Determinants and strategies influencing implementation of a clinically integrated breastfeeding peer counseling program: an application of the Implementation Research Logic Model

Abstract

Background

Breastmilk feeding improves long term health outcomes, but few mother-infant dyads in the US meet recommendations, and breastfeeding duration is lowest for racially minoritized populations. Clinically integrated Breastfeeding Peer Counseling (ci-BPC) is an evidence-based practice that has been associated with improved breastfeeding outcomes for minoritized populations, but implementation evidence is limited. Our objective was to systematically evaluate how and why a ci-BPC program worked by identifying how implementation strategies addressed barriers and leveraged facilitators in the implementation setting, and explaining results using Implementation Research Logic Model (IRLM).

Methods

Explanatory mixed methods were utilized to triangulate findings from semi-structured interviews and qualitative document review to identify barriers and facilitators to implementation, as well as strategies used to address barriers and leverage facilitators. Interviews were conducted in 2022–2023 with patients, providers, nurses, and clinical leaders at the tertiary perinatal center and affiliated outpatient clinic where the ci-BPC program was implemented, and analyzed using directed content analysis with the Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) framework. Documents included publications, meeting minutes, workflows, protocols, correspondences, quality improvement data, electronic medical records, job descriptions, and grant applications from 2015 to 2024.

Results

Saturation of themes was achieved with 10 clinical team and 18 patient interviews and qualitative document review. Implementation barriers included patient education needs, insufficient staff capacity to provide breastfeeding care, and lack of continuity between inpatient and outpatient service lines. The ci-BPC model addressed these barriers and achieved implementation outcomes with position criteria that prioritized experience and shared traits with patients that supported acceptability and effectiveness; a multidisciplinary leadership team guiding implementation that aided adoption and feasibility; clinical integration via specialized workflows, EMR access, and ongoing training and communications that supported adoption, fidelity, and feasibility; and a dedicated physical workspace for outpatient counseling that supported feasibility and fidelity.

Conclusions

Use of the IRLM demonstrated how implementation strategies leveraged existing facilitators and overcame barriers at the individual, team, and system level and to achieve program effectiveness and implementation outcomes. These findings can inform future implementation of ci-BPC, and other clinically integrated perinatal community health worker models, with evidence-based strategies for implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08851-6.

Background

Breastmilk feeding improves long term health outcomes for both the birth parent and infant [1–4], and the World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for the first 4–6 months of a baby’s life and breastfeeding with complementary table foods through 12–24 months of age [1–6]. Few parent-infant dyads in the US meet these recommendations, and notable disparities in breastmilk feeding by race, ethnicity, and socioeconomic status exist [7, 8]. Breastfeeding peer counseling (BPC) is an effective way to improve exclusive breastfeeding rates and duration, particularly among minoritized and marginalized populations in the US, and has been operationalized in both community and healthcare settings [9–16]. A particularly effective model of BPC is clinically-integrated BPC (ci-BPC), in which BPCs are employed by the health system and deliver care within the healthcare setting on the inpatient and/or outpatient units. Despite evidence from nine randomized clinical trials that ci-BPC can substantially improve breastfeeding intensity and duration [16–25], few healthcare organizations employ ci-BPC among their lactation staff. In part, this may be due to limited evidence on how to implement ci-BPC, including availability of resources, training and support for a BPC, and the optimal design of a feasible, acceptable model of ci-BPC care.

In 2016 our research team implemented a ci-BPC program at a large community hospital and the affiliated health clinic that included outpatient prenatal breastfeeding education, inpatient lactation care, and outpatient breastfeeding care at no cost to publicly-insured patients receiving high- and low-risk obstetric care. Observational results from this non-randomized intervention indicate that the model was associated with increased breastfeeding exclusivity in the hospital from 21% in 2015 to 31% in 2016–2019 and increased breastfeeding at 6 weeks post-delivery from 29% in 2015 to 65% in 2016–2019, and that it demonstrated high reach and fidelity with > 90% of eligible patients reached and an average of 3 encounters per patient with one full time BPC delivering care to 250 patients/year¹³.

Previously, we published our approach to implementing the intervention [26] using the Replicating Effective Programs Framework [27], describing the steps from pre-implementation through to sustainability. Here we use explanatory mixed methods to systematically evaluate how the implementation strategies addressed barriers and leveraged facilitators in the implementation setting. The Implementation Research Logic Model (IRLM) is an increasingly used implementation science framework which synthesizes multiple frameworks and lines of evidence to describe the barriers and facilitators, strategies, and mechanisms through which the strategies work, and implementation and effectiveness outcomes of a given clinical intervention [28].

