an urban residence with the remaining 24.5% residing in a rural residence. Complete demographic tables including occupation type for each participant can be found in Table 1.
Table 1. Sociodemographic Information for Interview Participants
Representative
|
Occupation
|
Age
|
Race/ethnicity
|
Geographic Residence
|
Individual
|
Nutritionist (Breastfeeding Mother)
|
41
|
Caucasian
|
Urban
|
Individual
|
Works Inside the Home (Breastfeeding Mother)
|
38
|
Caucasian
|
Rural
|
Individual
|
Works Inside the Home (Breastfeeding Mother)
|
26
|
Caucasian
|
Urban
|
Individual
|
Teacher (Breastfeeding Mother)
|
23
|
Caucasian
|
Urban
|
Individual
|
Teacher (Breastfeeding Mother)
|
29
|
Caucasian
|
Urban
|
Individual
|
Teacher (Breastfeeding Mother)
|
27
|
Caucasian
|
Urban
|
Individual
|
Works Inside the Home (Breastfeeding Mother)
|
27
|
Caucasian
|
Rural
|
Individual
|
Associate Professor (Breastfeeding Mother)
|
37
|
Caucasian
|
Urban
|
Individual
|
Teacher (Breastfeeding Mother)
|
35
|
Caucasian
|
Urban
|
Individual
|
Works Inside the Home (Breastfeeding Mother)
|
32
|
African American
|
Urban
|
Individual
|
Controller (Breastfeeding Mother)
|
32
|
Caucasian
|
Urban
|
Individual
|
Human Resources Director (Breastfeeding Mother)
|
31
|
Caucasian
|
Urban
|
Interpersonal
|
Childcare Worker
|
43
|
Hispanic
|
Rural
|
Interpersonal
|
Childcare Worker
|
37
|
Caucasian
|
Rural
|
Interpersonal
|
Childcare Worker
|
39
|
Caucasian/Asian
|
Urban
|
Interpersonal
|
Childcare Worker
|
40
|
Caucasian
|
Rural
|
Interpersonal
|
Childcare Worker
|
23
|
Caucasian
|
Urban
|
Interpersonal
|
Childcare Worker
|
42
|
Caucasian
|
Urban
|
Interpersonal
|
Manager (Father)
|
35
|
Caucasian
|
Urban
|
Interpersonal
|
Information & Technology (Father)
|
38
|
Caucasian
|
Urban
|
Interpersonal
|
Teacher (Father)
|
36
|
Caucasian
|
Urban
|
Interpersonal
|
Histologist (Father)
|
27
|
Caucasian
|
Urban
|
Community
|
Certified Lactation Consultant
|
29
|
Caucasian
|
Urban
|
Community
|
Certified Lactation Consultant
|
33
|
Caucasian
|
Urban
|
Community
|
Certified Lactation Consultant
|
32
|
Caucasian/Asian
|
Urban
|
Community
|
Social Worker
|
58
|
African American
|
Urban
|
Community
|
Childcare Center Director
|
30
|
Caucasian
|
Rural
|
Community
|
Childcare Center Director
|
61
|
Caucasian
|
Rural
|
Community
|
Childcare Center Director
|
43
|
Caucasian
|
Urban
|
Community
|
Childcare Center Director
|
48
|
Caucasian
|
Urban
|
Community
|
Childcare Center Director
|
50
|
Caucasian
|
Rural
|
Community
|
Childcare Center Director
|
50
|
Caucasian
|
Rural
|
Community
|
Peer Counselor
|
31
|
Caucasian
|
Urban
|
Community
|
Medical Librarian/Community Advocate
|
37
|
African American
|
Urban
|
Organizational
|
Maternal/Child Health Program Coordinator
|
39
|
Caucasian
|
Urban
|
Organizational
|
Labor & Delivery Administrator
|
26
|
Caucasian
|
Rural
|
Organizational
|
Nonprofit Director
|
31
|
Caucasian
|
Urban
|
Organizational
|
Nurse Administrator
|
55
|
Caucasian
|
Urban
|
Organizational
|
Hospital Administration
|
38
|
Caucasian
|
Urban
|
Organizational
|
Nonprofit Director
|
44
|
Caucasian
|
Urban
|
Organizational
|
Maternal Child Program Administrator
|
35
|
Caucasian
|
Rural
|
Organizational
|
Maternal Child Program Administrator
|
61
|
Caucasian
|
Urban
|
Organizational
|
Health Director
|
40
|
Caucasian
|
Urban
|
Organizational
|
Hospital Administration
|
52
|
Caucasian
|
Rural
|
Policy
|
IBCLC
|
55
|
Caucasian
|
Urban
|
Policy
|
IBCLC, NP
|
33
|
African American
|
Urban
|
Policy
|
MD, IBCLC
|
49
|
Caucasian
|
Urban
|
Policy
|
Health Department Division Chief
|
59
|
Caucasian
|
Urban
|
Policy
|
Physician Assistant, IBCLC
|
35
|
Caucasian
|
Urban
|
Supports and Barriers to Breastfeeding
Two figures were created to demonstrate the major themes determined for each level of the SEM. The stakeholders identifying these themes is denoted via a symbol. Figure 1 notes the most commonly reported themes for breastfeeding support among the interviewed sample and Figure 2 denotes the most common breastfeeding barriers discussed.
