Contraceptive Method Use Among a Population-Based Cohort During the South Carolina Choose Well Initiative.

Importance: Evaluating the impact of statewide contraceptive access initiatives is necessary for informing health policy and practice. Objective: To examine changes in contraceptive method use among a cohort of women of reproductive age in South Carolina during the Choose Well contraceptive access initiative. Design, Setting, and Participants: In this cohort study, baseline data from the initial Statewide Survey of Women administered from October 1, 2017, to April 30, 2018, to a probability-based sample of women of reproductive age in South Carolina and a peer state (Alabama) were linked with 3 follow-up surveys given in 2019, 2020, and 2021. Responses about contraception use from the initial survey were compared with responses across follow-up surveys using the regression-based differences-in-differences method. Data analysis was performed from October 2023 to February 2024. Exposure: The South Carolina Choose Well contraceptive access initiative seeks to fill contraceptive access gaps and increase provision of a full range of contraceptive methods through engagement with a wide range of health care organizations across the state. Main Outcomes and Measures: Changes in contraceptive method use, including long-acting reversible contraception (LARC), intrauterine devices (IUDs), implants, short-acting hormonal injection, and barrier or other methods between the baseline survey (2017-2018) and 3 subsequent surveys (2019-2021). Results: A total of 1344 female participants (mean [SD] age, 34 [7] years) completed the first survey (667 in Alabama and 677 in South Carolina). Use of LARC significantly increased in South Carolina (119 [17.6%] to 138 [21.1%]) compared with Alabama (120 [18.0%] to 116 [18.1%]; P = .004). Use of IUDs increased in South Carolina (95 [14.0%] to 114 [17.4%]) compared with Alabama (92 [13.8%] to 102 [15.9%]; P = .003). These associations persisted in the adjusted analysis, with a significant increase in the odds of LARC (adjusted odds ratio, 1.24; 95% CI, 1.06-1.44) and IUD (adjusted odds ratio, 1.19; 95% CI, 1.06-1.32) use at follow-up in South Carolina compared with Alabama. Conclusions and Relevance: In this cohort study of 1344 participants, increases in the use of IUDs in South Carolina were noted after the implementation of the South Carolina Choose Well initiative that were not observed in a peer state with no intervention. Our findings may provide support in favor of statewide contraceptive access initiatives and their role in promoting access to reproductive health services.

Impact of the Choose Well Contraceptive Access Initiative on Method Use Among Women Enrolled in South Carolina's Medicaid Program: A Mid-line Assessment.

INTRODUCTION: A six-year statewide contraceptive access initiative focused on equitable access to contraception, removing cost barriers, capacity building and training, raising consumer awareness, and expanding contraceptive care at safety net clinics was implemented in South Carolina beginning in 2017. This study assessed changes in contraceptive method use among women enrolled in the South Carolina Medicaid program during the first three years of Choose Well. METHODS: Contraception use among a retrospective cohort of women aged 15 to 45 enrolled in South Carolina Medicaid from 2012 to 2020 was examined. Interrupted time series regression analysis was used to assess changes in the use of intrauterine devices (IUDs) and contraceptive implants between 2012 and 2016 and 2017 and 2020. Analyses were conducted for all women and stratified by age groups. RESULTS: Long-acting reversible contraception use increased from 8.5% during the pre-Choose Well period to 10.9% during the Choose Well period (p < .001), with IUD use increasing from 4.3% to 5.2% (p < .001) and implant use increasing from 4.6% to 6.0% (p < .001). The interrupted time series analysis found a significant positive change in the average level of monthly IUD use after Choose Well began (0.493 percentage points; 95% confidence interval, 0.311-0.675). The effect was stronger among women 20 to 25 years of age. Choose Well significantly increased the trend in IUD use among all women by a positive 0.013 percentage points (95% confidence interval, 0.006-0.020) per month beyond expected values. CONCLUSIONS: At the mid-point of the Choose Well Evaluation, the use of IUD methods increased significantly beyond what would be expected had pre-Choose Well trends continued. This was particularly evident among women 20 to 25 years of age. These findings suggest that Choose Well succeeded in reducing barriers to the use of IUDs.

