Insights in Public Health

Abstract

Healthy Mothers, Healthy Babies Coalition of Hawai‘i (HMHB) is a local nonprofit organization dedicated to eliminating health disparities and improving Hawai‘i's maternal, child, and family health though collaborative efforts in public education, advocacy, and partner development. A review of HMHB services revealed overwhelming requests for both breastfeeding and postpartum depression (PPD) support. The purpose of this article is to present the findings of two surveys that highlight the awareness of existing breastfeeding and PPD resources based on both parents and health care providers; perceptions of where and how care is accessed; and whether mothers throughout Hawai‘i have equitable access to support. Results helped assess gaps in resources and determine barriers to care, as well as provide suggestions for new services or resources.

Web-based surveys were sent to 450 providers and 2,955 parents with response rates of 8.9% and 4.0%, respectively. Less than half of parent participants reported that their health provider discussed PPD with them. Participants identified a number of barriers to increasing access and utilization of PPD support resources, including: not feeling like symptoms were server enough, feeling embarrassed to seek help, not knowing where to find support/information, and not able to afford or insurance wouldn't cover PPD support. Only 40% of providers reported screening for PPD and 33% felt they had not received adequate training. Barriers identified by providers were a lack of trained providers, lack of PPD specific support groups, cultural stigma, and lack of PPD awareness among providers.

Of the women who did not exclusively breastfeed for the full six-month recommendation, the most common breastfeeding concerns included: perceptions of low milk supply; lack of lactation support; medical reasons; and pain. Providers described an environment of uneven distribution of resources, general lack of awareness of available resources, along with a widespread lack of support for breastfeeding efforts.

Recommendations for future efforts include comprehensive breastfeeding and PPD training for health care providers enhanced support groups, and improving awareness and access to information and support resources.

Background

Founded in 1992, Healthy Mothers Healthy Babies Coalition of Hawai‘i (HMHB; http://www.hmhb-hawaii.org) is a local nonprofit organization dedicated to eliminating health disparities and improving Hawai‘i's maternal, child, and family health. HMHB offers services statewide, with a focus on increasing access to resources and information among low-income communities.

HMHB operates a free and confidential MothersCare phone line in addition to a detailed website to help clients access preconception, prenatal and postpartum resources, referrals, and information. HMHB staff manages client resources, including comprehensive directories of health information, in addition to providing sensitive, caring, and personal support. The information helps link pregnant women and families to resources including health care providers, health insurance, family planning services, prenatal educational classes, substance use/abuse intervention services, domestic violence support services, mental health providers, breastfeeding supports, and oral health providers.

HMHB also operates a mobile health messaging service, Text4baby. This service provides timely, evidence-based information to subscribers every week on topics related to pregnancy and the baby's first year, and refers recipients to local resources, such as health insurance, WIC, breastfeeding support, and immunization information. This service has been demonstrated to increase consumer health knowledge, facilitate interaction with health providers, improve adherence to appointments and immunizations, and strengthen access to health services.^1,2

Hawai‘i Cribs for Kids is a comprehensive family-oriented safe sleep education program offered by HMHB to high-risk, low-income families. Education is culturally tailored, utilizing American Academy of Pediatrics (AAP) safe sleep guidelines, in addition to providing a crib for parents to take home. The program is currently available on O'ahu, with immediate plans to implement on Maui and future plans to expand throughout neighboring islands.

Further, HMHB accomplishes the following: coordination and planning of trainings for perinatal support service providers and collaborative meetings with community partners and stakeholders; development and dissemination of educational and informational material to target audiences; and advocacy efforts at the state and federal level. To appropriately reach the target population, HMHB also utilizes various social media outlets to provide information, outreach, news and updates.

The continuous monitoring and review of social media, calls to the MothersCare phone line and HMHB website visits revealed overwhelming requests for postpartum support information and resources with breastfeeding and postpartum depression as important recent topics. Periodically, HMHB conducts surveys to gather more information in order to improve planning efforts. This article summarizes some information from a recent set of surveys to highlight an example of some of the work that HMHB does with both individuals in the community and providers.