Our objective was to develop an IRLM for the ci-BPC program by explanatory mixed methods synthesizing program data and qualitative interview data. The IRLM maps contextual factors to ci-BPC implementation strategies and explains how those strategies improved breastfeeding outcomes. These findings can inform future adaptations of the ci-BPC model to other healthcare settings.

Methods

This explanatory mixed methods study was part of a multicomponent evaluation of an ongoing ci-BPC program.

Setting

The ci-BPC study was conducted at Endeavor Health Evanston Hospital (EH), a suburban level 3 perinatal center in the Chicago metropolitan area. EH is an academic affiliate of the University of Chicago Pritzker School of Medicine and provides clinical training for medical students, residents, and fellows. The ci-BPC program is centered in the resident- and fellow-managed NorthShore Community Health Center (NSCHC), an outpatient clinic serving approximately 200–250 publicly-insured perinatal patients every year which has been described previously [13, 26].

Intervention and population

The ci-BPC program at the NSCHC launched in 2016 was an evidence-based intervention and consisted of a single full time equivalent (40 h) BPC staff member who provided (1) prenatal lactation education; (2) hands on lactation care in the hospital; and (3) on-demand postpartum infant feeding support to every NSCHC patient 5 days/week. The program model has been published previously [26], and the intervention components are summarized in Table 1. During this period (2016–2024), the ci-BPC program’s patient population identified as Hispanic Latine (36%), Black or African American (21%), Asian (14%), or another race or ethnicity, including white (29%).

Table 1.

Intervention components delivered by BPC

Prenatal lactation education • Provided during the 2nd prenatal care appointment to every patient, with the exception of those planning termination or adoption. • Intake appointment identified patient knowledge and attitude toward breastfeeding and customized education to respond to questions and concerns • Prenatal breastfeeding class included proactive, anticipatory guidance about what to expect when starting breastfeeding, including common issues and strategies to overcome them • Was available in clinic for follow up questions, and via dedicate telephone “warmline” Breastfeeding resources • Assisted patients with obtaining breast pumps and breastmilk storage supplies through insurance Hands on lactation care in the hospital • Helped with infant positioning and attachment • Instructed on hand expression and use of breast pump • Provided proactive guidance about infant behavior and milk supply regulation • Made referrals to lactation and clinical experts for more complex needs On-demand postpartum support • Provided anticipatory follow up after discharge during first few weeks • Was available for questions and advice via telephone “warmline” or in person appointments • Conducted automatic 6-week postpartum check in during postpartum appointment • Offered outpatient support group every Thursday afternoon

Data sources

Data sources included existing program documents and semi-structured interviews with patients, obstetric care providers, bedside nurses, and clinical unit leaders.

Data collection timeframe

Trained investigators and staff collected data across the implementation period. This included pre-implementation 2015–2016 when program preparation was underway, as well as the active intervention period from 2016 through 2024, inclusive of the COVID-19 pandemic when the program continued without interruption.

Document review

Documents included publications, meeting minutes, workflows, protocols, correspondences among leadership team members, results from QI tracking and survey feedback, EMR records, focus group feedback, job descriptions, and grant applications.

Semi-structured interviews

Interview participants were purposively sampled to include individuals with a range of specializations (nurses, physicians, and clinical leaders) and diverse patient experiences (patients of varying racial and ethnic identity with differential uptake of the ci-BPC program). Sample size was planned at 20 staff and 20 patients with the goal of reaching saturation of themes [29]. Interviews took place from July 2022 to April 2023 and were conducted by author LKD and two experienced research staff who were trained on the interview protocol and experienced in qualitative methods. All 3 interviewers and all subjects were female. LKD had existing relationships with all clinical team participants who were interviewed, and these individuals were purposively sampled based on their involvement with the intervention. Clinical team subjects included postpartum nurses, physicians, and outpatient staff on all of the units where the BPC worked. Clinical team members who were both “high” and “low” users of BPC services were interviewed. “High” and “low” use was defined qualitatively reflecting clinical team member engagement of the BPC in care for their patients, based on input from the BPC and the BPC clinical manager about the BPC’s working relationships with various individuals.

Eligible patients were identified from a retrospective chart review of those who received care at the NSCHC and delivered at the intervention hospital during the program mid-point between 2018 and 2020. Patients were identified as high, moderate, and low users of the program based on the number of encounters they had with the BPC, with high users having 9 or more encounters, moderate users having 6–8 encounters, and low users having 1–5 encounters. Sampling was also stratified by patient race and ethnicity to reflect the demographics of the clinic. Patients were recruited via phone call, and those who agreed to participate completed informed consent and conducted the audio-recorded interview via telephone.

