Virtual delivery of evidence-based, person-centered breastfeeding peer counseling: a qualitative evaluation of women’s experiences and perceptions

Abstract

Background

Virtual breastfeeding peer counseling services have the potential to increase access to breastfeeding support and reduce breastfeeding inequities. However, little is known about how well these services can be implemented virtually. We conducted an implementation research study to evaluate virtual delivery of the Breastfeeding Heritage and Pride™ (BHP) program, which offers evidence-based, person-centered breastfeeding peer counseling for women with low incomes in the United States. This paper aims to explore women’s experiences and perspectives on virtual counseling provided by trained BHP community health workers.

Methods

We conducted in-depth interviews in English and Spanish with 28 women participating in BHP. We used rapid qualitative analysis to identify themes, and then organized themes according to two implementation outcomes specified in the Implementation Outcomes Framework by Proctor and colleagues: acceptability, defined as the perception that virtual counseling is agreeable, palatable, or satisfactory; and appropriateness, defined as the perceived fit, relevance, or compatibility of virtual counseling for participants.

Results

Themes related to acceptability included: (1) life fit, highlighting how the convenience of virtual counseling promoted engagement amidst competing demands; and (2) comfort with being seen on video. Themes capturing the appropriateness of virtual counseling were: (3) building relationships with peer counselors, which some women felt was best supported in person; (4) evolving needs across the breastfeeding journey, reflecting how perceptions of the suitability of virtual counseling varied by the stage of their breastfeeding journey and types of breastfeeding challenges encountered; and (5) fit between mode of communication and individual needs and preferences, capturing how different communication modes were more or less useful depending on women’s needs, such as informational, emotional, or lactation management support. A cross-cutting theme was (6) access to technology, which influenced women’s ability to engage with virtual counseling.

Conclusions

Women described benefits and limitations of virtual counseling. These findings indicate a need to work with women to co-design hybrid models that integrate telehealth with in-person counseling and can be tailored to meet diverse individual needs and preferences as breastfeeding support needs change dynamically over time. Such hybrid models should be evaluated for effectiveness, cost-effectiveness, and equity to guide future implementation.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-026-00844-7.

Background

Breastfeeding offers numerous health benefits for women and infants [1–6]. However, most women in the United States (US) do not meet the American Academy of Pediatrics recommendations for exclusive breastfeeding for the first 6 months and continued breastfeeding until 2 years or beyond, and large socio-economic and racial/ethnic inequities in breastfeeding persist [7–11]. Strong evidence that in-person and hybrid (in-person and virtual) breastfeeding peer counseling programs improve breastfeeding outcomes among women experiencing breastfeeding inequities have been available for over two decades [12–15]. In 2025, the National Academies of Sciences, Engineering, and Medicine report on breastfeeding in the US recommended more federal investment in these programs so that they can be scaled to adequately meet the needs of all women and families who wish to breastfeed [13]. Expanding virtual delivery of breastfeeding peer counseling has the potential to increase access to these services at scale and advance breastfeeding equity. However, little is known about how well fully virtual breastfeeding peer counseling services can be implemented.

The COVID-19 pandemic accelerated virtual breastfeeding support services, and virtual delivery models continue to proliferate [16–19]. Among The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) agencies, counseling sessions by phone rose from 62.4% pre-pandemic to 83.2% by 2022 and video calls jumped from 5.8% to 31.6% [20]. By 2022, nearly 95% of WIC participants were served by agencies offering virtual breastfeeding services [20]. Telelactation – virtual breastfeeding support provided by International Board Certified Lactation Consultants (IBCLCs) via video – expanded rapidly during the pandemic, with more than one-third of women in the US using these services in 2020 and 2021 [21, 22].

Alongside the rapid expansion of virtual breastfeeding support, a growing body of evidence indicates that these virtual models can be effective, feasible to implement, and acceptable. A meta-analysis of randomized controlled trials found that diverse forms of virtual breastfeeding support were associated with higher exclusive breastfeeding rates at 1 month and 6 months postpartum [23]. Another systematic review and meta-analysis found that remote breastfeeding support can be effective for improving exclusive breastfeeding at 3 months but the quality of the evidence was low [24]. Improvements in exclusive breastfeeding at 4–8 weeks and 6 months were found when studies at high risk of bias were excluded [24]. The Telehealth for Mothers to Improve Lactation Confidence (Tele-MILK) digital randomized clinical trial found that telelactation services improved breastfeeding rates among Black parents, though not in the overall population [21]. Among a subsample of Latina parents who participated in interviews, almost all reported high satisfaction with telelactation due to the convenience of having immediate 24/7 support and not having to leave their homes [25]. At the same time, some Latina parents believed that telelactation may not be appropriate for all situations, noting that such services might be less helpful for issues like latch and positioning that require observation by IBCLCs [25]. Similarly, a subsample of Black parents who participated in interviews perceived telelactation as acceptable given that it was easy to use and convenient [26]. They also described telelactation as less burdensome than in-person support because it requires less time and does not pose challenges such as transportation and traveling with an infant, though the perceived need to look presentable for a video visit was a burden for some [26]. Additionally, a few Black parents who valued building relationships with IBCLCs did not like that telelactation typically did not allow for support from the same IBCLC across visits [26].

