https://orcid.org/0009-0004-1308-5709
Figures
Abstract
Despite the growth of breastfeeding and lactation medicine as a specialty, the care of breastfeeding families is compromised because few standards and recommendations exist for its practice and integration into health systems. We conducted a qualitative study involving three focus groups (N = 13) with breastfeeding and lactation medicine physician leaders who currently work within large health systems across the United States. Our study aimed to gather the perspectives of physician leaders regarding breastfeeding care in health systems, to summarize current practices and recommendations for optimal care, and to explore barriers and facilitators to the implementation of these recommendations. A deductive content analysis approach guided by the Exploration, Preparation, Implementation, and Sustainment Framework was used to analyze the transcripts. Resulting themes revealed the important role that health systems play in modeling breastfeeding supportive practices and the strong influences of leadership and staff personal breastfeeding experiences on health system policies. Recommendations included the creation of breastfeeding and lactation medicine divisions, adequate staff education, staffing and coordination of lactation care across the system and community, support for lactating employees, and public awareness of resources and programs. Barriers to implementation included siloing of lactation services by department, lack of breastfeeding-supportive workplaces, deficient clinical billing for lactation services, and low prioritization by training programs. Facilitators included multidisciplinary collaborations, employee supportive lactation policies, appropriate dyadic lactation billing, and electronic health record workflows. Our focus groups revealed many barriers to the delivery of optimal breastfeeding care within health systems, but strategies were identified for systemic changes. Next steps include identification of breastfeeding and lactation medicine divisions and health systems already implementing the best practices described here. Further research should engage additional stakeholders to better understand administrative and financial points of view regarding barriers and facilitators of breastfeeding support.
Citation: Hall MM, Patterson JA, MacMillan Uribe AL, Simon L, Eglash AR, Standish KR (2026) Building breastfeeding knowledgeable health systems: Focus groups with physician leaders. PLoS One 21(5): e0350146. https://doi.org/10.1371/journal.pone.0350146
Editor: Tanya Doherty, Medical Research Council, SOUTH AFRICA
Received: August 5, 2025; Accepted: May 8, 2026; Published: May 28, 2026
Copyright: © 2026 Hall et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: We have uploaded our data set to figshare: https://figshare.com/articles/dataset/dx_doi_org_10_6084_m9_figshare_30655229/30655229?file=59679782.
Funding: JP - Northern Illinois University (NIU) College of Health and Human Sciences School of Health Studies - Internal departmental funds, no grant number - https://www.chhs.niu.edu/health-studies/index.shtml. MH - Health Resource and Services Administration - T32HP10010 - https://www.hrsa.gov/. Neither NIU or HRSA played any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Breastfeeding is normative infant feeding and associated with lower risk of infant morbidity and mortality as compared to formula feeding [1]. Although birth parents in the United States have a high intention to breastfeed, with over 84% initiating breastfeeding, exclusive breastfeeding rates drop off rapidly, with only 25% of infants exclusively breastfeeding at 6 months of age [2,3]. Shorter breastfeeding duration or lack of exclusivity increases lifelong health risks for mother-infant dyads and may contribute to postpartum depression, anxiety, and feelings of guilt or failure for the lactating parent [4]. Although all infants benefit from breastfeeding, it is critical for infants with medical vulnerabilities, such as prematurity, low birth weight, congenital heart defects, prenatal opioid exposure, metabolic diseases, and genetic diseases, to be fed human milk [5,6]. These children are often cared for in health systems that may not adequately support breastfeeding or do not use donor milk when parental milk is unavailable [5–7]. Suboptimal breastfeeding practices across all infant populations result in significant social and economic costs, estimated at US$100 billion annually in the US [8].
Multiple systemic barriers, beyond personal control, prevent families from meeting their breastfeeding intentions. Leading medical organizations, including the US Preventive Services Task Force, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics, strongly recommend routine breastfeeding counseling and support [1,9–11]. Breastfeeding care, however, is poorly integrated into healthcare, with many health professionals lacking adequate education and training, leading to insufficient lactation support ultimately contributing to a decline in breastfeeding rates over time. [12,13]. While some outpatient pediatric [14,15] and obstetrics [16,17] clinics offer breastfeeding support, it is not widely implemented.
At the same time, physician employment within the US is increasingly concentrated within large multispecialty health systems. In 2023, 77.6% of physicians were employed by hospitals or health systems, up from 25.8% in 2012 [18]. Breastfeeding families interact with multiple departments in these systems, yet support typically ends after the short, one-to-three day inpatient stay following delivery [19]. Many hospitals have adopted initiatives such as the Baby Friendly Hospital Initiative (BFHI) [20,21] to improve breastfeeding rates during the immediate postpartum period [22]. However, systematic integration of follow-up breastfeeding support into outpatient care remains limited, access to a higher level of care for complex cases is lacking in many communities [23], and evidence-based strategies are not widely shared. Policies and infrastructure needed to support breastfeeding for two years and beyond [24] have yet been to be fully developed [25,26]. Lack of physician and provider education and medical system breastfeeding support has been found to be a barrier in the continuation of care in breastfeeding support [27].
In recognition for the need to better support lactating families within health systems, Breastfeeding and Lactation Medicine (BFLM) has emerged as a subspecialty. New fellowship and organizational training programs and board certification [28–31] have helped define and formalize the field. BFLM clinics, programs and academic divisions have launched efforts to improve care, but standard and broad implementation is lacking [32–34]. To bridge these critical gaps, we conducted a qualitative study with BFLM physician leaders exploring their perspectives on the implementation of optimal breastfeeding care in health systems, including barriers, facilitators and recommendations.
