Breastfeeding Disparities Among Rural Breastfeeding Dyads in High-Income Countries: A Scoping Study

Abstract

Background/Objective:

Low breastfeeding initiation and duration of exclusivity put rural mothers and infants at risk for morbidity and mortality and significant economic costs. This scoping study aimed to identify determinants of breastfeeding disparities among rural dyads in high-income countries and their modifiable factors.

Methods:

The Arksey and O'Malley methodological framework was used. A literature review was conducted using PubMed, CINAHL Complete, Embase, and APA PsycInfo databases to identify studies related to rural breastfeeding that met criteria published between 2012 and 2022.

Results:

Twenty-five studies were included. Rural mothers from high-income countries are more likely to be younger, be unmarried, have lower educational attainment, have lower socioeconomic status, smoke, and have a higher prepregnancy body mass index than their urban counterparts. Rural mothers across White, Black, and Hispanic racial and ethnic groups have significantly lower breastfeeding rates compared to urban mothers. Maternal physiological preparedness, breastfeeding problems, lifestyle choices, support from family, evidence-based practice, workplace support, and policy development and implementation for breastfeeding promotion were identified as modifiable factors. Interventions using technology are an emerging field to overcome rurality.

Conclusions:

Although breastfeeding disparities are prevalent in rural dyads, the basic challenges mothers face when breastfeeding are universal, despite geographical locations in high-income countries. More specific support needs to be provided for breastfeeding dyads to continue breastfeeding. Resource allocation needs to be improved to increase access to care. Patient-centered technology interventions may decrease breastfeeding barriers in rural areas.

Background

Breastfeeding has many health benefits for mothers^1–4 and children,^5–7 yet worldwide there is a huge variation in initiation, duration, and exclusivity. Understanding this variation in rates in terms of breastfeeding disparities has become an important public health concern because health outcomes differ substantially for mothers and infants who breastfed compared to those who never breastfed. For example, if all children between 0 and 23 months old were exclusively breastfed for the first 6 months and continue breastfeeding with a combination of nutritionally adequate complementary foods for the first 24 months and beyond, it is estimated to save over 820,000 children's lives every year worldwide.⁸ Breastfeeding reduces countries' economic costs in both lives saved, and health care dollars spent. To obtain optimal health benefits for both mothers and children, it is recommended that mother and infant dyads initiate breastfeeding within an hour after birth,⁵ establish and sustain exclusive breastfeeding for the first 6 months,^9,10 and continue to breastfeed at least 24 months total after the introduction of complementary nutrients.^9,10 Despite these recommendations, only 44% of infants between 0 and 6 months old were exclusively breastfed between 2015 and 2022 globally. Worldwide, this rate varies widely between low- and middle-income countries and high-income countries.

For example, only 78.5% of infants in high-income countries ever breastfed compared to 97.6% of infants in low- and middle-income countries who did so. Ever breastfed is defined as infants who received some breast milk.¹¹

Barriers to breastfeeding are multifaceted: individual/interpersonal factors,¹² demographic variables,¹³ social environment factors,¹⁴ and structural factors such as breastfeeding policies.¹⁵ Rural mother and infant dyads have lower initiation and shorter duration of exclusive breastfeeding than urban dyads.^16–19 Rural was defined as all territory, population, and housing units located outside of urban areas designated by the U.S. Census Bureau.²⁰ Rural dyads have limited access to care, including transportation issues and lack of in-person visits.²¹ These challenges may affect mothers' breastfeeding decisions during the hospital stay or shortly after being discharged and profoundly impact breastfeeding disparities, resulting in early breastfeeding discontinuation. However, little research has addressed this inequity with rural dyads.

This scoping study aimed to answer the following research questions: (1) What is the available evidence on the determinants of breastfeeding among rural breastfeeding dyads in high-income countries? and (2) What factors that contribute to rural breastfeeding disparities are identified in the literature as modifiable? In this, only high-income countries are included for this study because the proportion of infants who were ever breastfed was lower among infants in high-income countries compared to infants in low-and middle-income countries.¹¹ In addition, there are differences in social context and infrastructure between low/middle-income countries and high-income countries.

Methods

Research design

The methodological framework developed by Arksey and O'Malley²² guided this scoping study. It included (1) identifying research questions, (2) searching relevant studies, (3) selecting studies, (4) charting studies, and (5) collating, summarizing, and reporting the results. Selected studies were not based on design or evidence quality assessment. Instead, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and checklist ensured the appropriateness of this scoping study (Fig. 1).

FIG. 1.

PRISMA 2020 Flow Diagram. From: Page et al.⁵⁵ For more information, visit: www.prisma-statement.org PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Sample and search strategy

A literature search was conducted using search engines in PubMed, CINAHL Complete, Embase, and APA PsycInfo by the librarian who is the third author of this study. These databases were identified as the most likely to hold information relevant to this scoping study. Due to the overlap of Medline content in both PubMed and Embase, Medline was searched only in PubMed, and records that appear in Medline were eliminated from the Embase results to prevent duplication of records.

Each database was searched twice: Once with a formal subject heading-based search, and once with a more informal keyword-based search. This was done to ensure the broadest search possible within each database. Combinations of the following search terms were used to identify relevant studies: breastfeeding, rural, initiation, duration, exclusivity, infant feeding, breastfeeding promotion, wean, barrier, and intervention. The search terms used for specific databases are listed in Table 1.