Although findings from research on telelactation and other virtual breastfeeding support services may offer useful insights, breastfeeding peer counseling programs complement but differ from these services in important ways that may influence the success of implementation of fully virtual models. Unlike telelactation services delivered by IBCLCs, for example, breastfeeding peer counseling is provided by individuals who draw on their own lived breastfeeding experience, offer emotional support along with lactation management, and typically build trusted relationships with clients through repeated contact across the breastfeeding journey, which usually is more frequent than the on-demand IBCLC lactation consultations. Given these distinct features, there is a need to understand how well breastfeeding peer counseling can be delivered virtually to guide efforts to implement and scale these programs. Women participating in virtual breastfeeding peer counseling can share insights about virtual delivery as experts on their experiences. We therefore explored women’s experiences and perspectives on the acceptability and appropriateness of virtual delivery of the Breastfeeding Heritage and Pride™ (BHP) program when it shifted to a fully virtual breastfeeding peer counseling model during the COVID-19 pandemic.

Breastfeeding Heritage and Pride™ program

The BHP program is an evidence-based breastfeeding peer counseling program implemented in Connecticut and Massachusetts by the Hispanic Health Council, a community-based organization [15]. The BHP program has been endorsed as an exemplar program by the World Health Organization (WHO) and stands out as a strong program model for several reasons [27]. First, the program was designed with community input to address barriers to breastfeeding experienced by historically marginalized women and families and with a focus on promoting breastfeeding equity from the very beginning [15]. According to the BHP model, BHP peer counselors are paid community health workers who breastfed and provide free counseling, starting prenatally and continuing up to one year postpartum. The program is clinically integrated; clinicians at partner healthcare facilities refer pregnant women to the program and peer counselors provide in-person one-on-one counseling at these facilities, as well as in homes, community settings, and by phone. Clients are offered three in-person prenatal visits, usually provided in prenatal clinics; one in-person perinatal visit in the hospital after delivery; and five postpartum home visits. Visits are supplemented with seven phone calls, and additional in-person visits and calls as needed. In addition to English, some peer counselors speak Spanish or other languages. BHP IBCLCs provide peer counselors with training, supportive supervision, and clinical guidance.

Second, the BHP program offers breastfeeding peer counseling that is both effective in promoting breastfeeding equity and highly person-centered. In two randomized controlled trials, we demonstrated that the program improves any and exclusive breastfeeding among women with low incomes who identify as Black, Hispanic, other minoritized racial and ethnic identities, and White [28, 29]. Through qualitative research, we found that women had positive experiences in their interactions with peer counselors, given that peer counselors used effective communication, treated them with respect, and provided emotional support – all of which women highly valued [30]. Finally, the BHP program has a robust monitoring and evaluation system to continuously improve service delivery and ensure the provision of high-quality, person-centered breastfeeding support that is responsive to clients’ needs [15].

During the COVID-19 pandemic, the BHP program shifted to virtual delivery only, prioritizing video calls when possible [31]. To evaluate the virtual only BHP program model, we conducted a community-driven implementation research study [31]. We documented program adaptations as the program shifted to virtual delivery and explored the perceived impacts of these adaptations on four implementation outcomes specified in the Implementation Outcomes Framework by Proctor and colleagues: adoption, defined as the action to employ video calls as a substitute for in-person visits; feasibility, defined as the extent to which a virtual BHP program model can be successfully used or carried out; acceptability, defined as the perception that virtual counseling is agreeable, palatable, or satisfactory; and appropriateness, defined as the perceived fit, relevance, or compatibility of virtual counseling for the practice setting, individuals delivering the program, and individual clients participating in the program [32]. These implementation outcomes were prioritized in collaboration with the Hispanic Health Council and partner healthcare facilities to address their key questions about virtual delivery of the BHP program. In line with guidance from Proctor and colleagues on how to apply the framework, we evaluated adoption, feasibility, acceptability, and appropriateness at the level of individuals delivering the BHP program, including BHP program leaders, staff, and peer counselors. We also evaluated the acceptability and appropriateness of virtual program delivery at the level of individual clients. We previously reported that BHP program leaders, staff, and peer counselors thought virtual counseling worked well but in-person visits were better for building relationships with clients, assisting with breastfeeding challenges like latching, and identifying breastfeeding barriers in the home environment such as limited family support [31].

In the present paper, our objective is to explore women’s experiences and perspectives on the acceptability and appropriateness of virtual counseling provided by BHP peer counselors. These findings can inform health systems, organizations, and payors making decisions about how to leverage digital health solutions to increase access to breastfeeding peer counseling at scale.

