Conversations about infant feeding and postpartum contraception tend to occur at the same time during the perinatal period. Given the importance of postpartum contraception to reduce short interpregnancy intervals and the many health benefits of breastfeeding, it is important to investigate these interrelated topics together. This study explores the intersection between infant feeding and postpartum contraception among postpartum individuals and providers throughout western North Carolina.
Key Words: breast feeding, contraception, patient-centered care, postpartum period, reproductive health
Abstract
Objectives
Short interpregnancy intervals are associated with preterm births. Increasing access to postpartum contraception is a preventive intervention. Best practice recommendations suggest that postpartum individuals exclusively breastfeed for up to 6 months. Conversations about these two topics tend to occur simultaneously throughout the perinatal period. This study explores the intersection between infant feeding and postpartum contraception.
Methods
Semistructured key informant interviews were conducted with postpartum individuals and providers from throughout western North Carolina. Interviews were audio recorded and transcribed. The “Sort and Sift, Think and Shift” method was applied. Emergent themes were identified by systematically generating summaries, memoranda, and quotation diagrams independently by two coders.
Results
Key themes included the need to prioritize individual decision-making autonomy and to provide prenatal patient education about infant feeding and postpartum contraception. Participants also discussed the types of social support needed for successful breastfeeding efforts and the impact of infant feeding on mental health. Contextual factors related to infant feeding and postpartum contraceptive decision-making encompassed cultural influences (eg, the historical context of reproductive rights and breastfeeding in public), the inherent challenges of rurality (eg, lack of transportation and the closure of labor and delivery units), and family leave and workplace policies.
Conclusions
Infant feeding method and postpartum contraception are highly individualized decisions, which are supported through patient education and shared decision making, particularly during the prenatal period. Findings suggest the importance of incorporating infant feeding within the sexual and reproductive health literature.
Key Points
Centering individual decision-making autonomy about infant feeding method and postpartum contraception is of paramount importance and may be actualized through education and shared decision-making between patients and providers, particularly during the prenatal period.
Robust social systems of support, including support from the community, providers, and family, are critical for successful breastfeeding efforts. These social systems of support also may help to mitigate the impact of infant feeding on mental health symptoms.
Infant feeding and postpartum contraception decisions are made within the broader contextual environment. These contextual factors include cultural and historical influences, the inherent challenges of rurality, and family leave and workplace policies.
Preterm births (PTBs) are associated with negative health outcomes, including neurocognitive deficits, pulmonary dysfunction, and infant mortality.1 Healthy People 2030 aims to reduce the PTB rate in the United States by 2030.2 In North Carolina, the PTB rate was 10.7% in 2022,3 as compared with 11.2% between 2018 and 2021 in the western region of the state.4
One mechanism for reducing the risk of PTB is to promote adequate birth spacing because short interpregnancy intervals (SIPIs) are associated with PTB.5 Another Healthy People 2030 goal is to reduce the proportion of pregnancies conceived within 18 months of a previous birth.6 Although increasing access to postpartum contraception may prevent SIPIs,7,8 grounding contraceptive care in reproductive autonomy (when individuals have the power to make decisions and control matters associated with contraceptive use, pregnancy, and childbearing) is imperative.9
Another important maternal and child health (MCH) outcome is the rate of infants who are exclusively breastfed through 6 months of age, which is recommended by Healthy People 2030, the World Health Organization, and the American College of Obstetricians and Gynecologists.10–12 The short- and long-term benefits of breastfeeding for mothers and infants are well documented,13 including enhancing cognitive development, lowering obesity rates, and protecting against chronic diseases such as hypertension and diabetes mellitus.14 The rate of exclusive breastfeeding through 6 months in North Carolina is 22.1%, which is lower than the national average (24.9%).15
Given the importance of postpartum contraception in preventing SIPIs and the significance of exclusive breastfeeding through at least 6 months, it is essential to examine decisions and experiences of these two interrelated health topics together since they occur simultaneously during the perinatal period. The intersection of infant feeding and postpartum contraception was previously explored within the context of an urban hospital environment.16; however, western North Carolina is situated in Appalachia and is a predominantly rural area.17
Rurality has a negative impact on MCH outcomes, including breastfeeding initiation rates.18 Similarly, rural patients have less access to healthcare providers and longer travel distances to receive care than urban patients.18 Within western North Carolina, five rural hospital-based labor and delivery (L&D) units closed between 2013 and 2017.19 Rural L&D unit closures disproportionately affect women with fewer resources19 and increase the risk of adverse birth outcomes, including unplanned out-of-hospital deliveries, increased induction rates, PTBs, and longer neonatal intensive care unit stays.20,21
This study aimed to explore and illuminate perspectives regarding the intersection of infant feeding and postpartum contraception among postpartum individuals and providers throughout western North Carolina. These findings contribute to the sexual and reproductive health field and suggest areas for further scientific investigation.
