Impact of Doula-Led Lactation Education on Breastfeeding Outcomes in Low-Income, Minoritized Mothers

Abstract

Prenatal education may improve breastfeeding outcomes among low-income women. Our objective was to assess breastfeeding intentions and knowledge among women participating in doula-facilitated prenatal education classes from August 2016 to October 2017. Breastfeeding knowledge and infant feeding intentions were assessed before and after the classes. Breastfeeding rates were assessed at birth, 2–4 weeks postpartum, and 6–8 weeks postpartum. Paired t-tests tests were conducted. A total of 121 racially diverse, low-income women were enrolled. Intentions to breastfeed increased pre- to post-intervention (p = 0.007). Breastfeeding knowledge scores increased pre- to post-intervention (p <.001); specifically, among women who were exclusively breastfeeding or breastfeeding while supplementing with formula at birth (p < .001 and p = 0.046, respectively). Doula-facilitated breastfeeding education may help improve breastfeeding outcomes for low-income women.

BACKGROUND

Breastfeeding rates for low-income women and women of color are lower than the average breastfeeding rate in the United States (Anstey et al., 2017; Centers for Disease Control and Prevention[CDC], 2017; Louis-Jacques et al., 2017). Sixty-four percent of non-Hispanic Black women initiate breastfeeding, while 82% of Hispanic and non-Hispanic White women initiate breastfeeding (Anstey et al., 2017). Seventy-one percent of low-income women initiate breastfeeding while 91% of women ≥600% of the federal poverty level initiates breastfeeding. Additionally, evidence suggests that low-income women are more likely to face barriers to breastfeeding initiation and duration such as an early return to work and low workplace support for breastfeeding (Lauer et al., 2019). While prenatal education has a positive effect on breastfeeding outcomes (Patnode et al., 2016), it is often inaccessible for low-income women due to factors such as time constraints and transportation issues (Heaman et al., 2015; Shah et al., 2018). It is important for researchers to develop intervention strategies that take into account the unique barriers that low-income women may face in attempting to breastfeed.

A recent literature review identified several factors that may promote and prolong breastfeeding among women of color, including community support, support from health-care providers, confidence in breastfeeding abilities, and having a breastfeeding role model (Spencer & Grassley, 2013). Community-based doula programs may provide low-income women of color with the necessary breastfeeding information and support through the provision of doula services for free or at a lower cost (Wint et al., 2019). Community-based doula programs provide support during the prenatal period, during birth, and on occasion, postnatally (Edwards et al., 2013; Thullen et al., 2014). Another advantage of community-based doula programs is that most of the doulas are typically from the same communities in which they serve (Edwards et al., 2013; Thullen et al., 2014).

Although research regarding doula support is limited (Bohren et al., 2017; Caughey et al., 2014), published literature indicates doula support can reduce medical costs and improve health outcomes (Kozhimannil et al., 2016), especially among lower income women (Kozhimannil et al., 2013). Doulas also provide mothers with breastfeeding education and support (Cattelona et al., 2015); however, doulas are often underutilized among low-income women and women of color (Kozhimannil et al., 2014). This may be a result of the view that doula services are traditionally limited to White women and those with the financial capabilities to hire doulas (Bohren et al., 2017). Furthermore, doula support has not been widely implemented as part of community-based strategies for improving maternal and infant health outcomes (Kozhimannil et al., 2016).

Based on emerging data regarding the positive influence that doulas have on maternal and infant outcomes and a local qualitative research project on disparities in breastfeeding and factors that influence infant feeding decisions (Deubel et al., 2019; Louis-Jacques et al., 2017; Miller et al., 2017), a prenatal breastfeeding education quality improvement (QI) initiative was designed. Research interviews with mothers indicated that those who opted to receive free care from a clinic-based, state-funded doula program had positive childbirth and breastfeeding experiences (Deubel et al., 2019). Thus, the aims of this QI initiative were to increase breastfeeding knowledge and intentions by providing doula-facilitated prenatal breastfeeding education in low-income birth clinics. The objectives of this study were to assess differences in participants' breastfeeding intention and knowledge scores before and after participating in a doula-led prenatal breastfeeding education class and assess postpartum breastfeeding outcomes of women participating in the QI initiative.

METHODS

Design

The data from this study were obtained as part of a QI initiative that included a doula-facilitated prenatal breastfeeding education class. The class was delivered on a recurring basis throughout the duration of the QI initiative. The QI initiative was reviewed by the Institutional Review Board and determined to be exempt. Written informed consent was obtained prior to participation.

