Abstract
The Michigan Department of Community Health (MDCH) funded 9 local breastfeeding coalitions to implement breastfeeding support groups and to develop breastfeeding resources for mothers and health professionals. The authors conducted qualitative analyses of reports, success stories, and MDCH grantees’ interview responses (via follow-up call with 3 coalitions) to assess key barriers, facilitators, and lessons learned for coalitions implementing breastfeeding support groups. Coalitions noted implementation barriers related to their organizational structure and to recruiting mothers and finding meeting locations. Facilitators to implementing breastfeeding support groups included referrals, expertise, resources, and incentives. The following themes emerged from the reports analysis regarding how to implement breastfeeding support groups: “meet moms where they are,” build community partnerships, and leverage in-kind and financial resources to sustain breastfeeding support groups.
Keywords: breastfeeding, breastfeeding support, coalitions, community-based
Background
The Surgeon General’s Call to Action to Support Breastfeeding (CTA) was issued in 2011 and provides guidance to multiple sectors and individuals to encourage supportive breastfeeding practices. The CTA includes a specific charge to communities to strengthen programming for mother-to-mother support and peer counseling. The CTA also encourages funding of community-based organizations (CBOs) and using CBOs to promote and support breastfeed-ing (Note 1).1 The Michigan Department of Community Health (MDCH) used the Centers for Disease Control and Prevention’s (CDC) Nutrition, Physical Activity, and Obesity Program’s Cooperative Agreement funds to implement 5 breastfeeding support projects that aligned with the CTA recommendations. This article discusses the barriers, facilitators, and recommendations gleaned from 1 of the MDCH’s 5 projects: Enhancing Breastfeeding Support Through Community-Based Support Groups.
The MDCH funded 9 local breastfeeding coalitions to establish or expand breastfeeding support groups (BSGs) and to develop breastfeeding resources for mothers and health professionals. Coalitions were represented across the state of Michigan (a Midwestern state within the USA), including 1 coalition from each of the following counties: Calhoun, Wayne, Genesee, Muskegon, Jackson, and Huron counties as well as the Capital Area Breastfeeding Coalition, Southwest Breastfeeding Coalition, and Breastfeeding Education Support Team in Chippewa County. Mothers who participated in BSGs were 5.6% mixed race, 0.7% Asian, 0.7% American Indian, 23.8% black or African American, and 69.2% white. The goal of this project was to provide posthospital discharge support for breastfeeding mothers to encourage exclusive breastfeed-ing and to extend breastfeeding duration through the first 6 to 12 months of the infant’s life.
Methods
The authors conducted a secondary qualitative analysis of available reports, success stories, and MDCH subgrantees’ interview responses (via follow-up calls with 3 coalitions; Note 2) to assess key barriers, facilitators, and lessons learned for coalitions implementing BSGs. The CDC authors used an inductive qualitative approach similar to the methods described in the overview manuscript for this special issue of the Journal of Human Lactation2; this included coding reports and interview responses, conducting a thematic analysis, and summarizing the findings.3
Overview of Activities
Coalitions established and facilitated support groups using various formats including Baby Cafés (Note 3),4 peer support through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) peer counselors, and meetings led by trained lay breastfeeding facilitators through La Leche League. Coalitions were also charged with developing or enhancing a website and breastfeeding resource guide for breastfeeding moms and health professionals who promote breastfeeding. Some coalitions also provided support group participants with access to a breast pump loaner program and referral programs such as “warm line” support (Note 4).5 All coalitions offered incentives as described in the facilitators section below.
Implementation Barriers
Recruitment
One recruiting challenge noted in coalition reports and the coalition follow-up call was getting interested mothers to attend meetings and another was reaching African American mothers. Although mothers expressed interest in participating in support groups initially, they may have not actually participated due to winter weather complications, concern with meeting locations (ie, location safety), or the inconvenience of scheduled meeting times. One coalition partnered with a community organization to reach African Ameri-can mothers. Although coalitions marketed BSGs through flyers and in-person recruiting events, some of the recruitment barriers were overcome through health professional referrals as will be discussed in the facilitators section.
Meeting location
Securing mother–baby friendly meeting locations also presented a challenge to coalitions. Whereas some coalitions were able to hold support group meetings in the same venues where mothers were recruited (eg, WIC office, church location) at no cost, other coalitions needed to rent meeting spaces. One coalition found it helpful to use the public library and schedule the meeting immediately following story time, making it convenient for mothers already present. Another coalition originally started its meetings in a local church but soon discovered that mothers preferred locations in safer neighborhoods.
Organizational structure
Two coalitions reported their organizational structure or size as an implementation barrier. One coalition could not start a pump rental program because they did not have nonprofit status and had not established a bank account. The grant gave them an incentive to initiate these tasks. Although 2 coalitions reported implementation challenges related to loaning breast pumps, it did not hinder their implementation of breastfeeding support groups.
Implementation Facilitators
Referrals
Coalitions reached breastfeeding mothers through referrals. Most coalitions (8 of 9) used flyers in hospitals or health departments to recruit participants and relied on providers to refer mothers to BSGs. Six of the 9 coalitions used WIC/Maternal Infant Health Program as a referral source.