METHODS
Recruitment and Data Collection
A cross-sectional key informant interview study was conducted (July 2023–December 2023) with postpartum individuals and perinatal care providers. Postpartum recruitment flyers were disseminated through a recruitment champion, which was an institutional review board–approved role (Appendix 1, http://links.lww.com/SMJ/A450). The recruitment champion was selected based on their role adjacent to the study population and disseminated flyers to Women, Infant, and Child offices throughout western North Carolina. Recruitment flyers included a QR code to the eligibility screener and informed consent document, which were administered via REDCap software.22,23 To be eligible, postpartum individuals must have been at least 18 years of age, live in western North Carolina, given birth to their current baby between 6 weeks and 1 year prior, and breastfed for any length of time.
Providers were purposively sampled through preexisting professional networks using scripted e-mails. In addition, providers were snowball sampled, whereby interview participants invited colleagues to register. Providers completed the informed consent document via REDCap software.22,23 Providers who deliver perinatal care services in western North Carolina were eligible (eg, obstetricians, certified nurse midwives, lactation consultants, doulas). We defined western North Carolina as the 18 western-most counties in North Carolina: Cherokee, Graham, Clay, Macon, Swain, Jackson, Haywood, Transylvania, Henderson, Buncombe, Madison, Yancey, Mitchell, Avery, McDowell, Burke, Rutherford, and Polk.
The semistructured interview guide was developed from the questions used by Pearlman Shapiro et al.16 and was adapted for each group, resulting in one guide for postpartum individuals and one guide for providers. Interviews were conducted via telephone (by L.M.V. and M.W.), audio recorded, and transcribed by a third-party service. The average interview length was 18 minutes for postpartum individuals and 29 minutes for providers. Recruitment and data collection efforts resulted in a robust dataset determined to have reached thematic saturation.24
A post hoc demographic survey was developed and e-mailed to participants. There was a 50.0% (N=8) response rate among postpartum individuals and a 62.5% (N=5) response rate among providers. This study was approved by the institutional review board at East Tennessee State University.
Coding and Analysis
The “Sort and Sift, Think and Shift” (hereafter, Sort and Sift) method was applied to analyze transcripts. Key principles of the Sort and Sift method include making iterative analysis efforts, obtaining a holistic perspective of each interview event, monitoring emergent and evolving topics, and noting how the topics coalesced across interviews.25
A rapid analytic approach was applied during the data collection phase, in which each interview was summarized into a matrix. The summaries were developed independently by two coders (M.W. and R.S.) and verified for reliability.26 The dataset was further analyzed, whereby two coders (L.M.V. and R.S.) independently developed memoranda for each interview. Guiding questions for memo development included “What did I learn from this interview event?” and “Why is this interview event important to the study?”27 Key quotations from each interview were identified and populated into a quotation diagram. The quotation diagram was generated using PowerPoint (Microsoft, Redmond, WA), in which like-quotations were grouped together.28 Through conducting ongoing, team-based analysis meetings between coders (L.M.V. and R.S.), themes emerged and were threaded throughout the dataset (see the themes below). Regarding reflexivity, one coder had previous experiences with breastfeeding, but the others had not.