Interviews with clinical team members and patients were conducted with standardized open-ended questions based on CFIR 2.0 [30] domains selected apriori to answer questions that the research team identified as relevant to clinical integration and justifying the mission and purpose of the ci-BPC program. These included Implementation Process (assessing needs, assessing context), Inner Setting (compatibility, relative priority, and available resources), and Individuals (innovation recipients) [30]. Additionally, we gathered information about barriers and facilitators to implementation using questions from a previously published Breastfeeding Unit Culture interview [31]. The full interview guides are available in Appendix A.

Informed written consent was obtained from all interview participants prior to interviews. Participants received $50 compensation for their time. Patients who were not employed by the health system received a $50 gift card, and employee participants received payment through their paycheck per organizational policy. Interviews were audio recorded with permission, transcribed, and uploaded to Dedoose.

Analysis

Qualitative data were analyzed using directed content analysis with the goal of identifying barriers and facilitators in CFIR domains, and linking to related strategy categories defined by Expert Recommendations for Implementing Change (ERIC) [32] associated with program outcomes. CFIR coding was applied to interviews by an initial reviewer, and then re-coded by an independent reviewer with discrepancies being reconciled. Quantitative implementation outcomes following the RE-AIM framework [33], including acceptability, feasibility, fidelity, and effectiveness, were extracted from documents, and qualitative document analysis was used to systematically identify determinants and strategies [34]. Program data, including quantitative and qualitative content from reviewed documents, were triangulated with themes from interview analysis to identify barriers and facilitators to implementation and strategies used to address barriers and leverage facilitators. Qualitative results were mapped to strategies and integrated into the IRLM to explain how the intervention led to improved breastfeeding outcomes.

Ethics approval

Study procedures were approved by the Institutional Review Board at Endeavor Health (EH21-249). The StaRI checklist was used to report results.

Results

Implementation outcomes were identified by document review, and saturation of themes was achieved with qualitative document analysis and 10 clinical team and 18 patient interviews. Clinical team participants primarily identified as white (55%) or Black (36%) race, had more than 10 years of clinical experience in mother-baby care, and were parents themselves (Supplemental Table 1). Patient participants were between the ages of 17 and 39, identified as Hispanic/Latine (61%), Black (22%), or another race or ethnicity (27%), and 30% were primiparous when they received ci-BPC, reflecting the demographics of the clinic.

Implementation outcomes

We identified high patient acceptability, staff adoption, and maintenance aided by BPC retention for at least 3 years and uninterrupted service for the project duration (Table 2). The success of the program was a result of strategies that leveraged facilitators and mitigated barriers for lactation care in the healthcare environment.

Table 2.

Implementation outcomes, quantitative results, and qualitative evidence of the outcomes for the clinically integrated breastfeeding peer counselor (ci-BPC) program

Outcomes	Quantitative Results	Qualitative Evidence of the Outcome
Reach	90% of eligible patients at the NSCHC had at least 1 encounter with the BPCA	“we got a new patient coming in next week. Let me give them a call now and say, ‘Hey, I am another person that you need to see as your new patient provider’…So, therefore they will know, ‘Okay, I need to see her’.” (peer counselor)
Effectiveness	Compared to before the ci-BPC program, exclusive breastfeeding increased 10% with the implementation of the ci-BPC program and breastfeeding at 6 weeks increased from 29% to 65%A	“I was able to [breastfeed] with the help of the specialist in the hospital, who gave me her phone number and I was able to text her or call her or email her if I had any questions or concerns. If I had any questions about breastfeeding, if I was doing good or even before I had the baby, she was really helpful. We went to a class because of it and it was a lot of help. I was able to breastfeed him until he was 3!” (patient)
Adoption (clinical staff)	Internal survey of 34 staff (16 physicians and 18 nurses) indicated BPC was easy to contact (average 3.9/5 on a Likert scale) and provided important services for patientsE	“I see [the BPC role] as being their best advocate. So, finding out every day what their patients are doing, what they need help with, what they’re struggling with, and then talking with the nurse and letting them know where they’re at with breastfeeding, and if they’re comfortable helping them breastfeed. Like, tell a nurse “I’m happy to come back and help them with the feeding”, or, you know, telling them “I think this mom needs a little bit more help if you could help her or have lactation see her because I think she needs more help”. Really becoming a member of the team.” (nurse)
Adoption (BPC)	All BPCs counseled a total 900 eligible patients from 2016-2024B	“when I’m rounding to those patients, I’ve seen her [the BPC] in the room and helping them. I know on Monday, I felt like I was following her. Every time I turned around, I was like “This is your patient too?” and she was in there.” (nurse manager)
Acceptability	All (100%) of patients who the BPC approached completed at least one encounter and reported positive experiences with the intervention.BCD	“I think that offering me you know counseling prior to having my child and then you know following up with me and providing me with a lot of resources to get informed to get me a free pump to take home as well - it was excellent.” (patient)
Feasibility	BPC saw 90.4% of eligible NSCHC patients during their perinatal care, 81.7% prenatally and 71.4% in the hospitalA	“Well she answered all the questions I had, if I had a problem I would just text her or email her and she will call me so she was really, how do I say it, she gave me like a good experience or she would always pay attention to me.” (patient)
Fidelity	The average patient had 3 encounters, one prenatal, one inpatient, and one postpartumA	“then I went to my last visit, she was there to give me some flyers and to give me some points to tell the doctors right away after I have my baby that I’m doing breastfeeding that way they don’t give her the formula. And after I had my baby, before I go to my checkup, the first checkup, she was there too and she gave me more tools…I met her probably more than four or five times.” (patient)
Maintenance	Two BPC staff remained in the position for 3 years or longer, providing uninterrupted BPC services 2016-2024 F	“everyone has been so welcoming, and they’ve all expressed how they feel like what I offer is needed for the patients” (peer counselor)