Postpartum Health

Postpartum depression (PPD) and breastfeeding support are each critical to influencing health outcomes. PPD is a serious mental health condition affecting an estimated 10–20% of women within six months of giving birth.³ PPD can interfere with a woman's ability to function. Women with PPD are less likely to interact with their infants or to breastfeed. Untreated PPD can impact the long-term developmental health and well-being of a child.⁴ According to data from the Hawai‘i Pregnancy Risk Assessment Monitoring System (PRAMS), about 1 in 7 women (14.5%) with a recent live birth reported Self-Reported Postpartum Depressive Symptoms (SRPDS), and an additional third had possible SRPDS.³ All Asian and Pacific Islander groups have a higher odds of experiencing SRPDS than white women. For Asian and Pacific Islander groups, the adjusted odds ratios ranged from 1.7 to 3.3.³

Breast milk is the most complete form of nutrition for infants and one of the most effective preventive health measures.⁵ Also cost-effective, breastfeeding reduces the risk for developing various chronic conditions compared to formula. According to the Centers for Disease Control and Prevention's (CDC) 2014 Breastfeeding Report Card, of the infants born in 2011 in the United States, 79.2% were ever breastfed, 49.4% were still breastfeeding at six months (18.8% receiving exclusively breast milk), and 26.7% were still breastfeeding at 12 months.⁶

In Hawai‘i, 89.5% of mothers initiated breastfeeding, 61.5% were still breastfeeding at six months, and 36.5% were still breastfeeding at 12 months among infants born in 2011.⁶ According to a recent study, “In Hawai‘i, breastfeeding rates are higher than national averages except in Native Hawaiian and other Pacific Islander populations.”⁷ Further, Hawai‘i PRAMS data indicates that, “women who initiated breastfeeding but did so for less than eight weeks were more likely to be Black, Hawaiian, Samoan, Filipino, …[have] a high school or lower education, … [and be] Medicaid/QUEST insured.”⁸ It is important to highlight the discrepant low rates among Asian, Black, and Native Hawaiian or Other Pacific Islander subgroups with each 20–40% less likely to breastfeed exclusively compared to white mothers.⁹

Efforts to improve access to information, resources, and services are critical to improving statewide maternal and child health outcomes. Two surveys were used to determine the awareness and utilization of existing local resources and support among both parents and perinatal health care providers in Hawai‘i. The study asked participants to identify and assess existing resources and trainings, and suggest strategies for addressing services gaps. Results are currently being used to assist in improving postpartum support programs, with the potential to improve the quality of support for Hawai‘i residents, particularly among populations considered most at-risk.

Methods

In 2014, data was collected via two anonymous web-based surveys for two distinct audiences throughout the Hawaiian Islands: (1) parents who may have used or needed breastfeeding or PPD support resources and (2) perinatal health care providers, health educators, and home visitors. Provider contacts consisted of perinatal providers at health centers, government agencies, and nonprofit organizations with long-established relationships with HMHB.

Participants were drawn from HMHB's social media accounts, and contact databases of parents and providers for a total 3,405 potential participants (2,955 parents and 450 providers). Potential participants were sent an email with a link to the survey and a reminder email was also sent. Parent contacts had an existing relationship with HMHB, having received services, connected at parent support events, and/or volunteered with the organization. Both surveys included a combination of qualitative and quantitative questions. Basic demographics were collected in both the parent and provider survey. For the parental survey questions about postpartum depression and breastfeeding included experience, awareness of resources, perceived challenges, and recommendations to improve access to resources. Similar categories were also included in the provider survey, but also included questions about clients served and experience of working with women on postpartum depression and breastfeeding.

Analysis of quantitative responses was conducted utilizing SurveyMonkey® (Palo Alto, CA, www.surveymonkey.com) analysis feature and qualitative responses were coded and quantified by HMHB researchers.

