To inform development of a breastfeeding intervention for public assistance clients, we aimed, through qualitative methods, to explore public health staff members’ perspectives of facilitators and barriers to initiating and continuing breastfeeding for clients and strategies to improve breastfeeding rates.
We conducted focus groups with staff from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Massachusetts and Virginia to identify the strategies WIC staff uses to encourage and support breastfeeding by leveraging facilitators and overcoming barriers to inform the development of a breastfeeding intervention. Data collection and analysis followed an iterative process using constant comparison by a diverse group of researchers with expertise in qualitative methods. Focus groups were continued until thematic saturation was reached.
Fifty-one WIC staff members participated in 7 focus groups. Themes related to strategies used to promote breastfeeding included providing education with subthemes relating to anticipatory guidance, normalization of breastfeeding, and the importance of tailored messaging; education format with subthemes regarding timing of education and engagement of support networks; relationship building including subthemes of establishing rapport and sharing personal experiences; and resource provision.
WIC staff identified the importance of providing specific, concrete information about breastfeeding and strategies to breastfeed while working and caring for other children. The importance of connecting with clients to build trust and increase social support for breastfeeding clients was also identified. This study provided valuable information to help guide the development of a breastfeeding intervention.
Families with low income are less likely to provide breast milk for their infants than families with more resources. The Special Supplemental Nutrition Program for Women, Infants, and Children staff is poised to provide strategies to leverage facilitators and overcome barriers to improve breast milk provision among their clients.
The Special Supplemental Nutrition Program for Women, Infants, and Children staff provides key insights into specific strategies to leverage facilitators and overcome barriers to improve breastfeeding among their clients to help guide the development of a breastfeeding intervention.
Introduction
Despite the many benefits of human milk for infants and children, supporting and maintaining breastfeeding for mothers with low incomes remains difficult in the United States.1–5 The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a US federal government-sponsored public health program aimed at supporting the nutritional needs of clients who have low income and their children, with emphasis on providing breastfeeding education and support in the peripartum period. Despite the use of WIC, due to several factors, including lack of home and hospital lactation support, need to return to work, concerns about supply, and difficulty breastfeeding (eg, pain with breastfeeding, trouble with latch), mother-infant dyads who participate in WIC are less likely to initiate breastfeeding (74%) than those ineligible for the program based on higher income (91.5%).6,7 Given the broad range of benefits from breastfeeding for both mother and child, including lower rates of sudden infant death syndrome, reduced infant mortality, and lower rates of otitis media, inflammatory bowel disease, obesity, and asthma in children as well as lower rates of type 2 diabetes mellitus, breast cancer, ovarian cancer, and endometrial cancer in mothers, it is vital that efforts be made to continue to improve breastfeeding rates in this population.2,4,5,8–11
Past interventions to improve breastfeeding rates among mothers with low income have had varying success.12–14 Although the public health staff that serves at WIC has extensive experience addressing known breastfeeding barriers and promoting facilitators to improve breastfeeding, there is a lack of published data to describe these strategies used by WIC staff. As frontline educators and promoters of breastfeeding for populations with low income, perspectives of WIC staff can add valuable knowledge about effective means to improve breastfeeding uptake and maintenance.
Given the American Academy of Pediatrics recommendation that infants be exclusively breastfed for the first 6 months with continued breastfeeding up to 2 years of age, the multiple medical benefits of breastfeeding, and the lower breastfeeding rates among mothers who participate in WIC, improving rates of breastfeeding in this population is crucial.15 Thus, as an initial step to develop a breastfeeding intervention aimed at increasing rates among mothers who are WIC eligible, we conducted a qualitative study with WIC staff to learn their perspectives about the facilitators and barriers to breastfeeding for the mothers whom they serve and—vitally—their strategies to support and encourage parents to breastfeed.
Methods
We conducted 7 focus groups with WIC staff between November 2019 and February 2020 at 7 different WIC centers in Virginia (3) and Massachusetts (4). Because we wanted to know about views of facilitators and barriers to breastfeeding as well as strategies to encourage breastfeeding, we used a purposeful sampling strategy aimed at including WIC staff members who provided breastfeeding prenatal education and postpartum support. After verbal informed consent was obtained, participants completed a questionnaire ascertaining individual demographics.
We chose to conduct focus groups because group discussion could add richness to the data. All group members had experience with the topic, and the topic was unlikely to be too sensitive or uncomfortable for participants to discuss in a group setting because breastfeeding support was a key part of the participants’ job responsibilities.16 Focus groups were conducted at WIC centers and led by a member of the research team with experience leading focus groups. We asked about participants’ perspectives of influences on decision making regarding breastfeeding, facilitators and barriers to breastfeeding, and strategies used to encourage breastfeeding and address barriers among clients. Focus groups were audio recorded and transcribed by an independent, Health Insurance Portability Accountability Act certified transcription service. Transcripts were compared with corresponding audio recordings by a member of the research team to ensure accuracy.
