Workplace Lactation Support: Using Implementation Climate to Inform a New Model.

Introduction: Breastfeeding (BF) duration remains problematic, especially among women returning to work. Given that use of workplace lactation support programs has not gained traction in improving BF duration, there appears to be elements missing from lactation support initiatives that need further exploration. The field of Implementation Science, in explaining organizational behavior, provides an opportunity to inform a better model for workplace BF support. Materials and Methods: To inform a new model for workplace lactation support, data from the Breastfeeding and Employment Study (BESt) were combined with Implementation Climate theory. BESt surveyed companies on their BF supports, and used hierarchical linear modeling to determine the association of those supports with company employee perceptions of and manager attitudes toward BF supports. Results: Employee scores were not associated with any company scores. Total company scores were associated with more positive manager attitudes (p < 0.01), due to structural supports, or those supports most visible to managers. Considering these results along with other studies, it is proposed that employees and managers are influenced by tangible (physical) as well as intangible (people) workplace lactation supports. Furthermore, strategies are needed to design and implement approaches to these components to increase workplace lactation support and improve BF durations. Conclusions: Implementation strategies will vary with the diversity of workplaces and how they function. A better understanding of the application of implementation climate for workplace lactation support will help tailor programs and their implementation to improve BF duration in employed women.

Development and Evaluation of the Infant Feeding Education Questionnaire for the Expanded Food and Nutrition Education Program.

OBJECTIVE: Develop and evaluate the Infant Feeding Education Questionnaire (IFEQ) to measure the impact of the Expanded Food and Nutrition Education Program (EFNEP) infant-feeding education on knowledge, attitudes, and behavioral intent. METHODS: Evaluation included content validity testing through expert reviews and cognitive interviews with low-income mothers (n = 37); construct validity using the known-groups technique (n = 679); convergent validity testing using the Infant Feeding Practices Study II questionnaire (n = 66); and test-retest reliability (n = 66). RESULTS: The IFEQ had strong construct validity for knowledge and attitudes; IFEQ scores were significantly higher for the high-knowledge/attitude group (29.6 ± 3.08) than the low-knowledge/attitude group (14.5 ± 5.81; P < .001). The IFEQ failed to show convergent validity. The percent agreement between baseline and retest questions was moderate to high, indicating reliability over time. CONCLUSIONS AND IMPLICATIONS: This study represents the first steps in the development of the IFEQ. There's a need to perform further testing to establish convergent validity and pilot-test the questions following EFNEP infant-feeding education.

Outpatient Breastfeeding Champion Program: Breastfeeding Support in Primary Care.

Background: Breastfeeding support offered by trained professionals can increase breastfeeding success. The Outpatient Breastfeeding Champion (OBC) program creates a network of Breastfeeding Champions (typically nurses) who are trained to identify and resolve common breastfeeding issues and refer to lactation professionals as needed. The objective of this study was to evaluate the impact the OBC program on nurses' attitudes toward breastfeeding and self-confidence in providing breastfeeding care. Materials and Methods: The OBC program was implemented in 11 medical offices within a health care system. Nurses were surveyed before (n = 9) and immediately after (n = 9) participating in OBC training sessions, and 6 months following the implementation of the OBC training (n = 15). Data were collected on their breastfeeding attitude and self-confidence in providing breastfeeding care, and the responses at the different time points were compared using Wilcoxon Rank-Sum tests. Results: Nurses' attitudes toward breastfeeding (p = 0.049) and self-confidence in managing breastfeeding position and attachment (p = 0.09) were higher immediately after completion of the OBC training than they were before training. There was no significant difference in either response between immediately after completion and 6 months following training. Conclusion: This study presents a model of breastfeeding care that extends the reach of an International Board Certified Lactation Consultant to improve breastfeeding support in the primary care setting. Nurses' more positive breastfeeding attitudes and self-confidence in providing breastfeeding care following training suggest that the use of a breastfeeding training program may improve the breastfeeding support provided by nurses, which could be sustained over time.