Individual Factors
Specific to breastfeeding support, at the individual level, the main themes found were related to viewing breastfeeding as a valued behavior and a desire for mothers to try. Breastfeeding mothers (individual level), significant others (interpersonal level) and community representatives reported that they were seeing women personally valuing breastfeeding to a greater degree than in the past. Those at the organizational and policy level reported mothers as having a strong desire to “try” to breastfeed. For instance, a Community Health coordinator reported, “I think it is becoming more popular nowadays, to at least attempt to start breastfeeding. Women will brag that they made it a whole year or breastfed six months.”
Individual barriers were typically related to time commitment, exhaustion, and isolation. Specific to time commitment, representatives of the individual, interpersonal and organizational level most often reported this issue. For example, a labor and delivery nurse stated, “just the time commitment of it. I mean I always say it’s not hard it’s just demanding you to live on a two-hour clock.” Exhaustion was a common theme reported by those at the interpersonal, community and policy level. For instance, a community program coordinator noted, “I think the lack of sleep that comes with a newborn. You know you’re not well-rested and you’re trying to have good mental health and it’s a struggle.” Finally, specific to isolation, all currently breastfeeding mothers reported this as an issue. For example, “I would definitely say like kind of the isolation factor of it. You’re the only one who can do it and sometimes it’s a little lonely just feeling stuck sometimes” (Breastfeeding Mother).
Interpersonal Factors
At the interpersonal level, the greatest supports focused on social media, peer-to-peer, and family. Related to social media representatives of the individual and community level most commonly reported this as a support. For example, a County Health Director stated, “I see a really strong social media presence, a supportive social media presence. It seems like women are going to social media to find support.” General peer-to-peer support was also reported by interpersonal and community representatives. A husband of a breastfeeding women noted, “I think what really helped my wife was the support groups she found that allowed for mother-to mother peer counseling.” Finally, familial support was often stated as a key influencer of breastfeeding support by those at the individual, community, organizational and policy level. A community program coordinator stated, “Some of the biggest support pieces that I feel like are critical are having support from your own family.”
The main barrier identified by all interviewed participants was related to a lack of support from family and/or friends. For example, a social worker stated: “I would say probably lack of social supports. A lot of our moms they want to breastfeed and they don’t have a lot of support from like dads or friends.”
Community Factors
At the community level, representatives of the community, organizational and policy level reported that normalization of breastfeeding was occurring to at least some degree and representatives at the individual, interpersonal and organizational level reported ample access to community lactation support. When describing breastfeeding normalization, an in-home childcare provider stated, “I think it’s becoming better, it’s more socially normally to see a mother breastfeeding in public. I think it’s not as shunned upon not to do it in public and everything.” Related to community lactation support, many interviewees reported the existence of several community organizations or support groups that women could access. For example, a currently breastfeeding mother reported, “definitely places like [community breastfeeding non-profit] for lactation support…it’s helpful I feel like just to have places like that in the community that women can go.”
Barriers at the community level were related to a lack of community resources in rural and underserved areas as well as a lack of normalization which is contrary to the supports stated previously.
Specific to the rural disparities, participants at the community, organizational and policy levels identified this most frequently. One nurse residing in a rural area reported, “we have very minimal support. When I moved here I searched for support groups and there was nothing to be found.” A lack of normalization was mainly reported by those representing the individual and interpersonal level. One mother noted, “It’s just hard to breastfeed in public. I know it’s supposed to be a thing you can do everywhere but sometimes it’s just not really looked at as acceptable yet”.
Organization Factors
At the organizational level, reported breastfeeding supports most commonly consisted of hospitals having helpful procedures in place regarding breastfeeding and that in-hospital education directly after birth were useful and effective. Those at the community, organization and policy level typically reported the hospital procedures as supportive. For example, a home-visiting IBCLC stated, “I think they [hospitals] have done a great job with all of the new policies that we’ve put in place so the sacred hour, skin-to-skin, delaying the bath, they’ve put a lot of things in place to help breastfeeding moms.”
Conversely, although not a majority, two healthcare providers stated that they worked in facilities in which mothers were given formula even prior to their child’s birth. For example, a labor and delivery nurse residing in a rural area stated,
“They give out formula at your first visit when you come to the hospital to register before you come in for delivery..they send you home with a bunch of [formula brands]..”
An additional organizational barrier cited focused on having a lack of hospital resources despite good procedures. One example came from an IBCLC that stated,
“It would be nice if they could have more CLC’s or IBCLC’s on staff because what I hear from families is that there was an IBCLC there but they weren’t able to spend much time with them”.
Policy Factors
Finally, at the policy level breastfeeding supports typically discussed by representatives at all levels were the laws currently in place that make it legal to breastfeed anywhere as well as the workplace protections that exist. An IBCLC stated, “I think they [laws] have been very helpful, especially with moms going back to work, you know the laws to breastfeed in public and the pumping laws have definitely been a huge help”.
Conversely, participants at all levels felt there was still a lack of specificity within the existing breastfeeding laws/policies that left women unprotected. A community program manager noted“I know there are policies and laws but I feel like some of those still have loopholes. Like it doesn’t seem to cover every occupation especially those teachers and nurses who need varying pumping schedules.”