Data analysis followed an iterative, inductive approach.17 As such, transcripts were reviewed by investigators (E.R.C., B.N.C., and M.C.) with backgrounds in general pediatrics, neonatology, and qualitative analysis. At least 2 members of this team independently reviewed each transcript to identify tentative codes. The team met at regular intervals to review and revise the coding structure to ensure uniform coding in the final analysis. Transcripts were then independently coded using the coding structure by at least 2 investigators, and any coding discrepancies were resolved through group discussion. The team used an iterative approach to continuously analyze data and refine the question guide and develop themes through the identification and organization of the codes. We believe data sufficiency (also called “thematic saturation”) was reached given the richness of the conversations, specificity of the questions guiding the project, participant knowledge of the topic, and repetition of themes discussed across conversations.18 We used Dedoose software (Dedoose version 9.0.86, Sociocultural Research Consultants, LLC) to organize the data during analysis. This study was approved by institutional review boards as required.
Results
A total of 51 WIC staff members participated in 7 focus groups. Participant characteristics were self-described and are presented in Table 1. Themes related to participant experience with facilitators and barriers to breastfeeding included client beliefs about breast and formula feeding, breastfeeding experiences, social supports, competing priorities, subjective norms, and self-efficacy. Themes related to strategies suggested by participants to encourage breastfeeding included education content and format, relationship building, and resource provision.
Sociodemographic Information of Participants (N = 51)
| Characteristics | n (%)a | |
|---|---|---|
| Race | White | 31 (61) |
| Unknown/declined | 7 (14) | |
| Black or African American | 4 (8) | |
| American Indian or Alaskan Native | 3 (6) | |
| Asian | 3 (6) | |
| >1 race | 3 (6) | |
| Ethnicity | Non-Hispanic | 31 (61) |
| Hispanic | 18 (35) | |
| Unknown/declined | 2 (4) | |
| Years of age | 20–29 | 8 (16) |
| 30–39 | 19 (37) | |
| ≥40 | 22 (43) | |
| Unknown/declined | 2 (4) | |
| Years of employment at WIC | <1 | 2 (4) |
| 1–5 | 17 (33) | |
| >5 | 31 (61) | |
| Unknown/declined | 1 (2) | |
| Education | High school graduate | 5 (10) |
| Some college | 7 (14) | |
| Graduated 2-y college | 6 (12) | |
| Graduated 4-y college | 29 (57) | |
| Postgraduate | 3 (6) | |
| Unknown | 1 (2) | |
| Staff role | Breastfeeding peer counselor | 4 (8) |
| Nutritionist | 16 (31) | |
| Nutrition associate | 14 (27) | |
| Other | 7 (14) | |
| Unknown | 10 (20) |
| Characteristics | n (%)a | |
|---|---|---|
| Race | White | 31 (61) |
| Unknown/declined | 7 (14) | |
| Black or African American | 4 (8) | |
| American Indian or Alaskan Native | 3 (6) | |
| Asian | 3 (6) | |
| >1 race | 3 (6) | |
| Ethnicity | Non-Hispanic | 31 (61) |
| Hispanic | 18 (35) | |
| Unknown/declined | 2 (4) | |
| Years of age | 20–29 | 8 (16) |
| 30–39 | 19 (37) | |
| ≥40 | 22 (43) | |
| Unknown/declined | 2 (4) | |
| Years of employment at WIC | <1 | 2 (4) |
| 1–5 | 17 (33) | |
| >5 | 31 (61) | |
| Unknown/declined | 1 (2) | |
| Education | High school graduate | 5 (10) |
| Some college | 7 (14) | |
| Graduated 2-y college | 6 (12) | |
| Graduated 4-y college | 29 (57) | |
| Postgraduate | 3 (6) | |
| Unknown | 1 (2) | |
| Staff role | Breastfeeding peer counselor | 4 (8) |
| Nutritionist | 16 (31) | |
| Nutrition associate | 14 (27) | |
| Other | 7 (14) | |
| Unknown | 10 (20) |
Abbreviation: WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
Percentages may not add up to 100 due to rounding.