Exploring Human Resource Managers' Decision-Making Process for Workplace Breastfeeding-Support Benefits Following the Passage of the Affordable Care Act.

Objectives To explore factors that shape decisions made regarding employee benefits and compare the decision-making process for workplace breastfeeding support to that of other benefits. Methods Sixteen semi-structured, in-depth interviews were conducted with Human Resource Managers (HRMs) who had previously participated in a breastfeeding-support survey. A priori codes were used, which were based on a theoretical model informed by organizational behavior theories, followed by grounded codes from emergent themes. Results The major themes that emerged from analysis of the interviews included: (1) HRMs' primary concern was meeting the needs of their employees, regardless of type of benefit; (2) offering general benefits standard for the majority of employees (e.g. health insurance) was viewed as essential to recruitment and retention, whereas breastfeeding benefits were viewed as discretionary; (3) providing additional breastfeeding supports (versus only the supports mandated by the Affordable Care Act) was strongly influenced by HRMs' perception of employee need. Conclusions for Practice Advocates for improved workplace breastfeeding-support benefits should focus on HRMs' perception of employee need. To achieve this, advocates could encourage HRMs to perform objective breastfeeding-support needs assessments and highlight how breastfeeding support benefits all employees (e.g., reduced absenteeism and enhanced productivity of breastfeeding employee). Additionally, framing breastfeeding-support benefits in terms of their impact on recruitment and retention could be effective in improving adoption.

Exploring Family-Medicine Providers' Perspectives on Group Care Visits for Maternal and Infant Nutrition Education.

OBJECTIVE: Explore current maternal and infant nutrition education practices and family medicine primary care providers' views on a group care model to deliver nutrition education to mother-infant dyads. DESIGN: In-depth interviews. SETTING: Family medicine clinics in 1 Midwestern US hospital system. PARTICIPANTS: Family medicine primary care providers (n = 17) who regularly see infants during well-baby visits. PHENOMENON OF INTEREST: Current maternal and infant nutrition education practices; views on ideal way to deliver nutrition education to mother-infant dyads; feedback on group care model to deliver nutrition education to mother-infant dyads. ANALYSIS: Audio recordings transcribed verbatim and coded using conventional content analysis. RESULTS: Family medicine primary care providers are limited in the ability to provide maternal and infant nutrition education and desire a different approach. Group care was the preferred method; it was shared most frequently as the ideal approach to nutrition education delivery and participants reacted favorably when presented with this model. However, there were many concerns with group care (eg, moderating difficult conversations, program implementation logistics, sufficient group volume, and interruption in patient-provider relationship). CONCLUSION AND IMPLICATIONS: Family medicine primary care providers desire a different approach to deliver nutrition education to mother-infant dyads in clinic. A group care model may be well-accepted among family medicine primary care providers but issues must be resolved before implementation. These results could inform future group care implementation studies and influence provider buy-in.

Exploring Healthy Eating and Exercise Behaviors Among Low-Income Breastfeeding Mothers.

BACKGROUND:: Postpartum weight retention is often a significant contributor to overweight and obesity. Lactation is typically not sufficient for mothers to return to pre-pregnancy weight. Modifiable health behaviors (e.g., healthy eating and exercise) are important for postpartum weight loss; however, engagement among mothers, especially those who are resource-limited, is low. A deeper understanding of low-income breastfeeding mothers' healthy-eating and exercise experience, a population that may have unique motivators for health-behavior change, may facilitate creation of effective intervention strategies for these women. RESEARCH AIM:: To describe the healthy-eating and exercise experiences of low-income postpartum women who choose to breastfeed. METHODS:: Focus group discussions were conducted with low-income mothers ( N = 21) who breastfed and had a child who was 3 years old or younger. Transcript analysis employed integrated grounded analysis using both a priori codes informed by the theory of planned behavior and grounded codes. RESULTS:: Three major themes were identified from five focus groups: (a) Mothers were unable to focus on their own diet and exercise due to preoccupation with infant needs and more perceived barriers than facilitators; (b) mothers became motivated to eat healthfully if it benefited the infant; and (c) mothers did not seek out information on maternal nutrition or exercise but used the Internet for infant-health information and health professionals for breastfeeding information. CONCLUSION:: Low-income breastfeeding mothers may be more receptive to nutrition education or interventions that focus on the mother-infant dyad rather than solely on maternal health.

