Table 2 Theme and sub-theme titles, references, and exemplar quotes

Theme 1: Education and dissemination

271

37%

 Sub-theme 1a: Education and dissemination challenges

213

29%

“Not all nurses teach the same thing…some of them [were educated] in nursing school [which could be] 35 years ago. [At that time,] some [nurses] didn’t even [learn] information on safe sleep or, let alone, breastfeeding and safe sleep.”

 Sub-theme 1b: Education opportunities

49

7%

“I think what is needed in our state is tools for open, candid conversations to talk with families about this intersection between breastfeeding and safe sleep. We see that they’re often [taught] separate but parents experience them together...And so I would like more tools that would help…to have conversations that are less prescriptive, less... preachy.”

 Sub-theme 1c: Dissemination opportunities

9

1%

“[Nighttime parenting plans are] a chance to [establish], ‘Let’s walk through what’s going to happen at 2 AM and you’re exhausted and all the best intentions in the world [around ISS and breastfeeding] are gone out the window.’”

Theme 2: Relationship building and social support

252

34%

 Sub-theme 2a: Patient-provider relationship building

171

23%

“Having the Maternal Nurse Navigators that...reach out, even if it’s a small population, [to] give them information, make sure they have resources... I think that’s a really great start. I know we’re catching some of the moms [who we would normally miss].”

 Sub-theme 2b: Peer-to-peer connections

81

11%

“I’ve also learned to maintain connections with mothers and families that I have served in the past because they can tell their [breastfeeding and ISS] stories to clients that I’m serving now and I think that stories are so powerful.”

Theme 3: Working with clients’ personal circumstances and considerations

144

20%

 Sub-theme 3a: Capacity

88

12%

“The biggest resource I think moms need is someone to help them, but I don’t know how you...take the load off them, because we do see...they’re just at their wits end sometimes. They’ve got so many things going on in their life, especially if they’ve got socio-economic factors affecting them.”

 Sub-theme 3b: Social determinants

38

5%

“[ISS promotion makes] assumptions that [the client] has a crib or room for a crib. [But,] we don’t always know their living circumstances and how that impacts what they’re able to do”.

 Sub-theme 3c: Generational barriers

18

2%

“Things have changed a lot since our clients’ mothers and grandmothers were having babies. [Extended family members will say]...‘you’ve got to give both [formula and breastmilk] because the baby is not [eating] enough,’ or, ‘you put the baby on their stomach to sleep because that’s what we did.’ We educate our moms, but then there’s that missing piece – how does it get from the mom, to the grandma, and the auntie and the older generation who did things differently?”

Theme 4: Tools and systems

71

10%

“All of our clients are Black mothers...Our initiation rate is excellent, but we run into issues [when they] go back to work. A lot of them don’t have [comprehensive] maternity leave...or they work in jobs that don’t allow them time to pump. That’s where we see the breastfeeding [rates] fall off.”

TOTAL

738

100%