Data sources: ^A Keenan-Devlin et al. 2021;^BInternal QI tracking from annual EMR reviews; ^CInterviews; ^DFocus group; ^EInternal QI survey of clinical teams; ^FHR records

Implementation strategies

The strategies used to implement the ci-BPC program overcame a number of implementation barriers, including substantial patient education needs, strain on inpatient and outpatient staff to provide and coordinate breastfeeding care, supervision and teamwork for lactation staff, and a disconnect between inpatient and outpatient service lines (Table 3). Those strategies are discussed in detail below.

Table 3.

Clinically integrated breastfeeding peer counseling (ci-BPC) implementation strategies and strategy types, mapped to determinants identified through interviews and implementation outcomes for the Implementation Research Logic Model

Strategy	ERIC strategy type	Barriers addressed or facilitators leveraged	Implementation outcomes supported
Position criteria for BPC (certified, experienced, multilingual preferred)	Tailor, Iterate, and Adapt to Context	Barriers Insufficient time for RNs to deliver lactation education and care Insufficient staffing of lactation experts Busy outpatient clinic with many providers seeing patient Patients have limited knowledge or resources for breastfeeding Patients with complex pregnancies have more barriers to breastfeeding Patients have distrust in clinical system Facilitators Majority of patients desire to breastfeed Leader support in both outpatient and inpatient units	Feasibility, acceptability, effectiveness
Multidisciplinary clinical team leadership engagement	Mobilize Site Staff for Implementation Provide Interactive Assistance and Site Support	Barriers Disconnect between outpatient and inpatient units Complex care team Facilitators Nurses supportive of breastfeeding, consider themselves champions	Reach, effectiveness, adoption, feasibility, fidelity, maintenance
Clinical training	Train Site Staff and Clinicians	Barriers BPC was a new, unprecedented position Complexity of care team organization, hierarchy, and communication Facilitators Clear definition of positions and workflows	Reach, effectiveness, adoption, feasibility, fidelity, maintenance
Integrated workflows	Prepare Site for Implementation	Barriers Insufficient time for RNs to deliver lactation education and care Insufficient staffing of lactation experts Busy outpatient clinic with many providers seeing patient Patients have limited knowledge or resources for breastfeeding Patients with complex pregnancies have more barriers to breastfeeding Patients have distrust in clinical system Complexity of care team organization, hierarchy, and communication Facilitators Nurses supportive of breastfeeding, consider themselves champions Well-defined workflows and protocols on units	Reach, effectiveness, adoption, feasibility, fidelity, maintenance
EMR utilization	Support Clinician Practice Change	Barriers Disconnect between inpatient and outpatient units Facilitators EMR central communication tool for clinical teams	Reach, effectiveness, adoption, feasibility, fidelity, maintenance
Regular program data review	Prepare Sites for Implementation Engage Patients and Families	Barriers Disparities recognized but not regularly monitored Incomplete or missing data Facilitators EMR tools for data abstraction Leadership support in both outpatient and inpatient units	Feasibility, adoption, fidelity
Regular and diverse communication outreach  posting routine hours on units  inpatient pager for BPC  Grand Rounds presentations  monthly staff meetings  weekly lactation team meetings  quarterly newsletter distribution to clinical teams  BPC co-led monthly outpatient support group	Support Clinician Practice Change Provide Interactive Assistance and Site Support Tailor, Iterate, and Adapt to Context	Barriers Disconnect between inpatient and outpatient units Complexity of care team organization, hierarchy, and communication Facilitators Diverse communication opportunities	Adoption, feasibility, maintenance
Dedicated physical space	Tailor, Iterate, and Adapt to Context	Barriers Limited physical space Busy outpatient clinic with many providers seeing patient Facilitators Leadership supportive of breastfeeding	Feasibility, fidelity, maintenance