RESULTS
In total, 24 interviews were conducted. Sixteen postpartum individuals were interviewed. Thirteen individuals were breastfeeding at the time of the interview, and three individuals had ceased breastfeeding. Eight providers were interviewed, including four lactation consultants, two certified nurse midwives, one postpartum doula, and one perinatal-focused psychotherapist. Six providers worked with women throughout the perinatal period, whereas two providers supported women during the postpartum period only.
Demographic Data
The average age of postpartum individuals was 31 years. Seven postpartum individuals identified as White, non-Hispanic, and one identified as Native American, Alaska Native, or American Indian, non-Hispanic. Regarding educational attainment, one postpartum individual indicated having some college/technical training, one indicated having an associate’s degree, two indicated having a bachelor’s degree, and four indicated having a postgraduate degree (Table 1). Postpartum individuals were from the following counties: Graham (n = 2), Macon (n = 2), Swain (n = 1), Jackson (n = 1), Transylvania (n = 4), Buncombe (n = 4), Yancey (n = 1), and Mitchell (n = 1) (Table 2).
TABLE 1.
Participant demographics
TABLE 2.
Distribution of participants by county in western North Carolina
The average age of providers was 41 years. All of the providers (n = 5) identified as White, non-Hispanic. Two providers indicated having a bachelor’s degree, and three reported having a postgraduate degree (Table 1). Providers served patients from across 18 counties in western North Carolina, including Cherokee (n = 3), Graham (n = 3), Clay (n = 2), Macon (n = 3), Swain (n = 4), Jackson (n = 5), Haywood (n = 5), Transylvania (n = 4), Henderson (n = 4), Buncombe (n = 6), Madison (n = 1), Yancey (n = 5), Mitchell (n = 3), Avery (n = 2), McDowell (n = 2), Burke (n = 2), Rutherford (n = 2), and Polk (n = 1). Most of the providers served patients from more than one county (Table 2).
Theme 1: Prioritize Individual Decision-Making Autonomy about Infant Feeding Method and Postpartum Contraception
Providers and postpartum participants emphasized the importance of individual decision-making autonomy about infant feeding method and postpartum contraception (Table 3). Notably, providers discussed centering each patients’ individual goals and preferences. As one provider noted, “First we go over what parents’ goals are, so that’s a big part of it. What they’re anticipating, and what they know already, and just meeting them where they’re at before we even start any conversation about lactation.” Another provider emphasized, “This is one of those categories where you can say we have data that shows [breastfeeding] is beneficial, and some women have a really hard time or choose not to. That’s okay as well, as long as they feel well supported in their choices.”
TABLE 3.
Themes identified related to infant feeding and postpartum contraception, perspectives of postpartum individuals and perinatal care providers throughout western North Carolina
Similarly, postpartum participants highlighted the importance of having choice, specifically regarding postpartum contraception. “As far as birth control, I can’t really say much because everybody has a right to their own choice with their body.” Also, postpartum participants noted making decisions about postpartum contraception based on their infant feeding goals. As one postpartum individual said, “I did not want to go on any oral contraceptives while breastfeeding. I know there are some that are safe for breastfeeding, but I just personally didn’t want to.” Postpartum individuals discussed the need for men to be involved in the conversation about contraception and the need for increased access to vasectomies.
Theme 2: Provide Prenatal Patient Education about Infant Feeding and Postpartum Contraception
Providers and postpartum participants discussed the benefit of education during the prenatal period. As one provider highlighted, “Educating on what’s normal and what kind of support we can provide for [patients] is big for this community.” Similarly, another provider said, “I think the most straightforward thing is education. Informed consent is huge. It doesn’t matter where you think this person is coming from or going home to. It’s up to [providers] to listen, and just meet them where they’re at, and give them as many, many resources as possible to make a decision.”