The effect of maternity practices on exclusive breastfeeding rates in U.S. hospitals.

The Baby-friendly Hospital Initiative (BFHI) includes a set of 10 evidenced-based maternity practices that when used together have been shown to improve breastfeeding outcomes. In 2007, the Centers for Disease Control and Prevention launched the Maternity Practices in Infant Nutrition and Care (mPINC) survey to assess and monitor these and other evidenced-based maternity practices. The purpose of this study was to explore individual maternity practices measured in the 2013 mPINC survey, along with hospital demographic information, and their relationships with exclusive breastfeeding (EBF) rates, using a sample of United States (U.S.) hospitals. We obtained mPINC survey data from 69 BFHI hospitals and 654 non-BFHI hospitals in the U.S., and EBF rates from The Joint Commission, a leading hospital accreditation agency. On the basis of linear regression analysis, we found that most maternity practices studied were significantly associated with EBF rates (max adjusted R2  = 14.9%). We found a parsimonious model with an adjusted R2 of 47.3%. This study supports the need for a systematic approach in providing breastfeeding support as no one maternity care practice was able to explain the variability in EBF rates as well as a collection of maternity care practices.

The effect of Baby-friendly status on exclusive breastfeeding in U.S. hospitals.

In 2014, a leading hospital accreditation agency, mandated hospitals publicly report their exclusive breastfeeding (EBF) rates. This new regulation provided an opportunity to explore differences in EBF outcomes using a standardized definition across a large hospital sample in the United States. The purpose of this study was to examine the relationships between population demographics and the Baby-friendly (BF) hospital designation on EBF rates in hospitals throughout the United States. We obtained EBF rates from 121 BF hospitals and 1,608 hospitals without the BF designation. Demographic variables were computed using census tract data for the population surrounding each hospital. Relationships were explored using linear regression. We found that EBF rates were positively correlated with a bachelor's degree, log income, and those who identified as White or Asian and negatively correlated with those without college attendance, individuals living below the poverty line, and those who identified as African American or Hispanic. For all models, the BF designation of a hospital was associated with higher EBF rates (p < 0.01; effect sizes, 0.11-0.49) with the exception of the model containing log income. Using a multiple linear regression model that was allowed to contain more than one independent variable, we were able to explain 22% of the variability in EBF rates. The BF hospital designation was associated with significantly higher EBF rates independent of demographic variables. Support for hospitals to attain the BF hospital designation is a meaningful public health goal.

The Relationship Between Dietary Acculturation and Type 2 Diabetes Risk Among Asian Indians in the U.S.

Asian Indians have a high prevalence of type 2 diabetes in the U.S. (17.4-29 %). This study examined the relationship between dietary acculturation of Asian Indians in the U.S. and their future risk for type 2 diabetes. A validated Asian Indian Dietary Acculturation Measure (AIDAM) and the Finnish Diabetes Risk Score (FINDRISC) were completed by 153 Asian Indians in the U.S. via a cross-sectional web-survey. Correlations and relative risk ratios were used to examine the association between AIDAM and FINDRISC. A significantly larger proportion of Non-Indian Oriented participants (44.7 %) had higher FINDRISC scores (scores 7-26) compared to the Asian Indian Oriented group (27.9 %) (p = .024), and also had increased relative predictive risk for type 2 diabetes (relative risk ratio = 1.6). A positive association between dietary acculturation and diabetes risk was evident in our sample, which highlights the importance of assessing dietary acculturation in non-native groups when investigating type 2 diabetes risk factors.