Position criteria

Hiring experienced BPCs with certification, years in practice, and traits shared with the clinic populations was important for achieving acceptability, adoption, and subsequently feasibility and fidelity. The hospital lacked the infrastructure to train a new BPC and provide certification, so the hiring team required that candidates have completed BPC certification from a qualified organization (WIC, HealthConnect One, Healthy Children Project, Happy Mama Healthy Baby Alliance, and others) and had multiple years of experience working as a BPC at WIC or in a clinical setting. Certification provided expertise in patient-centered counseling strategies that included motivational interviewing, accessible language, and non-judgmental counseling, as well as strategies for trouble-shooting common lactation challenges and normalizing postpartum experiences. Importantly, BPC certification requires personal breastfeeding experience, which equipped BPC with both expertise and empathy as they guided patients in planning for and getting started with breastfeeding.

“a peer counselor is someone you can relate to. Someone who has experienced what you’ve experienced. You know, someone who is knowledgeable, but don’t use big terminology that you don’t understand.” (peer counselor).

“[I] created a relationship with her, felt confident and safe in the information that I was giving her. So, I definitely think she made it easy to try to talk to her about, you know, some very personal issues. Breastfeeding I think is definitely like a very personal type. Doing so she definitely made it easy to talk to, kind of a stranger almost, about something like that.” (patient).

The hiring process prioritized candidates with shared traits with the patient population. Clinical team members found this to be an important differentiator between peer care and their own, making the position acceptable and clinical team members willing to adopt it.

“a lot of people of color or those that are socioeconomically disadvantaged have somewhat of a mistrust and have a mistrust of the medical world ‘cause they may not have always been listened to or heard or spoken to kindly. All of those things. So, it should be someone who isn’t so medical, so is more of someone on their level who has a lot of information to share about this subject and can support you and answer those questions.” (nurse).

Patients in particular valued the ability of the BPC to combine their personal experience and expert training in the way that they counseled, engendering trust that supported both acceptability and feasibility.

“I trusted what they were saying because I know if they were not knowledgeable, they wouldn’t be in that position. And also because of the things I’ve learned from them as well. So, so it’s just easy to trust them.” (patient).

““she was just very realistic about the journey” (patient).

Prior to program implementation, it was identified that Latine Spanish-speaking patients and Black/African American patients had higher rates of early formula supplementation and early weaning, and thus peer traits with one or both of these patient groups would be most appropriate. The first BPC was English and Spanish-speaking and identified as Latina, and the second BPC identified as Black. Patients highlighted how shared traits, particularly language, improved accessibility and supported acceptability and feasibility.

“sometimes Hispanics tend to not be informed about things like this or they have other beliefs from how they were raised. But I really think it is all super helpful that they have people because of the languages that way they can be informing people and educating people.” (patient).

The BPC being both a peer and expert made patients feel like they had a personal “coach” supporting them through the challenges of lactation, which facilitated acceptability, feasibility, and fidelity to the model.

“She just brought in her own personal experiences, I think that’s definitely key. [the BPC] obviously went through it herself having a child herself, so I think like being able to talk through experiences that she’s had helps…I think being able to connect with her on a level that, maybe we wouldn’t be able to for somebody that hasn’t had a child.” (patient).

“she was like someone to take care of me, like that baby had me, but I needed help too” (patient).

Because they trusted their BPC to give them sound information and practical advice, patients were motivated to follow the BPC’s breastfeeding guidance, increasing early initiation of breastfeeding and delaying formula supplementation. Per one patient:

“although the lactation consultant was great, it just wasn’t on like that personal level, she was kind of just going at it and just like the facts and what I should do and shouldn’t do, but then [the BPC] coming in and following up on everything that I had talked to the lactation consultant about, she was able to kind of put it in a way that was easier for me to understand and not feel like it’s this way or the highway and kind of gave me those options on other ways to do things in order to get what I was trying to get out of it…With the consultant it was more so you need to do this, this, and this. And it was kind of just a list of things not into account like what my every day is like. With [the BPC] I built that relationship where she kind of understood like not necessarily have the time to do X, Y, or Z exactly how like the nurse or lactation consultant laid it out, and she’s like ‘it’s ok if it’s not on that same schedule, try to keep it around the schedule if you can, but as long as you’re doing the things you need to do, everything will be ok’.” (patient).