Association of Health Insurance with Contraceptive Use and Interpersonal Quality of Contraceptive Care in the Southeast United States.

OBJECTIVES: Health insurance remains an important dimension of contraceptive access. This study investigated the role of insurance in contraceptive use, access, and quality in South Carolina and Alabama. METHODS: The study used a cross-sectional statewide representative survey that assessed reproductive health experiences and contraceptive use among reproductive-age women in South Carolina and Alabama. The primary outcomes were current contraceptive method use, barriers to access (inability to afford wanted method, delay/trouble obtaining wanted method), receipt of any contraceptive care in the past 12 months, and perceived quality of care. The independent variable was insurance type. Generalized linear models were applied to estimate prevalence ratios for each outcome's association with insurance type while adjusting for potentially confounding variables. RESULTS: Nearly 1 in 5 women (17.6%) was uninsured, and 1 in 4 women (25.3%) reported not using a contraceptive method at the time of the survey. Compared with women with private insurance, women with no insurance had a lower likelihood of current method use (adjusted prevalence ratio 0.75; 95% confidence interval 0.60-0.92) and receipt of contraceptive care in the past 12 months (adjusted prevalence ratio 0.61; 95% confidence interval 0.45-0.82). These women also were more likely to experience cost barriers to access care. The insurance type was not significantly associated with the interpersonal quality of contraceptive care. CONCLUSIONS: Findings highlight the need for expanding Medicaid in states that did not do so under the Patient Protection and Affordable Care Act, interventions to increase the number of providers who accept Medicaid patients, and protections to Title X funding as key elements for enhancing contraceptive access and population health outcomes.

Contraception Use and Pregnancy Outcomes for Alabama Medicaid Enrollees: A Baseline Analysis Using 2012-2017 Data.

OBJECTIVES: Access to the full range of contraceptive methods, including long-acting reversible contraception (LARC), is key for preventing unintended pregnancies and improving health outcomes. In 2019, Alabama Medicaid started paying for LARC devices for postpartum women. In anticipation of evaluating the impact of this programmatic change, we conducted a baseline study exploring contraception use and pregnancy-end outcomes for enrollees before the change. METHODS: A retrospective cohort of women enrolled in Alabama Medicaid from 2012 to 2017 was examined. Outcomes include pregnancy-end events for all enrollees, teen pregnancy-end events, and short-interval (SI) pregnancy-end events. Pregnancy events in year t are matched to contraception in year t - 1. Contraception is categorized as "no evidence," short-acting contraception (SAC), LARC, and sterilization. Bivariate and multivariate models were estimated. RESULTS: Our final sample included 135,807 unique women who contributed 258,959 person-years. There was no evidence of contraception for 55.4% and evidence of SAC, LARC, and sterilization for 36.4%, 6.2%, and 2.0%, respectively. Relative risks for pregnancy-end events for SAC and LARC users were 0.63 (95% confidence interval [CI] 0.61-0.0.65) and 0.56 (95% CI 0.52-0.0.59), respectively, compared with women with no evidence of contraceptive use. For teen pregnancy-end events, relative risks for SAC and LARC users were 0.65 (95% CI 0.61-0.67) and 0.58 (95% CI 0.51-0.66), respectively. For SI pregnancy-end events, relative risks for SAC and LARC users were 0.71 (95% CI 0.68-0.76) and 0.40 (95% CI 0.34-0.46), respectively. CONCLUSIONS: LARC and SAC are associated with lower likelihood of pregnancy-end events compared with no evidence of contraception, and on average, LARC is associated with lower relative risk than SAC, especially for SI pregnancy-end events.

Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012-2018.