Materials and methods
Study design
Qualitative focus groups were conducted with BFLM physicians working within large health systems in the US to explore their perspectives on 1) the role and rationale of health systems engaging in breastfeeding support and care, 2) current health systems’ practices, 3) recommendations for developing breastfeeding knowledgeable health systems (BKHS), and 4) barriers and facilitators to implementing such changes. For this study, large health systems were defined as multispecialty practices within a hospital system or academic medical center. The Consolidated Criteria for Reporting Qualitative Studies guided study design and reporting [35].
Framework
This study was guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, which influenced the development of the focus group questions and qualitative analysis. The framework provides a comprehensive approach to understanding and guiding the implementation of evidence-based practices through four distinct phases: Exploration, Preparation, Implementation, and Sustainment [36]. This study focused on the Exploration and Preparation phases to identify needs, define core tenets of the innovation (i.e., characteristics of BKHS), and identify barriers and facilitators to implementation. Globally, EPIS has been applied across a wide range of public, social, and allied health service systems to investigate the implementation of a specific evidence-based practice [37]. The EPIS framework includes several key constructs that influence the implementation process: 1) inner context that encompasses an organization’s characteristics (e.g., leadership organizational structure, individual characteristics); 2) outer context that is external to the organization and includes recipients’ characteristics (e.g., pregnant and lactating individuals and the breastfeeding infant); 3) bridging factors that identify relationships between the inner and outer domain; and 4) innovation factors that characterize the innovation itself. Definitions, EPIS domains, and constructs are in S1 Table.
Focus group guide
The focus group guide was developed by study team members who were 1) similar to study participants in having extensive experience with BFLM in large health systems, and 2) were able to ascertain the terminology and language context used in the focus group were consistent with the field. Iterative modifications refined the guide to address emerging topics. Open-ended questions and probing techniques encouraged in-depth discussions. Focus group questions are included in S2 Table.
Participants and recruitment
We used a purposeful critical case sampling approach, identifying key experts who can reveal critical patterns, issues, and themes within a niche phenomenon [38]. We identified BFLM physicians as critical cases (experts) to provide the most information and understanding of how to develop and implement BKHS because of their deep knowledge of patients’ lactation-related needs and the diversity of their experiences implementing best practices in breastfeeding within health systems. Inclusion criteria were: 1) adults over 18 years old, 2) physicians who practice BFLM within a large, multi-specialty health system, and 3) physicians who function as leaders in BFLM at their institutions and have experience implementing clinical and/or policy changes in their health system. To identify individuals who met inclusion criteria, study team members KS and AE identified eligible BFLM programs based on their professional networks and relationships in the BFLM field, and among them selected individuals for whom BFLM comprised a substantial portion of their professional responsibilities (e.g., a neonatologist implementing human milk-focused programs).
Participants were recruited through personal email invitations and interested individuals were asked to reply to be enrolled and scheduled for one of three focus groups from 01/09/2022–31/10/2022. The resulting focus group participants had a professional relationship with KS and AE due to their shared disciplines as BFLM physicians, a subspecialty with a small number of physicians in the US. Our objective was to gather strategic and implementation-relevant insights and expert perspectives from physician leaders. The Institutional Review Boards (IRB) of Northern Illinois University and Boston University approved this study as Exemption Category 2, which permits the use of oral consent when written documentation is not required and may increase risk. Because the BFLM community is small and professionally identifiable, obtaining written consent would have created additional identifiers; therefore, oral consent was deemed the most protective approach.
Data collection
Before starting the recording, verbal consent to participate in the online focus group and permission to record the session were obtained. Verbal consent was deemed sufficient due to the minimal risk to participants posed by online focus groups regarding professional activities and due to the added logistical complexity of obtaining written consent in a virtual setting. Participants in the online focus groups could choose whether and what information they would like to share and were permitted to leave the group at any time. Their verbal consent was documented in a protected record, noting the date and time, confirming that consent was obtained and was witnessed by the three research team members who led and moderated the focus groups (JP, KS, and AE), per IRB approval.
Focus groups were conducted using video conferencing software and audio- and video-recorded using the software features (Zoom, version 5.12.0 [Zoom Video Communications, Inc., 2022, San Jose, CA, USA]). Each focus group lasted 60–90 minutes. Two research team members led and moderated the focus groups (KS and AE); other study team members (KS, AE, and JP) actively participated in the discussion. Additionally, one team member (JP) took notes during each discussion. Following the focus groups, participants were asked to fill out a brief, anonymous, demographic survey. Subjects did not receive any compensation or incentives for their participation.
Data analysis
Audio-recorded focus group discussions were transcribed verbatim and checked for errors by JP and KS. Participant confidentiality was safeguarded by the de-identification of all transcripts, including the removal of names, institutions, geographic locations, and other potentially identifying details. De-identified quotations were then categorized by focus group number (1–3) and uploaded to NVIVO version 1.7.1 (QSR International Pty Ltd., Burlington, MA, USA) to assist with data organization and analysis. Given the limited number of BFLM physicians in the US, data saturation, defined as consistent responses or exhaustion of possible responses to the primary research question, was not determined [39].
Transcripts were analyzed using a directed content analysis approach [40] in which EPIS was used to develop an initial deductive codebook. Initially, all study team members read the transcripts. Two team members, KS and JP, coded all transcripts using deductive codebook. As codes were applied using line-by-line coding, the research team met regularly to build consensus around the codebook, during which inductive codes and code sub-categories were created and added to the codebook. Once all transcripts were coded, any deductive codes (i.e., from EPIS) that proved minimally relevant were dropped or revised prior to finalizing codebook. The final codebook included 1) deductive codes informed by EPIS; 2) inductive codes created for relevant data that did not align with EPIS; and 3) code sub-categories of each of the former to further reflect emerging ideas. Coded segments pertaining to each code were reviewed by KS, JP, and MH who grouped together relevant segments to identify emerging themes. Emerging themes were then discussed with the full team until consensus was reached.