Multidisciplinary clinical leadership engagement

The BPC role was integrated into both an inpatient and outpatient unit with complex team structures, and these units were disconnected from one another, documenting in two different EMR environments and operating with largely separate teams and different leadership structures. Therefore, a key implementation strategy created to help implement and sustain the BPC program was an advisory ci-BPC clinical leadership team comprised of nurses, nursing leaders, perinatal educators, social workers, and physicians working in both the inpatient and outpatient units who identified strategies for feasibility and adoption of the intervention. The leadership team met monthly pre-implementation to develop BPC workflows in the outpatient clinic and on the postpartum unit, and continued to meet monthly through 2024 because “there was a lot of troubleshooting, but then there were things like, ‘I need access to this’” (administrator), including EMR charting access and pagers. The leadership team also helped the BPC learn new charting and clinical lactation skills, navigate challenging cases, and identify adaptations to the BPC workflow, providing multidisciplinary input to maintain high adoption.

Clinical training and supervision for BPC

Clinical team members had clear, distinct protocols and scope of responsibility, and it was important for the BPC to understand their scope of practice and “fit in” with workflows. BPC training involved shadowing the outpatient nurses, inpatient nurses, and lactation staff and reviewing existing protocols. As a nurse described the clinical workflow, “This is what I do and then I leave, and this is what you do and then you leave.” To support adoption and feasibility, the BPC was required to complete the same lactation orientation checklist as nurses. Initially the BPC was supervised by the outpatient clinic manager, however the outpatient manager felt that the BPC inpatient workflow “was a lot harder to keep track of — there was a lot going on. I felt like I was — not that I was losing that supervisory piece, but I felt again like, ‘I wonder what she’s doing up there’”. To address this barrier, the BPC position was moved under the inpatient lactation reporting structure to provide better supervision and consistency with lactation practice.

Integrated workflows

With recognition that optimizing breastfeeding outcomes required prenatal education and preparation, ci-BPC care was standard for every patient of the clinic starting at the second prenatal visit. This universal approach supported the high reach of the program as well as acceptability. Patients endorsed this strategy because they recognized that every baby is different and there was always something new to learn, even if they had other children. One patient stated “everything was different with my second one, and even on the second one you know I’m learning.”

A key barrier to prenatal breastfeeding counseling was time, as the clinic provided care for high-risk pregnancies requiring multiple specialty providers. With long appointments and many competing priorities, nurses and physicians found it difficult to deliver breastfeeding education. Outpatient nurses adopted the BPC program because they saw that the BPC provided universal breastfeeding counseling that they did not have time to deliver.

“But if you’re at the, I don’t know if I want to breastfeed stage then yeah to have a conversation about well tell me you know – when you think of breastfeeding what does that mean? Or if you think of bottle feeding what does that mean? What might be the hindrances? Yeah, I don’t think most of us [nurses] have the time or take the time…that’s why we have a peer counselor, because that’s her job.” (outpatient nurse).

Critically, the BPC maintained an autonomous schedule, allowing her to prioritize workflows on both units to gain access to patients during scheduled appointments and inpatient admissions The BPC reviewed the outpatient schedule and the inpatient census every morning, prioritizing admitted patients and new prenatal obstetric visits, and moved between the outpatient clinic and the postpartum unit throughout the day to meet patients in both spaces. From the patient perspective this provided care continuity and personalization for their needs at each stage of new parenthood.

“I really didn’t expect for her to pretty much keep in contact and things like that as much as she does because there are people how they are all busy and things like that, but she did actually a great job.” (patient).

EMR utilization

Workflow integration required security and charting access on both inpatient and outpatient units, which was a combination of access typically only available to physicians and the perinatal social work team. Dual access allowed the BPC to view the outpatient schedule and the inpatient census to identify when patients were on the hospital campus for perinatal care and coordinate visits accordingly. This access made the model feasible and contributed to fidelity, and was also highly acceptable for patients who appreciated the personalized and personal approach.

“[the BPC] did meet with me at one of the doctors’ visits, a checkup, and then said she would be offering a class for more facts and talking about breastfeeding…And then after that class, she said I’ll be in touch with you because I know you’ll be due around this time and here’s my number. I just felt really happy knowing that there was somebody at the hospital that was supporting that and was there for me. I loved it.” (patient).