Facilitators and Barriers to Breastfeeding
Themes and subthemes describing facilitators and barriers to breastfeeding are consistent with what has been previously described in the literature, thus we have summarized the findings in Table 2.19–22
Facilitators and Barriers to Breastfeeding
| Theme | Subtheme | Exemplar Quote |
|---|---|---|
| Beliefs about breastfeeding and formula | Milk supply | “We’d say 95% of the people I see that are breastfeeding when they come back, they say they don’t have enough milk. Almost everybody that sits at my desk tells me they don’t have enough milk. For various reasons, they pump and they think they don’t have enough, or the baby cries and they think they don’t have enough.” |
| Infant attachment | “I think a lot of them see it as being tied down to the baby, you know, and they don’t want that, because a lot of them are very young, you know, they’re 20, 21, 22, they want to go out with their friends, they want to be able to leave the baby with their sister or their mother, whoever, and so, they think, ‘Oh, breastfeeding, it’s not going to work,’ you know, ‘I can’t do that.’” | |
| Breasts as sexual objects | “Sometimes their boyfriends are pressuring them, too. And they’re like, oh my breasts are just for my boyfriend, and they don’t want…the baby on there.” | |
| Intensity of breastfeeding | “I think the other thing that scares moms away is when you tell them in the beginning, you’re going to have to put the baby to the breast every hour and a half or two hours. They’re like ‘oh, no. I can’t do that.’” | |
| Ease of formula use | “The ease and the accessibility to formula, and they can get it in the hospital, they come here [WIC] and they get it…If they’re not on WIC, they’re forced to either do it out of pocket or breastfeed more. And especially in their countries where formula isn’t as easily accessible, versus here, it’s very easily accessible…You know, and so there’s no real like push that’s saying ‘oh, I’ll have to spend this much money [on] formula,’ because WIC will just give it to me.” | |
| Breastfeeding experience | Difficulty with latch | “They’re not doing it right…The baby’s mouth is not wide open. So you can see that’s why it hurts. You try to say, ‘Yeah, you will feel something, it hurts like the first two weeks.’ But then it’s so normal, it’s so easy that you’ll want to keep breastfeeding. But that’s why they stop, because they’re not doing it right.” |
| Prior experience | “Some people that may not want to breastfeed that second time, as they had a bad experience that first time.” | |
| Pumping | “The biggest problem with the pumps is that when I see a mom in the clinic and she’s doing mostly pumping, that’s probably going to be a mom that stops breastfeeding because they’ll use the pump as a substitute for going to get help with breastfeeding.” | |
| Infant health | “I can see here when some mothers have like babies who are very sick…most of them, they breastfeed, because they know…They do breastfeed, they pump, they bring the breast milk to the hospital and it’s amazing…the difference.” | |
| “A lot of times in the hospital they can get thrown off track of their goal of breastfeeding when the babies are offered formula by the nursing staff. Sometimes they say this baby has jaundice and they want to give them formula to flush that out. So their initial breastfeeding experience is off.” | ||
| Social support | Home support | “They don’t have the support, they don’t have the moms, the people around them to encourage them, so right away, they give them formula.” |
| “I think the more successful women—the women who would tend to be more successful with breastfeeding tend to be surrounded with a very strong support system, and we just don’t see that that much [with the WIC population]. Sometimes, we do, but most of the time, we don’t.” | ||
| Health care support | “I think they start off having difficulties breastfeed most often when they’ve received formula in the hospital because usually when they’re given formula in the hospital to supplement for…whatever reason the doctor deems necessary, it’s not very common that they’re given a plan by the doctor to get off of the formula. And so then when we tell moms it’s okay to just be breastfeeding when baby’s gaining weight very well, and there’s not a medical reason anymore for the baby to be supplemented then the moms think we’re going against the doctor. And so just preventing early supplementation in the hospital is huge.” | |
| Competing priorities | Employment | “I think a large reason…is a lot of our moms…are going back to work. They don’t have that luxury of…getting paid during this time…They…have to pay bills. [They have] to go back to work in two weeks…and so then they’re back in work and they’re like, well, my job doesn’t let me pump at work…I can’t breastfeed either. I’m working 12-hour shifts. I work through the night and so forth. And so…what is their option? I can’t argue with them… they need their job. I get it—I can tell you all the laws and everything but they might working at a facility where—that doesn’t apply in that facility because they only have five employees. That law doesn’t apply.” |
| Care of other children | “A mom who has toddlers in the house, and she’s just got a newborn running around, a two-year-old…it’s pretty tough. I do get those complaints that she can’t breastfeed, because she has another toddler to care for, and therefore, she stops breastfeeding, or do both [formula and breast feed].” | |
| Subjective norms | Generational knowledge | “I think that a large barrier today is that a lot of the moms, it’s been generation after generation after generation of formula, formula, formula. And they haven’t had that experience of someone breastfeeding. They don’t have that, oh yeah, I saw my mom do that before with my brother or my sister or whatever or what have you.” |
| “They’ve seen their grandmother or their auntie or whoever breastfeeding, so they kind of already are at an advantage, opposed to young people growing up thinking, ‘Oh, yeah, I’m going to breastfeed,’ but have never really even experienced it or seen it happening. So, they may get into those barriers of the pain, or get into the engorgement or whatever, and they can’t get past it. So I kind of feel like we’re really in a good position to support and encourage to get past the—you know, once they initially start breastfeeding.” | ||
| Cultural knowledge | “A lot of the women who come there are from other countries, and they already breastfeed, and it’s all that they do.” | |
| Friends | “They don’t have any friends that have breastfeed. And all the friends they do have that did breastfeed stop because it hurts.” | |
| Self-efficacy | “They just don’t believe in themselves…They just don’t have that internal belief that, ‘I can do this, I can feed my baby, I will have enough milk, I will be successful at breastfeeding.’” | |
| “When I ask women how they plan to feed the baby, they’ll say, ‘I want to breastfeed if I can.’ So, they have this doubt from the beginning.” | ||