Methods

To understand women’s experiences and perspectives on virtual delivery of the BHP program, we used a rapid qualitative approach [33]. We selected this approach because the project required rapid turnaround of findings for BHP program implementers at the Hispanic Health Council and partner healthcare facilities as they worked to optimize virtual program delivery [33, 34]. The study applies the Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA) framework for designing, conducting, and reporting, and it meets Standards for Reporting Qualitative Research reporting guidelines [34, 35].

Study team and reflexivity statement

The study team included researchers with expertise in breastfeeding counseling and qualitative methods, two research assistants with MPH degrees, and program implementers. We practiced reflexivity throughout the study by reflecting on the ways in which our knowledge and views of the BHP program may influence data collection, data analysis, and interpretation of the findings [36]. The researchers and research assistants worked together closely to design the study, conduct data collection and analysis, and report the findings; program implementers provided critical input on the research question, design of data collection instruments, and interpretation of the findings.

Sampling and recruitment

Women were eligible to participate if they were 18 or older and spoke English and/or Spanish. We purposively sampled BHP clients using a maximum variation approach to achieve sample diversity by maternity facility, assigned peer counselor, and race/ethnicity and recruited them via phone and text. We intentionally recruited BHP clients who enrolled in BHP prior to the pandemic and experienced both in-person and virtual counseling, as well as clients who enrolled after the pandemic began and received virtual counseling only. Our rationale was that the immediate purpose of the study was to generate relevant, actionable, and timely findings for BHP program implementers who sought to use the findings to inform program adjustments and optimize virtual delivery for all active BHP clients regardless of whether they had prior experience with in-person counseling. As such, including clients with varied prior experience enhanced the relevance of the findings for BHP program implementers. Of the 61 women invited to participate in an interview, 19 women preferred not to participate, and 42 women (69%) agreed to participate. Of the 42 women who initially agreed, 28 women (46%) were ultimately available to participate.

Data collection and analysis

We conducted 28 in-depth interviews by Zoom between April and mid-June 2020 during the early phase of the COVID-19 pandemic, and thus participants were reflecting on experiences shortly after the shift to virtual program delivery occurred in March 2020. We developed a semi-structured interview guide in English, translated it into Spanish, then pilot tested and refined it in both languages (Supplementary material). Interviews were conducted in English or Spanish and lasted approximately 30 to 45 min to keep the interview length low burden for participants. Women who participated in interviews received a $30 gift card. As interviews were completed, a professional service transcribed audio-recordings verbatim in English and translated and transcribed Spanish-language interviews into English. We reviewed transcripts against audio-recordings to ensure accuracy and, for Spanish-language interviews, to verify translations preserved the original meaning. Lastly, we de-identified transcripts.

Throughout data collection, researchers and research assistants initiated a rapid qualitative analysis [33, 34]. Specifically, we developed and pilot tested a user-friendly summary template and then used the template to develop summaries of each transcript in MS Word. To ensure consistency and accuracy in summaries, two research assistants used the template to summarize the same transcript, and then the researchers and research assistants reviewed the summaries, identified any differences, and met to discuss and resolve discrepancies. This process was repeated several times until we established consistency in the formatting, amount of detail, and inclusion of transcript line numbers, quotations, and time stamps used to link the raw data so that we could re-examine the original data as needed for clarification, validation, and expansion. Then, the transcripts were divided up and research assistants completed transcript summaries independently with spot checks of summaries by researchers.

Researchers and research assistants held debriefing sessions one or more times each week throughout data collection to identify topics raised by women and add probes to the interview guide to further explore topics in greater depth in subsequent interviews [36]. These debriefing sessions were also used to review and discuss transcripts and transcript summaries, reflect on the data, and identify when we achieved code saturation (defined as the point in data collection when no additional topics are identified) and meaning saturation (defined as the point when topics are fully understood) [36, 37]. Once saturation had been achieved, we stopped data collection.

Next, researchers and research assistants worked collaboratively to transfer the full set of transcript summaries into an Excel matrix, closely review data in the matrix, and write descriptions that synthesized the data. Themes were identified and refined through team consensus with input from program implementers to inform interpretation, and then organized by the two implementation outcomes of acceptability and appropriateness [32]. As such, we used a hybrid approach in which we blended inductive and deductive processes by first using inductive processes to generate themes that were grounded in and driven by the data and then using an implementation science framework to organize the themes [38, 39]. In line with best practices for rapid qualitative analysis, we wrote memos and recorded notes from debriefing meetings to create an audit trail, which helped our team to track how our thoughts evolved as we engaged with the data and to document our steps to ensure methodological rigor [34].