Regular program data review

Before program implementation, extensive baseline data were collected to identify disparities in breastfeeding outcomes and patient-reported needs for lactation education and care. Progress in achieving ci-BPC program goals was evaluated through monthly patient feedback forms completed during prenatal BPC-led breastfeeding classes, annual review of medical records for breastfeeding outcomes and program reach/fidelity, and repeat surveys and interviews three and six years into the program implementation.

Regular and diverse communication outreach

The flexibility of the BPC schedule was positively perceived by patients, however, it created challenges with clinical staff acceptability. Postpartum nurses were used to a lactation care model centered on the inpatient unit where they could see and engage with lactation providers throughout their shift on the basis of patient needs. Nurses indicated that the lack of prompt, predictable access to the BPC when she was working in the outpatient setting was a barrier for collaborative care.

“[the BPC] can’t be in two places at one time. And even though she told me to page her, if she’s in the middle of class she just can’t walk out. And by the time she walks from there to here, that baby could be sound asleep again.” (nurse).

In addition to lack of consistent access to the BPC for the inpatient nursing team, there were frequent misunderstandings about the BPC scope of practice in the early days of the program. Many inpatient nurses believed that the BPC would replace the lactation consultant effort.

“You’re going to have someone up here to help the clinic patients breastfeed”. I was like, “Perfect because we are swamped up here”. Then, when [the BPC] … was really just talking, more doing hand-expression, I was like that’s not really helping. We still have to see all of her patients…I think the role has been confusing” (lactation nurse).

In response to these challenges, the leadership team employed a number of new strategies to aid in visibility and understanding of the role. These included posting routine hours when the BPC was expected to be on the inpatient unit; providing the BPC with an inpatient pager so she could be easily contacted; sharing results of the program impact at Grand Rounds; integrating the BPC into monthly staff meetings and weekly lactation team meetings; circulating a quarterly newsletter to nurses highlighting program accomplishments; and having the BPC co-lead the monthly outpatient support group. These strategies improved acceptability as well as feasibility, as they increased opportunities for referrals and coordination of care between the BPC and nursing staff.

“We recently had a Grand Round where I learned much more about [the BPC] role and now I’m very excited about it. I didn’t realize how much she was doing and all the options I had available for patients.” (physician).

Dedicated physical space

A final critical strategy was commitment of dedicated space and resources for the ci-BPC program. Outpatient appointments were too busy with other providers to allow for dedicated breastfeeding counseling time while the patient was in the clinic room, necessitating a dedicated, private space or office for outpatient counseling and follow up care.

“I think it’s important for the counselors to have a home that is equipped to see moms, that is comforting and — they need a home.” (administrator).

The hospital did not have an existing outpatient lactation office prior to the start of the ci-BPC program, so the Leadership Team which included the clinic administrator identified a private workspace near the clinic where the BPC was resourced with a computer, dedicated phone line, printer, and breastfeeding supplies including baby doll models, breast models, breastfeeding pillows, and other supplies. The dedicated space allowed the BPC to meet with patients before or after their appointments to deliver one on one breastfeeding education or postpartum consults.

“the nurses will make the appointments with all the other doctors and things of that nature, but I’ll be able to say…‘Hey, I am another person that you need to see as your new patient provider…when you’re done on the third floor, please come downstairs and we will talk about your thoughts on infant feeding’” (peer counselor).

Additionally, a large conference space was scheduled once a month for prenatal group classes and weekly for a postpartum support group. Having a number of strategies and spaces allowed the BPC flexibility to provide dedicated lactation care when and where patients needed it, improving feasibility and fidelity.

Implementation Research Logic Model

The results were synthesized in the Implementation Research Logic Model shown in Fig. 1. The framework illustrates the mechanisms through which the implementation strategies addressed barriers to support the observed implementation outcomes.

Fig. 1.

Implementation Research Logic Model for ci-BPC

Discussion

Using mixed methods to synthesize findings from multiple sources, we were able to deepen understanding of implementation outcomes for a ci-BPC program. Use of the IRLM demonstrated how implementation strategies leveraged existing facilitators and overcame barriers at the individual, team, and system level and to achieve program effectiveness.

Ci-BPC has been shown to address patient barriers including access to qualified, accessible information about breastfeeding during pregnancy and instrumental lactation care and encouragement after birth to improve breastfeeding outcomes [35–38]. BPCs engender trust through their shared experiences with infant feeding [37] as well as their lactation expertise, supporting feasibility, fidelity, and effectiveness of the intervention. We were able to identify the strategies used that led to the implementation outcomes, using the IRLM to elucidate mechanisms explaining why and how those strategies were successful.