Results

Demographics

A total of 112 parent participants completed the survey (4.0% response rate), with the majority at 84% living on O'ahu (Table 1). All parents reported speaking English at home with 26% also speaking other languages in the home (Hawaiian, Spanish, Japanese, Chinese, Ilocano, Korean, Portuguese, Tagalog, Vietnamese, Chamorro, Thai, and Tokelauan). The majority of participants were White (61%), followed by Chinese (24%), Japanese (18%), Hawaiian (17%), Filipino (15%), Hispanic (9%), or Other Asian (6%), with participants able to select multiple races. All participants had a high school diploma or higher, with just under half the respondents (47%) having a college degree and 29% having a postgraduate degree. Income levels varied widely, but 58% were of middle-upper SES (incomes above $50,000), 36% were of low SES (incomes <$50,000), and 7% declined to report their income. The age of participants also varied, with 10% between 18–25 years of age, more than half (54%) between 26–35 years of age, and 37% over the age of 35.

Table 1.

Characteristics of Parental Respondents

	Frequency of Responses	% of Respondents(N=112)
County of Residence
Hawai‘i	9	8%
Honolulu	94	84%
Kaua‘i	3	3%
Maui	6	5%
Language Spoken at Home*
English	112	100%
Hawaiian	6	5%
Spanish	5	4%
Other (Japanese, Chinese, Ilocano, Korean, Portuguese, Tagalog, Vietnamese, Chamorro, Thai, Tokelauan)	18	16%
Race/Ethnicity*
White	68	61%
Chinese	27	24%
Japanese	20	18%
Hawaiian	19	17%
Filipino	17	15%
Hispanic	10	9%
Other Asian	7	6%
Black	6	5%
Korean	6	5%
Other Pacific Islander	8	7%
Other	6	5%
Education
I didn't finish high school	0	0
High school diploma or GED	5	4%
Some college	21	19%
College degree	53	47%
Postgraduate degree	32	29%
Preferred not to answer	1	1%
Income
Low SES	40	36%
Middle-Upper SES	64	58%
Preferred not to answer	8	7%
Ages
18–25 years	11	10%
26–35 years	60	54%
Over 35	41	37%

^*Participants were able to choose more than one option.

A total of 409 health care providers participated in the second survey (8.9% response rate). Eleven of the respondents were registered nurse; the remaining 29 included nonprofit/community advocates, health educators, home visitors, lactation consultants, and OB/GYNs (Table 2). Provider participants provided services in a variety of settings but primarily at community health centers or an in-home setting. Providers reported working primarily with low-SES patients/clients who spoke a variety of languages other than English, including Chuukese, Marshallese, Ilocano, Tagalog, Samoan, Spanish, and others). By geography, 48% provided services on O'ahu, 38% on Hawai‘i, 13% on Maui, and 13% on Kaua'i.

Table 2.

Characteristics of Provider Respondents

	Frequency of Responses	% of Respondents(N=40)
Provider Types
Registered nurse	11	28%
Nonprofit/community advocacy	6	15%
Health educator	5	13%
Home visitor	5	13%
Physician	5	13%
Other (lactation consultant, midwife, mental health professional, support group facilitator)	8	20%
Care Venue*
Community health center/local medical center	19	48%
In-home	11	28%
Hospital	9	23%
Community or nonprofit organization	9	23%
Other (private practice clinic, and birth center)	4	10%
SES
Low SES	32	80%
Middle-Upper SES	8	20%
Languages Spoken by Patients*
English	40	100%
Chuukese	16	40%
Marshallese	15	38%
Ilocano	9	23%
Tagalog	9	23%
Samoan	8	20%
Spanish	5	13%
Other (Chinese, Japanese, Korean, Vietnamese, and Hawaiian)	8	20%
County Where Services are Provided*
O‘ahu	19	48%
Hawai‘i	15	38%
Maui	8	20%
Kaua‘i	5	13%

^*Participants were able to choose more than one option.