The emerging themes were organized by EPIS domains to build final themes, which then served as the foundation for the development of the eight recommendations by the full team. These recommendations were then refined and finalized through team discussions. Member checking with focus group participants was performed via online survey to validate and confirm agreement with finalized recommendations. Memos and notes were created during every meeting to document the process. S3 Table includes codes used in analysis across EPIS Domains.
Trustworthiness
Trustworthiness addressing the findings’ credibility, transferability, and confirmability was obtained through multiple strategies, including the use of multiple coders and team-based data analysis. To enhance credibility, two research team members independently coded all transcripts (KS and JP), and all members participated in consensus-building meetings in which excerpts within each code were discussed in depth, contributing to theme construction. Expert triangulation was conducted with other BFLM physicians and midwives (n = 5) to review preliminary findings including the 8 recommendations. They agreed with the findings and did not identify any missing themes. Transferability was addressed through purposive sampling, in which critical cases were recruited as participants, and a thick description of study results, allowing readers to identify transferability to other contexts.
Description of research team
Six members formed the research team: four practicing physicians and two PhD researchers. Of the physicians, two are BFLM clinicians with research experience (KS, AE), one is a pediatric intensivist with health systems breastfeeding implementation expertise (LS), and the fourth is a BFLM physician gaining research training at the post-doctoral fellowship level (MH). The doctoral researchers, JP and LMU, have training and expertise in behavioral research, qualitative methods, and infant feeding. KS, AE, and JP designed the original study. MH, KS, JP, AE, LMU and LS completed the formal analysis. MH, KS and JP created initial draft of manuscript. MH, KS, JP, AE, LMU, and LS all edited the final manuscript.
All researchers identify as female, with 3 members representing mixed races/ethnicity (2 White/Latina, and 1 Asian/White), and 3 identifying as White. All have personal experience breastfeeding their children. These attributes of research team members were thoughtfully considered throughout the analysis process.
Results
In total, 13 BFLM physicians from across the U.S. participated in the three focus groups, with each group including 2–6 participants. The focus groups included physicians from the following specialties: pediatrics (n = 10), family medicine (n = 2), and obstetrics and gynecology (n = 1). Illustrative quotes were drawn in relative proportions from the three focus groups with the greatest number participants and quotations from focus group 1 (FG1 – n = 5), followed by focus group 2 (FG2 – n = 6), and lastly focus group 3 (FG3 – n = 2).
All participants were female, with the majority being over the age of 40 (85%) and White (83%). Most were International Board Certified Lactation Consultants (IBCLCs) (92%) practicing in outpatient settings (42%), inpatient settings (17%), or both (42%), and primarily within academic healthcare systems (75%). Three quarters of the participants (75%) reported serving as directors of lactation, and 25% did not report holding an official lactation-related title within their institution. One participant did not respond to the demographic questions, leaving their information unknown.
Importance of health systems in breastfeeding care
Participants emphasized the important role of health systems in implementing breastfeeding support practices and programs, underscoring their considerable power across the broader health ecosystem (see supporting quote “Q1” of Table 1 - T1-Q1). They stated that most physician education and training occur in health systems, so it is incumbent upon health systems to incorporate learning in BFLM for physicians (T1-Q2). As health systems are the major providers of health services, participants viewed health systems as uniquely positioned to significantly influence breastfeeding outcomes by implementing evidence-based practices (T1-Q3, T1-Q4). Finally, the historical role of health systems in perpetuating racial and social health disparities in the US was identified as a reason why these institutions must take responsibility for rectifying these injustices as related to breastfeeding (T1-Q5, T1-Q6).
Current breastfeeding care practices in health system
Participants reported on instances of both well-functioning and suboptimal breastfeeding care in health systems. The overarching theme that emerged from the focus groups was the absence of a current systems-based approach to implementing and sustaining evidence-based breastfeeding interventions in health systems throughout the trajectory of breastfeeding. Participants described this gap in evidence-based care spanning all areas of the health systems that interact with the breastfeeding parent-infant dyad, including care for both healthy infants and those with special care needs, inpatient and outpatient, and all disciplines. The subthemes and supporting quotes within each construct of the EPIS framework are provided in Table 2 and are described below.
Individual characteristics and leadership.
Healthcare professionals’ personal experience with breastfeeding, either positive or negative, was shared by participants as often affecting the breastfeeding care that is provided to patients (T2-Q1). Failure of providers and entire units to follow evidence-based medicine or implement evidence-based breastfeeding interventions was identified as a significant problem in all focus groups (T2-Q2). Some participants worked within divisions or centers for breastfeeding medicine which facilitated more widespread implementation of optimal breastfeeding support across their health systems. All participants agreed that the establishment of BFLM departments/divisions would provide the infrastructure to oversee the implementation of best practices in breastfeeding support, coordination of care, training, and clinical care for breastfeeding patients (T2-Q3, T2-Q4, T2-Q5). Participants highlighted the importance of integrating breastfeeding leadership within other departments, including those less directly connected to perinatal care but which may care for lactating women or breastfeeding dyads, such as surgery or the emergency room, and designating a “champion” in each unit or department.
Organizational characteristics, structures and staffing.