| Theme | Subtheme | Exemplar Quote |
|---|---|---|
| Beliefs about breastfeeding and formula | Milk supply | “We’d say 95% of the people I see that are breastfeeding when they come back, they say they don’t have enough milk. Almost everybody that sits at my desk tells me they don’t have enough milk. For various reasons, they pump and they think they don’t have enough, or the baby cries and they think they don’t have enough.” |
| Infant attachment | “I think a lot of them see it as being tied down to the baby, you know, and they don’t want that, because a lot of them are very young, you know, they’re 20, 21, 22, they want to go out with their friends, they want to be able to leave the baby with their sister or their mother, whoever, and so, they think, ‘Oh, breastfeeding, it’s not going to work,’ you know, ‘I can’t do that.’” | |
| Breasts as sexual objects | “Sometimes their boyfriends are pressuring them, too. And they’re like, oh my breasts are just for my boyfriend, and they don’t want…the baby on there.” | |
| Intensity of breastfeeding | “I think the other thing that scares moms away is when you tell them in the beginning, you’re going to have to put the baby to the breast every hour and a half or two hours. They’re like ‘oh, no. I can’t do that.’” | |
| Ease of formula use | “The ease and the accessibility to formula, and they can get it in the hospital, they come here [WIC] and they get it…If they’re not on WIC, they’re forced to either do it out of pocket or breastfeed more. And especially in their countries where formula isn’t as easily accessible, versus here, it’s very easily accessible…You know, and so there’s no real like push that’s saying ‘oh, I’ll have to spend this much money [on] formula,’ because WIC will just give it to me.” | |
| Breastfeeding experience | Difficulty with latch | “They’re not doing it right…The baby’s mouth is not wide open. So you can see that’s why it hurts. You try to say, ‘Yeah, you will feel something, it hurts like the first two weeks.’ But then it’s so normal, it’s so easy that you’ll want to keep breastfeeding. But that’s why they stop, because they’re not doing it right.” |
| Prior experience | “Some people that may not want to breastfeed that second time, as they had a bad experience that first time.” | |
| Pumping | “The biggest problem with the pumps is that when I see a mom in the clinic and she’s doing mostly pumping, that’s probably going to be a mom that stops breastfeeding because they’ll use the pump as a substitute for going to get help with breastfeeding.” | |
| Infant health | “I can see here when some mothers have like babies who are very sick…most of them, they breastfeed, because they know…They do breastfeed, they pump, they bring the breast milk to the hospital and it’s amazing…the difference.” | |
| “A lot of times in the hospital they can get thrown off track of their goal of breastfeeding when the babies are offered formula by the nursing staff. Sometimes they say this baby has jaundice and they want to give them formula to flush that out. So their initial breastfeeding experience is off.” | ||
| Social support | Home support | “They don’t have the support, they don’t have the moms, the people around them to encourage them, so right away, they give them formula.” |
| “I think the more successful women—the women who would tend to be more successful with breastfeeding tend to be surrounded with a very strong support system, and we just don’t see that that much [with the WIC population]. Sometimes, we do, but most of the time, we don’t.” | ||
| Health care support | “I think they start off having difficulties breastfeed most often when they’ve received formula in the hospital because usually when they’re given formula in the hospital to supplement for…whatever reason the doctor deems necessary, it’s not very common that they’re given a plan by the doctor to get off of the formula. And so then when we tell moms it’s okay to just be breastfeeding when baby’s gaining weight very well, and there’s not a medical reason anymore for the baby to be supplemented then the moms think we’re going against the doctor. And so just preventing early supplementation in the hospital is huge.” | |
| Competing priorities | Employment | “I think a large reason…is a lot of our moms…are going back to work. They don’t have that luxury of…getting paid during this time…They…have to pay bills. [They have] to go back to work in two weeks…and so then they’re back in work and they’re like, well, my job doesn’t let me pump at work…I can’t breastfeed either. I’m working 12-hour shifts. I work through the night and so forth. And so…what is their option? I can’t argue with them… they need their job. I get it—I can tell you all the laws and everything but they might working at a facility where—that doesn’t apply in that facility because they only have five employees. That law doesn’t apply.” |
| Care of other children | “A mom who has toddlers in the house, and she’s just got a newborn running around, a two-year-old…it’s pretty tough. I do get those complaints that she can’t breastfeed, because she has another toddler to care for, and therefore, she stops breastfeeding, or do both [formula and breast feed].” | |
| Subjective norms | Generational knowledge | “I think that a large barrier today is that a lot of the moms, it’s been generation after generation after generation of formula, formula, formula. And they haven’t had that experience of someone breastfeeding. They don’t have that, oh yeah, I saw my mom do that before with my brother or my sister or whatever or what have you.” |
| “They’ve seen their grandmother or their auntie or whoever breastfeeding, so they kind of already are at an advantage, opposed to young people growing up thinking, ‘Oh, yeah, I’m going to breastfeed,’ but have never really even experienced it or seen it happening. So, they may get into those barriers of the pain, or get into the engorgement or whatever, and they can’t get past it. So I kind of feel like we’re really in a good position to support and encourage to get past the—you know, once they initially start breastfeeding.” | ||
| Cultural knowledge | “A lot of the women who come there are from other countries, and they already breastfeed, and it’s all that they do.” | |
| Friends | “They don’t have any friends that have breastfeed. And all the friends they do have that did breastfeed stop because it hurts.” | |
| Self-efficacy | “They just don’t believe in themselves…They just don’t have that internal belief that, ‘I can do this, I can feed my baby, I will have enough milk, I will be successful at breastfeeding.’” | |
| “When I ask women how they plan to feed the baby, they’ll say, ‘I want to breastfeed if I can.’ So, they have this doubt from the beginning.” | ||
Abbreviation: WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
WIC Staff Strategies to Overcome Barriers and Leverage Facilitators
A summary of strategies WIC staff uses to overcome barriers and leverage facilitators to breastfeeding are found in Table 3.