This study assesses cost savings associated with specific contraceptive methods provided to beneficiaries enrolled in South Carolina Medicaid between 2012 and 2018. Incremental cost-effectiveness ratios, defined as the additional cost of contraception provision per live birth averted, were estimated for 4 contraceptive methods (intrauterine devices [IUDs], implants, injectable contraceptives, and pills), relative to no prescription method provision, and savings per dollar spent on method provision were calculated. Costs associated with publicly funded live births were derived from published sources. The analysis was conducted for the entire Medicaid sample and separately for individuals enrolled under low-income families (LIFs), family planning, and partners for healthy children (PHC) eligibility programs. Sensitivity analysis was performed on contraceptive method costs. IUDs and implants were the most cost-effective with cost savings of up to $14.4 and $7.2 for every dollar spent in method provision, respectively. Injectable contraceptives and pills each yielded up to $4.8 per dollar spent. However, IUDs and implants were less cost-effective than injectable contraceptives and pills if the average length of use was less than 2 years. Medicaid's savings varied across Medicaid eligibility programs, with the highest and lowest savings from contraceptive provision to women in the LIFs and PHC eligibility programs, respectively. The results suggest the need to account for unique needs and preferences of beneficiaries in different Medicaid eligibility categories during contraception provision. The findings also inform program administration and provide evidence to justify legislative appropriations for Medicaid reproductive health care services.

Contraceptive Use and Pregnancy Outcomes Among Women Enrolled in South Carolina Medicaid Programs.

OBJECTIVE: State medicaid programs provide access to effective contraception for people with lower incomes. This study examined contraception use and pregnancy among reproductive-age women enrolled in the South Carolina Medicaid, by eligibility program and socio-demographic sub-groups. METHODS: A retrospective cohort of women aged 15-45 who were newly eligible for South Carolina Medicaid from 2012 to 2016 was examined. Log-binomial regression and average marginal effects assessed relationships between contraception use and pregnancies ending in live and non-live births. Contraception was categorized as permanent, long acting reversible contraception (LARC), short-acting hormonal contraception (SAC), or no contraceptive claims. Women with family planning or full-benefit medicaid coverage were included. RESULTS: Approximately 11% of women used LARC methods, 41% used SAC methods, and 46% had no evidence of contraceptive claims. Method utilization varied by eligibility program, race/ethnicity and age. The likelihood of pregnancy was lower among SAC users and lowest among LARC users compared to women with no evidence of contraception across all three programs (family planning APR = 0.44; 95% CI 0.41-0.49 and APR = 0.13, 95% CI 0.10-0.17; Low income families APR = 0.82; 95% CI 0.77-0.88 and APR = 0.33, 95% CI 0.28-0.38; Partners for Healthy Children APR = 0.72; 95% CI 0.68-0.77 and APR = 0.35, 95% CI 0.30-0.43, respectively). Non-Hispanic Black and Hispanic teens were less likely to experience a pregnancy than non-Hispanic white teens. CONCLUSIONS FOR PRACTICE: The likelihood of pregnancy was lower among women using SAC methods and markedly lower among women using LARC. Variation in contraceptive use among racial/ethnic groups was noted despite Medicaid coverage. As new policies and initiatives emerge, these findings provide important context for understanding the role of Medicaid programs in reducing financial barriers to contraceptive services and ensuring access to effective contraception, while fostering reproductive health autonomy among women.

Health Equity Within Inequity: Timing of Diagnostic Breast Cancer Care in an Underserved Medical Population.

BACKGROUND/AIM: We evaluated timeliness of care at a safety-net hospital after implementation of a multidisciplinary breast program. PATIENTS AND METHODS: A prospective database of patients with breast cancer was created after multidisciplinary breast program initiation in 2018. Patients were tracked to obtain time to completion of diagnostic imaging, biopsy, and treatment initiation. Patients with breast cancer diagnosed from 2015-2017 were reviewed for comparison. RESULTS: A total of 102 patients were identified. There was no statistical difference in time to completion of imaging, biopsy, and initial treatment between the 2018 and the 2015-2017 cohorts (p>0.05). No statistical difference was observed in time to completion of imaging, biopsy, and initial treatment between different races (p>0.05). CONCLUSION: Within the same socioeconomic status, there was no differential delivery of screening, work-up, and treatment by race. Despite protocol implementations, efficiency of care remained limited in a safety-net hospital with lack of financial resources.

Adolescent Birth Rates and Rural-Urban Differences by Levels of Deprivation and Health Professional Shortage Areas in the United States, 2017-2018.