Postpartum participants emphasized wanting more information about breastfeeding while they were pregnant or at the time of delivery, such as being more educated about adequate nutrition and hydration for breastfeeding, breastfeeding equipment, and latching. Notably, one postpartum participant said, “I wish that I would have been educated more all around, because I felt like I was in the dark about how this all works. It was almost like at the beginning just having to figure it out myself, and I wish I maybe would have done more research and reached out to people beforehand to know what to expect.” In addition, being educated about the benefits of breastfeeding was a motivating factor for many postpartum participants to continue breastfeeding. “Just the fact that my milk is helping them. I’m not saying that formula is bad. It’s proven that breastmilk is more beneficial. That’s what helps me and motivates me to feed them my breastmilk.”
Postpartum individuals also discussed receiving education from their providers about postpartum contraceptive options. Overall, this education was noted to be helpful. As one postpartum individual emphasized, “I have never really been educated in the past about birth control. I’m really, really thankful for my OB [obstetrician] because they’ve really explained different birth controls that I can take.”
Theme 3: Strengthen Social Support for Successful Breastfeeding Efforts
Participants from both groups emphasized the types of social support needed for successful breastfeeding efforts, including community support, provider support, and partner/family support. Regarding community support, providers emphasized the benefits of breastfeeding support groups. One provider noted, “The first thing that pops into my head is having been around other people breastfeeding. Having knowledge and experience of what it looks like, and even the challenges.” Postpartum individuals also discussed the importance of community support for breastfeeding, such as online support groups and milk-sharing networks. A postpartum participant noted, “Sometimes I’ll refer to the breastfeeding support groups on Facebook… If I have a question or a doubt, I’ll ask a question online and get some insights from other moms.”
Provider support (eg, doctors, midwives, lactation consultants, doulas) also was mentioned by both groups, especially immediate assistance from lactation consultants in the hospital postdelivery. In addition, partner/family support was discussed as helpful for breastfeeding. As one postpartum individual highlighted, “My husband just stayed right there with me, kept me calm, and kept everybody calm, and just gave words of encouragement.” Conversely, a lack of support was noted as a challenge to breastfeeding. As one provider emphasized, “Where I’m located in WNC [western North Carolina], a lot of folks start out breastfeeding or wanting to do that and there is a lack of social support and family support for a lot of folks and they don’t feel like it’s very sustainable long-term for them for many reasons.” Similarly, one postpartum participant shared, “I didn’t receive any help from, specifically, a lactation consultant at the hospital, and then had problems when we came home. I ended up paying a lot of money out of pocket, which was discouraging. I think a lot of women who might not have access to that, or be able to afford that, that’s a huge barrier.”
Theme 4: Monitor the Impact of Infant Feeding on Mental Health
Providers and postpartum individuals readily discussed the impact of breastfeeding on mental health. As one provider said, “A few times I’ve seen mental health be a challenge, where a mom feels like she has to choose between getting enough sleep for her mental health and breastfeeding.” Similarly, postpartum individuals noted the challenges of breastfeeding affecting mental health, including a lack of sleep, physical pain, and being the sole food source. Notably, “I think if you’re battling with postpartum depression, pumping is not an easy thing to go through because it’s very stressful thinking about producing enough.” Another postpartum individual noted, “I think a lot of it is really in my head, the mental part of it. As the mom, I feel like I need to do it all. I feel like I need to take care of everyone. I’m not sure where that comes from, maybe society over the years, always chasing this goal of being able to balance it all.”
Theme 5: Consider Contextual Factors Influencing Infant Feeding and Postpartum Contraception
Several contextual subthemes emerged, including cultural and historical influences, the inherent challenges of rurality, and family leave and workplace policies. Providers discussed the importance of normalizing breastfeeding and taking historical context into account when providing contraceptive counseling (Table 4). As one provider said, “In my opinion, people don’t breastfeed, cultures do.” This sentiment was shared by another provider who highlighted, “I think the way that you talk about [contraception], you definitely have to have some knowledge of our history. In North Carolina, it wasn’t that long ago that we were still sterilizing people without consent.” Similarly, postpartum participants highlighted that societal constraints prevent comfortably breastfeeding in public. One participant stated, “I think societal constraints, not having access to a nursing area when out and about, running errands and things like that.”