Participants noted that quality of breastfeeding care is impacted by coordination – or a lack thereof – between departments and levels of care (T2-Q6). For instance, in some health systems improved access to hospital delivery records enhanced the continuity of care and facilitated breastfeeding support at the outpatient newborn or postpartum visit. Participants recognized that the siloing of lactation care within different departments further complicated efforts to support the breastfeeding dyad (T2-Q7, T2-Q8). Participants discussed shifting towards a model that included joint comprehensive lactation care for the parent-infant dyad upon discharge. While standards exist, participants highlighted that evidence-based policies were not implemented due to the overwhelming numbers of barriers within the health systems, which impacted lactation care. (T2-Q9, T2-Q10).
Insufficient number of lactation staff for clinical need and patient volume was expressed by participants (T2-Q11), while others had robust lactation staffing following national guidelines (T2-Q12). Staffing of lactation was further complicated by poor pay (T2-Q13). Lactation staff were found to be dispersed across different departments, undermining cohesion and coordination (T2-Q14). Participants cited that lack of clinical supervision for lactation staff creates risk and impacts the quality of lactation support (T2-Q14, T2-Q15).
Staff education and quality and fidelity monitoring.
Participants described highly variable policies and benefits for lactating employees. Some health systems had insufficient resources and support for employees, while others had significant infrastructure and had implemented national standards for support of lactating medical trainees (T2-Q16, T2-Q17). Participants emphasized a lack of adequate breastfeeding education for residents, highlighting gaps in knowledge among residency faculty and insufficient resources, which perpetuates a cycle of inadequate care (T2-Q18). A notable example was the lack of breast exams documented in obstetric notes, which was criticized as a serious oversight, bordering on malpractice (T2-Q19). The EMR was highlighted by participants as having significant limitations, such as the inability to access comprehensive breastfeeding data across departments, which hampers efforts to track key metrics (T2-Q20).
Recommendations for optimal breastfeeding care in health systems
Focus groups resulted in 8 key recommendations for BKHS, summarized in Table 3 and illustrated in Fig 1, reflecting many of the optimal practices described above. Member checking from survey respondents (12 out of 13) to confirm the recommendations resulted in near unanimous agreement.
This figure illustrates the multilevel structures required to deliver high‑quality, equitable breastfeeding care, aligned with the eight recommendations in Table 3, and describes outer context and inner context factors. Arrows represent bridging factors that connect these domains as the system supports the dyad from pregnancy through postpartum and beyond. BFLM Breastfeeding and Lactation Medicine; BFHI Baby-Friendly Hospital Initiative; L&D Labor and Delivery; NICU Neonatal Intensive Care Unit; PICU Pediatric Intensive Care Unit; ER Emergency Room; WIC Special Supplemental Nutrition Program for Women, Infants, and Children.
Barriers and facilitators to implementing optimized breastfeeding care
Participants reported barriers and facilitators that were both internal and external to the health system, representing themes in both EPIS internal and external contexts (Table 4).
Individual characteristics and leadership.
The personal breastfeeding experiences of staff were noted by participants as potential barriers (if negative) or facilitators (if positive, or if interpreted as a desire to help others) to the adoption of breastfeeding-supportive policies (T4-Q1, T4-Q2). They expressed that finding the “right” people in leadership with positive attitudes toward or personal experiences of breastfeeding was required for crafting and implementing health system practices (T4-Q3, T4-Q4). At the clinical level, participants shared that breastfeeding problems were not always seen as medical concerns, hindering efforts to incorporate BFLM into health systems. (T4-Q5, T4-Q6).
Organizational characteristics, structures and staffing.
Participants described centralized breastfeeding medicine leadership as a facilitator of health system transformation. In organizations where policies were not overseen by a BFLM department or division, there was a lack of prioritization of breastfeeding (T4-Q7) and siloing of care (T4-Q9), but in health systems where BFLM was championed, the culture of the organization was transformed (T4-Q8) and multidisciplinary groups of specialties and departments worked together synergistically to support breastfeeding and lactation (T4-Q10).
Participants also shared that hiring policies, such as requiring lactation consultants to also have nursing degrees, limited the ability of organizations to hire lactation professionals, particularly those that have racial/ethnic or cultural concordance with patients. (T2-Q11; T2-Q12). In systems without supportive employee lactation policies, participants reported that staff’s personal breastfeeding experiences were likely to be poor, exacerbating barriers to health systems change (T4-Q13).
Quality and fidelity monitoring, infrastructure, and financial resources.
Measurable benchmarks and incentives were reported to drive health systems to make improvements in breastfeeding support. For instance, Baby-Friendly certification succeeded in one institution for this reason (T4-Q14, T4-Q15). The capacity of the EMR to drive systemic change in breastfeeding support was noted by participants. Built-in prompts, hard stops, and forced pathways within EMRs were identified as effective tools to standardize practices and ensure compliance, often proving more impactful than education or persuasion alone (T4-Q16).
Participants noted that underbilling for lactation care created fiscal barriers to implementing adequate breastfeeding support (T4-Q17), and that when billing appropriately for both members of the dyad, breastfeeding and lactation support could be profitable for institutions (T4-Q18).
Funding and patient characteristics.
Participants reported that inadequate implementation of the Affordable Care Act hindered access to prenatal education, due to insufficient billing for these services (T4-Q19), but some shared that clinics thrived by billing private insurance for both parent and infant care, demonstrating sustainability potential (T4-Q20). Providing culturally appropriate lactation care in multiple languages and directed recruitment efforts for concordant staff (T4-Q22) were identified as critical by participants, but often underprioritized (T4-Q21). Participants reported that societal norms regarding the perceived “ease” of breastfeeding often undervalued lactation needs (T4-Q23), though they cited cultural shifts recognizing its importance (T4-Q24).