Expertise
Breastfeeding professionals attended support group meetings to provide on-site expertise to mothers. Breastfeeding professionals included International Board Certified Lactation Consultants (IBCLCs), Certified Lactation Consultants, trained peer counselors, doulas, and coalition members. International Board Certified Lactation Consultants were present for Baby Café sessions, and other licensed professionals were available for non-Baby Café sessions (eg, BSGs held at WIC clinics, La Leche League support groups). Doulas and coalition members also led some support groups. Most coalitions consisted of registered dietitians, doulas, mothers, nurses, and breastfeeding advocates who were equipped to lead support group meetings. Lay persons were trained through organizations such as La Leche League to facilitate support meetings, whereas other coalitions used WIC peer counselors. The majority of coalitions reported having the necessary breastfeeding expertise available for support groups.
Resources and incentives
Coalitions offered incentives to encourage support group participation and encourage mothers to breastfeed. All coalitions provided breastfeeding-friendly items such as breast pads, nursing pillows, and milk storage bags as well as functional incentives such as grocery store gift cards, gas cards, and diapers. One coalition established a lending library consisting of reference books to supplement the support mothers received during peer meetings. Coalitions expressed plans to continue using these resources to sustain future breastfeeding efforts.
Lessons Learned
Based on this analysis of coalition reports and the MDCH report, 3 themes emerged that could guide future efforts to implement and sustain community-based BSGs.
Recommendation #1: Meet Mothers Where They Are
Coalitions strategically worked to enhance breastfeeding mothers’ access to support groups. Coalitions built awareness of support groups through referrals, flyers, special events, and word of mouth. Meeting locations and times were established to meet the needs of mothers on the basis of transportation concerns and work schedules. Providing incentives that fit mothers’ needs was another strategy for “meeting moms where they are.” These actions were implemented to recruit mothers and encourage continual engagement in BSGs.
Recommendation #2: Build Community Partnerships
Coalitions established partnerships with health professionals who work with pregnant women and new mothers for recruitment and support group implementation. As noted in the referral section, fewer coalitions used WIC as a referral source compared with using hospitals and health departments. However, WIC professionals were the primary referral source referenced by mothers. Some WIC offices served as the meeting group location and also staffed the support groups with peer counselors. Coalitions reached minority mothers and hard-to-reach mothers through community partnerships and referrals. Partnering with support referral programs such as warm lines also allowed mothers to receive after-hours support.
Recommendation #3: Leverage Additional Resources to Implement and Sustain Breastfeeding Support Groups
Coalitions reported their plans to leverage additional funds and to sustain their support groups. One coalition leveraged in-kind donations for meeting space and food for support groups before the end of the grant. Three coalitions will continue working with health professionals such as WIC peer counselors, coalition members who are IBCLCs, and other community support groups and health clinics offering breast-feeding support at no cost. Two coalitions mentioned seeking additional funds from partners and other grantors. One coalition decided to apply for nonprofit status that would increase eligibility for additional future funds. Most coalitions also reported seeking in-kind donations for facilitation time and meeting space in order to sustain BSGs.
Conclusion
The MDCH’s Enhancing Breastfeeding Support Through Community-Based Support Groups project supported coalitions in their implementation of community breastfeeding support for mothers. Coalitions overcame recruitment barriers by partnering with health care providers and health care facilities to reach mothers. Partners were also important for implementing and sustaining support groups. Each coalition used varying levels of breastfeeding experts as facilitators for BSGs. Overall, coalitions emphasized the importance of addressing the target audiences’ needs by “meeting moms where they are”—including recruitment, types of incentives, and securing meeting space—to encourage breastfeeding among mothers.
Acknowledgments
The authors gratefully acknowledge the following contributors and 9 coalitions that participated in Michigan’s Breastfeeding Initiative: Gwendoline Imes, MS, RDN, Beth Eggleston, MS, RD, Calhoun County Breastfeeding Coalition Capital Area Breastfeeding Coalition, Breastfeeding Education Support Team in Chippewa County, Genesee County Breastfeeding Coalition, Huron County Breastfeeding Support Group, Breastfeeding Coalition of Jackson County, Muskegon Breastfeeding Coalition, Southwest Michigan Breastfeeding Coalition, Wayne County Breastfeeding Coalition.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: US Department of Health and Human Services, Centers for Disease Control and Prevention CDC-RFA-DP08-8050501PPHF12.
Footnotes
These recommendations reflect Actions 3 and 4, respectively, as noted in the Surgeon General’s Call to Action to Support Breastfeeding.1
Each of the 9 coalitions was invited to participate in 1 of 2 follow-up calls, however, only 3 coalition representatives were available to join the scheduled calls.
Baby Cafés are breastfeeding centers that allow mothers to drop in for breastfeeding support.
Breastfeeding warm lines are telephone help lines open for individuals to call for breastfeeding support.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors prepared the article within the scope of their employment with the Centers for Disease Control and Prevention. Accordingly, the content of this article is a US government work and in the public domain within the United States.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References
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