Objectives. To examine the differences in adolescent birth rates by deprivation and Health Professional Shortage Areas (HPSAs) in rural and urban counties of the United States in 2017 and 2018.Methods. We analyzed available data on birth rates for females aged 15 to 19 years in the United States using the restricted-use natality files from the National Center for Health Statistics, American Community Survey 5-year population estimates, and the Area Health Resources Files.Results. Rural counties had an additional 7.8 births per 1000 females aged 15 to 19 years (b = 7.84; 95% confidence interval [CI] = 7.13, 8.55) compared with urban counties. Counties with the highest deprivation had an additional 23.1 births per 1000 females aged 15 to 19 years (b = 23.12; 95% CI = 22.30, 23.93), compared with less deprived counties. Rural counties with whole shortage designation had an additional 8.3 births per 1000 females aged 15 to 19 years (b = 8.27; 95% CI = 6.86, 9.67) compared with their urban counterparts.Conclusions. Rural communities across deprivation and HPSA categories showed disproportionately high adolescent birth rates. Future research should examine the extent to which contraceptive access differs among deprived and HPSA-designated rural communities and the impact of policies that may create barriers for rural communities.

Use of Highly Effective Reversible Contraception in Title X Clinics: Variation by Selected State Characteristics.

BACKGROUND: The use of long-acting reversible contraceptive (LARC) methods, such as intrauterine devices (IUDs) and implants has demonstrated high effectiveness in preventing pregnancy. While LARC use in Title X programs has increased over the past decade, little is know about the extent to which gains are occurring uniformly across states. METHODS: We examined state-level changes in LARC use among Title X clients between 2012 and 2016 using a repeated cross-sectional study design. States were characterized by the proportion of reproductive age women in need of publicly funded contraception. Variation in LARC use by level of need was examined using GEE models. RESULTS: Across all states, LARC use in Title X clinics increased from 9.1% to 16.2% during the study period. In 2012, LARC use in the states with the highest and lowest level of need differed by 2.3 percentage points (7.8% compared to 10.1%). By 2015 the gap in LARC use between high and low need states widened to reach 5.3 percentage points, more than double what was observed in 2012. However, by 2016 the margin of the gap narrowed. CONCLUSIONS: Observed increases in LARC use among states with the highest level of need for publically funded services are much lower than what is observed among states with the lowest level of need. However, we did find this gap is narrowing. This finding is important given states with greater need are those with higher proportions of low-income and younger women who are at greater risk for experiencing unintended pregnancies.

The association between chronic disease and physical disability among female Medicaid beneficiaries 18-64 years of age.

BACKGROUND: Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. OBJECTIVE: This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005. METHODS: Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability. RESULTS: Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts. DISCUSSION: Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

Differential trends in racial preferences for cosmetic surgery procedures.

There appears to be an increasing acceptance of cosmetic surgery procedures among minority populations in America. Our objective was to determine trends in elective cosmetic procedure utilization as they apply to racial/ethnic differences. A retrospective analysis was performed using the Nationwide Inpatient Sample. Adult patients undergoing elective cosmetic procedures defined by the appropriate International Classification of Disease 9 Clinical Modification procedure codes were included. Demographic characteristics and hospital course particulars were evaluated. There were 71,775 patients meeting the inclusion criteria. Median age was 48 years. The majority were female (90%), and white (65%). The median household income for the patient's zip code was most commonly in the highest economic quartile (4th quartile, 40%). The most common cosmetic procedure was liposuction (67%). The overall mean percentage change in the frequency of these procedures showed a 1.8 per cent decline among white patients, whereas Black, Hispanic, Asian, and Native American patients had an increase of 7.5 per cent, 4.7 per cent, 14.5 per cent, and 105.5 per cent, respectively. We conclude that there is an identified increasing trend in the proportion of racial/ethnic minorities represented among the recipients of cosmetic surgery procedures.

Assessment of two 3-D fluoroscopic systems for articular fracture reduction: a cadaver study.