Discussion
This is the first study to explore physician perspectives on the delivery of optimal breastfeeding care and support within large health systems. BFLM physicians in the focus groups highlighted their perspectives on the leadership role which health systems should play in the delivery of breastfeeding services within the US and the training of the healthcare workforce. From the study, we identified strategic implementation recommendations from BFLM experts for optimal breastfeeding support in health systems and barriers and facilitators related to the implementation of BKHS. These recommendations (Table 3) and the model (Fig 1) of health system breastfeeding services and structures provide a practical framework for those who endeavor to develop and implement a BKHS [41], outlining key domains and contextualizing the health system within the socioecological system of breastfeeding [42].
To deliver integrated, evidence-based, full-spectrum breastfeeding and lactation care within health systems, participants in our study recommended permanently funded medical director positions within BFLM departments, including protected time for education and research, in line with other studies [30,32,43,44]. Currently, few BFLM divisions or centers exist in the U.S. with only one division of BFLM formally incorporated within a medical school in the U.S. [32,45,46]. Coordination of breastfeeding medical care can be strengthened through system-wide breastfeeding-support policies developed collaboratively by key stakeholders, including clinical departments, health system leadership and administration, and community partners [12].
Respondents in our study suggested that health system capacity can be addressed by adopting existing US Lactation Consultant Association staffing guidelines for IBCLCs in inpatient postpartum hospital units, neonatal intensive care units, and post-discharge care [47]. New research is needed to update recommendations for appropriate staffing ratios of the growing interdisciplinary breastfeeding workforce, including BFLM physicians, other BFLM providers, lactation consultants and trained peer and community support.
Similar to previous reports, our respondents described that clinicians who have had negative experiences with breastfeeding may be less likely to prioritize lactation support and may apply their personal experiences in place of evidence-based medicine [48,49]. Our study extends this to health systems leaders, whose personal breastfeeding experiences were noted to influence system-wide policy, decision-making and resources for breastfeeding support. Breastfeeding mothers want evidence-based care from their physicians and other providers [50], however the personal breastfeeding experiences of healthcare providers has been shown to play a major role in breastfeeding support [51]. Increased support for lactating employees and evidence-based lactation training for health systems’ staff and clinicians has been shown to improve patient breastfeeding outcomes [52–56]. Lactation education also improves staff attitudes, confidence, and competence [52,57,58].
BFLM physician leaders in our study recommended that quality improvement and tracking of breastfeeding status within the EMR may provide opportunities to implement breastfeeding support practices within health systems. Although there can be inconsistencies in the way that lactation data are recorded in the EMR [59] and challenges in connecting parental and infant records [60], EMRs might affect change by tracking breastfeeding metrics [61], monitoring key indicators like rates of human milk feeding and skin-to-skin contact, creating standardized workflows to promote evidence-based breastfeeding practices, and instituting algorithms and security mechanisms to alert clinicians and staff to situations of risk [62]. Improved documentation through the use of the EMR may enhance lactation care reimbursement by insurance providers and health systems payors [63]. The need for tracking breastfeeding data including the identification of breastfeeding issues prior to discharge extends beyond healthcare institutions to the community. The National Association for County and City Health Officials included the need for a shared database system in the Community Infrastructure recommendations as a means to advance chest/breastfeeding continuity of care [64].
The negative effect of racism and implicit and explicit bias on breastfeeding outcomes has been described in the literature and was highlighted by our respondents [65,66]. The lack of diversity among lactation consultants and breastfeeding medicine physicians and other providers, the vast majority of whom are non-Hispanic White and are fluent only in English [63], precludes staff-patient racial or ethnic concordance in many health systems. Ensuring breastfeeding support that is truly accessible and equitable for all patients requires diversity, equity, and inclusion training for all lactation and BFLM staff, along with health system hiring practices that promote racial, ethnic, and cultural concordance between clinicians and patients [61]. This includes expanding access to IBCLC training opportunities and eliminating additional nursing certification requirements when hiring lactation consultants. Collaboration with community breastfeeding support programs plays an important role in achieving continuity of care and increasing breastfeeding exclusivity and duration in the surrounding communities of health systems, especially in minoritized groups with historically low breastfeeding rates [41,67–70].
Our findings highlight the complexity of integrating a new clinical care model into health systems. The integration of BFLM has similar opportunities and challenges to the field of addiction medicine, as both require care that extends into a variety of clinical settings from inpatient to outpatient, surgery to ICU and beyond. Popular breastfeeding misconceptions, such as breastfeeding is “natural and easy,” are believed to undermine medical concerns and disease processes. A paradigm shift to legitimize and prioritize BFLM within health systems is felt to be long overdue [71]. The focus group participants emphasized that it is time for the development of new patient care models, increased research into the pathophysiology of breastfeeding and lactation, and an understanding of how to best deliver BFLM care within health systems to the breastfeeding dyad. Health systems are also best positioned financially to negotiate appropriate compensation with insurers for services, including those for breastfeeding and lactation, across the entire system [72,73]. With large health systems providing the majority of medical care within the US [74], the implementation of evidence-based practices, policies and leadership structures within these entities is believed to be essential to ensuring optimal breastfeeding and lactation outcomes.
Next steps for this research include surveying BFLM physicians to identify BFLM divisions and health systems already implementing some of the best practices described here. Further research must also engage other health system stakeholders, including administration, finance, and nursing leadership, to better recognize administrative and financial factors in the development of BKHS.
Strengths and limitations
Strengths of this study lie in our ability to explore the knowledge and experiences of highly accomplished physician leaders in this field and the use of the EPIS framework to understand and guide the implementation of a BKHS. Limitations of this study relate to the small sample size and homogeneity of participants, where collected perspectives may not represent all possible viewpoints within BFLM, including representativeness of the sample potential biases, and limits of saturation. This study included a sample of just 13 participants, all of whom held leadership positions in breastfeeding and lactation medicine. At the time of manuscript writing, only 159 individuals were publicly listed as board-certified by the North American Board of Breastfeeding and Lactation Medicine, which began board certification in 2023 [75]. A recent US-wide survey identified 138 physicians and other providers practicing breastfeeding and lactation medicine [76]. Given the small and specialized nature of this professional community, the high proportion of representation enhances the relevance and depth of the study findings.