Table 1.

Search Strings

Database	Search	Limiters	No. of results
PubMed	MeSH-based search: “Breast Feeding”[MeSH Terms] AND (“Rural Population”[MeSH Terms] OR “Rural Nursing”[MeSH Terms] OR “Rural Health Services”[MeSH Terms] OR “Rural Health”[MeSH Terms] OR “hospitals, rural”[MeSH Terms]) AND (“initial”[All Fields] OR “initially”[All Fields] OR “initials”[All Fields] OR “initiate”[All Fields] OR “initiated”[All Fields] OR “initiates”[All Fields] OR “initiating”[All Fields] OR “initiation”[All Fields] OR “initiations”[All Fields] OR “initiator”[All Fields] OR “initiators”[All Fields] OR (“duration”[All Fields] OR “durations”[All Fields]) OR (“exclusive”[All Fields] OR “exclusively”[All Fields] OR “exclusiveness”[All Fields] OR “exclusivities”[All Fields] OR “exclusivity”[All Fields]))	Date: 2012–2022	557 Without limiter; 254 with date limiter
PubMed	Keyword-based search: breast feeding AND rural AND (barrier OR intervention OR facilitator OR health disparities OR illness OR newborn OR neonat^* OR perinat^* OR postnat^* OR poli^* OR ethnic^* OR experien^*)	Date: 2012–2022	1,855 Without limiter; 776 with date limiter
CINAHL Complete (EBSCO)	Subject heading-based search: ((MH “Infant Feeding+”) OR (MH “Breast Feeding”) OR (MM “Breast Feeding Promotion”) ) AND ((MH “Rural Population”) OR (MH “Rural Health Services”) OR (MH “Rural Areas”) OR (MH “Rural Health Nursing”) OR (MH “Rural Health”)) AND (initiat^* OR duration OR exclusiv^*)	Date: 2012–2022	259 Without limiter; 188 with date limiter
CINAHL Complete (EBSCO)	Keyword-based search: (breastfe^* OR “breast feeding” OR “breast-feeding” OR lactat^* OR wean^* OR “infant feeding” OR “chest feeding” OR “chest fed” OR chestfe^) AND rural AND (initi^ OR exclus^* OR durat^* OR barrier^* OR interven^* OR health disparities OR illness OR newborn OR neonat^* OR perinat^* OR postnat^* OR poli^* OR ethnic^* OR experien^*)	Date: 2012–2022	1,103 Without limiter; 748 with date limiter
APA PsycInfo (Proquest)	Subject heading-based search: (initi^* OR duration OR exclus^*) AND (MAINSUBJECT.EXACT.EXPLODE(“Breast Feeding”) OR MAINSUBJECT.EXACT(“Lactation”) OR MAINSUBJECT.EXACT(“Weaning”)) AND (MAINSUBJECT.EXACT.EXPLODE(“Rural Environments”) OR MAINSUBJECT.EXACT.EXPLODE(“Rural Health”))	Date: 2012–2022	36 Without limiter; 24 with date limiter
APA PsycInfo (Proquest)	Keyword-based search: (“breast feeding” OR breastfe^* OR “breast fed” OR “infant feeding” OR “chest feeding” OR “chest fed” OR chestfe^) AND rural AND (init^ OR duration OR exclus^* OR health disparities OR illness OR newborn OR neonat^* OR perinat^* OR postnat^* OR poli^* OR ethnic^* OR experien^*)	Date: 2012–2022	257 Without limiter; 148 with date limiter
Embase	Emtree-based search: ‘rural area’/exp AND (‘breast feeding’/exp OR ‘breast feeding education’/exp) AND (initi^* OR duration OR exclus^*)	Date: 2012–2022 Database: Exclude Medline, Exclude Embase +Medline	367 Without limiters; 236 with date limiter; 105 without Medline content
Embase	Keyword-based search: (“breast feeding” OR breastfe^* OR “breast fed” OR “infant feeding” OR “chest feeding” OR “chest fed” OR chestfe^) AND rural AND (init^ OR duration OR exclus^* OR health disparities OR illness OR newborn OR neonat^* OR perinat^* OR postnat^* OR poli^* OR ethnic^* OR experien^*)	2012–2022 Database: Exclude Medline, Exclude Embase +Medline	1,854 Without limiters; 1,106 with date limiter; 323 without Medline content

First, the search was run with no limiter in place. Then, the automated date limiter was applied, June 2012 to June 2022, in each case. Within Embase searches, the search was then further limited to Embase-only results (i.e., no record that appeared in Medline appeared in the final search results). While the search strategy included eliminating non-English results, the automated language limiter was not applied due to the likelihood that it would eliminate articles that had no or incorrect language metadata. Therefore, this limit was applied manually during the screening stage of the review, rather than during the search.

