Degree Name

DrPH (Doctor of Public Health)


Public Health

Date of Award


Committee Chair or Co-Chairs

Megan Quinn

Committee Members

Kate Beatty, Bill Brooks, Mike Smith, Randy Wykoff


Background: Breastfeeding protects against a variety of adverse health outcomes for mothers and babies. Global best practices, known as the Baby-Friendly Hospital Initiative (BFHI), have been developed to support the initiation and exclusivity of breastfeeding during the post-delivery hospital stay. The aims of this study were to explore the literature related to the impact of the BFHI on breastfeeding disparities in the U.S.; compare the impact of exposure to these best practices on exclusive breastfeeding rates in Appalachian and non-Appalachian hospitals; and to understand knowledge, perceptions, and barriers to breastfeeding of postpartum mothers receiving care in a Northeast Tennessee OB/GYN clinic and regional International Board Certified Lactation Consultants’ (IBCLCs®) knowledge, perceptions, and barriers to implementation of the BFHI.

Methods: A scoping review was completed to explore literature related to exposure to the BFHI and breastfeeding disparities using the Levac, Colquhoun, and O’Brien methodology. A linear regression analysis of Maternity Practices in Infant Nutrition and Care (mPINC) breastfeeding best practice scores and breastfeeding rates at discharge was conducted comparing this relationship in Appalachian and non-Appalachian hospitals. Finally, a qualitative study was conducted using semi-structured interviews and thematic analysis to gather information from postpartum mothers and regional IBCLCs®.

Results: The BFHI has been found to reduce both geographic and racial/ethnic disparities in the U.S., but there are limited studies examining this topic. While there was a significant negative relationship between Appalachian hospitals and exclusive breastfeeding rates at discharge (p=0.0003), there was no significant difference in the relationship between total mPINC scores and exclusive breastfeeding rates at hospital discharge between the two designations (0.4539). Furthermore, both postpartum patients and regional IBCLCs® reported that support, education, and self-efficacy were all necessary to assist mothers on their infant feeding journey.

Implications: These findings highlight the need for studies examining the impact of the BFHI on breastfeeding disparities. Research also needs to be conducted to better understand breastfeeding rates in economically distressed, rural areas of the country. Ultimately, risk-stratified interventions supporting the specific needs of a population should be identified or developed to support and empower postpartum mothers to achieve their infant feeding goals.

Document Type

Dissertation - embargo


Copyright by the authors.