Setting

The QI initiative was conducted from August 2016 to October 2017 at four prenatal care clinics. Breastfeeding education was presented in a 1-hour educational class that was delivered in an interactive format and included materials from the American College of Obstetrics and Gynecology (ACOG) breastfeeding support toolkits (American College of Obstetricians and Gynecologists) such as breastfeeding infographics and frequently asked questions (FAQ) handouts. All educational materials were included in English and Spanish. The educational class provided practical information and hands-on techniques that women could practice with doula guidance using props that included breast, infant, and infant stomach capacity models. The prenatal breastfeeding education class was administered at least once a week at the prenatal care sites during the QI initiative. An International Board Certified Lactation Consultant (IBCLC) was available after the sessions if the women wanted to receive more one-on-one breastfeeding counseling. All women were offered free doula services at the conclusion of the class.

The doulas facilitating the prenatal breastfeeding education sessions were part of a state-funded program that provides free services to low-income or pregnant women at high risk for poor birth outcomes. Services include labor and birth support, postpartum support, and breastfeeding information. Typically, doulas provide support to pregnant women beginning at 36 weeks of gestation and continue weekly until birth. The doulas may also conduct home visits at five days, two weeks, and two months postpartum. All doulas in the program received certification through Doulas of North America International and were certified lactation counselors. Seven doulas of African American or Hispanic descent facilitated the prenatal breastfeeding education sessions. The doulas had a pre-existing relationship with the QI clinic sites because the doulas received client referrals from the prenatal care clinics. The doulas were between the ages of 25–54 years old. The doulas' levels of experience ranged from 7 months to 17 years and six doulas of the seven doulas had a personal history of breastfeeding.

Sample

A racially and ethnically diverse group of pregnant women ages 18–50 were recruited at four prenatal care sites that provide services to low-income women in the Tampa Bay area. Low-income indicates the primary population served by these care sites meet Medicaid income eligibility requirements. Women were eligible to participate during any stage of gestation. Postpartum women and those with a contraindication to breastfeeding were excluded. The 121 women enrolled in the QI initiative attended a single prenatal breastfeeding education session facilitated by a doula who was also a certified lactation support counselor.

Measurement

Infant feeding intentions (IFI) were measured using a validated five-item scale with response options ranging from “Very Much Agree” to “Very Much Disagree” (Nommsen-Rivers et al., 2010; Nommsen-Rivers & Dewey, 2009). Cronbach's alpha for the IFI scale has ranged from 0.81 to 0.90 (Nommsen-Rivers et al., 2010; Nommsen-Rivers & Dewey, 2009). IFI scores range from 0 to 16, with higher scores indicating stronger intentions to breastfeed (Nommsen-Rivers et al., 2010; Nommsen-Rivers & Dewey, 2009). IFI scores were calculated by adding the mean for the first two scale items to the sum of the last three scale items (Nommsen-Rivers et al., 2010; Nommsen-Rivers & Dewey, 2009).

Breastfeeding knowledge questionnaire consisted of 14-items spanning seven domains (benefits to mother, benefits to infant, human milk components, breastfeeding mechanics, problem-solving feeding frequency, human milk production) (Dreesmann, 2014). Two questions were listed under each domain; response options were “True,” “False,” and “Not Sure” (Dreesmann, 2014). Scores can range from 0 to 14, with higher scores indicating greater breastfeeding knowledge (Dreesmann, 2014). Breastfeeding knowledge scores were calculated by assigning 1 point for every question answered correctly on the knowledge scale and 0 points for every question answered incorrectly or “Not Sure” (Dreesmann, 2014). Points were summed to create a total score (Dreesmann, 2014).

Data Collection

Data collection occurred at baseline (pre-education), post-education, birth, 2–4 weeks postpartum, and 6–8 weeks postpartum for all participants. At baseline, questionnaires were used to assess breastfeeding knowledge and IFI. Additional data were collected regarding participant demographics and general breastfeeding concerns. Post-education, the women completed the breastfeeding knowledge and IFI scales. Birth medical record review included information about maternal, neonatal, and breastfeeding outcomes. At 2–4 and 6–8 weeks postpartum, doulas or research staff collected infant feeding information during a home visit or telephone interview. All data collection tools were made available in English and Spanish.