OBJECTIVE: The most commonly used imaging device for assessment of fracture reduction is the two-dimensional X-ray fluoroscope. Two recently introduced 3D fluoroscopic devices, the Siremobil ISO-C3D (Siemens) and the C-InSight (Mazor Surgical Technologies), enable the surgeon to obtain spatial information for the assessment of articular reduction and hardware placement. The purpose of this study was to assess the reliability and accuracy of these two 3D fluoroscopic systems in measuring articular reduction in a cadaveric tibial plateau fracture. METHODS: Six cadaveric knee specimens were osteotomized at the lateral tibial plateau and fixed with a maximal articular step-off of 0, 1, 2.5, 5 and 7.5 mm. Each specimen was scanned 10 times with two 3D fluoroscopes, the Siremobil ISO-C3D and the C-InSight. The resulting images were reformatted and interpreted for articular displacements at four different locations at the plateau level and were compared with high-resolution CT scans by an independent observer. RESULTS: For the non-displaced fracture, no displacement (mean < 0.1 mm) was observed in either modality. The mean scanning time for the ISO-C3D was 2 min, while each C-InSight scan took 20 s. The readings at four different points along the malreduced fractures were similar for most measurements with either of the two modalities. The C-InSight readings were less accurate than those of the ISO-C3D, relative to the CT scan, but most errors were within clinically acceptable limits (< 2 mm) and used less radiation. CONCLUSIONS: Intraoperative 3D fluoroscopes can detect clinically significant intra-articular step-off with acceptable measurement errors, using newer devices that enable the use of a conventional C-arm and reduced radiation.

Predictors for survival of penetrating trauma using emergency department thoracotomy in an urban trauma center: the Cardiac Instability Score.

BACKGROUND: Emergency department thoracotomy (EDT) is a procedure used in an attempt to save lives of patients in extremis. This study aims to determine predictors of survival and futility by proposing a scoring scale that measures cardiac instability and its use in predicting survival of victims of penetrating trauma undergoing EDT. METHODS: This retrospective study analyzes patients who underwent EDT during a 45-month period at Howard University Hospital, Washington, DC. Vital signs and Glasgow Coma scale (GCS) scores were analyzed at the scene and in the emergency department. A cardiac instability score (CIS) was devised to assign values to vital signs, and the GCS was based on scores from the emergency department. RESULTS: Emergency department vital signs, female gender, absence of cardiopulmonary resuscitation (CPR), and high CIS were found to be statistically significant predictors of survival. CONCLUSIONS: The CIS correlated with survival of patients who underwent EDT and was found to be statistically significant in determining the outcome of an EDT.

Breast-feeding initiation in low-income women: Role of attitudes, support, and perceived control.

Despite the documented health and emotional benefits of breast-feeding to women and children, breast-feeding rates are low among subgroups of women. In this study, we examine factors associated with breast-feeding initiation in low-income women, including Theory of Planned Behavior measures of attitude, support, and perceived control, as well as sociodemographic characteristics. A mail survey, with telephone follow-up, of 733 postpartum Medicaid beneficiaries in Mississippi was conducted in 2000. The breast-feeding initiation rate in this population was 38%. Women who were older, white, non-Hispanic, college-educated, married, not certified for the Supplemental Nutrition Program for Women, Infants, and Children, and not working full-time were more likely to breast-feed than formula-feed at hospital discharge. Attitudes regarding benefits and barriers to breast-feeding, as well as health care system and social support, were associated with breast-feeding initiation at the multivariate level. Adding the health care system support variables to the regression model, and specifically support from lactation specialists and hospital nurses, explained the association between breast-feeding initiation and women's perceived control over the time and social constraints barriers to breast-feeding. The findings support the need for health care system interventions, family interventions, and public health education campaigns to promote breast-feeding in low-income women.

The loving support breastfeeding campaign: awareness and practices of health care providers in Mississippi.