Postpartum Depression Support Assessment

Parent Participant Results (N=112)

Only 49% (n=54) of parents reported that their health care providers discussed PPD with them (Table 3). Of those 44% reported that they did so while still pregnant, 26% indicated that it was brought up immediately after birth while they were still in the hospital or birthing center, 15% indicated at a well-baby check up, 9% at a post-partum checkup, and 6% reported an other setting.Nearly half (45%; n=50) reported receiving PPD patient education materials, 24% reported no materials, and 29% reported not knowing or didn't answer the question. More than half (53%; n=59) reported not being aware of providers who provide PPD support on the island where they live, 16% reporting not knowing, 15% reporting yes, and 16% not answering the question.

Table 3.

Parent Participants' Experience with Health Care Providers on PPD Discussion and Support Resources

	Frequency of Responses	% of Respondents(N=112)
Provider discussed PPD
Yes, they discussed it	54	48%
Time frame of provider discussion (N=54)
While I was pregnant	24	44%
Right after I gave birth	14	26%
At a well-baby check-up	8	15%
Post-partum check up	5	9%
Other	3	6%
No, they did not discuss it	34	30%
I don't know/I'm not sure	7	6%
Non-response	16	14%
Received PPD patient education materials
Yes	50	45%
Source of PPD education materials* (N=50)
Health care provider/OB/GYN	24	48%
Hospital	20	40%
WIC or other community health care provider	9	18%
Other	6	12%
Pediatrician	2	4%
No	27	24%
I don't know	15	13%
Non-response	18	16%
Awareness of health care providers who provide PPD support
Yes	17	15%
No	59	53%
I don't know	18	16%
Non-response	18	16%
Reasons women don't access PPD support resources*
Didn't feel like symptoms were severe enough	68	61%
Felt embarrassed/ashamed to seek help or support	65	58%
Didn't know where to find support or information	52	46%
Couldn't afford/insurance wouldn't cover PPD support	26	23%
There were no local resources for PPD support	18	16%
Did not have transportation to support services	16	14%
Desired resources more widely available*
Postpartum screening for PPD	64	57%
Private counseling	59	53%
Health care provider support	58	52%
Support groups	54	48%
Hotlines (such as MothersCare Line)	41	37%
Home visitors	38	34%
Classes	36	32%
Community/nonprofit services	34	30%
Pamphlets and other fact sheets	30	27%
Culturally-appropriate information	27	24%

^*Participants were able to choose more than one option.

Participants were able to select multiple reasons why women don't access PPD support resources with the four leading reasons focusing on not feeling like symptoms were severe enough (61%), feeling embarrassed/ashamed to seek help (58%), not knowing where to find support/information (46%), and couldn't afford or insurance wouldn't cover PPD support (23%). When asked about recommendations for what parents would like to see more widely available, the four leading reported postpartum screening for PPD (57%), private counseling (53%), health care provider support (52%), and support groups (48%).

Provider Participant Results (N=40)

Only 40% (n=16) of providers reported screening for PPD, 33% reported not screening, and 28% didn't answer the question (Table 4). Of those that did screen, six reported providing support and the other 10 referred out for PPD support. Approximately 33% (n=13) of providers did not feel that they received adequate training around PPD support and treatment; 38% (n=15) of providers perceived that they received adequate training, and 31% did not know or didn't answer the question. Of the 15 that perceived they had adequate training, 10 said they could use additional training. When asked about categories of PPD support resources available, over half (56%) reported not knowing or didn't answer the question. Among providers who could identify resources, the four leading categories were: private counseling (23%); community health center/local medical centers (23%); hotlines or support lines (20%); and pamphlets/factsheets (15%).

Table 4.