The initial search retrieved 6,288 articles: 2,412 from PubMed, 1,362 from CINAHL, 293 from PsycInfo, and 2,221 articles from Embase. The search results were downloaded to Zotero, and then deduplicated 4,744 articles using a combination of the deduplication function and deduplicating manually. The final search results, 1,534 articles, were transferred to CSV file. Two reviewers independently appraised the titles and abstracts and categorized as eligible, ineligible, or unclear using eligibility criteria. Inclusion criteria were articles published in English and on humans. Exclusion criteria were studies that were not peer-reviewed articles and did not focus on rural. Additional exclusion criteria were unpublished studies, published in abstract form only, studies focusing on outcomes for child growth and development (e.g., hospitalization), complementary food, mothers who are HIV positive, and focus on the Baby Friendly Initiative. Disagreements were resolved through a consensus discussion. A total of 107 articles were selected for full text screening.

Measurement and charting the data

Two reviewers independently examined the full text screening. After studies that focus on low-income countries and did not match the research questions were eliminated, 25 articles were eligible for inclusion in the analysis. See Figure 1 for PRISMA 2020 Flow Diagram.²³ Consistent with the research questions, data extracted included author, year, study location, study design, objective, participants, and outcomes (Table 2).

Table 2.

Summary of Reviewed Articles

Author (year)	Study location	Study design	Objective	Participants	Outcome
Cox et al. (2015)	Rural Western Australia	Prospective longitudinal study	To determine the factors associated with exclusive breastfeeding and any breastfeeding at 6 months and any breastfeeding up to 12 months	N = 427 mothers were recruited during the hospital stay and followed up to 12 months.	97.7% of mothers initiated breastfeeding. 35.6% of mothers exclusively breastfed at 4 months. However, only 5.7% of mothers exclusively breastfed at 6 months. 36.4% of mothers practiced any breastfeeding at 12 months. Smoking during pregnancy was the strongest predictor of early exclusive breastfeeding discontinuation (aHR: 3.21; 95% CI: 1.89–5.46). A favorable attitude toward breastfeeding, a prepregnancy body mass index of <30 kg/m², and return to work after 6 months were significantly associated with reduced risk of breastfeeding discontinuation before 6 and 12 months.
Cox et al. (2015)	Rural Western Australia	Secondary analysis using the same data by Cox et al.³⁵	To describe the influence of infant feeding attitudes on breastfeeding duration	N = 427 mothers were recruited during the hospital stay and followed up to 12 months.	Mothers with higher infant feeding attitudes (the IIFAS ≥65) were less likely to discontinue exclusive breastfeeding at 6 months (aHR: 1.81; 95% CI: 1.30–2.51), and any breastfeeding at 6 months (aHR: 3.45; 95% CI: 2.05–5.81) and at 12 months (aHR: 2.38; 95% CI: 1.63–3.49). Father's preference of bottle feeding influenced exclusive breastfeeding discontinuation at 6 months (aHR: 1.4; 95% CI: 1.11–1.97) and any breastfeeding at 6 months (aHR: 1.71; 95% CI: 1.02–2.85). Maternal mother's feeding preference of feeding methods other than breastfeeding was reflected on the discontinuation of any breastfeeding at 6 months (aHR: 1.96; 95% CI: 1.08–3.54) as well as at 1 year (aHR: 2.05; 95% CI: 1.37–3.08).
Cox et al. (2017)	Rural Western Australia	Secondary analysis using the same data by Cox et al.³⁵	To describe the influence of breastfeeding support on breastfeeding duration	N = 427 mothers were recruited during the hospital stay and followed up to 12 months.	Mothers who attended prenatal classes were less likely to discontinue exclusive breastfeeding before 6 months (aHR: 0.61; 95% CI: 0.41–0.91) and any breastfeeding at 6 months (aHR: 0.40; 95% CI: 0.23–0.70).
Demirci et al. (2019)	Rural Pennsylvania, United States	Semistructured telephone interviews extracted from RCT by Uscher-Pines et al.⁴⁴	To evaluate the feasibility and acceptability of telelactation by participating mothers and health care providers at 4–6 weeks after childbirth	A total of N = 27; n = 17 participating mothers, n = 7 lactation consultants who delivered the intervention, n = 2 nurses, and n = 1 physician.	Mothers who used telelactation appreciated the availability of services 24/7. Barriers included reluctance to use video conferencing due to limited WiFi, unestablished relationship with lactation consultants, preference over a phone call, or community-based breastfeeding resources.
Dumphy et al. (2016)	Rural Georgia, United States	Pilot study using two groups	To examine the impact of primary care using the Academy of Breastfeeding Medicine Protocol #14: Breastfeeding-Friendly Physician's Office, Optimizing Care for Infants and Children, led and delivered by a dually certified nurse practitioner and IBCLC on exclusive breastfeeding or partial breastfeeding at 1 month, 2 months, and 4 months	Mothers were recruited when they had their initial newborn visit. n = 45 mothers in the intervention group. n = 43 mothers in the control group, who received usual care.	There was no difference between groups in any breastfeeding rate or exclusive breastfeeding rates.