Strategies to Promote Breastfeeding
| Theme | Subtheme | Exemplar Quote |
|---|---|---|
| Education content | Anticipatory guidance | “I use…these little baby balls. They’re like ping pong balls but there are three different sizes that show you the progression of the [infant’s] belly. I feel like when I show moms those at their last prenatal appointment…in the first few days their belly is only the size of a marble, this is all they need. You don’t need to be producing massive amounts of milk.” |
| “Sometimes they have a bad experience with the first baby, but it’s not going to be the same with the second or the third baby. It can be better, and every day is different. You can successfully breastfeed the second one and the third one. It doesn’t have to be ‘because I didn’t breastfeed the first time, I won’t be able to breastfeed next time.’” | ||
| “Just letting them know that they can come to our office as soon as they have the baby…if you’re uncomfortable with latch, you can always bring the baby in. I always say you don’t have to make an appointment, just call to make sure I’m there. But you can always bring [your] baby in. And that helps, because they’re like, oh, okay!” | ||
| Normalization of breastfeeding | “Just saying that our bodies are made for this, it knows exactly what to do. If we never had any formula, if we never had any of the support…our bodies would step in and know.” | |
| “My peer counselors contact each and every prenatal mom…and they have a conversation with them, and we have an infant nutrition group… It’s an hour class, and it’s not a how-to breastfeed, it’s a why-to breastfeed class, and they might see a little video during that time, they play a game, those are the headings up there, formula advantages, formula disadvantages, breastfeeding advantages, breastfeeding disadvantages, there’s little cards that go out and a visual is created that shows the many, many advantages of breastfeeding.” | ||
| Individually tailored messaging | “On one side [of a handout] it has the mom’s benefits of breastfeeding and the other side it has the baby’s benefits to breastfeeding. So I typically give that out at a prenatal appointment and I have the moms look at it and I say, ‘Pick a couple of things that are really, really important to you. What makes you want to breastfeed?’ I ask you to circle it and put it on your refrigerator. Because I want them to remember those things the first two weeks because I do tell them the first two weeks are hard, they’re the hardest.” | |
| “It’s really important that when we talk about the breastfeeding goals and the accommodations, we talk about setting your own feeding goals instead of well, you should be breastfeeding for a year or two.” | ||
| Education format | Timing | “I think…taking that time with the prenatal appointment, when you have that first appointment, really just sitting down. I dedicate at least 10 min, just to—I put a lot of effort just into breastfeeding.” |
| “I think initiation, so any contact with a peer—a breastfeeding peer consult from us, even the nutritionist, during prenatal visits asking them if they’re interested, exposure to breast feeding classes. So any resources earlier on helps guide them towards their decision.” | ||
| Engaging client support network | “I think reaching their support network, whether it’s a partner or their own parents or even their friends, is really, crucial, at least with our population.” | |
| “We have started asking if they want to bring their mom to the breastfeeding class, or the baby’s father to the breastfeeding class. Because it might be that nobody in the family breastfed before, and sometimes 2 sets of ears are better than one.” | ||
| Relationship building | Establishing rapport and building trust | “I think an important thing is to be personable. I know personally, if I have a mom who says it hurts, or she doesn’t have the support, or any of the other obstacles…just try to find the common ground. Usually when you find the common ground, or find that connection, you build that trust. Which, again, will give them the belief that you will know that they have the support.” |
| “So, support takes time. It takes time to build a rapport, it takes time to transfer information to people, and I think it’s not valued at maybe other places. I am pretty adamant about giving the time that’s needed.” | ||
| Sharing personal experiences | “I feel like the support and the education should also be given in a way where you do need to connect with your participant at a certain level so they’re not feeling like they’re just a client, so sharing your own personal experience could be a good factor to relate to that person specifically.” | |
| “That can be hugely beneficial, just to have somebody else who’s been through it too, and so they can…lend their expertise or their struggles, validate the mom’s concerns a little bit. I do try to use that in my counseling with the breastfeeding. I tell moms…it’s not always easy. I struggled with this, I struggled with that, or if moms come in and they’re struggling with latch or whatever…to try to help tweak them or say…something that I struggled with. It kind of gets them to create that bond so they can feel—might trust me a little bit more.” | ||
| Resource provision | “I bribe them. I offer them more support. You know we have, oh, do you need a bra? I know bras are expensive, we have pads, we have breast pads. Do you need a cover so you can safely and discretely breastfeed outside? Do you need a …[state] law card that helps protect you to breastfeed in public? Do you need referrals to other specialists and more help? That’s what, I think helps a little bit. But the bribery, yes. I say one year and I’ll give them an Amazon gift card!” | |
| “[WIC staff member] made us a really nice picture, and this definitely helps, and I use it all the time. It shows the packages of fully breastfeeding mostly, and it’s a great tool so you know, especially prenatally, I’m like, ‘This is what you’re going to get.’ And they look at it, ‘Oh!’ And they go, ‘Free?’ And I go, ‘Free, free, free! All good!’” | ||
| Theme | Subtheme | Exemplar Quote |
|---|---|---|
| Education content | Anticipatory guidance | “I use…these little baby balls. They’re like ping pong balls but there are three different sizes that show you the progression of the [infant’s] belly. I feel like when I show moms those at their last prenatal appointment…in the first few days their belly is only the size of a marble, this is all they need. You don’t need to be producing massive amounts of milk.” |