An Integrated Model of Breastfeeding Peer Counseling Support is Feasible and Associated with Improved Exclusive Breastfeeding.

Background Though in-person contacts in the home have demonstrated efficacy in improving breastfeeding outcomes in peer counseling programs, home contacts are resource-intensive. Objective To compare the feasibility and effectiveness of an Integrated Model of peer counseling breastfeeding support characterized by select home visits augmented with individual WIC clinic visits and group education, in contrast to the Standard Model which includes a standard number of in-person home contacts. Methods Six counties (n = 226 participants) and nine counties (n = 472 participants) were assigned to the Standard Model and the Integrated Model, respectively. Differences in demographic characteristics and breastfeeding outcomes were tested using Chi square tests and Cox proportional hazards regression models. Results Participants in counties where the Integrated Model was implemented had fewer home contacts (p = 0.03) and were more likely to have a hospital (p = 0.03) or group education (p < 0.001) contact, whereas Standard Model participants were more likely to receive an individual WIC clinic contact (p < 0.001). While there was no difference in the hazard of discontinuing any breastfeeding between groups, participants in the Integrated Model group had a lower hazard of discontinuing exclusive breastfeeding by 3 months postpartum (p = 0.02). Among participants within the Integrated Model, group education classes were associated with higher hazard of discontinuation (p = 0.04 and p = 0.003 for any and exclusive breastfeeding, respectively). Conclusions It was feasible for peer counselors to implement changes in program delivery to achieve fewer home visits without a detrimental impact on breastfeeding outcomes. However, group education classes did not appear to be beneficial for improving breastfeeding outcomes in this population.

Prioritization of resources for participants in a peer counseling breastfeeding support program.

BACKGROUND: Peer counseling (PC) breastfeeding support programs have proven effective in increasing breastfeeding duration in low-income women. OBJECTIVES: This study aimed to describe program participants and breastfeeding duration in a PC program according to (1) timing of enrollment (prenatal vs postnatal) and (2) breastfeeding status at program exit (discontinued breastfeeding, exited program while breastfeeding, and completed 1 year program) to improve understanding of how these groups differ and how services might be optimized when resources are limited. METHODS: This study is a secondary analysis of data from low-income women enrolled in a PC breastfeeding support program. Participant characteristics and breastfeeding duration were described using chi-square tests, analyses of variance, and logistic regression. RESULTS: Postnatal enrollees had longer breastfeeding duration than prenatal enrollees (F < .001) and were more likely to be older, to be married, to be more educated, and to have prior breastfeeding experience (each variable P < .01). Women who withdrew from the program while breastfeeding were more demographically similar to those who discontinued breastfeeding prior to 1 year than to those who continued in the program breastfeeding for 1 year, although they breastfed for significantly longer at exit (mean ± SD = 27.8 ± 14.8 weeks) compared to women who discontinued breastfeeding while in the program (15.7 ± 13.3 weeks) (P < .001). CONCLUSION: It may be advantageous for peer counselors to direct fewer resources to later postnatal enrollees and more to prenatal or early postnatal enrollees. It may also be advantageous to focus on supporting women at high risk of discontinuation rather than on retaining women who choose to withdraw from the program while breastfeeding.

Impact of peer counselling breast-feeding support programme protocols on any and exclusive breast-feeding discontinuation in low-income women.