Flood (2013)	Rural Hilo, Hawai'i, United States	Ethnographic study comparing with breastfeeding data from several existing national, state, and local data sets were accessed, including Hilo, Hawai‘i WIC program	To assess the breastfeeding patterns	N = 8,488 mothers in the state data. n = 475 mothers in (rural Hilo) Hawaii.	Early breastfeeding discontinuation and mixed feedings were common at 4 weeks. The most common reasons for early breastfeed discontinuation were not producing enough milk (25.5%), the infant's preference of a bottle (21.5%), poor latch, or sucking problems (14.9%).
Flood (2017)	Rural Hilo, Hawaii, United States	Focus group	To describe health care providers' views of breastfeeding services and support issues in the community	N = 23 health care providers, including nurses, dieticians, medical, or nursing assistants who were working with mothers and infants for the average of 12 years in a variety of settings in the community.	Health care providers expressed health care challenges in the existing health care structure, limited resources, cost, and the inconsistent communication between hospital and community providers.
Goodman et al. (2016)	Rural Pettis County Missouri, United States	Qualitative study using interviews and a focus group	To explore the challenges breastfeeding mothers face after being discharged from the hospital and ways health care providers support breastfeeding mothers in the community	N = 10 WIC participating mothers who were currently breastfeeding their infants or had breastfeeding experiences within the last 2 years for a focus group. N = 10 health care providers, including 3 nurses, 2 pediatricians, 1 obstetrician, 2 health administrators, and 2 public health WIC support and 3 WIC mothers from the focus group for interviews.	Three common themes emerged from mothers and health care providers: (1) lack of practical information about breastfeeding, especially about how to respond to infant behavior, (2) limited time due to time constraints of mothers returning to work or short staffing, and (3) time constraints due to short hospital stay and lack of continuous support by health care providers.
Hamilton and Tarasenko (2020)	Rural-Urban comparison in Georgia, United States	Secondary analysis	To examine rural-urban differences and trends over time in breastfeeding initiation and continuation at 8 weeks on 2004–2013 PRAMS Data	N = 12,722 mothers whose infants were between 2 and 4 months old.	Significantly fewer rural mothers (64.5%, 95% CI: 61.3–67.6) than urban mothers (72.9%, 95% CI: 71.1–74.6) initiated breastfeeding (p < 0.001). Fewer rural (35.9%, CI: 32.4–39.3) than urban mothers (44.7%, CI: 42.7–46.7) continued breastfeeding, but this difference was significant only in unadjusted analyses (p < 0.001).
Harris et al. (2015)	Rural Maine, United States	Cross-sectional study	To determine the impact of rurality on maternal child health, including breastfeeding	N = 12,600 mothers whose infants were 2–4 months old.	Rural mothers were significantly younger with the average age of 27.1 years compared to 29.0 years in urban mothers. Rural mothers were more likely to be younger than 20 years; 10.5% of rural mothers were teenagers compared to 6.2% of urban mothers. Additionally, they were more likely to be unmarried and had lower income households ≤$20,222/year. Rural mothers were more likely to smoke and had higher prepregnancy body mass index, but they were less likely to drink alcohol compared to urban mothers. Rural mothers were significantly less likely to breastfeed ≥8 weeks at 52.9% compared to 60.9% of urban mothers. Rural dyads had significantly shorter hospital stay than urban dyads. A cesarean section did not differ significantly by rurality. Rural mothers had significantly lower gestational weight gain (13.1 kg or 28.8 pounds) than urban mothers (13.7 kg or 30 pounds).
Hohl et al. (2016)	Rural Yakima Washington, United States	Qualitative study with face-to-face interviews	To explore perceptions, experiences, and attitudes toward breastfeeding	N = 20 Hispanic mothers whose children were younger than 5 years.	Nine themes were observed in Hispanic mothers' breastfeeding experiences. The most common themes were “Breast is best,” “Hispanic cultural and family expectations for breastfeeding,” and “Adapting to life in the United States: cultural norms in conflict.” Even though Hispanic mothers know breastfeeding is desirable and social norm in their culture, they experience difficulty in breastfeeding in the United States such as embarrassment to breastfeed in public. Female family members were influential in their breastfeeding decisions. Because they needed to return to work early and wanted to avoid feelings of shame, they used formula supplementation.
Hui et al. (2021)	Three rural or remote First Nations/Indigenous communities in Manitoba, Canada	A pilot feasibility study, pre-post between the two groups (intervention and control group)	To test acceptability and the impact of the community-based remote prenatal education program on breastfeeding initiation and duration at 1 year	n = 231 the First Nation pregnant women 1 year after the intervention, which consisted of a prenatal educational website, social media-assisted prenatal chat groups, and community support teams. n = 233 the First Nation pregnant women 1 year before the intervention for the control group.	The program was well accepted. Breastfeeding initiation significantly changed at 50% for the intervention group and at 34% for the control group (p < 0.001). Breastfeeding rates between 2 and 12 months, including exclusive breastfeeding at 6 months significantly increased before and after the program implementation (p = 0.03).