Results

Interviews were conducted with 28 BHP clients (Table 1). Participants were 18 to 44 years old, and self-reported as Black, White, bi- or multi-racial, or other and as Hispanic or non-Hispanic. More than half had more than a high school education, one child, and no prior breastfeeding experience. The sample of participants comprised clients who had received care at each of the three maternity facilities partnering with the Hispanic Health Council to deliver the BHP program and who had received counseling from each of the seven BHP peer counselors. Some clients enrolled in BHP pre-pandemic and received both in-person and virtual counseling, while others enrolled during the pandemic and received virtual counseling only.

Table 1.

Characteristics of women interviewed (n = 28)

Characteristics	n (%)
Age, years
18–21	3 (10.7)
22–34	21 (75.0)
35–44	4 (14.3)
Race
Black	12 (42.9)
White	7 (25.0)
Bi- or multi-racial	2 (7.1)
Other	7 (25.0)
Hispanic/Latina
Yes	12 (42.9)
No	16 (57.1)
Marital status
Single	3 (10.7)
With a partner (not married)	10 (35.7)
Married	15 (53.6)
Living with spouse/partner
Yes	24 (85.7)
No	4 (14.3)
Education
Some high school	1 (3.6)
High school graduate/general education diploma	10 (35.7)
More than high school	17 (60.7)
Parity
1	16 (57.1)
> 1	12 (42.9)
Past breastfeeding experience
Yes	11 (39.3)
No	17 (60.7)

Acceptability

Life fit

Compared with in-person visits, virtual communication was viewed as convenient, efficient, and easier to integrate into daily routines, facilitating engagement with peer counselors while women managed childcare, jobs, and school. Virtual counseling allowed women to multitask. A self-described “busy mom” preferred phone over video calls because she could care for her children while talking. Others described sitting with their infants or doing household chores while texting. One woman preferred virtual sessions because she did not have to “get [her] baby ready to go out for an appointment.” Women found texting convenient for getting questions answered quickly, brief communication while at work, and during nap times or when infants were fussy. Others appreciated the flexibility to send texts and respond later. However, some preferred phone calls for efficiency, with one noting that phone calls could “take less energy than texting” and another reporting faster answers by calling (Table 2).

Table 2.