| “Sometimes they have a bad experience with the first baby, but it’s not going to be the same with the second or the third baby. It can be better, and every day is different. You can successfully breastfeed the second one and the third one. It doesn’t have to be ‘because I didn’t breastfeed the first time, I won’t be able to breastfeed next time.’” | ||
| “Just letting them know that they can come to our office as soon as they have the baby…if you’re uncomfortable with latch, you can always bring the baby in. I always say you don’t have to make an appointment, just call to make sure I’m there. But you can always bring [your] baby in. And that helps, because they’re like, oh, okay!” | ||
| Normalization of breastfeeding | “Just saying that our bodies are made for this, it knows exactly what to do. If we never had any formula, if we never had any of the support…our bodies would step in and know.” | |
| “My peer counselors contact each and every prenatal mom…and they have a conversation with them, and we have an infant nutrition group… It’s an hour class, and it’s not a how-to breastfeed, it’s a why-to breastfeed class, and they might see a little video during that time, they play a game, those are the headings up there, formula advantages, formula disadvantages, breastfeeding advantages, breastfeeding disadvantages, there’s little cards that go out and a visual is created that shows the many, many advantages of breastfeeding.” | ||
| Individually tailored messaging | “On one side [of a handout] it has the mom’s benefits of breastfeeding and the other side it has the baby’s benefits to breastfeeding. So I typically give that out at a prenatal appointment and I have the moms look at it and I say, ‘Pick a couple of things that are really, really important to you. What makes you want to breastfeed?’ I ask you to circle it and put it on your refrigerator. Because I want them to remember those things the first two weeks because I do tell them the first two weeks are hard, they’re the hardest.” | |
| “It’s really important that when we talk about the breastfeeding goals and the accommodations, we talk about setting your own feeding goals instead of well, you should be breastfeeding for a year or two.” | ||
| Education format | Timing | “I think…taking that time with the prenatal appointment, when you have that first appointment, really just sitting down. I dedicate at least 10 min, just to—I put a lot of effort just into breastfeeding.” |
| “I think initiation, so any contact with a peer—a breastfeeding peer consult from us, even the nutritionist, during prenatal visits asking them if they’re interested, exposure to breast feeding classes. So any resources earlier on helps guide them towards their decision.” | ||
| Engaging client support network | “I think reaching their support network, whether it’s a partner or their own parents or even their friends, is really, crucial, at least with our population.” | |
| “We have started asking if they want to bring their mom to the breastfeeding class, or the baby’s father to the breastfeeding class. Because it might be that nobody in the family breastfed before, and sometimes 2 sets of ears are better than one.” | ||
| Relationship building | Establishing rapport and building trust | “I think an important thing is to be personable. I know personally, if I have a mom who says it hurts, or she doesn’t have the support, or any of the other obstacles…just try to find the common ground. Usually when you find the common ground, or find that connection, you build that trust. Which, again, will give them the belief that you will know that they have the support.” |
| “So, support takes time. It takes time to build a rapport, it takes time to transfer information to people, and I think it’s not valued at maybe other places. I am pretty adamant about giving the time that’s needed.” | ||
| Sharing personal experiences | “I feel like the support and the education should also be given in a way where you do need to connect with your participant at a certain level so they’re not feeling like they’re just a client, so sharing your own personal experience could be a good factor to relate to that person specifically.” | |
| “That can be hugely beneficial, just to have somebody else who’s been through it too, and so they can…lend their expertise or their struggles, validate the mom’s concerns a little bit. I do try to use that in my counseling with the breastfeeding. I tell moms…it’s not always easy. I struggled with this, I struggled with that, or if moms come in and they’re struggling with latch or whatever…to try to help tweak them or say…something that I struggled with. It kind of gets them to create that bond so they can feel—might trust me a little bit more.” | ||
| Resource provision | “I bribe them. I offer them more support. You know we have, oh, do you need a bra? I know bras are expensive, we have pads, we have breast pads. Do you need a cover so you can safely and discretely breastfeed outside? Do you need a …[state] law card that helps protect you to breastfeed in public? Do you need referrals to other specialists and more help? That’s what, I think helps a little bit. But the bribery, yes. I say one year and I’ll give them an Amazon gift card!” | |
| “[WIC staff member] made us a really nice picture, and this definitely helps, and I use it all the time. It shows the packages of fully breastfeeding mostly, and it’s a great tool so you know, especially prenatally, I’m like, ‘This is what you’re going to get.’ And they look at it, ‘Oh!’ And they go, ‘Free?’ And I go, ‘Free, free, free! All good!’” | ||
Abbreviation: WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
Education: Content
To support clients on their breastfeeding journey, participants described themes related to educational content including anticipatory guidance, normalization and benefits of breastfeeding, and individually tailored messaging. Regarding anticipatory guidance, participants mentioned the importance of emphasizing the small size of the infant stomach and using props to illustrate this point. For example, one participant reported the following:
I use…these little baby balls. They’re like ping pong balls but there are three different sizes that show you the progression of the [infant’s] belly. I feel like when I show moms those at their last prenatal appointment…in the first few days their belly is only the size of a marble, this is all they need. You don’t need to be producing massive amounts of milk.