OBJECTIVE: Peer counselling (PC) programmes have been shown to improve breast-feeding outcomes in populations at risk for early discontinuation. Our objective was to describe associations between programme components (individual and combinations) and breast-feeding outcomes (duration and exclusivity) in a PC programme for low-income women. DESIGN: Secondary analysis of programme data. Multivariable-adjusted Cox proportional hazards models were used to examine associations between type and quantity of peer contacts with breast-feeding outcomes. Types of contacts included in-person (hospital or home), phone or other (e.g. mail, text). Quantities of contacts were considered 'optimal' if they adhered to standard programme guidelines. SETTING: Programme data collected from 2005 to 2011 in Michigan's Breastfeeding Initiative Peer Counseling Program. SUBJECTS: Low-income (n 5886) women enrolled prenatally. RESULTS: For each additional home, phone and other PC contact there was a significant reduction in the hazard of discontinuing any breast-feeding by 6 months (hazard ratio (HR)=0·90 (95% CI 0·88, 0·92); HR=0·89 (95% CI 0·87, 0·90); and HR=0·93 (95% CI 0·90, 0·96), respectively) and exclusive breast-feeding by 3 months (HR=0·92 (95% CI 0·89, 0·95); HR=0·90 (95% CI 0·88, 0·91); and HR=0·93 (95% CI 0·89, 0·97), respectively). Participants receiving greater than optimal in-person and less than optimal phone contacts had a reduced hazard of any and exclusive breast-feeding discontinuation compared with those who were considered to have optimum quantities of contacts (HR=0·17 (95% CI 0·14, 0·20) and HR=0·28 (95% CI 0·23, 0·35), respectively). CONCLUSIONS: Specific components of a large PC programme appeared to have an appreciable impact on breast-feeding outcomes. In-person contacts were essential to improving breast-feeding outcomes, but defining optimal programme components is complex.

Self-reported reasons for breastfeeding cessation among low-income women enrolled in a peer counseling breastfeeding support program.

BACKGROUND: Peer counseling programs have demonstrated efficacy in improving breastfeeding rates in the low-income population, but there is little research concerning why women enrolled in these programs ultimately discontinue breastfeeding. OBJECTIVE: This study aimed to describe the self-reported reasons for discontinuing breastfeeding among women who are receiving peer counseling support by participant characteristics and timing of discontinuation. METHODS: This study is a secondary analysis of data collected from 7942 participants who discontinued breastfeeding while enrolled in a peer counseling breastfeeding support program from 2005 to 2011. Reasons for discontinuing breastfeeding were assessed in relation to participant characteristics and weaning age using chi-square analyses and Kruskall-Wallis analyses of variance. RESULTS: The most common reasons reported for discontinuing breastfeeding were mother's preference (39%) and low milk supply (21%), although reasons differed by age of infant weaning (P < .001). Among participants who discontinued the earliest, the most commonly cited reasons were breastfeeding challenges [median duration (interquartile range), 4.7 (2.0, 13.4) weeks], followed by low milk supply [8.9 (4.6, 19.1) weeks] and mother's preference [12.9 (5.0, 25.7) weeks]. Women who were younger, were less educated, were non-Hispanic black, were unmarried, and had no prior breastfeeding experience were the most likely to discontinue breastfeeding due to mother's preference. CONCLUSION: Peer counselors are in a unique position to offer breastfeeding education and encouragement and may be able to use evidence presented here to anticipate specified concerns either prenatally or postpartum, to prevent early breastfeeding discontinuation.

An evaluation of the effects of a breastfeeding support program on health outcomes.

OBJECTIVE: To estimate the causal effect of a Michigan peer counselor (PC) breastfeeding support program for low-income women on infant health outcomes. DATA SOURCES: Program referral forms, program forms (enrollment, birth, and exit data), and state administrative data from the Women Infants and Children program, Medicaid, and Vital Records. STUDY DESIGN: Quasi-random enrollment due to the excess demand for PC breastfeeding support services allowed us to compare the infants of women who requested services and were enrolled in the program (the treatment group, N = 274) to the infants of women who requested services and were not enrolled (the control group, N = 572). Data were analyzed using regression. PRINCIPAL FINDINGS: The PC program increased the fraction breastfeeding at birth by 19.3 percent and breastfeeding duration by 2.84 weeks. Program participation also reduced the fraction of infants with gastrointestinal disorders by a statistically significant 7.9 percent. The program, if anything, increased the overall health care utilization. CONCLUSIONS: This Michigan PC breastfeeding support program resulted in improvements in breastfeeding and infant health outcomes as measured by the diagnosis of ailments while increasing health care utilization.