Jacobson et al. (2015)	Urban versus Rural Kansas, United States	Secondary analysis	To describe factors associated with breastfeeding initiation	N = 17,067 WIC participating mothers whose children were younger than 5 years.	About 74% of all WIC mothers initiated breastfeeding. Urban mothers who were Hispanic (aOR: 1.65; 95% CI: 1.48–1.83) and 18–19 years of age (aOR: 1.19; 95% CI: 1.03–1.39) were more likely to breastfeed. The odds of breastfeeding initiation decreased with non-Hispanic Black (aOR: 0.74; 95% CI: 0.66–0.83), high school graduates (aOR: 0.55; 95% CI: 0.49–0.61), household income <$10,000/year (aOR: 0.80; 95% CI: 0.69–0.92), and WIC enrollment during the second (aOR: 0.84; 95% CI: 0.76–0.92) or the third (aOR: 0.73; 95% CI: 0.65–0.82) trimester compared to the first trimester enrollment. For both urban and rural WIC participating mothers, smoking during pregnancy and not using multivitamins reduced the odds of breastfeed initiation. Rural mothers who were non-Hispanic black (aOR: 0.48; 95% CI: 0.23–0.99) and had a high school graduate (aOR: 0.57; 95% CI: 0.46–0.72) were less likely to initiate breastfeed. Hispanic mothers were 1.5 times more likely to have breastfeed initiation for both urban and rural areas.
Johnson et al. (2017)	Rural South Island, New Zealand	Online qualitative study with space for free-text survey questions	To understand the impact of a breastfeeding peer supporter training program (Mum 4 Mum)	N = 41 breastfeeding mothers who completed the peer supporter program.	Five themes emerged: (1) Improved knowledge and skills in delivery of breastfeeding peer support; (2) increased confidence in having conversations with other breastfeeding mothers about breastfeeding and breastfeeding in public; (3) increased role models for peer support; (4) expanded breastfeeding acceptance in their community; and (5) gained personal satisfaction.
Joshi et al. (2013)	Rural Hispanic community in Scottsbluff, Nebraska, United States	Usability testing	To assess the usability of an interactive, bilingual touch screen program during a think-aloud session	N = 10 Hispanic mothers who had breastfeeding experience were recruited.	The program was well accepted and easy to use.
Joshi et al. (2016)	Rural Hispanic community in Scottsbluff, Nebraska, United States	Quasi-experimental study using a two-group, repeated measures	To evaluate the impact of an interactive, computer based, bilingual breastfeeding education on breastfeeding knowledge, breastfeeding self-efficacy, and intent to breastfeed	A total of N = 46 Hispanic mothers recruited in the third trimester and followed on days 3 and 7, at weeks 2 and 6, and at months 3 and 6. n = 23 mothers in the intervention group. n = 23 mothers in the control group, who received printed educational material.	Breastfeeding knowledge scores were significantly higher in the intervention group at 6 weeks (p = 0.03) compared to the control group. There was no difference in breastfeeding self-efficacy or intention to breastfeed between the two groups. The control group was more likely to decide to use formula supplementation earlier than the intervention group during the follow-up periods.
Kapinos et al. (2019)	Rural Pennsylvania, United States	Secondary analysis using the same data by Uscher-Pines et al.⁴⁴	To describe maternal characteristics of those who used telelactation	N = 203 completed the study. n = 102 mothers in the intervention group whose intervention consisted of the Tele-MILC: unlimited on-demand telelactaion through a mobile phone app over a 12-week period. N = 101 in the control group with usual care.	Mothers who used telelactation were more likely to be working at 12 weeks, no prior breastfeeding experience, less likely to exclusively breastfeed during the hospital stay than those who did not use telelactation. The majority of mothers who used telelactation in the first month after childbirth had questions about/or had teaching on breast pain, sore nipples, infection, use of a nipple shield, latching, and positioning.
Lynch et al. (2012)	Urban and Rural North Carolina, United States	Cross-sectional study	To examine race/ethnicity and urbanicity trends in breastfeeding initiation	N = 240,054 WIC participating mothers whose children were younger than 5 years.	65.4% of mothers in mixed-urban counties and 62.1% of mothers in urban counties initiated breastfeeding compared to only 49.8% of mothers in rural counties. Rural mothers across different races, including White, Black, and Hispanic mothers, had significantly lower breastfeeding rates compared to urban mothers. Hispanic mothers (aOR: 6.17; 95% CI: 5.99–6.36) and non-Hispanic White mothers (aOR: 1.49; 95% CI: 1.46–1.53) were more likely to ever breastfed than non-Hispanic Black mothers in both urban and rural areas.