OBJECTIVES: To evaluate the impact of the national breastfeeding promotion campaign, Loving Support Makes Breastfeeding Work, on health care providers in Mississippi. DESIGN: Cross-sectional study. SETTING: The Mississippi WIC (Women, Infants, and Children) program implemented the national Loving Support project for the state. Questionnaires were mailed to all hospitals with obstetric services and WIC clinics and to a random sample of one half of the practicing pediatricians and one third of the practicing family physicians in the state. PARTICIPANTS: Two hundred and two health care providers, including 104 nurses and 98 physicians, responded to the questionnaire. MAIN OUTCOME MEASURES: Health care providers' (a) awareness of the breastfeeding promotion activities in the state; (b) changes in practice in providing breastfeeding advice and referrals to lactation specialists and for breast pumps; and (c) changes in the management of breastfeeding-related problems. RESULTS: A significantly higher proportion of nurses than physicians mentioned breastfeeding benefits to mothers, provided breastfeeding management advice, and referred mothers for breast pumps and to lactation specialists after the campaign. CONCLUSIONS: This study showed the positive impact of the campaign on nurses' breastfeeding awareness and practices. More efforts are needed to continue breastfeeding outreach activities for health care providers.

Evaluation of a comprehensive loving support program among state Women, Infants, and Children (WIC) program breast-feeding coordinators.

BACKGROUND: Mississippi was selected as a pilot state in the national breastfeeding promotion campaign titled Loving Support Makes Breastfeeding Work (LSMBW). To reinforce the national LSMBW project, the Mississippi Women, Infants and Children (WIC) Breastfeeding Promotion Project Team developed a comprehensive program that included patient and family education, staff training, public awareness activities, health professional outreach, and partnerships with the community. The program also implemented a breastfeeding-friendly clinic environment project and a videotape project. This study was conducted to evaluate the impact of Mississippi's LSMBW activities among WIC breastfeeding coordinators in the United States. METHOD: The cross-sectional study was performed with the use of a mailed, self-administered questionnaire. RESULTS: Representatives of 50 state WIC agencies returned the survey. Of these 50 agencies, 36 (72%) had effectively used education materials created by the state of Mississippi. Breastfeeding coordinators reported that among the campaign activities, staff training, community outreach, and peer counseling were most beneficial. They also identified the videotape project developed by Mississippi as useful in addressing barriers to breastfeeding and in training support groups, staff, and health care professionals. CONCLUSION: This study showed that Mississippi's outreach activities and motivational videotape had a positive impact on coordinators' promotion of breastfeeding.

Improving breastfeeding knowledge, attitudes, and practices of WIC clinic staff.

OBJECTIVE: This study was conducted to assess the impact of a breastfeeding promotion clinic environment project implemented by the state of Mississippi on breastfeeding knowledge, attitudes, and practices of WIC clinic staff. METHODS: Thirteen pairs of matched intervention and comparison WIC clinics participated in the study. Clinical and administrative staff completed pre-test and post-test self-administered questionnaires in 1998 and 1999. RESULTS: A total of 397 staff members provided pre-test data, and 277 staff members provided post-test data. Before project implementation, the intervention and comparison groups were similar overall. The majority of staff had positive attitudes/beliefs about breastfeeding, but gaps in knowledge and practices were noted. Post-test data showed that the project improved knowledge, attitudes/beliefs, and confidence/practice of intervention clinic staff. CONCLUSIONS: Clinic environment projects, which combine physical improvements and staff training, are effective in promoting support for breastfeeding among public health clinic staff. Similar interventions may contribute to the overall effectiveness of breastfeeding promotion programs.

An innovative video succeeds in addressing barriers to breastfeeding among low-income women.

This study evaluates the effectiveness of an innovative breastfeeding promotion video intervention in addressing barriers to breastfeeding among low-income women in the state of Mississippi. The 15-minute video features a diverse group of women and their families. Survey data were collected from Special Supplemental Nutrition Program for Women, Infants and Children clients in the intervention group (n = 310) before and after watching the video, and from a comparison group (n = 204) that did not watch the video. The 2 groups were comparable at baseline. The intervention significantly improved women's perceptions with regard to the "embarrassment" and "time and social constraints" barriers to breastfeeding. In terms of the "lack of social support" barrier, the video positively affected participants' feelings that the baby's father encouraged breastfeeding but did not change their perceptions of support from female relatives and friends. The authors conclude that the video is an effective method of breastfeeding promotion among low-income women.