The homogeneity of the sample, recruited from among subjects who already had a professional relationship with study team members, may not fully encompass the diversity of BFLM physicians across demographic backgrounds, geographic regions, and health system types. This may have skewed the discussion in our focus groups and introduced potential bias, thereby limiting the generalizability of findings to more varied clinical contexts, especially among non-white, non-physician led BFLM departments/divisions and at non-academic, community-based health systems. However, even among this small and specialized group, most focus group participants did not have prior relationships with one another. Saturation was not assessed due to the limited population size, and the study aimed to capture a sample of expert perspectives rather than achieve thematic saturation. Future work will expand the breadth of BFLM providers and health systems surveyed.
Conclusion
Many barriers exist for the delivery of optimal breastfeeding care within health systems. In this study, we identified eight recommendations to facilitate systemic changes in large health systems as well as important implementation barriers to overcome, such as leadership and staff personal breastfeeding experiences impeding evidence-based care. These elements are intended to guide strategic planning and prioritization by offering a structured yet adaptable roadmap that health systems may tailor to their organizational context and readiness. The creation of a BKHS requires integrated breastfeeding care and management across entire health systems maintained and led by a dedicated BFLM division headed by an experienced clinician to ensure the implementation, monitoring, and quality improvement of breastfeeding supportive policies for all patients and employees in collaboration with community programs.
Supporting information
S1 Table. Definitions of domains and constructs within exploration, preparation, implementation, and sustainment (EPIS) framework.
https://doi.org/10.1371/journal.pone.0350146.s001
(DOCX)
S3 Table. Selected codes within exploration, preparation, implementation, and sustainment (EPIS) framework.
https://doi.org/10.1371/journal.pone.0350146.s003
(DOCX)
References
- 1. Meek JY, Noble L. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2022;150:e2022057988.
- 2.
CDC. 2022 Breastfeeding Report Card. 2022. https://www.cdc.gov/breastfeeding/data/reportcard.htm
- 3. Increase the proportion of infants who are breastfed exclusively through age 6 months — MICH‑15 - Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants/increase-proportion-infants-who-are-breastfed-exclusively-through-age-6-months-mich-15
- 4. Brown A. Breastfeeding as a public health responsibility: a review of the evidence. J Hum Nutr Diet. 2017;30(6):759–70. pmid:28744924
- 5. Call for authors - Systematic reviews on donor human milk banking processes. https://www.who.int/news-room/articles-detail/call-for-authors-systematic-reviews-on-donor-human-milk-banking-processes
- 6. Spatz DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Perinat Neonatal Nurs. 2004;18(4):385–96. pmid:15646308
- 7. Kashyap V, Choudhari SG. Unlocking the Potential: A Systematic Literature Review on the Impact of Donor Human Milk on Infant Health Outcomes. Cureus. 2024;16(4):e57440. pmid:38699095
- 8. Jegier BJ, Smith JP, Bartick MC. The economic cost consequences of suboptimal infant and young child feeding practices: a scoping review. Health Policy Plan. 2024;39(9):916–45. pmid:39087279
- 9.
Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary Care Interventions to Support Breastfeeding: Updated Systematic Review for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US). 2016. http://www.ncbi.nlm.nih.gov/books/NBK396073/
- 10. Breastfeeding challenges: ACOG committee opinion summary, number 820. Obstet Gynecol. 2021;137:394–5.
- 11. Breastfeeding, Family Physicians Supporting (Position Paper). https://www.aafp.org/about/policies/all/breastfeeding-position-paper.html
- 12. Garner CD, Ratcliff SL, Thornburg LL, Wethington E, Howard CR, Rasmussen KM. Discontinuity of Breastfeeding Care: “There’s No Captain of the Ship”. Breastfeed Med. 2016;11(1):32–9. pmid:26566010
- 13. Meek JY, Nelson JM, Hanley LE, Onyema-Melton N, Wood JK. Landscape Analysis of Breastfeeding-Related Physician Education in the United States. Breastfeed Med. 2020;15(6):401–11. pmid:32320260
- 14. Kawan M, Gregory EF, Spatz DL. Improving breastfeeding care & support in a large, urban, pediatric primary care practice. J Pediatr Nurs. 2023;70:e3–8. pmid:36424329
- 15. Conover N, Vanderpool J, Ginsberg J, Kawan M, Spatz DL. Establishing a Breastfeeding Consortium for Clinicians in Pediatric Outpatient Care. MCN Am J Matern Child Nurs. 2023;48(1):24–9. pmid:36136072
- 16. ACOG Committee. Optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2018;132:e187–96.
- 17. Breastfeeding challenges: ACOG committee opinion, number 820. Obstet Gynecol. 2021;137:e42–53.
- 18. Physicians Advocacy Institute. PAI-Avalere Study on Physician Employment-Practice Ownership Trends 2019-2023. https://www.physiciansadvocacyinstitute.org/PAI-Research/PAI-Avalere-Study-on-Physician-Employment-Practice-Ownership-Trends-2019-2023
- 19. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices?. Lancet. 2016;387(10017):491–504. pmid:26869576
- 20. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402–17. pmid:26924775
- 21. Ruzafa-Martinez M, Harillo-Acevedo D, Ramos-Morcillo AJ. Monitoring of the Implementation of a Breastfeeding Guideline for 6 Years: A Mixed-Methods Study Using an Interrupted Time Series Approach. J Nurs Scholarsh. 2021;53(3):358–68. pmid:33555124
- 22. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402–17. pmid:26924775
- 23.