A qualitative study to understand positive and negative child feeding behaviors of immigrant Asian Indian mothers in the US.

To understand current practice of child feeding behaviors, and underlying factors influencing these practices in Asian Indian mothers, qualitative in-depth interviews were conducted with 27 immigrant Asian Indian mothers of children ages 5-10 years. Using the theory of planned behavior as a guiding framework, child feeding behaviors employed, beliefs about the outcomes of feeding behaviors, perceived ease or difficultly in practicing feeding behaviors, and social norms were explored during the interviews. Thematic analysis was conducted using coding and display matrices. Mothers were motivated by nutrition outcomes when practicing positive and negative controlling feeding behaviors. Outcomes related to preservation of Indian culture and values also influenced feeding behaviors. Pressuring to eat was often practiced despite the perception of ineffectiveness. Use of food rewards was found, and use of TV to control children's food intake despite the clear understanding of undesirable nutrition outcomes was a unique finding. Asian Indian mothers need effective child feeding strategies that are culturally appropriate. Integrating cultural beliefs in nutrition education could help support existing motivation and behavior modification.

A qualitative study to understand cultural factors affecting a mother's decision to breast or formula feed.

BACKGROUND: The presence of barriers is not sufficient to explain breastfeeding rate disparities. A relatively unexplored area in coping with breastfeeding barriers is culture. OBJECTIVE: This research aims to better understand the role of culture in a woman's infant feeding decision by using race and socioeconomic status as indicators of culture. METHODS: Focus groups and individual interviews were conducted with 42 pregnant women or mothers of infants younger than 12 months. Focus group composition was determined by self-identified African American or white race and self-reported eligibility for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or ineligibility (non-WIC). RESULTS: Most participants acknowledged that breastfeeding was best, yet differences arose between groups in the perception of, and reaction to, breastfeeding barriers. WIC and non-WIC participants of both races indicated that some circumstances necessitated formula use. WIC participants felt that this was personally and socially acceptable due to need, whereas non-WIC participants felt that this was personally and socially unacceptable. When a barrier arose, WIC participants of both races felt that the infant feeding choice was not theirs and formula use might be inevitable. In contrast, non-WIC participants of both races expressed that they persevered to continue breastfeeding and did so by establishing small, achievable goals and seeking mentors. CONCLUSION: Educational and public health efforts to reduce breastfeeding disparities may be enhanced if support is tailored to acknowledge cultural differences among women and address factors that make either breastfeeding or formula feeding acceptable, or even preferable, within their communities.

Development, content validity, and piloting of an instrument designed to measure managers' attitude toward workplace breastfeeding support.

Manager attitude is influential in female employees' perceptions of workplace breastfeeding support. Currently, no instrument is available to assess manager attitude toward supporting women who wish to combine breastfeeding with work. We developed and piloted an instrument to measure manager attitudes toward workplace breastfeeding support entitled the "Managers' Attitude Toward Breastfeeding Support Questionnaire," an instrument that measures four constructs using 60 items that are rated agree/disagree on a 4-point Likert rating scale. We established the content validity of the Managers' Attitude Toward Breastfeeding Support Questionnaire measures through expert content review (n=22), expert assessment of item fit (n=11), and cognitive interviews (n=8). Data were collected from a purposive sample of 185 front-line managers who had experience supervising female employees, and responses were scaled using the Multidimensional Random Coefficients Multinomial Logit Model. Dimensionality analyses supported the proposed four-construct model. Reliability ranged from 0.75 to 0.86, and correlations between the constructs were moderately strong (0.47 to 0.71). Four items in two constructs exhibited model-to-data misfit and/or a low score-measure correlation. One item was revised and the other three items were retained in the Managers' Attitude Toward Breastfeeding Support Questionnaire. Findings of this study suggest that the Managers' Attitude Toward Breastfeeding Support Questionnaire measures are reliable and valid indicators of manager attitude toward workplace breastfeeding support, and future research should be conducted to establish external validity. The Managers' Attitude Toward Breastfeeding Support Questionnaire could be used to collect data in a standardized manner within and across companies to measure and compare manager attitudes toward supporting breastfeeding. Organizations can subsequently develop targeted strategies to improve support for breastfeeding employees through efforts influencing managerial attitude.