Majee et al. (2016)	Rural Missouri, United States	Qualitative study with using semi-structured interviews and a focus group	To examine workplace barriers and facilitators to breastfeeding	n = 10 WIC participating mothers who breastfed in the past 2 years for the focus group. n = 10 WIC participating mothers who breastfed in the past 2 years and 7 business managers of key employers in the community for interviews.	Three common themes that will promote breastfeeding in the workplace extracted by both mothers and employees were tolerance, flexibility, and proactiveness. For barriers in the workplace, lack of compliance with the Affordable Care Act, including adequate time, space, and support to continue breastfeeding, was identified. Mothers stated that there was inadequate breastfeeding information in the workplace.
Mckellar et al. (2018)	Rural Australia	Two focus groups	To explore breastfeeding experiences of mothers and health care providers	Focus group 1: n = 9 experienced breastfeeding, who breastfed longer than 6 months, and whose infants were older than 6 months. Focus group 2: n = 10 health care providers included midwives, speech pathologist, general practitioners, and dieticians.	Mothers expressed that being persistent and determined even during breastfeeding problems, as well as having support were important to breastfeed. Health care providers thought education and support were important. Midwives were concerned about lack of evidence-based practice in the medical profession.
Sjöström et al. (2013)	Rural areas of Sweden and Australia	Cross-sectional study	To compare maternal characteristics of breastfeeding in Sweden and Australia and to identify factors associated with any breastfeeding at 2 months	N = 300 Swedish breastfeeding mothers. N = 91 Australia breastfeeding mothers.	88.3% of Swedish mothers were doing any breastfeeding at 2 months, while only 75.8% of Australian mothers did so (OR: 2.41; 95% CI: 1.33–4.38). For Australian mothers, age <25 years old (OR: 0.1; 95% CI: 0.05–0.5), smoking before pregnancy (OR: 0.3; 95% CI: 0.1–0.7), primiparity (OR: 0.2; 95% CI: 0.1–0.6), an instrumental vaginal birth, or a caesarean section (OR: 0.2; 95% CI: 0.1–0.5) were associated with not breastfeeding at 2 months. For Swedish mothers, a low educational attainment (OR: 0.3; 95% CI: 0.1–0.7), smoking before pregnancy (OR: 0.3; 95% CI: 0.1–0.6), and infant in the NICU (OR: 0.2; 95% CI: 0.1–0.7) were negatively associated with breastfeeding. Factors associated with any breastfeeding at 2 months were satisfaction with information about breastfeeding during the hospital stay for Swedish mothers (OR: 2.3; 95% CI: 1.41–4.76), while receiving the best possible help from health care providers when they breastfed for the first time for Australian mothers (OR: 4.3; 95% CI: 1.50–12.45).
Stevenson (2019)	Rural South-West Victoria, Australia	Web-based qualitative study	To increase the number of businesses promoting and supporting breastfeeding using breastfeeding Welcome Here Stickers	N = 106 venues participated in the study. n = 7 partner agencies who were involved in the auditing process, n = 4 accredited businesses, and n = 23 breastfeeding mothers completed web-based qualitative survey.	Partner agencies stated that auditing process went smoothly. They recommended that the information on social media need to be up to date. Accredited businesses stated that the stickers from the Australian Breastfeeding Association's Breastfeeding Welcome Here Program were appreciated by breastfeeding mothers. 82.6% of mothers stated that they would feel more comfortable to breastfeed in a Breastfeeding Welcome Here location.
Uscher-Pines et al. (2019)	Rural Pennsylvania, United States	Randomized Controlled Trial/RCT	To evaluate feasibility and efficacy of telelactation on breastfeeding duration and exclusivity at 12 weeks	N = 203 enrolled in the study. n = 102 mothers in the intervention group who received Tele-MILC, which consisted of unlimited on-demand telelactaion using a mobile phone app over a 12-week period. n = 101 in the control group with usual care.	Only 50% (47/94) reported they used the telelactation. n = 187 (92%) completed follow-up. There was no group difference in any breastfeeding rate or exclusive breastfeeding at 12 weeks. The intervention group reported less breastfeeding satisfaction.
Wheaton et al. (2018)	Rural Australia	Feasibility study	To describe the impact of a breastfeeding smartphone app on infant feeding outcomes at baseline, 3, and 6 months and acceptability	N = 46 enrolled, but only n = 29 (37% attrition rate) were followed at 3 and 6 months.	The program was well accepted. At 3 months n = 23/29 (79%) were still breastfeeding, but the type and method of breastfeeding were not specified. n = 3/29 (10%) discontinued breastfeeding at 3 months.
Wilhelm et al. (2015)	Rural areas of western rural Nebraska, United States	Two-group comparison	To evaluate the impact of a motivational interviewing intervention at 3 days, 2 weeks, 6 weeks, and 6 months compared to the attrition control group	n = 26 breastfeeding Mexican Americans in the intervention group whose intervention consisted of breastfeeding information and ways to improve breastfeeding self-efficacy by a nurse at 3 days, 2 weeks, and 6 weeks. n = 27 in the attrition control group, who received infant safety.	High attrition rate (69% in the intervention group and 63% in the control group) was noted at 6 weeks. There was no group difference for intent to breastfeed, breastfeeding self-efficacy, and breastfeeding duration at 6 months.