Breastfeeding and the U.S. health care system. Breastfeeding in the United States: Strategies to support families and achieve national goals. The National Academies Press.
- 24. Szugye H, Murra A, Lam SK. A new policy update on breastfeeding: What all clinicians need to know. Cleve Clin J Med. 2023;90(8):469–73. pmid:37527873
- 25. Tomori C, Hernández-Cordero S, Busath N, Menon P, Pérez-Escamilla R. What works to protect, promote and support breastfeeding on a large scale: A review of reviews. Matern Child Nutr. 2022;18 Suppl 3(Suppl 3):e13344. pmid:35315573
- 26. Zhu DT, Gupta T, Pérez-Escamilla R. Empowering Global Health Systems to Protect, Promote and Support Optimal Breastfeeding. Matern Child Nutr. 2025;21(1):e13753. pmid:39482833
- 27. NACCHO. Continuity of Care in Breastfeeding Support: A Blueprint for Communities. https://www.naccho.org/blog/articles/continuity-of-care-in-breastfeeding-support-a-blueprint-for-communities
- 28.
NABBLM NAB of B and LM. North American Board of Breastfeeding and Lactation Medicine. https://nabblm.org/
- 29.
Fellowship - Breastfeeding & Lactation Medicine. Golisano Children’s Hospital. https://www.urmc.rochester.edu/childrens-hospital/breastfeeding-lactation-medicine/breastfeeding-fellowship.aspx
- 30. Rosen-Carole CB, Coyle L, Eglash A, Leeper K, Long S, Louis-Jacques A. Recommended Core Competencies for Specialists Practicing Breastfeeding and Lactation Medicine. Breastfeed Med Off J Acad Breastfeed Med. 2022;17:553–63.
- 31. Breastfeeding Education for Healthcare Providers - IABLE. https://lacted.org/breastfeeding-education-for-healthcare-providers/
- 32. Rosen-Carole CB. Medical directors of breastfeeding programs at academic medical centers: Duties and challenges. Breastfeed Med. 2017;12:58–62.
- 33. Elder E, Pianosi K, Lawlor CM, Graham ME. Supporting Lactation in Otolaryngology Patients Through Medication Optimization, Radiology Considerations, and More: A Literature Review. JAMA Otolaryngol Head Neck Surg. 2022;148(10):973–80. pmid:35951313
- 34. Rieth EF, Barnett KM, Simon JA. Implementation and Organization of a Perioperative Lactation Program: A Descriptive Study. Breastfeed Med. 2018;13(2):97–105. pmid:29271670
- 35. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. pmid:17872937
- 36. Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1):4–23. pmid:21197565
- 37. Moullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci. 2019;14(1):1. pmid:30611302
- 38. Suri H. Purposeful Sampling in Qualitative Research Synthesis. Qual Res J. 2011;11:63–75.
- 39. Braun V, Clarke V. To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales. Qualitative Research in Sport, Exercise and Health. 2019;13(2):201–16.
- 40. Hsieh HF, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual Health Res. 2005;15:1277–88.
- 41. Lilleston P, Nhim K, Rutledge G. An Evaluation of the CDC’s Community-Based Breastfeeding Supplemental Cooperative Agreement. J Hum Lact. 2015;31(4):614–22.
- 42. Pérez-Escamilla R, Tomori C, Hernández-Cordero S, Baker P, Barros AJD, Bégin F, et al. Breastfeeding: crucially important, but increasingly challenged in a market-driven world. Lancet. 2023;401(10375):472–85. pmid:36764313
- 43. Shaikh U, Smillie CM. Physician-led outpatient breastfeeding medicine clinics in the United States. Breastfeed Med. 2008;3(1):28–33. pmid:18333766
- 44. Eglash A. Aim for Breastfeeding Medicine Departments and Not Physician Champions at Teaching Institutions. Breastfeed Med. 2020;15(10):603–4. pmid:32846101
- 45. Nardella D, Rosen-Carole C, Colmenares Castaño M, Hernández-Aguilar MT, Young M, Swisher Rosa E. A national survey of U.S. prescribing clinicians who practice breastfeeding and lactation medicine in outpatient and inpatient healthcare settings. Breastfeed Med. 2025.
- 46. Breastfeeding & Lactation Medicine - Golisano Children’s Hospital - Rochester NY - University of Rochester Medical Center. https://www.urmc.rochester.edu/childrens-hospital/breastfeeding-lactation-medicine
- 47. Lober A. Professional lactation support staffing in the hospital setting. Clin Lact. 2021.
- 48. Dixit A, Feldman-Winter L, Szucs KA. “Frustrated,” “depressed,” and “devastated” pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding support. J Hum Lact. 2015;31(2):240–8. pmid:25588382
- 49. Hoyt-Austin AE, Phillipi CA, Lloyd-McLennan AM, King BA, Sipsma HL, Flaherman VJ, et al. Physician personal breastfeeding experience and clinical care of the breastfeeding dyad. Birth. 2024;51(1):112–20. pmid:37724625
- 50. Blixt I, Johansson M, Hildingsson I, Papoutsi Z, Rubertsson C. Women’s advice to healthcare professionals regarding breastfeeding: “offer sensitive individualized breastfeeding support”- an interview study. Int Breastfeed J. 2019;14:51. pmid:31889974
- 51. Chesnel MJ, Healy M, McNeill J. Experiences that influence how trained providers support women with breastfeeding: A systematic review of qualitative evidence. PLoS One. 2022;17(10):e0275608. pmid:36240230
- 52. Feldman-Winter L, Barone L, Milcarek B, Hunter K, Meek J, Morton J, et al. Residency curriculum improves breastfeeding care. Pediatrics. 2010;126(2):289–97. pmid:20603262
- 53. Balogun OO, Dagvadorj A, Yourkavitch J, da Silva Lopes K, Suto M, Takemoto Y, et al. Health Facility Staff Training for Improving Breastfeeding Outcome: A Systematic Review for Step 2 of the Baby-Friendly Hospital Initiative. Breastfeed Med. 2017;12(9):537–46. pmid:28930480
- 54. Rodriguez Lien E, Shattuck K. Breastfeeding education and support services provided to family medicine and obstetrics-gynecology residents. Breastfeed Med Off J Acad Breastfeed Med. 2017;12:548–53.