Provider Perspectives on PPD Services and Support

	Frequency of Responses	Percentage of Respondents (N = 40)
PPD support
I do not screen for PPD, but can refer patients/clients to outside resources, if needed	12	30%
I screen patients/clients for PPD, but refer out for additional counseling and/or treatment	10	25%
I screen patients/clients for PPD and provide support, including counseling and treatment	6	15%
I do not screen for PPD, and do not refer patients/clients to any outside resources	1	3%
Non-response	11	28%
Perceptions on adequacy of training in PPD
No	13	33%
Yes, but I could use additional training	10	25%
Yes	5	13%
I don't know	1	3%
Non-response	11	28%
Category of PPD support resources identified by providers*
Private counseling	9	23%
Community health centers/local medical centers	9	23%
Hotlines or other support lines:	8	20%
Pamphlets and other fact sheets	6	15%
Support groups, online or in person	5	13%
Community, government, or nonprofit services	4	10%
Non-response	15	38%
Barriers to accessing and using PPD support resources*
Lack of trained providers	16	40%
Lack of PPD-specific support groups or resources	15	38%
Cultural stigma	12	30%
Lack of PPD awareness among providers	12	30%
Patients/clients not interested or do not follow up on initial support	11	28%
Inefficient/inconsistent screening or lack of screening tools for PPD	11	28%
Funding for increasing support programs isn't available	9	23%
Materials or support not available in appropriate language (please explain in the box below)	9	23%
People live far away from health care services and don't have easy access to transportation	8	20%
Non-respondents	15	38%
Resources that would help improve access to care*
Additional training for health care providers	20	50%
More counselors or providers specializing in PPD support	17	43%
Support groups	17	43%
Hotlines (such as MothersCare Line)	15	38%
Pamphlets	13	33%
Enhanced insurance coverage for PPD support services	13	33%
Websites with local information (such as Healthy Mothers Healthy Babies)	12	30%
Non-response	15	38%

^*Participants could choose more than one option.

When asked about barriers to accessing PPD support resources, over one-third (38%) didn't answer the question. Of those that answered, the four leading barriers to increasing access and utilization of PPD support resources were a lack of trained providers (40%); lack of PPD-specific support groups or resources (38%); cultural stigma (30%); and lack of PPD awareness among providers (30%). Providers also commented that support and treatment for PPD was lacking, noting outdated treatment protocols, the lack of availability of outpatient treatment, and insufficient referral pathways and screening tools. When asked about resources to help improve access to care, the four leading suggestions were: additional training for health care providers (50%); more counselors or providers specializing in PPD support (43%), support groups (43%), and hotlines (38%). Pamphlets (33%), enhanced insurance coverage for PPD support services (33%), and websites with local information (such as HMHB) (30%) were also mentioned as resources that would help improve access to PPD support and treatment.

Breastfeeding Support Assessment

Parent Participant Results

Over 95% (n=106) of participants initiated breastfeeding and 73% of participants reported exclusively breastfeeding for at least six months (Table 5). Participants who breastfed exclusively for at least six months attributed their success to a variety of reasons, including: personal preference (70%); partner and family support (66%); knowing what to expect going into it (53%); available lactation support (33%); and having a relatively easy experience (33%). While rates of initiating and sustaining breastfeeding in this study were substantial, over half (54%) were concerned about milk supply, one-third (33%) were concerned child was not gaining enough weight, and 29% reported their milk didn't come in right away as the reasons for supplementing with formula among the 24 women that initiated and supplemented breastfeeding before 6 months.

Table 5.

Parent Participants Experience on Breastfeeding Behaviors and Selected Characteristics