Participants described how they addressed negative prior breastfeeding experience with their clients:
Sometimes they have a bad experience with the first baby, but it’s not going to be the same with the second or the third baby. It can be better, and every day is different. You can successfully breastfeed the second one and the third one. It doesn’t have to be ‘because I didn’t breastfeed the first time, I won’t be able to breastfeed next time.’
Participants also addressed the lack of health care support and concerns about latching by ensuring clients were aware of their availability and support:
Just letting them know that they can come to our office as soon as they have the baby…if you’re uncomfortable with latch, you can always bring the baby in. I always say you don’t have to make an appointment, just call to make sure I’m there. But you can always bring [your] baby in. And that helps, because they’re like, oh, okay!
Participants stressed the importance of normalizing breastfeeding and ensuring clients were aware of the many benefits of breastfeeding for encouragement. Participants shared with clients that breastfeeding is a typical body function and that their clients’ bodies were made to breastfeed: “Just saying that our bodies are made for this, it knows exactly what to do. If we never had any formula, if we never had any of the support…our bodies would step in and know.”
Participants also explained that clients are often unaware of the array of health benefits of breastfeeding for themselves or their infants and used the following information to encourage breastfeeding:
My peer counselors contact each and every prenatal mom…and they have a conversation with them, and we have an infant nutrition group… It’s an hour class, and it’s not a how-to breastfeed, it’s a why-to breastfeed class, and they might see a little video during that time, they play a game, those are the headings up there, formula advantages, formula disadvantages, breastfeeding advantages, breastfeeding disadvantages, there’s little cards that go out and a visual is created that shows the many, many advantages of breastfeeding.
Participants further emphasized the importance of tailoring educational messaging to each client, focusing their efforts on the information that is most meaningful to the individual client to provide confidence in their decision to breastfeed:
On one side [of a handout] it has the mom’s benefits of breastfeeding and the other side it has the baby’s benefits to breastfeeding. So I typically give that out at a prenatal appointment and I have the moms look at it and I say, ‘Pick a couple of things that are really, really important to you. What makes you want to breastfeed?’ I ask you to circle it and put it on your refrigerator. Because I want them to remember those things the first two weeks because I do tell them the first two weeks are hard, they’re the hardest.
Finally, participants emphasized that individual counseling and short-term goal setting were very important for clients. As an example, one participant said, “It’s really important that when we talk about the breastfeeding goals and the accommodations, we talk about setting your own feeding goals instead of well, you should be breastfeeding for a year or two.”
Education: Format
Participants described their broad approach to providing education, offering a variety of options in delivery method, timing, personnel, and family engagement. For instance, participants delivered education through formats including classes, videos, handouts, individual appointments, and group meetings. Regarding timing of education, participants particularly emphasized the importance of prenatal education because this is when clients begin making decisions about breastfeeding: “I think…taking that time with the prenatal appointment, when you have that first appointment, really just sitting down. I dedicate at least 10 minutes, just to—I put a lot of effort just into breastfeeding.”
Prenatal education had several purposes, including encouraging clients to make the decision to breastfeed, teaching them about the mechanics of breastfeeding, and providing anticipatory guidance about breastfeeding, thus preparing clients for breastfeeding prior to delivery. Finally, participants described an array of personnel, including nutritionists, lactation counselors, and peer support counselors, who support breastfeeding.
Participants stated it was “crucial” to engage the clients’ support network to foster breastfeeding, addressing the barrier of lack of home support: “I think reaching their support network, whether it’s a partner or their own parents or even their friends, is really crucial, at least with our population.” Participants encouraged their clients’ support network to attend educational sessions as an additional method to support their client: “We have started asking if they want to bring their mom to the breastfeeding class, or the baby’s father to the breastfeeding class. Because it might be that nobody in the family breastfed before, and sometimes 2 sets of ears are better than one.”
Relationship Building
Relationship building was also a key element used by participants to support clients. Participants described improved success with addressing clients’ barriers once rapport and trust was established:
I think an important thing is to be personable. I know personally, if I have a mom who says it hurts, or she doesn’t have the support, or any of the other obstacles…just try to find the common ground. Usually when you find the common ground, or find that connection you build that trust. Which, again, will give them the belief that you will know that they have the support.
Additionally, participants described sharing personal experiences as a method to build relationships:
I feel like the support and the education should also be given in a way where you do need to connect with your participant at a certain level so they’re not feeling like they’re just a client, so sharing your own personal experience could be a good factor to relate to that person specifically.
This method of communication and relationship building was found to be helpful when supporting breastfeeding clients:
That can be hugely beneficial, just to have somebody else who’s been through it too, and so they can…lend their expertise or their struggles, validate the mom’s concerns a little bit. I do try to use that in my counseling with the breastfeeding. I tell moms…it’s not always easy. I struggled with this, I struggled with that, or if moms come in and they’re struggling with latch or whatever…to try to help tweak them or say…something that I struggled with. It kind of gets them to create that bond so they can feel—might trust me a little bit more.