Themes and illustrative quotes from women

Theme	Illustrative quotes
Acceptability
Life fit	“I think, sometimes, because you’re not subject to being on video and whatnot, and you can be a little more flexible…It’s always nice to see someone’s face, but sometimes the convenience of just having a phone call or a text message is nice too…I would say post-baby a text or a phone call is probably easier to handle only because then it allows more multitasking ability that way.” (Non-Hispanic White woman, 34 years, no previous breastfeeding experience) “I don’t mind the texting because sometimes I’m busy, and I don’t really want to be on the phone ‘cause I have to pay close attention to my baby.” (Non-Hispanic Black woman, 28 years, previous breastfeeding experience) “As a new mom, it’s hard to get out of the house or set up appointments, so I kind actually preferred [virtual counseling]…just getting the baby ready, bath, clothes, in the car, or getting the house ready if [peer counselors] were to come to the house” (Non-Hispanic White woman, 31 years, no previous breastfeeding experience) “I’m a student. I do have two other kids and, you know, a home and a full-time fiancé. So, it’s kind hard for me to get out and go to every appointment that I need to go to and things like that. So it was pretty convenient for me to be able to text and to do a Zoom call, when I have time.” (Non-Hispanic Black woman, 31 years, previous breastfeeding experience)
Comfort with being seen on video	“I will say knowing that people are home, if I needed to do some sort of video-based call based on like, my breast health or latching, it might feel a little bit awkward, but if I needed the help I would need the help. So I would probably just do it no problem.” (Non-Hispanic White woman, 34 years, no previous breastfeeding experience) “I’m not ashamed about breastfeeding in front of other people.” (Non-Hispanic Black woman, 31 years, previous breastfeeding experience) “I mean, my man. The problem is my man don’t really like that. He don’t. Like I told you, I am from Africa. Over there we don’t really care about that, so breastfeeding in front of everybody. But him, it’s like he don’t really like it when I gotta breastfeed the baby. There is some people around, you know, he always want me to go in the room, so stuff like that. He don’t want me to breastfeed in front of people.” (Non-Hispanic Black woman, 27 years, no previous breastfeeding experience)
Appropriateness
Building relationships with peer counselors	“I would say in person is probably always going to be more successful. You know, [peer counselors] are able to connect a little bit better, and see the baby, see how things are working. So, I think in person is always preferred, but I think virtual, given the pandemic, is, of course, the next best thing.” (Non-Hispanic White woman, 32 years, no previous breastfeeding experience) “You know that the remote [visits] are a bit impersonal, because you know it is very different having a person right in front of you than having them on the phone.” (Hispanic Black woman, 32 years, no previous breastfeeding experience) “I actually liked the [home] visits. Physically, because you are talking to the person…I think you can share a lot better with that person…I like to talk to the person when they’re in front of me. It’s like, I feel that the person is there at the moment. It’s not the same over the phone when, you know, you are taking care of your other son…I like to talk to the person right in front of me because I feel that I am having the conversation like – the way I would like to.” (Hispanic woman, 27 years, previous breastfeeding experience) “But, obviously, when you have someone in front of you, I think the help you get is a lot better because you can – or the opportunity to talk to that person and feel more at ease…you develop a relationship.” (Hispanic woman, 36 years, no previous breastfeeding experience)
Evolving needs across the breastfeeding journey	“At the hospital…being able to talk to someone in person, to have them help you with techniques or just to be able to have them show you physically…I don’t think could be replaced with a virtual environment, right? …Having [counseling] be strictly remote was a little more, I think, challenging in that sense because you don’t necessarily get the same level, I think, that you would get if you were able to have a meeting in person.” (Non-Hispanic White woman, 34 years, no previous breastfeeding experience) “I would say now, like, if I physically needed [my peer counselor] in person, that would probably complicate things, but like I said, I’ve been pretty lucky with when I had him, and, you know, where I’m at now ‘cause now he’s 10 months old, whereas I was able to get the support in the beginning [in person], which is, I think, really where you need it the most.” (Non-Hispanic White woman, 32 years, no previous breastfeeding experience) Both [in-person and virtual] support was good, and to me, even without the pandemic [and counseling services shifting to being fully virtual], I feel like this is how it would have went because my daughter is maturing. So, I think it would have went just the same where the [in-person] visiting would not have been exactly necessary because she’s no longer – we are no longer at the stage where I’m concerned about latching or I’m concerned about a letdown or concerned about supply because at this point if my supply reduces, it’s perfectly fine ‘cause it’s time for her to eat solids anyhow.” (Non-Hispanic Black woman, 34 years, no previous breastfeeding experience)
Fit between mode of communication and individual needs and preferences	“Typically, just because of the fact that I’m, you know, kinda all over the place between working and, you know, with him [the baby] and naps and stuff, typically, if it’s just something quick, I prefer texts, but, if it’s gonna be somethin’ more detailed that’s hard to explain over text, I definitely, obviously, would rather talk to somebody over the phone.” (Non-Hispanic White woman, 32 years, no previous breastfeeding experience) “Even though I could read about the proper positioning, and I could watch videos, there’s nothing like someone actually coming to your home and telling you, ‘Okay. Get comfortable.’ And [during a home visit prior to the pandemic] they kind of positioned [my baby], and it was great. I think that was the most helpful, like, the hands-on.” (Hispanic Black woman, 31 years, no previous breastfeeding experience) “So I was kind of jealous because all my sisters got in-person support. And I only had, you know – ‘cause it’s COVID, and I’ve been in the house. So I’m like, ‘All right, well.’ It’s alright. But in-person it would probably be better because she can show me more, you know. I’m like a hands-on learner.” (Hispanic multi-racial woman, 29 years, no previous breastfeeding experience)
Access
Access to technology	“My phone was actin’ up, so I barely, like, can’t do anything on it…[peer counselors] know I can’t download any programs with cameras and stuff like that.” (Hispanic White woman, 30 years, previous breastfeeding experience)

Comfort with being seen on video

Several women were comfortable breastfeeding in public or around friends and family, which helped them feel at ease breastfeeding on camera during video calls. Others became desensitized to having their bodies seen after providers saw their bodies during labor and delivery. Trusting relationships with peer counselors also fostered comfort, particularly when the relationship had been established through in-person visits. One woman who had home visits pre-pandemic explained that she was comfortable breastfeeding on video, “I had known [my peer counselor] for, like, two months already, so I’d become more comfortable with her.” By contrast, a woman who preferred in-person counseling shared:

It was better when she was there [in person] ‘cause I was really open with her…when the baby got thrush…I showed her my nipples so she could really see ‘cause when you got thrush, nipples are…sometimes it would be red. It’ll be, you know, pain. Yep. So, I showed her my nipples, so just to say that it’s–of course it’s better when she’s here. (Non-Hispanic Black woman, 27 years, no previous breastfeeding experience).

Additionally, partner preferences influenced women’s decisions to breastfeed on camera. For example, one woman was comfortable breastfeeding on camera but decided not to because her partner preferred that she breastfeed in private.

Appropriateness

Building relationships with peer counselors

Women valued strong relationships with peer counselors, which played a large role in them seeking peer counselor support and feeling highly satisfied with the program. Women emphasized the importance of in-person visits for relationship building, especially early in the program. Compared with virtual communication, in-person interactions were viewed as fostering more conversation and stronger personal connections. For example, one woman felt that her experience with virtual counseling was “okay,” but noted that “perhaps face-to-face we would converse more, I feel we would be more connected.”