Data Analysis

Women were categorized into three groups: exclusive breastfeeding, combination feeding, and no breastfeeding based on breastfeeding outcomes reported in the birth medical record. Exclusive breastfeeding was defined as feeding an infant at the breast or providing mother's expressed milk without supplementation with formula, juice, or food. Combination feeding was defined as breastfeeding along with supplementation with formula, juice, or food. No breastfeeding was defined as feeding an infant with formula, juice, or food.

Descriptive statistics were calculated as means and standard deviations for continuous variables, and frequencies and percentages for categorical variables. First, percentages and frequencies were calculated for responses on each item of the IFI and breastfeeding knowledge scales. Next, to analyze the data continuously, paired sample t-tests were used to compare pre-post changes in breastfeeding knowledge and IFI scores for the total sample and for those women who were exclusively breastfeeding at birth. Due to the small sample size of the combination feeding and no breastfeeding subgroups at birth, related-samples Wilcoxon signed-rank tests (non-parametric tests) were used to examine pre-post changes in breastfeeding knowledge and IFI scores for these feeding groups. Women without infant feeding information in the medical record were not assigned an infant feeding category at birth.

Women who did not complete both questionnaires were not included in pre-post analyses of IFI and breastfeeding knowledge scores. Pairwise deletion was used to handle missing data in all statistical procedures. Analyses were performed using SPSS 25 (IBM Corp. Released 2017. Armonk, NY). A significance level of p < .05 was used for all statistical inferences.

Results

A total of 122 women were enrolled and one was excluded from analysis due to medical ineligibility (N = 121). Sociodemographic characteristics of the 121 women are provided in Table 1. The mean age of the women at baseline was 26.47 ± 4.98 years. Most of the women included in the study self-identified as Hispanic. The mean gestational age of the women at baseline was 25.31 ± 10.29 weeks and the mean birthweight of the infants was 3227 ± 510.9 g. The majority of participants had at least a high school education, were unemployed, had Medicaid insurance coverage, had an annual household income of less than $30,000, were multiparous, and had a vaginal birth. Eighty-eight percent of the women participating in the QI initiative received doula services.

TABLE 1. Demographic Characteristics of the Sample.

Characteristics	Baseline N = 121 N (%)
Ethnicity
Non-Hispanic	42 (34.7)
Hispanic	77 (63.6)
Race
White	27 (22.3)
Black/African American	32 (26.4)
Other	19 (15.7)
Marital status
Single	17 (14.0)
In a relationship	65 (53.7)
Married	37 (30.6)
Education
< High school	26 (21.5)
≥High school	91 (75.2)
Insurance
Yes	83 (68.6)
No	35 (28.9)
Employment
Unemployed	73 (60.3)
Employed	33 (27.3)
Other	6 (5.0)
Household income
≤$30,000/year	88 (72.7)
>$30,000/year	11 (9.1)
WIC
Yes	83 (68.6)
No	35 (28.9)
Parity
Nulliparous	30 (24.8)
Multiparous	89 (73.5)
Birth mode
Vaginal	81 (67.0)
Cesarean surgery	31 (25.6)
Infant feeding status at birth (n = 96)
Exclusive breastfeeding	78 (81.3)
Combination feeding	10 (10.4)
No breastfeeding	8 (8.3)

Note. Exclusive breastfeeding—breastfeeding without supplementation with formula or juice. Combination feeding—breastfeeding and formula feeding. No breastfeeding—only formula feeding.

Breastfeeding Prevalence

Overall, 91% of the women were breastfeeding at birth (exclusive and combination). The prevalence of exclusive breastfeeding decreased over time: 81% at birth, 52% at discharge, 44% 2–4 weeks postpartum, and 35% 6–8 weeks postpartum (Figure 1). The prevalence of combination feeding and no breastfeeding increased over time. Ten percent of the women were combination feeding at birth, 39% at discharge, 40% at 2–4 weeks postpartum, and 34% at 6–8 weeks postpartum (Figure 1). Eight percent of the women were not breastfeeding at all at birth, 9% at discharge, 16% 2–4 weeks postpartum, and 31% 6–8 weeks postpartum (Figure 1).

Figure 1. Infant feeding at birth, discharge, and postpartum.

Note. Infant feeding was assessed at birth, discharge, 2–4 weeks postpartum, and 6–8 weeks postpartum. Exclusive breastfeeding was defined as feeding an infant at the breast or providing mother's expressed milk without supplementation with formula, juice, or food. Combination feeding was defined as breastfeeding along with supplementation with formula, juice, or food. No breastfeeding was defined as feeding an infant with formula, juice, or food.

