Experiences of breastfeeding peer counseling among women with low incomes in the US: a qualitative evaluation.

BACKGROUND: Person-centered breastfeeding counseling is a key but often overlooked aspect of high-quality services. We explored women's experiences of the Breastfeeding Heritage and Pride™ program, an evidence-based breastfeeding peer counseling program serving women with low incomes in the United States. METHODS: This study was conducted through an equitable community-clinical-academic partnership and guided by the World Health Organization (WHO) quality of care framework for maternal and newborn health, which highlights three domains of positive experiences of care: effective communication; respect and dignity; and emotional support. In-depth interviews were conducted with a purposive sample of women participating in the Breastfeeding Heritage and Pride™ program. Women were asked to describe their experiences with the program including examples of when good quality counseling was or was not provided. Each interview was conducted in English or Spanish, audio-recorded, and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Once themes were generated, they were organized according to the three care experience domains in the WHO quality of care framework. RESULTS: Twenty-eight in-depth interviews were conducted with a racially/ethnically and socio-economically diverse sample of women. Three themes described effective communication practices of peer counselors: tailoring communication to meet women's individual needs; offering comprehensive and honest information about infant feeding; and being timely, proactive, and responsive in all communications across the maternity care continuum. Two themes captured why women felt respected. First, peer counselors were respectful in their interactions with women; they were courteous, patient, and non-judgmental and respected women's infant feeding decisions. Second, peer counselors showed genuine interest in the well-being of women and their families, beyond breastfeeding. The key theme related to emotional support explored ways in which peer counselors offered encouragement to women, namely by affirming women's efforts to breastfeed and by providing reassurance that alleviated their worries about breastfeeding. These positive experiences of counseling were appreciated by women. CONCLUSIONS: Women described having and valuing positive experiences in their interactions with peer counselors. Efforts to expand access to high-quality, person-centered breastfeeding counseling should, as part of quality assurance, include women's feedback on their experiences of these services.

Shifting to virtual breastfeeding counseling for low-income women in the US during COVID-19: A partner-engaged multimethod evaluation of program adaptations.

Background: The Breastfeeding Heritage and Pride program (BHP) provides evidence-based breastfeeding peer counseling to low-income women. Due to the COVID-19 pandemic, BHP shifted from delivering in-person and virtual services to providing only virtual services. Program adaptations can impact implementation success, which could influence program effectiveness. We documented program adaptations and explored their impacts on implementation outcomes, guided by the Model for Adaptation Design and Impact. Methods: Through a community-clinical-academic partnership, we conducted in-depth interviews with 12 program implementers and peer counselors and conducted a rapid qualitative analysis. To efficiently capture information on adaptations over time, we collected and analyzed information from program meetings and extracted data from a program report. We then triangulated data from these multiple sources. Results: Peer counselors received training on virtual service delivery and increased supportive supervision. They recruited women via phone instead of in hospitals, which was viewed as feasible. In-person counseling visits at hospitals and clients' homes were replaced with phone and video calls. Examples of changes to the content delivered included breastfeeding education in the context of the pandemic such as the latest COVID-related infant feeding guidance, provision of face masks, and more assistance with social and economic challenges. Although peer counselors increasingly adopted video calls as a substitute for in-person visits, they emphasized that in-person visits were better for relationship building, helping with breastfeeding problems like latching, and identifying barriers to breastfeeding in the home environment like limited familial support. While adaptations were reactive in that they were made in response to the unanticipated COVID-19 pandemic, most were made with clear goals and reasons such as to ensure the safety of peer counselors and clients while maintaining service delivery. Most adaptations were made through a systematic process based on program implementers' expertise and best practices for peer counseling and were largely but not fully consistent with BHP's core functions. Discussion: BHP was able to shift to virtual service delivery for continued provision of breastfeeding counseling during the pandemic. Overall, virtual services worked well but were less optimal for several aspects of counseling. Evaluations of program effectiveness of virtual services are still needed.

Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program.

BACKGROUND: In the United States, Black and Hispanic mothers have lower breastfeeding rates compared with White mothers. To address breastfeeding inequities, the Breastfeeding Heritage and Pride program (BHP) provides breastfeeding support for predominately low-income minority mothers in Connecticut and Massachusetts. We described the process of designing BHP, the program model, and its impact on breastfeeding outcomes. METHODS: This BHP case study is based on in-depth interviews with BHP designers and implementers, peer counselors, and clients; a literature review of BHP impact evaluation studies; and a review of BHP materials. To guide the analysis and organize results, we used the Community Energy Balance Framework, an equity-oriented, multi-level framework for fostering healthy lifestyles. RESULTS: The Hispanic Health Council designed BHP to address barriers to breastfeeding identified through formative qualitative research with the Latino community, namely lack of role models, limited social support, embarrassment when breastfeeding in public, lack of breastfeeding knowledge, and a norm of formula feeding. According to the BHP model, clients receive education and support through in-person home and hospital visits supplemented by phone calls, beginning prenatally and continuing through one year postpartum. Counseling is delivered by peer counselors, women who have successfully breastfed, have similar cultural roots and life experiences as the clients they serve, and have completed intensive training on lactation management and communication skills. International Board Certified Lactation Consultants provide clinical guidance and ongoing training to peer counselors, as well as direct support to clients, if more specialized knowledge and clinical expertise is needed. Clients facing housing and food insecurity or other socio-economic obstacles that may negatively influence breastfeeding and health and well-being more broadly are connected to other health and social services needed to address their social determinants of health needs, including health care access and food and rent assistance programs. To continuously improve service delivery, BHP has a robust monitoring and evaluation system. In two randomized-controlled trials, BHP was shown to improve breastfeeding initiation and duration of any and exclusive breastfeeding. CONCLUSIONS: BHP highlights the importance of community-engaged formative research for informing breastfeeding program design. It also provides an evidence-based example of a program model that offers a continuum of breastfeeding support, considers cultural-contextual influences on breastfeeding and social determinants of health, and incorporates continuous quality improvement.