Video and phone calls were considered more conducive to relationship building than text messages. One participant explained, “The video call is always better because at least you could see the person who you’re talkin’ to…makes you feel more comfortable.” Another woman liked phone calls because hearing her peer counselor’s voice helped her get to know her better. A few women felt comfortable relying primarily on text messages once a relationship was established and thought a strong relationship could be maintained virtually:

It’s not the end of the world for me…if possible being able to meet in person is always my favorite, but…I’m still getting the information I feel that I need. I still feel like I’m getting the attention from [my peer counselor]. (Non-Hispanic White woman, 34 years, no previous breastfeeding experience).

Evolving needs across the breastfeeding journey

Many women found virtual counseling to be appropriate during the prenatal phase, when they were learning about infant feeding and planning to breastfeed. They frequently described experiences in which peer counselors effectively shared detailed information about infant feeding and offered anticipatory guidance during video and phone calls. Video calls were viewed to be the most suitable virtual mode of communication when women needed to see peer counselors explain positioning and achieving a good latch, or when peer counselors used props like breast models to aid understanding. Women also appreciated that peer counselors were person- and family-centered, explaining the benefits of breastfeeding to them and involving their partners in calls.

Perspectives on the appropriateness of virtual counseling in the immediate postpartum period were more varied. Some women felt strongly that the usefulness of in-person lactation management support for breastfeeding initiation during the childbirth hospitalization period could not be replicated virtually. For example, one woman who gave birth pre-pandemic emphasized how crucial it was to have her peer counselor visit in the hospital to help her latch her newborn. However, others who gave birth during the pandemic found virtual counseling sufficient. As one woman shared, her peer counselor’s phone call after delivery was “enough.”

During the onset and establishment of lactation during the early postpartum period, some women felt in-person breastfeeding counseling was needed or would have been more helpful than virtual counseling:

I know it was due to COVID, but I was kinda sad that [my peer counselor] couldn’t come to my house. ‘Cause I know the support at home – her coming and, like, supporting me at my house would’ve been even more helpful. ‘Cause like the first couple days I was struggling [with breastfeeding]. (Hispanic White woman, 27 years, no previous breastfeeding experience).

As women sustained breastfeeding in the late postpartum period, many women found their need for in-person counseling lessened, and virtual modes became more appropriate again:

I feel like because of where I’m at a point in my breastfeeding journey … I don’t need quite as much help as I did in the beginning, so, I feel like for me it’s been perfect and everything has worked out fine. (Non-Hispanic White woman, 34 years, no previous breastfeeding experience).

Fit between mode of communication and individual needs and preferences

Women described how they matched the communication mode to their specific needs. One woman explained that she sent text messages for questions that could be addressed quickly. Another woman talked by phone when she had mastitis but used text messages for non-urgent communications. Other women found texting useful for quick questions or requests like advice about breast pumps. Women appreciated phone calls when experiencing breastfeeding challenges that required conversation and when peer counselors offered explanations difficult to convey via text.

For informational needs, women often used text messages and video calls to receive and revisit breastfeeding information. Participants valued receiving resources, such as links, videos, and photos, via text that they could return to:

With a text message, anything she sends me or writes back to me, I have it stored there. If I have any questions because I forgot something…I can go and search for the information. (Hispanic Black woman, 32 years, no previous breastfeeding experience).

Several women appreciated the ability to share these resources with partners:

When I first had [my baby], [my peer counselor] sent me some videos about how your spouse can be helpful to you while you’re breastfeeding and stuff like that, and I actually made sure he watched it. (Non-Hispanic Black woman, 20 years, previous breastfeeding experience).

For some women, particularly those with previous breastfeeding experience who were not facing breastfeeding difficulties, virtual counseling was perceived to be adequate, whereas in-person counseling was deemed most appropriate for some lactation management support needs. For example, one woman felt that latching issues or cracked nipples cannot be identified over video or phone. Women also viewed in-person counseling as optimal for addressing latching difficulties since peer counselors can observe and physically assist with positioning the infant. In-person visits also allow peer counselors to assist with pumping and massaging breasts. Furthermore, video calls presented logistical challenges:

With the phone call, we’d have an issue of, oh, the phone is not put in the right place where can’t see certain things, whether I’m holding him exactly the correct way…And then I’m trying to make sure that I’m showing where – what – how I’m holding the baby. So…it made it a bit hard. (Hispanic Black woman, 31 years, no previous breastfeeding experience).

Virtual communication, particularly phone calls, provided timely reassurance and encouragement, and supportive interactions made women feel cared for. Still, some women preferred in-person visits for more engaging discussions and valued in-person visits and video calls for observing non-verbal cues, noting that “you can see the other person’s expressions” and body language.

Access to technology

While virtual peer counseling was accessible for most women, lack of devices that supported video calls limited virtual communication options for a few. One woman could not download necessary applications or use her phone’s camera for video calls. Another woman used her mother’s phone for video calls since she did not have a “good phone.”