Hiring certified BPCs with characteristics of the target community aided nursing buy-in and clinical adoption, and language concordance aided acceptability, feasibility, and effectiveness by increasing accessibility for patients. There is relatively little description in the literature of how ci-BPCs help to overcome healthcare barriers to delivering acceptable lactation care. Merewood et al. and Meier et al. published qualitative assessments of two different ci-BPC programs in neonatal intensive care units (NICUs) that similarly described how BPCs addressed barriers of time and expertise among clinical staff to provide pump-dependent patients with lactation support as they pumped milk for their hospitalized infants [35, 39, 40]. Because of the extended hospitalization of these babies and the extensive care needs of their parents, the NICU models were entirely centered on inpatient care, without an outpatient component. Our findings extend prior work by identifying additional barriers for a clinically-integrated program model spanning pregnancy through postpartum. These barriers include the disconnection between outpatient and inpatient obstetric clinical teams and services, challenges in coordinating with multiple teams and workflows, and limited space for outpatient counseling. With the IRLM we illustrated how strategies like EMR integration, shared and customized clinical workflows, and responsive communication strategies with clinical staff responded to multiple determinants and resulted in high adoption, reach, fidelity, and effectiveness.

Critical among these strategies was the multidisciplinary BPC Leadership Team, with key inpatient and outpatient clinical staff, who advised on implementation strategies from the project’s initiation and throughout implementation. With a process of engaged formative research that has been used with other successful BPC programs [14], the BPC Leadership Team established integrated workflows for the ci-BPC staff that nurses were able and willing to adopt, allowing the ci-BPC access to patients on both units but still providing autonomy for the BPC to determine which patients were priority at a given time. The BPC Leadership Team was able to advocate for a unique EMR access profile that allowed the BPC to chart in all relevant contexts and communicate effectively with clinical teams. These strategies bridged the gaps between the outpatient and inpatient work environments for the BPC as well as for patients, providing patients with more seamless care that was highly acceptable to them. A number of ci-BPC program models spanning the perinatal period have been published, with variability in effectiveness possibly resulting from similar determinants [9, 16, 41]. Importantly, ongoing engagement of the BPC Leadership Team was critical during the COVID-19 pandemic, when the BPC program was adapted to be fully remote. The clinical team ensured that the adapted BPC protocols aligned with the telehealth strategies to maintain program fidelity and effectiveness [42].

Strengths of this study included a diverse set of respondents to identify determinants, as well as multiple converging lines of evidence to describe and link the strategies to mechanisms and implementation outcomes. There are several limitations to note. This study took place at a single site, which could limit generalizability since the ability to operationalize needed resources may not be as feasible in other health systems with unit leaders who are less empowered to steer significant resources toward local programs. We were also limited in our inability to interview patients whose dominant language is not English, though they comprised a minority of patients. Another limitation was the extended period over which the program was evaluated, as there were likely changes in the 9-year period beyond the pandemic that we were not able to capture. Finally, there may have been recall bias with the patient interviews as they occurred 1–3 years after BPC care was completed, though themes were consistent regardless of the time difference between care receipt and interview completion.

The findings presented in the IRLM can inform future implementation of ci-BPC with strategies for adoption. Moreover, as perinatal community health workers like BPCs and doulas are adopted more broadly in an effort to reduce morbidity and mortality across the US, it will be increasingly important to identify aspects of the intervention and implementation that contribute to their successful uptake by clinical organizations and patients alike.

Authors’ contributions

Lauren Keenan-Devlin : Conceptualization (lead), Methodology (equal), Investigation (lead), Data Curation (lead), Resources (lead), Project Administration (lead), Writing – Original Draft (lead), Writing – Review and Editing (equal), Funding Acquisition (lead). Lisa Hirschhorn : Conceptualization (supporting), Methodology (equal), Supervision (lead), Writing – Review and Editing (equal). Tricia Johnson : Conceptualization (supporting), Methodology (supporting), Writing – Review and Editing (equal). Ann Borders : Conceptualization (supporting), Methodology (supporting), Project Administration (supporting), Writing – Original Draft (supporting), Writing – Review and Editing (equal), Supervision (supporting).

Funding

Financial support for this study provided Agency for Healthcare Research and Quality 1 K01 HS027906-01A1 (Keenan-Devlin).

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This research was reviewed and approved by the Endeavor Health Institutional Review Board (EH21-249) and all participants completed informed consent prior to participation. All methods were carried out in accordance with relevant institutional guidelines and regulations.

Consent for publication

not applicable.

Competing interests

The authors declare no competing interests.