Breastfeeding Intention

Each of the five items on the IFI scale was analyzed separately. At baseline, 84% of women somewhat or very much agreed with the statement “I am planning to at least give breastfeeding a try.” When asked to respond to the statement “I am planning to only formula feed my baby (I will not breastfeed at all),” 25% of women somewhat or very much agreed with the statement. The remaining three items on the IFI scale asked women to respond to the statement “When my baby is X months old, I will be breastfeeding without using any formula, or other milk” for 1, 3, and 6 months postpartum. At baseline, intent to exclusively breastfeed (women who responded somewhat or very much agree) at 1, 3, and 6 months was 69%, 59%, and 53%, respectively. Post-education, these numbers increased significantly with 90% of women responding somewhat or very much agree to the statement “I am planning on giving breastfeeding a try” (p < .05). Additionally, 79%, 73%, and 67% of women responded somewhat or very much agree to the exclusive breastfeeding statements for 1, 3, and 6 months, respectively (p < .05). Post-education, 20% of women planned to only formula feed their baby.

When analyzed continuously, the mean IFI score at baseline showed moderately strong intentions to breastfeed; the mean score for the sample was 12.09 (±3.82) out of 16. Mean IFI scores increased significantly to 12.93 (±3.88) post-intervention (p = .007; Table 2). When assessing IFI scores by the infant feeding categories, IFI scores increased among women who were exclusively breastfeeding and combination breastfeeding at birth. However, the differences in pre-post IFI scores did not reach statistical significance (Table 2). IFI scores decreased among women in the non-breastfeeding group, but the trend was not statistically significant (Table 2).

TABLE 2. Breastfeeding Intention Scores^a.

	Mean/Median	SD	p
All participants (N = 112)
Pre	12.09	3.82	.007*
Post	12.93	3.88
Exclusive breastfeeding (n = 70)
Pre	12.88	3.43	.199
Post	13.27	3.76
Combination feeding (n = 10)b
Pre	11.05	3.69	.271
Post	12.40	4.72
No breastfeeding (n = 8)b
Pre	10.94	4.69	.588
Post	10.50	3.66

Note. Infant feeding was assessed at birth. Exclusive breastfeeding—breastfeeding without supplementation with formula or juice. Combination feeding—breastfeeding and formula feeding. No breastfeeding—only formula feeding.

^aIntentions scale scores ranged from 0 to 16, with higher scores indicating stronger intentions to exclusively breastfeed.

^bNonparametric test used; median reported.

^*p = <.01.

Breastfeeding Knowledge

Baseline breastfeeding knowledge scores were moderate. The mean scores were 8.23 (±3.19) out of 14. Mean breastfeeding knowledge scores increased to 10.25 (±3.43) post-education (p < .001; Table 3). When assessing breastfeeding knowledge by infant feeding category, scores significantly increased among women who exclusively breastfed (p < .001) or combination breastfed at birth (p = 0.046; Table 3). Although breastfeeding knowledge scores among women in the no breastfeeding group increased, the difference in scores was not statistically significant (p = .157; Table 3).

TABLE 3. Breastfeeding Knowledge Scores^a.

	Mean/Median	SD	p
All participants (N = 83)
Pre	8.23	3.19	<.001***
Post	10.25	3.43
Exclusive breastfeeding (n = 55)
Pre	7.80	3.11	<.001***
Post	10.42	3.77
Combination feeding (n = 7)b
Pre	8.86	1.86	.046*
Post	11.00	2.45
Nonbreastfeeding (n = 4)b
Pre	8.20	2.39	.157
Post	9.50	1.91

Note. Infant feeding assessed at birth. All participants did not have infant feeding information at birth. Exclusive breastfeeding—breastfeeding without supplementation with formula or juice. Combination feeding—breastfeeding and supplementation with formula or juice. No breastfeeding—only formula feeding.

^aKnowledge scale scores ranged from 0 to 14, with higher scores indicating greater breastfeeding knowledge.

^bNonparametric test used; median reported.

^*p = <.05.

^***p = < .001.

DISCUSSION

In our QI initiative of doula-facilitated prenatal breastfeeding education classes conducted at four prenatal sites serving low-income women, approximately 91% of the women initiated breastfeeding at birth. The proportion of women breastfeeding decreased over time. Breastfeeding knowledge and IFI scores increased significantly from baseline to post-education. Women who exclusively breastfed or combination fed at birth had a significant increase in breastfeeding knowledge scores. IFI scores did not increase significantly within any of the infant feeding categories.

