Table 2.

Themes and Illustrative Quotes

THEME	SUBTHEME	DESCRIPTION	EXAMPLE QUOTES
Telelactation expectations and patterns of use among rural mothers	Expectations/motivation to participate in telelactation trial	• Maximize chance of breastfeeding success, prevent problems • Convenient access to support • Ensure availability of support in geographically-isolated area	“…being able to know there's someone always there to talk to, even if it's in the middle of the night” (Multiparous mother, 1 telelactation visit) “…there's not a whole lot around here as far as breastfeeding support, so it was nice to have something available…” (Primiparous mother, 3 telelactation visits)
	Characteristics and patterns of telelactation visits with rural mothers	• Timing of first call most often in first 2 weeks postpartum • Calls made when interruptions/distractions anticipated to be minimal • Addressed wide range of issues (e.g., latching, nipple pain, engorgement, oversupply, use of devices such as pumps) • IBCLCs perceived differences between calls received from mothers in rural vs. metropolitan areas	“[I used the app] mostly at night, because it was quiet and my son was sleeping” (Multiparous mother, 5 telelactation visits) “I did one [telelactation visit] in the car…two of them in my bedroom” (Primiparous mother, 3 telelactation visits) “… And then my rural moms tend to be just more like really basic stuff. Like, ‘How often am I supposed to be pumping, how long?’ So just really questions that I think any mom who can Google stuff would already know, but these moms, I don't think that seek out medical information like a more urban mom or like a higher socioeconomic status mom would” (IBCLC)
Positive attributes of telelactation	Telelactation fills a void	• Bridged gap between pediatric office visits, reduced need for in-person follow-ups for feeding issues • On-demand breastfeeding support in area lacking such resources • Cultivated nurse confidence to provide breastfeeding support	“We live in a rural area and there's not a whole lot around here as far as breastfeeding support, so it was nice to have something available and be able to use it and not have to leave the house and travel to get somewhere to get that support” (Primiparous mother, 3 telelactation visits) “It's amazing, because just the fact that [the app is] available 24 hours a day, 7 days a week…other professionals, you know, may or may not be available, or [mothers] feel badly about calling us, you know, in the middle of the night with a breastfeeding question” (Pediatrician) “I like sitting in on [telelactation visits] because I, as a nurse, feel like I'm getting feedback too” (RN) “This app provides that immediate assistance. You're not going to get that by calling your pediatrician and getting a call back the next day. That face-to-face ability to show mom things and help her when she's really feeling like she's in crisis is really the most powerful thing about the app” (IBCLC)
	Ease of app use	• Simple, easy to use app design • Quick connection speed	“I connected fast. It was simple. It's an easy app to use. All you've got to do is click on ‘Connect with lactation consultant’ and they automatically sent [a lactation consultant]…There's not any extra buttons. There's not any extra stuff that you have to do” (Primiparous mother, 4 telelactation visits)
	Value of video	• Facilitated efficiency, convenience (e.g., visualization of breast anatomy, technique, body language, and mother's home environment) • Seeing IBCLC cultivated trust, reassurance • Potentially increases in maternal confidence through “hands-off” nature of video support in which mothers “do the work” (e.g., position infant)	“…it does make it more personal, personable when you can actually see that person and talk to them, I'd say” (Multiparous mother, 1 telelactation visit) “It's nice to be able to just sit down for a minute and talk to a lactation consultant while you have the time, not make an appointment, go in, drive and meet with someone” (Multiparous mother, 5 telelactation visits) “A lot of times the mom is telling me something that she thinks is what's going on, and when I see it on the video camera I'm like, ‘Oh, yeah, that's so simple. Baby's totally positioned incorrectly…’ [Telelactation] gives me a lot more than when I'm on the phone…There's nothing like actually seeing it, you know?” (IBCLC) “The one thing I do love about it is I can see the mom's facial expressions. And there's a huge element to that because you can see whether or not she's stressed, you can see on their faces if they're understanding. And I hope that it makes a difference that they can see my facial expression, my care, that there's somebody out there that is understanding what they're going through…versus just over the phone being able to try to communicate with just words” (IBCLC)