Resource Provision
Because one of WIC’s primary functions is the provision of physical goods (food, supplies, etc), participants described ways they used this function to support or encourage clients to breastfeed such as illustrating the differences in food packages provided to breastfeeding and formula-feeding clients:
[WIC staff member] made us a really nice picture, and this definitely helps, and I use it all the time. It shows the packages of fully breastfeeding mostly, and it’s a great tool so you know, especially prenatally, I’m like, ‘This is what you’re going to get.’ And they look at it, ‘Oh!’ And they go, ‘Free?’ And I go, ‘Free, free, free! All good!’
Participants also explained the additional material supports offered to breastfeeding clients:
I bribe them. I offer them more support. You know we have, oh, do you need a bra? I know bras are expensive, we have pads, we have breast pads. Do you need a cover so you can safely and discreetly breastfeed outside? Do you need a …[state] law card that helps protect you to breastfeed in public? Do you need referrals to other specialists and more help? That’s what, I think helps a little bit. But the bribery, yes. I say one year and I’ll give them an Amazon gift card!
Discussion
This study notably incorporated the perspectives of WIC staff providing day-to-day breastfeeding support to populations with low income, thereby providing crucial data needed to inform future interventions. WIC staff members provided in-depth descriptions of known barriers and facilitators to breastfeeding and, importantly, multiple strategies to promote breastfeeding. They reported on elements of educational content including management of expectations and anticipatory guidance, normalization of breastfeeding, emphasizing health benefits of breastfeeding, and tailoring message content to the individual client. WIC staff also described beneficial educational formats such as ensuring education was delivered prenatally, in a variety of formats (meetings, videos, one-on-one), with a diverse array of staff, and inclusive of social support networks. Relationship building, especially through sharing personal experience, was a key element for successful client interactions that enabled staff members to connect with clients and encouraged them in individual and powerful ways. Finally, WIC staff provided material resources tailored to breastfeeding to encourage clients to initiate or maintain breastfeeding.
The barriers described by WIC staff are consistent with previous findings in the literature.19–22 For example, concerns about milk supply and difficulty with latch are frequently noted barriers.19,20 Lack of social support is another commonly noted barrier to breastfeeding, particularly for Black families.21 While the barriers to breastfeeding that face WIC clients, as described by WIC staff, are consistent with previous findings in the literature,19–22 the insights offered by WIC staff to overcome these barriers are essential when planning interventions targeted at this population.
Although site-to-site variation in support practices and success in breastfeeding practices exist, WIC participation is an important source of breastfeeding support for families with low income.23 One study describes site-level supports associated with improved breastfeeding duration, including WIC client access to breastfeeding, peer counselors, and International Board Certified lactation consultants.24 However, this study does not describe the specific strategies used by individual WIC staff members to support breastfeeding practices. Notably, in our study WIC staff provides concrete examples of practices to improve breastfeeding. For instance, the use of visual aids to illustrate the size of the newborn’s stomach can help overcome the client’s worry concerning milk supply. Ensuring client awareness of WIC support for overcoming latch difficulties before delivery enables clients to use these resources, which otherwise may be unknown. Additionally, incorporating each client’s social network, especially family members, into education before and after delivery can increase social support to improve breastfeeding success.
While we conducted focus groups in 2 states, encompassing more than 1 geographic area (Massachusetts and Virginia), only these East Coast states were represented, potentially limiting the generalizability of our results to the rest of the country. However, qualitative research is not meant be generalizable,25 and the experiences noted by the varying WIC offices included in the study provide important perspectives when faced with varying clientele, both of background (domestic and immigrant) and race or ethnicity. Further, the barriers and facilitators to breastfeeding described by WIC staff have been described by mothers across many demographic groups and US regions, which suggests that perspectives on strategies to support mothers may be used for intervention development among many populations.7,19–22,26,27 Another potential limitation of this study is selection bias, specifically self-selection bias. Individuals who are more inclined to participate in interviews may differ from those who are not inclined. This limitation may be mitigated by this study’s use of focus groups, but, because we did not collect information on staff members who did not participate, the potential effect is unknown.
Conclusion
Improving breastfeeding initiation and continuation is an important public health focus. Developing and sharing strategies for overcoming barriers and leveraging facilitators, as was done in our study, are critical to improve interventions to support breastfeeding. This study is an exemplar of how to ensure that important voices, in this case WIC staff, inform the development of interventions to change health-related behaviors. Our future efforts will examine the effect of the strategies identified in this study on improving breastfeeding practices of WIC clients.
Dr Colvin carried out the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Cunningham carried out the initial analyses, and reviewed and revised the manuscript; Ms Forbes and Peguero collected data and coordinated and supervised data collection; Ms Boguszewski coordinated and supervised data collection; Drs Kiviniemi, Hauck, Moon, and Parker conceptualized and designed the study and reviewed and revised the manuscript; Dr Kellams conceptualized and designed the study, acquired funding for the study, and reviewed and revised the manuscript; Dr Colson conceptualized and designed the study, carried out the initial analyses, acquired funding for the study, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose.
FUNDING: This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD R01HD072815).