aHR, adjusted hazard ratio; aOR, adjusted odds ratio; app, application; CI, confidence interval; IBCLC, international board certified lactation consultant; IIFAS, Iowa Infant Feeding Attitudes Scale; NICU, neonatal intensive care unit; OR, odds ratio; PRAMS, pregnancy risk assessment monitoring system; RCT, randomized controlled trial; Tele-MILC, Telehealth for Mothers to Improve Lactation Confidence; WIC, special supplemental nutrition program for women, infants, and children.

Data analysis and collating, summarizing, and reporting the results

The results are reported as a summary of selected articles focusing on the research questions. Three themes were identified: (1) demographic factors (e.g., age, income, and rurality), (2) modifiable factors, (e.g., maternal psychological preparedness), and (3) policy/program recommendations (e.g., technology infrastructure).

Results

An overview of findings of the scoping studies

A total of 25 articles were selected. This included eight qualitative studies,^24–31 five secondary analyses,^{17,18,32–34} one longitudinal study,³⁵ three cross-sectional studies,^16,19,36 one ethnographic study,³⁷ four pilot feasibility studies,^38–41 one group comparison,⁴² one quasi-experimental study,⁴³ and one randomized control study.⁴⁴ Within the quantitative studies, four studies presented rural and urban comparison groups.^16–19 Table 2 presents an overview of the included studies. Among the 25 studies, 16 studies were from the United States, one from Canada, one from Sweden, and seven from Australia. Sample sizes ranged from 19 to 24,005 participants. Regarding the objectives of the studies, six studies focused on demographic factors, 23 studies identified factors as modifiable, and nine studies were policy/program recommendations.

Demographic factors

Six studies reported demographic variables of non-breastfeeding initiation or early breastfeeding discontinuation. There were lower rates of breastfeeding initiation^17–19 among rural mothers compared to urban mothers in the United States. Although the proportion of breastfeeding continuation is lower in rural mothers than urban mothers^18,19 one study conducted in the United States showed that breastfeeding continuation between rural and urban mothers was not significantly different in their multivariate analysis.¹⁷ Rural mothers were more likely to be younger, including teenagers and unmarried parents with lower socioeconomic statuses,¹⁶ and highest educational level was high school graduates¹⁸ compared to urban mothers. Those who delayed returning to work for at least 6 months were less likely to stop breastfeeding at 6 and 12 months.³⁵ Rural mothers across different races, including White, Black, and Hispanic mothers, had significantly lower breastfeeding rates compared to that of urban mothers.¹⁹ Among those, non-Hispanic Black mothers had the lowest breastfeeding initiation rates across both rural and urban areas.¹⁸ Hispanic mothers were 1.5 times more likely to have breastfeeding initiation for both urban and rural areas compared to mothers with other race/ethnicity. Hispanic mothers and non-Hispanic White mothers were more likely to ever breastfed than non-Hispanic Black mothers in both urban and rural areas.¹⁹ Late enrollment for the special supplemental nutrition program for women, infants, and children (WIC) was associated with the decreased odds of breastfeeding initiation.¹⁸

Australian mothers who were younger than 25 years and first time mothers were less likely to practice any breastfeeding at 2 months. In Sweden, mothers who had low educational attainment were less likely to provide any breastfeeding at 2 months.³⁶

Factors identified in the literature as modifiable

Twenty-three studies identified factors that are modifiable. We categorized them into the six domains because these were the most cited factors in the reviewed articles. The six domains are health care professional help, lifestyle choices, maternal psychological preparedness, breastfeeding problems, work experience while breastfeeding, and family support.

Health care professional help

Seven studies reported health care professionals' provision of breastfeeding support. Heath care professionals such as nurses, pediatricians, and obstetricians are keenly aware of their roles to support breastfeeding in the community setting. However, in reality, professionals do not meet mothers' expectations due to time constrains and lack of knowledge, as well as poor continuity of skilled support.²⁶ Health care professionals, including physicians, nurses, lactation consultants, and doulas, were concerned about the types of social factors, such as health care structure, limited resources, cost, sparse communication between the hospital and community professionals,²⁵ lack of evidence-based practice,³⁰ and continuity of care for breastfeeding dyads.^17,26,30 Even though support from health care professionals was a crucial component for breastfeeding continuation,³⁰ mothers participating in the WIC felt that the focus of heath care professionals (e.g., nurses, pediatricians, obstetrician) was mainly on breastfeeding benefits, which largely lacked practical application.²⁶ In one attempt to counter the distinctly declining breastfeeding rates in rural New Zealand, a Primary Health Organization helped arrange peer supporters to gain knowledge and skills in supporting other breastfeeding mothers. This was found to increase mothers' confidence in sharing their experiences, while making them feel more comfortable breastfeeding their infants in their community.²⁸

To optimize care for the primary care workplace, the Academy of Breastfeeding Protocol #14: Breastfeeding Friendly Physician's Office⁴⁵ was used as an intervention. However, there was no significant difference in exclusive breastfeeding rates or any breastfeeding rates at 1, 2, or 4 months between the intervention group and the control group.³⁸

Lifestyle choices

Smoking before and/or during pregnancy is the most common characteristic found in mothers with non-breastfeeding initiation or early breastfeeding discontinuation across four studies.^16,18,35,36 Mothers' body mass index (BMI) <30 kg/m² was associated with reduced risk of breastfeeding discontinuation before 6 and 12 months.³⁵

Maternal psychological preparedness

Four studies reported psychological characteristics of mothers. Mothers who attended prenatal classes were less likely to discontinue exclusive breastfeeding at 12 weeks than those who did not. However, the relationship between prenatal classes and any breastfeeding at 6 months was positively associated only with the univariate analysis.³² One study examined the impact of a motivational interviewing intervention on intent to breastfeed, increasing breastfeeding self-efficacy, and increasing breastfeeding duration among Mexican American Mothers.⁴² However, there were no group difference on the outcomes. Two studies with the same authors reported the relationship between infant feeding attitudes and breastfeeding duration. Rural mothers who had negative infant feeding attitudes were more likely to discontinue exclusive breastfeeding at 6 months,³³ as well as any breastfeeding at 12 months.³⁵ Determination and persistence were attributes mothers possessed for continuing to breastfeed.³⁰