Development and piloting of an instrument that measures company support for breastfeeding.

BACKGROUND: Maternal employment has been cited as a barrier to continued breastfeeding, yet there have been few studies identifying company breastfeeding support. OBJECTIVES: The study objectives were to develop and pilot an instrument that measures formal breastfeeding support in companies. METHODS: A survey of company breastfeeding supports was developed, based on the literature and expert review, and the survey piloted with Michigan-based companies. RESULTS: Completion of the surveys and open-ended comments indicated survey items were generally well understood. In the study sample (N = 151), significantly more support was offered in companies having more employees as compared to fewer, and in companies from the health care versus all other sectors (P < .01). More support was also found in companies reporting requests for support, upper management combining breastfeeding and work, and a population that they felt likely to require breastfeeding support (P < .01). Few companies (3%) had written policies on breastfeeding or pumping at work. However, the majority of companies allow women to pump milk at the worksite (94%), and provide time (73%) and nonrestroom space to pump (78%). Fewer companies allow breastfeeding at the company (22%) or designate a room solely for breastfeeding or pumping (32%). CONCLUSIONS: The survey instrument is appropriate to determine breastfeeding supports in companies. In Michigan, larger companies and those in the health care sector provide more supports, most companies provide some type of space and time to pump, but other supports are limited.

Perspectives of managers toward workplace breastfeeding support in the state of Michigan.

Managers' attitudes influence female employees' perceptions of workplace breastfeeding support. Five focus groups were conducted with managers in the state of Michigan (N = 25) to assess their attitudes toward supporting breastfeeding. All focus group discussions were recorded, transcribed verbatim, and analyzed for themes. Participants supported efforts by managers and companies to assist breastfeeding employees, but the extent of accommodations they supported varied. Most participants reported no company breastfeeding policy or were unaware of their company having one and showed mixed attitudes about needing a policy. Participants acknowledged the potential for lower productivity and coworker jealousy toward time for breastfeeding or expressing milk but believed that benefits of support included employee recruitment and retention. Participants demonstrated some understanding of breastfeeding benefits. They identified barriers and facilitators for breastfeeding support at both the organizational and individual levels. Results of this study will be used for instrument development to measure managers' attitudes toward supporting breastfeeding.

A quasi-experimental evaluation of a breastfeeding support program for low income women in Michigan.

We examined the effectiveness of a peer counseling breastfeeding support program for low income women in Michigan who participate in WIC. Because there was more demand for services than could be met by the program, many women who requested services were not subsequently contacted by a peer counselor. We used a quasi-experimental methodology that utilized this excess demand for services to estimate the causal effect of the support program on several breastfeeding outcomes. We relied on data derived from administrative and survey-based sources. After providing affirmative evidence that our key assumption is consistent with the data, we estimated that the program caused the breastfeeding initiation to increase by about 27 percentage points and the mean duration of breastfeeding to increase by more than 3 weeks. The support program we evaluated was very effective at increasing breastfeeding among low income women who participate in WIC, a population that nationally breastfeeds at rates well below the national average and below what is recommended by public health professionals. Given the substantial evidence that breastfeeding is beneficial for both the child and mother, the peer counseling breastfeeding support program should be subjected to a cost/benefit analysis and evaluated at other locales.