Breastfeeding initiation among women in our QI initiative was 91%. Our reports of breastfeeding initiation at birth exceeded breastfeeding initiation rates for the state of Florida (86%) (Florida Charts), reported rates for Hispanic (83%) and non-Hispanic Black (74%) women in the United States (CDC, 2018), and reported rates for low-income women in the United States (75%) (CDC, 2018). However, evidence has shown that a large proportion of women initiate breastfeeding at birth, but the proportion of women that continue to breastfeed throughout the first year of life decreases with time (CDC, 2018). Although breastfeeding initiation in our population was high, exclusive breastfeeding decreased over time while combination and formula feeding increased over time. These trends in decreases in exclusive breastfeeding have been seen for national data for women of all socioeconomic backgrounds (CDC, 2018) and in other studies among low-income women that reported declines in exclusive breastfeeding over the first 3 months of infancy (Lewkowitz et al., 2018). Future research should continue to emphasize methods to improve breastfeeding initiation and duration such as increasing support from health care providers, increasing breastfeeding self-efficacy, providing breastfeeding role models, creating an environment of support for breastfeeding in the community, and including culturally sensitive and specific recommendations for breastfeeding (Spencer & Grassley, 2013).

Kozhimannil et al. (2013) found similar breastfeeding initiation estimates (97.9%) in their sample of low-income women in the mid-western United States who received doula support (Kozhimannil et al., 2013). Doulas in the aforementioned study also provided a range of services that included labor support, postpartum visitation, and breastfeeding education (Kozhimannil et al., 2013). Doulas in the Kozhimannil et al. (2013) study did not facilitate formal breastfeeding education classes as was done in our study. Yet, 92.7% of women with doula support initiated breastfeeding, which was significantly higher than breastfeeding initiation outcomes for women in the general Medicaid population that were not receiving doula services (Kozhimannil et al., 2013). Results from this study in conjunction with the results from our study provide further evidence that doula support may bolster positive breastfeeding outcomes among low-income women.

Prenatal breastfeeding education is helpful in increasing breastfeeding outcomes among expectant mothers (Wouk et al., 2017), including lower-income women (Bonuck et al., 2014). In one community doula intervention for low-income, women of color, participants received doula services that included a primary focus on breastfeeding advocacy and support during prenatal home visits, at childbirth, and during the first 3 months of the postpartum period. Women in the control group received regular prenatal care (Edwards et al., 2013). Women who received doula support with a primary focus on breastfeeding had significantly higher breastfeeding initiation (63.9% vs 49.6%) and 6-week breastfeeding duration (28.7% vs 16.8%) than those in the control group (Edwards et al., 2013). While breastfeeding initiation and 6-week duration in our study was higher than reported for Edwards et al. (2013), these differences in breastfeeding outcomes may be due in part, to the women in Edwards et al. (2013) being younger (mean age 18.2 ± 1.7) than those participating in our study (mean age: 26.47 ± 4.98). Results for Edwards et al. (2013) and Kozhimannil et al. (2013) combined with the success of this innovative, state-funded doula program aimed at reaching diverse, low-income women in our study, suggests that expanding doula services to include a formal breastfeeding education class may be a beneficial strategy to increase breastfeeding rates and improve mother-infant health outcomes in diverse populations (Van Zandt et al., 2016).

With evidence that community doula support contributes to positive breastfeeding outcomes for lower-income women (Cattelona et al., 2015; Edwards et al., 2013; Kozhimannil et al., 2013), doula support services are still underutilized by lower-income women and women of color (Kozhimannil et al., 2014). Additionally, publicly insured and uninsured women are more likely to desire doula support, but not have it when compared to privately insured women (Kozhimannil et al., 2014). Changes to Medicaid policies that provide reimbursements for doula services (Strauss et al., 2016) may help to address this unmet desire for doula support among lower-income women. In doing so, the state Medicaid programs benefit through potential cost savings on various birth outcomes such as a reduction in cesarean surgeries (Kozhimannil, Hardeman, et al., 2013). However, women may need to be made aware of doula services (Kozhimannil et al., 2014) and their level of access to this type of support whether through Medicaid or community-based doula programs.