Discussion

Women viewed virtual breastfeeding peer counseling as acceptable and, in some cases, preferable to in-person counseling because of its convenience and fit with daily routines. However, the acceptability of video calls varied based on comfort with breastfeeding or showing breastfeeding challenges on camera. Women’s perspectives on the appropriateness of virtual counseling was shaped by their ability to establish connections with peer counselors, breastfeeding stage, and type of support needed. Most women had devices and internet connectivity that supported all virtual communication modes but a few lacked video-capable devices.

Findings reflect women’s views on virtual counseling as delivered within a person-centered model. In our prior work, women described that BHP peer counselors communicated effectively, treated them with respect, and offered emotional support [30]. Rodriguez and colleagues found that patients with limited English proficiency have worse experiences with video visits compared with in-person visits [40]. In contrast, we did not find differences in experiences by language preference, possibly because BHP peer counselors are bilingual. Kong and colleagues found that patients with non-English language preferences reported language-concordant clinicians and clinic staff as facilitators to video visits [41]. Our findings also align with studies demonstrating the importance of language-concordant care during pregnancy for patients with Spanish language preference [42–44], as well as a study in which Spanish-speaking women reported that communicating in Spanish allowed them to better share their breastfeeding questions and concerns with healthcare providers, which in turn enabled providers to be responsive to their informational needs [45].

Given that our study captured women’s experiences and perspectives of virtual counseling during the early phase of the pandemic, it is important to consider the current relevance of these findings. Given the increasingly important role of virtual communication across healthcare, work, and daily life, concerns around comfort with video and technology access may have diminished over the past several years, potentially making virtual counseling even more acceptable and accessible for some individuals [46]. However, according to recent research, barriers such as lack of broadband access, low digital literacy, and limited English proficiency continue to hinder the equitable access to and use of digital health services [46, 47]. At the same time, given the appeal of virtual counseling for its convenience for women and fit with daily routines combined with the rising use of perinatal digital health services since the pandemic, the acceptability of virtual delivery of breastfeeding peer counseling may be even greater today [25, 26, 48]. Our finding that the appropriateness of virtual counseling varied throughout the breastfeeding journey remains highly relevant, as this finding reflects the dynamic nature of women’s breastfeeding support needs. Furthermore, in-person lactation management support from peer counselors remains essential for resolving complex breastfeeding challenges and identifying issues that require referral to an IBCLC or other provider with specialized knowledge and clinical expertise [15]. The importance of aligning different virtual modes of communication with individual needs and preferences remains necessary for ensuring the appropriateness and effectiveness of virtual counseling. Finally, the advantage of in-person interactions for building relationships with peer counselors likely persists, as women highly value peer counselors who listen carefully to their questions and concerns, offer encouragement and reassurance, and provide personalized support in the context of trusted relationships cultivated through in-person interactions [30]. Therefore, hybrid program models offering both in-person and virtual counseling options may be optimal.

Hybrid models can be tailored to local contexts and populations through co-design with communities to optimize relevance, uptake, and sustainability [13]. Based on our findings, we recommend six actions to improve breastfeeding peer counseling programs with virtual components and optimize acceptability, appropriateness, and equitable access: (1) offer flexible modes of communication to support integration with daily life demands; (2) respect women’s autonomy in video participation while building trust to enhance comfort; (3) foster trusting relationships through intentional sequencing of in-person and virtual interactions; (4) tailor modes of communication to evolving needs across the breastfeeding journey; (5) support peer counselors in matching communication modes to specific needs and individual preferences and delivering high-quality virtual counseling; and (6) address technology barriers (Table 3).

Table 3.

Actions for designing and implementing hybrid telehealth and in-person breastfeeding peer counseling programs