TABLE 4.
Theme 5: Consider contextual factors that influence infant feeding and postpartum contraception, perspectives of postpartum individuals and perinatal care providers throughout western North Carolina
The inherent challenges of rurality were discussed, including a lack of transportation, the closure of L&D units, and less access to in-person breastfeeding support groups. Notably one provider said, “Transportation is a huge barrier, the distance they have to travel is a huge barrier. If you think about it and you have a newborn, who wants to get in the car for two hours?”
Providers and postpartum individuals discussed the need for family leave and workplace policies to support breastfeeding efforts. A postpartum participant suggested, “More policy decisions being made to support new families. Things like paid leave and more affordable childcare. Making the issues and the difficulties that new families face, bringing those more to the forefront I think would help.”
DISCUSSION
This study highlights postpartum individual and perinatal care provider perspectives regarding the intersection between infant feeding and postpartum contraception throughout western North Carolina. Findings underscore the importance of centering individual decision-making autonomy, patient education, and shared decision-making, particularly during the prenatal period. Shared decision-making is defined as patients sharing their values, goals, and preferences and providers sharing medical knowledge and information without judgment, and together, a healthcare decision is made.29 Implementing patient education and shared decision-making during the prenatal period may help to better prepare individuals for the postpartum period.
Although the topic of breastfeeding is largely absent from the broader sexual and reproductive health literature,30 postpartum contraceptive counseling often includes discussion about birth spacing, the impacts of breastfeeding on contraception, and contraceptive choice on breastfeeding.31 Although the lactational amenorrhea method may be considered, whereby exclusive breastfeeding is used as contraception, this method is unpredictable, is not often used correctly, and can delay the transition to a reliable contraceptive method.32 Previous research found that postpartum individuals trusted their providers more about information regarding breastfeeding than about information on contraception, which emphasized a need to reframe discussions about birth spacing to include benefits to the newborn and maternal health.16 Further research is warranted to investigate infant feeding as a component of contraceptive care service provision and, more broadly, reproductive autonomy.
As uncovered in this study, robust social systems of support, including support from community, providers, and partners and family, are critical for successful breastfeeding efforts, and may help to mitigate the negative impact of infant feeding on mental health. This finding is consistent with the literature that decreased social support networks may lead postpartum individuals to feel frustrated and isolated.33 Also, postpartum individuals who reported having social supports were more likely to exclusively breastfeed for longer durations.34 One mechanism of community support includes online support groups, which were found to normalize breastfeeding, increase breastfeeding self-efficacy, and potentially increase the duration of breastfeeding.35
Postpartum individuals in rural environments, such as western North Carolina, have less access to healthcare providers and thus less access to both support for breastfeeding and postpartum contraceptive care services.36 In addition, there is variability in prenatal care adequacy, particularly among counties in western North Carolina where L&D units have closed.19 The rural environment may reduce access to additional supports, including online breastfeeding support groups.37 A protective contextual factor includes family leave. Paid family leave policies are associated with improved MCH outcomes, including reduced mental health symptoms among postpartum individuals.38
The findings of our study were triangulated between postpartum individuals and providers—postpartum individuals shared their direct experiences and providers shared a population-level perspective. The triangulation of these data sources offered a unique approach, which we consider a strength. Another strength is that two coders were used for reliability throughout the data analysis process. Considering the limitations of our study, the postpartum group was largely homogenous regarding race/ethnicity and educational attainment, suggesting a skewed sample. Notably, rapid repeat pregnancies are more prevalent among postpartum individuals with lower educational attainment.39 In addition, postpartum recruitment was not limited based on parity nor was parity assessed in the demographic survey. Future studies should focus on recruiting diverse subpopulations to gain differing perspectives.