The strengths of this prospective QI initiative included a diverse population of participants and a sustainable model of prenatal lactation education that can be replicated. Classes have continued over a year after the QI initiative ended, which contributes to the long-term sustainability of the program. Secondly, using doulas to deliver the classes was innovative and cost-effective. Patients also had the option to obtain longer-term support, if desired, by accessing free doula services. The use of evidence-based tools in the classes (e.g., ACOG breastfeeding support toolkit) provided clear and effective communication about key breastfeeding messages.

Limitations

This study is limited by a small sample size and the number of women missing infant feeding data from their birth medical records. Not having a comparison group of women who did not receive prenatal lactation education is a limitation of the QI initiative. The inclusion of a larger sample in a randomized controlled trial would be useful for future studies. The majority of women in this study were of Hispanic ethnicity and evidence has shown that Hispanic women have higher overall rates of breastfeeding (CDC, 2017, 2018). This may have impacted the high level of breastfeeding initiation in this QI initiative. Our QI initiative used a new breastfeeding knowledge scale that has not previously been validated but was helpful in assessing breastfeeding knowledge among our participants. Additionally, women were aware that the focus of the prenatal session was breastfeeding, therefore, reports of breastfeeding intention are subject to social desirability bias and may be overestimated. Finally, the follow-up period of the QI initiative was relatively short. Longer follow-up periods would help to understand the long-term outcomes of the QI initiative.

IMPLICATIONS FOR PRACTICE

This QI initiative provides evidence that participation in a doula-led interactive prenatal breastfeeding education session may improve breastfeeding knowledge and intentions and thus increase breastfeeding rates. As the benefits of breastfeeding for moms and babies are well defined and breastfeeding rates for low-income women of color in the United States continue to fall below the national average, it is imperative that we explore ways to improve these maternal and infant outcomes. This work indicates incorporating doulas into community-based programming may help increase positive breastfeeding outcomes among low-income populations of color.

Biographies

ADETOLA LOUIS-JACQUES is an Assistant Professor in the Maternal-Fetal Medicine Division at the University of South Florida, Morsani College of Medicine in Tampa, Florida. Her research has centered on disparities in lactation and the impact of lactation on maternal health across the life span.

SHANDA VEREEN is a doctoral candidate in the College of Public Health at the University of South Florida. Her research interests include father involvement and adolescent sexual health, with an emphasis on parent-adolescent communication regarding sexual risk. In recent years, Shanda has focused on community-engaged approaches to understanding public health issues.

IVONNE HERNANDEZ is an Assistant Professor at the University of South Florida College of Nursing in Tampa, Florida. Dr. Ivonne Hernandez has over 16 years of experience in maternal child health with a specialization in Lactation. Her clinical experience and research interest are rooted in providing breastfeeding support for underserved populations and vulnerable infants in the NICU.

SARAH OBICAN is an Assistant Professor in the Maternal-Fetal Medicine Division at the University of South Florida, Morsani College of Medicine in Tampa, Florida. She has particular research and clinical interest in teratology, fetal echocardiography and fetal therapy.

TARA DEUBEL is an Assistant Professor of Anthropology at the University of South Florida. Her research interests include anthropology of development and human rights, political and legal anthropology, gender and women's rights, food security, microfinance, childbirth and infant feeding, forced migration and refugee resettlement, cultural heritage conservation, language and performance, and visual anthropology.

ELIZABETH MILLER is an Associate Professor of Anthropology at the University of South Florida. She is a biological anthropologist specializing in human biology, with interest in evolutionary and biocultural approaches to maternal and child health. Her research includes the study of human milk composition and infant feeding practices, infant immune function in diverse ecologies, maternal iron homeostasis, and early microbiome maturation.

DIANE SPATZ is a Professor of Perinatal Nursing and Professor of Nutrition at the University of Pennsylvania. As a clinician educator and a nurse researcher in lactation and director of the Lactation Program at CHOP, Dr. Spatz educates and consults in the breastfeeding care of families, including providing prenatal and post-birth education for mothers with infants diagnosed with complex surgical and nonsurgical anomalies. She developed the 10-step model for human milk and breastfeeding in vulnerable infants to helps clinicians and mothers make an informed choice about human milk.

RONEÉ WILSON is an Assistant Professor of Epidemiology at the University of South Florida, College of Public Health. She is faculty in the Center of Excellence in Maternal & Child Health and a fellow in the Lawton and Rhea Chiles Center for Healthy Mothers and Babies. Her area of specialization is Reproductive and Perinatal Epidemiology.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Organization of Teratology Information Specialists awarded to Sarah Obican.