	Frequency of Responses	Percentage of Respondents (N = 112)
Breastfeeding behavior
Exclusively, for at least 6 months	82	73%
Reasons for breastfeeding success (n=82)*
Personal preference	662	76%
My partner and family supported me	559	72%
I knew what to expect going into it	447	57%
Lactation support was available	229	35%
It was relatively easy	229	35%
As much as possible, but with some formula supplementation, for at least 6 months	13	12%
As much as possible, but with some formula supplementation, for less than 6 months	8	7%
Exclusively, for less than 6 months, then switched to formula	3	3%
Reasons for supplementing with formula (n=24)*
I was concerned about my milk supply/not making enough milk	13	54%
My child was not gaining enough weight	8	33%
My milk didn't come in right away	7	29%
Medical reasons	4	17%
It was too painful	4	17%
I did not breastfeed my child	5	4%
Non-response	1	1%
Lactation consultant available at birthing facilities
Yes	84	75%
No	24	21%
Non-response	4	4%
Aware of providers who provide breastfeeding support, not including lactation consults
Yes	43	38%
Information source (n = 43)*
Friend or family member	14	33%
Media (Internet, TV)	11	26%
Other health care provider	7	16%
Hospital	7	16%
Other	6	14%
No	48	43%
I don't know	17	15%
Non-response	4	4%
Aware of lactation consultants
Yes	73	65%
No	19	26%
I don't know	14	19%
Non-response	6	8%
Aware of breastfeeding classes
Yes	59	53%
No	2	2%
I don't know	41	37%
Non-response	10	9%
Aware that a pediatrician can provide breastfeeding support
Yes	30	27%
No	19	17%
I don't know	52	46%
Non-response	11	10%
Aware of websites or online groups
Yes	49	44%
No	52	46%
Non-response	10	9%
Aware of hotlines
Yes	19	17%
No	81	72%
Non-response	12	11%
Identified barriers*
Better marketing of existing resources needed	23	21%
Stigma, lack of community support	20	18%
Lack of education (parents)	17	15%
Desired resources*
Breastfeeding classes	59	53%
Home visitors/breastfeeding peer counselors	57	51%
Support groups	52	46%
Places to rent or buy a breast pump or other equipment	45	40%
Lactation consultants	43	38%
Community/nonprofit lactation services	43	38%

^*Participants could choose more than one option.

About three-quarters (76%) of all parents reported that there were lactation consultants available at their birthing facility. About 38% said they were aware of health care providers who provided breastfeeding support (not including lactation consultants), 43% were not aware, and 19% reported not knowing or skipped the question. Of the 43 respondents who reported they knew a health provider who provided breastfeeding support, 33% had been told by a friend or family member, and 26% found out via the media. Almost two-thirds (65%, n=73) of all parents responding were aware of lactation consultants that provide breastfeeding support, 17% were not aware, and 18% did not known or didn't answer the question.

Only 53% (n=59) of respondents were aware of local breastfeeding classes, 2% were not aware, and 46% did not know or did not answer the question. Only27% (n=30) of parent respondents reported they were aware of pediatricians who provide breastfeeding support, 17% were not aware, and 56% did not know or did not answer the question. Less than half (44%) of respondents were aware of local breastfeeding websites, 46% were not aware, and 9% did not answer the question. Few respondents (17%) knew of any local breastfeeding support hotlines. Participants identified a range of barriers to accessing breastfeeding support resources, including the need for better marketing of existing resources (21%), stigma and lack of community support (18%), and the lack of parental education (15%). When asked about desired resources for breastfeeding support, 53% reported breastfeeding classes, 51% reported home visitors/breastfeeding peer counselors, 46% reported support groups, 40% reported places to rent or buy a breast pump or other equipment, 38% reported lactation consultants, and 38% reported community non-profit lactation services.

Provider Participant Results

Three-quarters (75%) of provider respondents reported discussing breastfeeding with their patients/clients as a routine part of the care, 15% reported only if the client asks for help, and 10% reported not routinely discussing it (Table 6). When asked to identify support resources that help clients breastfeed, 58% reported supportive patterns and/or families, 43% reported the availability of lactation support, 30% reported personal preferences, and 28% reported easy access to breast pumps and other equipment. Providers identified a variety of reasons that their patients/clients supplement with formula. Similar to responses from parents, the primary reason that patients/clients do not breastfeed is a perception of a milk supply issue (50%), followed by: infant not gaining enough weight (38%), disinterest in breastfeeding (23%); lack of workplace support (23%); and lack of partner and/or family support (20%). Although 14 providers (35%) indicated that they did not think women in Hawai‘i had adequate lactation support, six providers (15%) did think lactation support was adequate, and half (50%) did not know or did not answer the question.

Table 6.