CONCLUSIONS
Decisions about infant feeding and postpartum contraception are highly individualized. Patient education, particularly during the prenatal period, is supportive for individuals to prepare for the postpartum period. Individuals’ autonomous decisions must be supported by providers through a shared decision-making approach. Due to the influence of infant feeding goals on postpartum contraceptive decision-making, it is important to further investigate infant feeding methods within the broader context of sexual and reproductive health and reproductive autonomy.
ACKNOWLEDGMENT
We would like to acknowledge our community partners in western North Carolina who supported this work, including but not limited to assisting with participant recruitment efforts.
Footnotes
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (http://sma.org/smj).
This work was funded by a grant from the Dogwood Health Trust (grant no. 2531). The views and conclusions provided here do not reflect the views or conclusions of Dogwood Health Trust.
The authors did not report any financial relationships or conflicts of interest.
Contributor Information
Melissa White, Email: WHITEML2@etsu.edu.
Rebecca Strasser, Email: STRASSERR@etsu.edu.
Kate E. Beatty, Email: beattyk@etsu.edu.
REFERENCES
- 1.Wen SW Smith G Yang Q, et al. Epidemiology of preterm birth and neonatal outcome. Semin Fetal Neonatal Med 2004;9:429–435. [DOI] [PubMed] [Google Scholar]
- 2.Office of Disease Prevention and Health Promotion . Healthy People 2030. Reduce preterm births—MICH-07. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-preterm-births-mich-07. Accessed February 11, 2024.
- 3.March of Dimes . A profile of prematurity in North Carolina. https://www.marchofdimes.org/peristats/reports/north-carolina/prematurity-profile. Accessed May 2, 2024.
- 4.Huang Q Beer M Ventura L, et al. North Carolina maternal and child health dashboard. https://storymaps.arcgis.com/collections/d17b3f44e6534e06a3c4519ca6376186. Accessed August 22, 2024.
- 5.Ahrens KA Nelson H Stidd RL, et al. Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: an updated systematic review. Paediatr Perinat Epidemiol 2018;33:O25–O47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Office of Disease Prevention and Health Promotion . Healthy People 2030. Reduce the proportion of pregnancies conceived within 18 months of a previous birth—FP-02. https://health.gov/healthypeople/objectives-and-data/browse-objectives/family-planning/reduce-proportion-pregnancies-conceived-within-18-months-previous-birth-fp-02. Accessed August 4, 2022.
- 7.Wise MK, Urrutia RP. Interpregnancy care and access to long-acting reversible contraception. N C Med J 2023;84:31–35. [Google Scholar]
- 8.de Bocanegra HT Chang R Howell M, et al. Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol 2014;210:311.e1–311.e8. [DOI] [PubMed] [Google Scholar]
- 9.Upadhyay UD Dworkin SL Weitz TA, et al. Development and validation of a reproductive autonomy scale. Stud Fam Plann 2014;45:19–41. [DOI] [PubMed] [Google Scholar]
- 10.Office of Disease Prevention and Health Promotion . Healthy People 2030. Increase the proportion of infants who are breastfed exclusively through age 6 months—MICH-15. https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants/increase-proportion-infants-who-are-breastfed-exclusively-through-age-6-months-mich-15. Accessed May 2, 2024.
- 11.World Health Organization . Breastfeeding. https://www.who.int/health-topics/breastfeeding. Accessed August 27, 2024.
- 12.Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists . ACOG Committee Opinion No. 361: breastfeeding: maternal and infant aspects. Obstet Gynecol 2007;109(2 Pt 1):479–480. [DOI] [PubMed] [Google Scholar]
- 13.Couto G, Dias V, Oliveira I. Benefits of exclusive breastfeeding: an integrative review. Nurs Pract Today 2020;7:https://npt.tums.ac.ir/index.php/npt/article/view/951. [Google Scholar]
- 14.Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health 2016;28:7–14. [DOI] [PubMed] [Google Scholar]
- 15.Centers for Disease Control and Prevention . Breastfeeding report card. https://www.cdc.gov/breastfeeding/data/reportcard.htm. Published August 31, 2022. Accessed February 11, 2024.