- 55. Patterson JA, Keuler NS, Eglash AR, Olson BH. Outpatient Breastfeeding Champion Program: Breastfeeding Support in Primary Care. Breastfeed Med. 2020;15(1):44–8. pmid:31397581
- 56. Witt R, Vatti T, Lasko L, Witt AM. Team-Based Breastfeeding Support at a Federally Qualified Health Center: Efficacy, Utilization, and Patient Satisfaction. Breastfeed Med. 2021;16(9):741–9. pmid:33956505
- 57. Ortiz Worthington R, Adams DR, Fritz CDL, Tusken M, Volerman A. Supporting Breastfeeding Physicians Across the Educational and Professional Continuum: A Call to Action. Acad Med. 2023;98(1):21–8. pmid:35921171
- 58. Holmes AV, McLeod AY, Thesing C, Kramer S, Howard CR. Physician breastfeeding education leads to practice changes and improved clinical outcomes. Breastfeed Med. 2012;7(6):403–8. pmid:23046226
- 59. Bartsch E, Park AL, Young J, Ray JG, Tu K. Infant feeding practices within a large electronic medical record database. BMC Pregnancy Childbirth. 2018;18(1):1. pmid:29291732
- 60. List BA, Ballard JL, Langworthy KS, Vincent AM, Riddle SW, Tamayo OW, et al. Electronic health records in an outpatient breastfeeding medicine clinic. J Hum Lact. 2008;24(1):58–68. pmid:18281357
- 61. Revheim I, Balthasar MR, Akerkar RR, Stangenes KM, Almenning G, Nygaard E, et al. Trends in the prevalence of breastfeeding up to 6 months of age using structured data from routine child healthcare visits. Acta Paediatr. 2023;112(1):100–5. pmid:35442538
- 62. Leante-Castellanos JL, Mañas-Uxo MI, Garnica-Martínez B, Tomás-Lizcano A, Muñoz-Soto A. Implementation of a Regional Standardised Model for Perinatal Electronic Medical Records. J Med Syst. 2022;46(12):103. pmid:36446948
- 63. Chetwynd E, Meyer A-M, Stuebe A, Costello R, Labbok M. Recognition of International Board Certified Lactation Consultants by health insurance providers in the United States: results of a national survey of lactation consultants. J Hum Lact. 2013;29(4):517–26. pmid:23962773
- 64. Blueprint - BreastfeedingCoC. https://www.breastfeedingcontinuityofcare.org/blueprint
- 65. Robinson K, Fial A, Hanson L. Racism, Bias, and Discrimination as Modifiable Barriers to Breastfeeding for African American Women: A Scoping Review of the Literature. J Midwifery Womens Health. 2019;64(6):734–42. pmid:31710173
- 66. Safon CB, Heeren TC, Kerr SM, Clermont D, Corwin MJ, Colson ER, et al. Disparities in Breastfeeding Among U.S. Black Mothers: Identification of Mechanisms. Breastfeed Med. 2021;16(2):140–9. pmid:33539248
- 67. Haider SJ, Chang LV, Bolton TA, Gold JG, Olson BH. An evaluation of the effects of a breastfeeding support program on health outcomes. Health Serv Res. 2014;49(6):2017–34. pmid:25039793
- 68. Reis-Reilly H, Fuller-Sankofa N, Tibbs C. Breastfeeding in the Community: Addressing Disparities Through Policy, Systems, and Environmental Changes Interventions. J Hum Lact. 2018;34(2):262–71. pmid:29596763
- 69. Reis-Reilly H, Bernard E, Ritter S. Local health systems promoting, protecting, and supporting optimal infant feeding: blueprint for continuity of care in community breastfeeding support. J Public Health Manag Pract. 2021;27:332–5.
- 70. Burke LG, Burke RC, Orav EJ, Duggan CE, Figueroa JF, Jha AK. Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries. JAMA Netw Open. 2023;6(2):e2254559. pmid:36723939
- 71.
Addiction medicine in America: Its birth, early history, and current status (1750-2022). Seventh Edition ed. Lippincott Williams & Wilkins. 2024.
- 72. Roberts ET, Chernew ME, McWilliams JM. Market share matters: evidence of insurer and provider bargaining over prices. Health Aff Proj Hope. 2017;36:141–8.
- 73. Zigrang TA. Healthcare Compensation Plans: Current Challenges and Novel Approaches. Front Health Serv Manage. 2022;38: 26–32.
- 74. Furukawa MF, Machta RM, Barrett KA, Jones DJ, Shortell SM, Scanlon DP. Landscape of Health Systems in the United States. Med Care Res Rev. 2020;77:357.
- 75. Verify Credentials – NABBLM. https://nabblm.org/verify-credentials
- 76. Laroche D, Scheive M. Diversity, equity, and inclusion in healthcare and society: A historical imperative, ethical framework, and strategic pathway amidst evolving challenges. J Natl Med Assoc. 2025;117(6):364–9. pmid:40975631