Provider Participants Breastfeeding Support Characteristics

	Frequency of Responses	Percentage of Respondents (N = 20)
Frequency of breastfeeding discussion
It is a routine part of the care I provide	15	75%
Only if they ask for help	3	15%
I do not routinely discuss it	2	10%
	Frequency of Responses	Percentage of Respondents (N = 40)
Support resources that help clients breastfeed*
Supportive partners and/or families	23	58%
Lactation support was available	17	43%
Personal preference	12	30%
Easy access to breast pumps and other equipment	11	28%
Preparation, such as classes	10	25%
Other	2	5%
Non-response	14	35%
Reasons for supplementing with formula*
Perception of a milk supply issue	20	50%
Infant not gaining enough weight	15	38%
Disinterest in breastfeeding	9	23%
Lack of workplace support	9	23%
Lack of partner and/or family support	8	20%
Lack of lactation support services	6	15%
Medical problem with infant	5	13%
They didn't know the AAP guidelines of exclusive breastfeeding for 6 months	4	10%
Cultural stigma around breastfeeding	3	8%
Medical problem with mother	3	8%
Lack of access to breast pumps or other equipment	3	8%
Cultural barriers	3	8%
Other	7	18%
Non-response	14	35%
Adequacy of lactation support
Not sufficient	14	35%
Sufficient	6	15%
I don't know	6	15%
Non-response	14	35%
Barriers to increasing access and use of existing resources*
Mothers wait too long to ask for help/don't know where to access help	19	48%
Lack of lactation support or resources (IBCLCs or certified lactation educators)	16	40%
Lack of trained care providers (physicians, OB/GYNs, pediatricians)	15	38%
Insurance does not cover lactation support or equipment	14	35%
Employers are not supportive of breastfeeding mothers	13	33%
People don't have money or insurance to access breastfeeding support services	12	30%
Providers/health centers are not supportive of breastfeeding	8	20%
People live far away from health care services and don't have easy access to transportation	7	18%
Schools are not supportive of breastfeeding mothers	7	18%
Funding for increasing support programs isn't available	7	18%
Breastfeeding support is not offered/not available at time of birth	6	15%
Breastfeeding is not part of the culture	5	13%
Resources are not available in the right languages	4	10%
Non-response	14	35%
Equal access to breastfeeding support across incomes
Yes it is equal	11	28%
No it is not equal	11	28%
I don't know	4	10%
Non-response	14	35%
Desired resources more widely available*
Lactation consultants to refer patients/clients to	21	53%
Home visitors with lactation training	20	50%
Support groups	16	40%
Culturally-appropriate information	14	35%
Classes	13	33%
Places to rent breast pumps and other equipment	13	33%
Pamphlets and other fact sheets	13	33%
WIC clinics	10	25%
Hotlines (such as MothersCare Line)	9	23%
Community health centers/local medical centers	8	20%
Community or nonprofit services	8	20%
Resources/materials in languages other than English	8	20%
Lactation support training for health care providers	2	5%
Non-response	14	35%

^*Participants could choose more than one option.

Providers identified a variety of barriers to increasing access and use of existing resources, including: mothers waiting too long to ask for help or not knowing where to access help (48%); lack of lactation support or resources (40%); lack of trained care providers (physicians, OB/GYNs, pediatricians; 38%); lack of insurance coverage for lactation support or equipment (35%); and employers being unsupportive of breastfeeding mothers (33%). Of note, 35% did not answer the question. 28% of providers reported there was equal access to breastfeeding support and the same proportion did not (28%), and nearly half (45%) reported not knowing or didn't answer the question. When asked about resources that providers desired to see more widely available, 53% of providers desired having lactation consultants to refer clients to, 50% desired home visitors with lactation training, 40% desired support groups, 35% desired culturally appropriate information, 33% desired classes, 33% desired places to rent breast pumps and other supplies, and 33% desired pamphlets and fact sheets.