	Quality and experience of IBCLCs	• IBCLCs perceived to have excellent communication and listening skills • Perceived as personable, empathetic, astute, professional	“Oh, yeah, she was a good listener. She was caring. She cared what I had to say, too. She didn't mow over what I had to say and, it was an actual conversation, two-sided” (Primiparous mother, 3 telelactation visits) “I just showed her quickly and she knew exactly what was wrong about how I had him [positioned]… [All of the IBCLCs] listened so carefully and…they just knew what I was talking about…Even with any doctor, you can say your issue and they'll name off a million different things could be wrong, and they're still wrong half the time…” (Multiparous mother, 3 telelactation visits)
	Effect of app on maternal breastfeeding confidence and breastfeeding outcomes	• Increased breastfeeding confidence • Resolved breastfeeding problems, prevented exacerbation of issues • Enabled efficient use of time at well-baby visits	“[If I didn't have the app], I would have kept my [breastfeeding] questions and waited until the pediatrician's visit…but I was able to get my questions answered before that, and then I didn't have to spend time during his visit to talk to them about that stuff. I was able to focus on other things” (Multiparous mother, 1 telelactation visit) “Obviously, there was nothing like this app [when I had my first child]. If they had this a couple years ago, I probably would have breastfed him longer, if I had someone that I could call right at home” (Multiparous mother, 3 telelactation visits)
Barriers to telelactation and solutions	No perceived need for telelactation	• Convenient access to in-person support that mother preferred to telelactation • Previous breastfeeding experience, lack of challenges • Competing demands that deprioritized breastfeeding concerns (e.g., infant's re-hospitalization)	“I tried to think of questions to ask, but I really don't have any because I've done this [breastfeeding] before” (Multiparous mother, no telelactation visits) “I used [the telelactation app], and then I also have a lactation consultant as well through a WIC program. Sometimes it's easier for me to just send a quick text to the [WIC] lactation consultant…[rather] than get on and do a video” (Multiparous mother, 1 telelactation visit)
	Apprehension about telelactation	• Discomfort with taking to a stranger over video • Mothers overcame apprehension by having initial test call with hospital clinicians, encouragement by family and friends, and/or experiencing worsening or persistent problem for which other supports had been inadequate	“I know some people feel uncomfortable with video chatting. I know for me, that was kind of a thing, too, like I wasn't too positive on video chatting somebody I didn't quite exactly know” (Primiparous mother, no telelactation visits) “I was so nervous and I felt so awkward at the same time, but I'm really glad that the people at the hospital had me [do a test] call, and my first experience [using the app] was really good and helpful. Because when I got home, I had some more issues. And looking back on my first time calling, it made me want to really push myself to call again” (Multiparous mother, 3 telelactation visits)
	Getting the app to work	• Logging in/updating app, poor reception/inadequate WiFi coverage, problems positioning phone while holding infant • Overall did not present as major barriers to app use	“I'm sure that if I could get [the app] to work, that it would be very helpful for me, but obviously, I'm not in a very good place for it…I'm in a very small town right now. Every public place [with WiFi coverage] is like half-an-hour away from me” (Multiparous mother, attempted 1 telelactation visit but could not connect)
	Recommendations to improve the app: offer text and audio/phone visits in addition to video visits	• Would address maternal reluctance to initiate video visits • Alternative to video when time or private space is lacking	“I'm the type of person who doesn't really like face-to-face…and then talking about my breasts to a stranger it makes me even more nervous. So, if there was like a phone call instead of video chat…” (Primiparous mother, 3 telelactation visits) “Yeah, if there was like a live chat option, I think it would be helpful, too. Because if I'm breastfeeding in the middle of the night and I had a question that I thought of, I probably wouldn't want to do a video chat when it's dark. You know, get lights on and stuff like that…If there was [a live chat] option, I probably wouldn't go to Google as often for the same kind of questions” (Multiparous mother, 1 telelactation visit)
	Recommendations to improve the app: Support follow-up with the same IBCLC	• To enhance continuity of care, build relationships/familiarity	“There's no guaranteed follow-up with the same lactation consultant and, as a provider, I don't get to know that they're doing okay. So I always tell them ‘Try to just let the next provider know what we talked about, and they'll be able to pick up where I left off.’ And so that's one limiting factor is there's that lack of continuity with the same provider” (IBCLC)

IBCLC, international board-certified lactation consultant.