- 16.Pearlman Shapiro M, Avila K, Levi EE. Breastfeeding and contraception counseling: a qualitative study. BMC Pregnancy Childbirth 2022;22:154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Appalachian Regional Commission . About the Appalachian region. https://www.arc.gov/about-the-appalachian-region. Accessed December 15, 2023.
- 18.Lemas DJ Layton C Ballard H, et al. Perinatal health outcomes across rural and nonrural counties within a single health system catchment. Womens Health Rep 2023;4:169–181. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Sullivan MH Denslow S Lorenz K, et al. Exploration of the effects of rural obstetric unit closures on birth outcomes in North Carolina. J Rural Health 2021;37:373–384. [DOI] [PubMed] [Google Scholar]
- 20.Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res 2011;11:147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Kozhimannil KB Hung P Henning-Smith C, et al. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA 2018;319:1239. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Harris PA Taylor R Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform 2019;95:103208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Harris PA Taylor R Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Morse JM. “Data were saturated… .” Qual Health Res 2015;25:587–588. [DOI] [PubMed] [Google Scholar]
- 25.Maietta R Mihas P Swartout K, et al. Sort and Sift, Think and Shift: let the data be your guide. An applied approach to working with, learning from, and privileging qualitative data. Qual Rep 2021;26:2045–2060. [Google Scholar]
- 26.Hamilton A. Qualitative methods in rapid turn-around health services research. https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=780. Published December 11, 2013. Accessed September 7, 2020.
- 27.Birks M, Chapman Y, Francis K. Memoing in qualitative research: probing data and processes. J Res Nurs 2008;13:68–75. [Google Scholar]
- 28.Buckley CA, Waring MJ. Using diagrams to support the research process: examples from grounded theory. Qual Res 2013;13:148–172. [Google Scholar]
- 29.Shuler TO. Promoting shared decision-making in maternal health care. N C Med J 2023;84:https://ncmedicaljournal.com/article/67779-promoting-shared-decision-making-in-maternal-health-care. [Google Scholar]
- 30.Stone C, Smith JP. The visibility of breastfeeding as a sexual and reproductive health right: a review of the relevant literature. Int Breastfeed J 2022;17:18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Bullington BW, Sata A, Arora KS. Shared decision-making: the way forward for postpartum contraceptive counseling. Open Access J Contracept 2022;13:121–129. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Van der Wijden C, Manion C. Lactational amenorrhoea method for family planning. Cochrane Database Syst Rev 2015;10:CD001329. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Snyder K, Worlton G. Social support during COVID-19: perspectives of breastfeeding mothers. Breastfeed Med 2021;16:39–45 [DOI] [PubMed] [Google Scholar]
- 34.Isiguzo C Mendez DD Demirci JR, et al. Stress, social support, and racial differences: dominant drivers of exclusive breastfeeding. Matern Child Nutr 2023;19:e13459. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Morse H, Brown A. The benefits, challenges and impacts of accessing social media group support for breastfeeding: a systematic review. Matern Child Nutr 2022;18:e13399. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.American College of Obstetricians and Gynecologists . ACOG Committee Opinion No. 586: health disparities in rural women. Obstet Gynecol 2014;123(2 Pt 1):384–388. [DOI] [PubMed] [Google Scholar]
- 37.Grubesic TH, Durbin KM. The complex geographies of telelactation and access to community breastfeeding support in the state of Ohio. PLoS One 2020;15:e0242457. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Niel M Bhatia R Riano N, et al. The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications. Harv Rev Psychiatry. 2020;28:113–126. [DOI] [PubMed] [Google Scholar]
- 39.Luff A, Menegay M, Gallo MF. Prevalence and correlates of very rapid repeat pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 2009–2020. Paediatr Perinat Epidemiol 2024;38:56–65. [DOI] [PMC free article] [PubMed] [Google Scholar]