Discussion

A number of overarching themes emerged from these surveys, providing a strong foundation for future programmatic and advocacy efforts to improve PPD support and breastfeeding in Hawai‘i. The lack of consistent screenings for PPD may be due to a lack of provider training, a lack of both providers' and parents' understanding of the importance of addressing symptoms, and cultural stigma and shame. While screening for PPD is crucial, it is also important to consider that screening should be done at multiple time periods and in different settings. As one respondent revealed, “I received a screening questionnaire on my first pediatrician visit one week after birth but I was still on adrenaline. The exhaustion and the emotions did not hit me until a few weeks later but I never got screened again or was ever asked about it in person by my OB/GYN or pediatrician.” Finally, many new mothers may not be aware of available services, or might not even know that they have PPD and need help.

Participants also shared similar perceptions of the landscape of breastfeeding support resources in Hawai‘i, including a lack of trained providers and inequitable access to services. Overwhelmingly, participants reported that traditional health care providers fell short in providing adequate, ongoing breastfeeding support which one respondent revealed: “The biggest gap is the lack of support from the medical community. Having lactation consultant or lactation counselor trained staff could be instrumental in helping mothers succeed (especially so with the pediatrician well baby checks).” Whereas, another highlighted the importance of availability and reinforcement of breastfeeding with the following: “There needs to be more support offered prenatal and after leaving the hospital. So many women have issues after leaving the hospital but don't have access to immediate help when it's needed.” Several respondents noted that many populations are underserved and available resources in certain languages are scarce. This supports results from the Hawai‘i PRAMS survey and other local studies.^3,7,9 Such studies stress the importance of culturally sensitive and appropriate approaches to promoting exclusive breastfeeding, emphasizing that high breastfeeding initiation rates among Asian subgroups may not necessarily lead to rates of high breastfeeding exclusivity.9 Recommendations include enhanced breastfeeding support groups, better trained and more supportive medical staff, and access to comprehensive breastfeeding information, including advocacy and social marketing, as well as promoting work environments that provide breastfeeding support.

There are limitations to this study. The response rate was low, as only 152 parents and providers (4.5% of potential participants) submitted a complete survey. Using HMHB's database of contacts and social media followers for the parent survey population may have led to selection bias on several levels. Firstly, participants were limited to those who have Internet access. Secondly, the length of the survey may have narrowed the participant population, with parents of a higher-than-average SES completing it more easily than those with a lower SES. Thirdly, parent participants, by virtue of their interest in and affiliation with HMHB, have a higher-than-average commitment to breastfeeding, compared to the general population. Further, neighbor islands were underrepresented which increases uncertainty about the representativeness state wide, particularly related to support services and areas of need across all the islands. Results from parent respondents failed to capture the support needs and experiences of low-income mothers, yet responses provided unique perspectives on the topics. Responses were combined with those from provider participants, the majority of whom work with low-SES patients, to describe breastfeeding and PPD support environments. While many women who successfully breastfed attributed their success at least in part to lactation consultants (available at most Honolulu-based birthing facilities and hospitals), women who gave birth on other islands and even in certain locations on O'ahu were much less likely to have easy access to a lactation consultant.

Conclusion

To optimize both maternal and infant health outcomes, it is crucial that families access necessary postpartum support services in a timely fashion. Recommended cost-effective approaches include: enhanced breastfeeding training for healthcare providers; routine screenings for PPD symptoms; more educational classes for parents; improved access to, and awareness of, existing resources (including classes and support groups); and continued advocacy efforts. HMHB helps fulfill a valuable role, serving as a central agency for information and referrals (via website and social media, MothersCare phone line, and Text4baby), and anticipates continued growth to meet the identified postpartum support needs. The development of, and access to, more peer support groups for new mothers is one such tool being developed by HMHB to help fulfill the need for services and education. Outreach efforts to health providers are also currently being developed, and HMHB is actively looking for ways to collaborate with perinatal health providers to enhance awareness of resources to improve the health of mothers, children and families in Hawai‘i.

Conflict of Interest

None of the authors identify a conflict of interest.