Theme	Core Insight	Recommended actions	Example practices to operationalize actions
Acceptability
Life fit	Flexibility in communication modes eased engagement with peer counselors by supporting integration with daily life demands.	Offer flexible modes of communication to support integration with daily life demands.	• Enable women to choose from and switch between video calls, phone calls, and text messaging based on their needs and preferences.
Comfort with being seen on video	Comfort with video calls varied based on personal preferences, partner influence, past experiences, and strength of relationships with peer counselors.	Respect women’s autonomy in video participation while building trust to enhance comfort over time.	• Avoid pressuring women to use video and instead engage in shared decision-making about communication modes, considering both client preferences and lactation management support needs. • When visual assessment is beneficial (e.g., for assessing latch and positioning), offer in-person visits for women who are uncomfortable on camera. • Recognize that trust-building through established relationships may increase comfort with video over time, and that partner preferences may influence women’s choices regardless of personal comfort levels.
Appropriateness
Building relationships with peer counselors	Strong relationships with peer counselors promoted program satisfaction and engagement, with in-person visits viewed as optimal for initial relationship building and virtual modes suitable for maintenance.	Foster trusting relationships through intentional sequencing of in-person and virtual interactions, starting with in-person visits to build trust and then transitioning to virtual visits to maintain relationships.	• Conduct recruitment and/or visits early in the program in person at health facilities or women’s homes, when possible, to establish personal connections and trust. Once strong relationships are established, women may feel comfortable maintaining connections primarily through virtual modes of communication, including text messaging.
Evolving needs across the breastfeeding journey	Women’s needs for breastfeeding support changed across the breastfeeding journey, influencing what mode of communication felt most appropriate.	Tailor modes of communication to evolving needs across the breastfeeding journey through ongoing check-ins and conversations.	• Ensure peer counselors have ongoing conversations with women about how they are doing, challenges they are experiencing, and the kind of support they want and need across the breastfeeding journey. • Maintain the person-centered nature of individualized, tailored support – a core strength of peer counseling – across all interactions, whether delivered in person or virtually, ensuring that each woman receives responsive support aligned with individual circumstances and breastfeeding goals.
Fit between mode of communication and individual needs and preferences	Perceived appropriateness of communication modes varied depending on the type of support women needed (informational, lactation management support, or emotional support).	Train and provide supportive supervision to peer counselors for matching communication modes to women’s needs and preferences and delivering high-quality virtual counseling.	• In addition to following program protocols and procedures, flexibility to accommodate women’s needs and preferences is important. Equip peer counselors with skills to recognize when different communication modes are most appropriate, such as text messaging for quick questions and resource sharing, phone calls for emotional support, video calls for visual demonstrations, and in-person visits for hands-on lactation management.
Access
Access to technology	Technology barriers, including lack of video-capable devices, limited virtual communication options for some women.	Proactively identify and address technology barriers to ensure equitable access to virtual support.	• Screen women for technology limitations, including lack of devices capable of supporting video calls, inability to download applications, or inadequate internet access. • Provide alternative solutions such as loaning devices, assisting with app installation, or connecting women with technology support resources to promote equitable access to the full range of virtual communication options and breastfeeding peer counseling services.

A strength of this study is its diverse sample that includes racially and ethnically diverse women and Spanish speakers – groups underrepresented in research [49, 50]. Additionally, the rapid qualitative analysis was conducted with scientific rigor [34]. One limitation is that the sample was drawn from a program operating in urban areas during the pandemic when virtual counseling became the only option available, which may limit the transferability of findings to other contexts such as rural areas. Additionally, it is possible that prior experience with in-person counseling may have shaped perceptions of virtual counseling. However, our interview guide was not designed to explore this issue, which may explain why we did not identify notable differences in perceptions by prior in-person counseling experience.

Our findings are timely given recent policy efforts that could increase access to virtual breastfeeding support [13]. These include extending Medicaid postpartum coverage to 12 months [51]; federal investments in broadband infrastructure for low-income households [52]; and strengthening WIC’s digital platforms for virtual counseling options [13]. Peer counselors need training in delivering high-quality virtual breastfeeding services; in 2022 only half of local WIC agencies reported that staff had access to training on virtual breastfeeding support and counseling [20].

Future research should evaluate hybrid models, particularly among historically marginalized communities. Key priorities include: assessing effectiveness, cost-effectiveness, sustainability, and scalability; developing strategies for promoting equitable reach and engagement and for building trust in virtual peer counseling relationships; examining how language-concordant peer counselors may promote positive experiences and use of virtual counseling among communities that speak Spanish or other languages; and evaluating impacts on person-centered outcomes. Research should also examine how artificial intelligence can strengthen hybrid models while preserving the tailored communication, emotional support, and trusted relationships that women value in peer counseling [30, 53].

Conclusions

This study advances understanding of the acceptability and appropriateness of virtual breastfeeding peer counseling from women’s perspectives and identifies considerations for equitable person- and family-centered program delivery. In line with WHO breastfeeding counseling recommendations, findings suggest that virtual counseling may complement but not replace in-person counseling, unless in-person counseling capacity or access is limited or not available [54].

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

BHP

Breastfeeding Heritage and Pride™

IBCLC

International Board Certified Lactation Consultant

US

United States

WHO

World Health Organization

WIC

The Special Supplemental Nutrition Program for Women, Infants, and Children

Author contributions

ECR obtained funding for the study. ECR and RP-E conceptualized and designed this study and acquired and analyzed the data. All authors contributed to the interpretation of the data, drafting of the manuscript, and critical review of the manuscript for important intellectual content.

Funding

ECR was supported by grant number K12HL138037 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute. This research was supported by the Cooperative Agreement Number 5 U48DP006380-02-00 funded by the Centers for Disease Control and Prevention, Prevention Research Center Program (PI. RP-E). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

Data availability

Data from this qualitative study are not publicly available. We are committed to protecting the privacy and confidentiality of the participants. This study contains deidentified data from in-depth interviews but given the sample size and sensitive nature of the interviews, there is still a possibility they could be identified by the details of their experiences.

Declarations

Ethics approval and consent to participate

This study was deemed exempt from further review by the Yale University Institutional Review Board. We chose to obtain verbal informed consent to participate in an audio-recorded interview from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.