Breastfeeding problems

Two studies reported breastfeeding problems. During mother and infant interactions over the course of breastfeeding, mothers were concerned about insufficient milk supply with unspecified reasons (actual versus perceived).³⁷ Problems with latching-on or infant suckling were identified as common problems in infant feeding behavior during breastfeeding.³⁷ Mothers were concerned about breast pain, sore nipples, having an infection, using a nipple shield, and latching or positioning infant to the breast.³⁴

Work experience while breastfeeding

Three studies reported maternal work experiences while they were breastfeeding. Although Hispanic mothers who originated from Mexico reported positive feelings about breastfeeding, they need to return to work early and felt embarrassed and ashamed about breastfeeding in the United States. For many, this led to the use of formula supplementation and early breastfeeding discontinuation.²⁷ Time constraints in breastfeeding were noted when mothers returned to work.²⁶ Employed low-income breastfeeding mothers felt obligated to work for their employers. They did not want to be seen as lacking in their commitment to work so that they remained reticent to ask for pumping accommodations at work.²⁹

Family support

Two studies indicated significant others' influence of infant feeding decisions.^27,33 The fathers' preference of bottle feeding was associated with early exclusive breastfeeding discontinuation.³³ Likewise, maternal mothers' feeding preferences other than breastfeeding was significantly associated with the discontinuation of any breastfeeding at 6 months and 1 year.³³ Female family members were influential in their breastfeeding decisions in rural Hispanic mothers.²⁷

Policy/program recommendations

Nine studies identified factors related to policy/program recommendations. Those are classified as technology infrastructure and workplace and social awareness campaigns.

Technology infrastructure

Seven studies reported interventions using technology. A single-site randomized control trial was conducted to evaluate the feasibility and efficacy of telelactation in the United States.⁴⁴ However, there was no group difference in any breastfeeding or exclusive breastfeeding at 12 weeks. A pilot feasibility study implemented in the community-based prenatal education program among the First Nations pregnant women in Canada significantly improved breastfeeding initiation rates and breastfeeding rates between 2 and 12 months, included increasing exclusive breastfeeding for the first 6 months compared to before its implementation.³⁹ Other interventions focused on the acquisition of knowledge (e.g., breastfeeding benefits, breast milk production, colostrum, formula feeding, breastfeeding discomfort, and weaning), breastfeeding confidence, the intention to breastfeed,⁴³ and breastfeeding support.^41,44 However, none of these interventions significantly improved breastfeeding outcomes such as any breastfeeding at 7 days,⁴³ 2 and 6 weeks,⁴³ 12 weeks,^41,43,44 or 24 weeks,⁴³ or exclusive breastfeeding at 12 weeks.⁴⁴ The interventions were delivered remotely, using various platforms such as computer based,^40,43 website,³⁹ smartphone app,⁴¹ or telehealth.^24,34,44

Most participating mothers appreciated the availability of services. However, mothers experienced difficulties in Wi-Fi connectivity and video conferencing with different lactation consultants.³⁴ High attrition rates were also noted.^41,44

Workplace and social awareness campaigns

Two studies reported workplace or social community barriers and support for breastfeeding. One U.S. study²⁹ reported employers' perspectives about breastfeeding support in the workplace in the United States. Although most employers in the small rural community were aware of a basic accommodation, for example, time and space for employed mothers to express or pump breast milk after the passage of the Affordable Breastfeeding Care Act in 2010, the unsupportive work environment made unrealistically short breaks and integrated pumping into lunch or breaks. Employers expressed concerns about the financial burden due to reduced productivity of breastfeeding employees and providing more frequent or longer breaks for pumping. They viewed breastfeeding as a personal decision so that they were unwilling to bring up required accommodation for pumping to their breastfeeding employees. The authors concluded that workplace policies influenced mothers' decisions to breastfeed after they returned to work.²⁹

An Australian study found that the Breastfeeding Welcome Here project encouraged Australian business to publicly identified themselves as a place where mothers were welcome to breastfeeding. The project also helped mothers feel more supported and comfortable to breastfeed in their community.³¹

Discussion

The purpose of this study was to describe determinants of breastfeeding among rural breastfeeding dyads in high-income countries and to identify factors that relate to breastfeeding disparities in the current literature as modifiable. Analysis of results of the studies revealed that low breastfeeding initiation or early breastfeeding discontinuation reported in rural mothers included being younger, having lower educational attainment, being unmarried, and having lower socioeconomic status than urban mothers. In other words, rural young mothers with low socioeconomic status, reflected in poverty, and low education levels experience low breastfeeding initiation and duration. Risk factors, such as higher BMI, obesity, and smoking, more commonly seen in lower socioeconomic groups⁴⁶ were also found in this population.^16,18,35,36

Rural mothers across different races, including White, Hispanic, and Black mothers, have lower breastfeeding rates compared to urban mothers in the United States.¹⁹ Among those, Black mothers were least likely to breastfeed.¹⁸ Black mothers in the United States were reported to have the highest rates of being overweight or obesity,⁴⁷ which is tied to lower breastfeeding rates. Other possible contributions might be explained by historical structural racism, implicit bias, cultural norms, social acceptance, and culturally relevant breastfeeding practices.⁴⁸ In contrast, U.S. Hispanic mothers were more likely to initiate breastfeeding than other racial/ethnic groups,¹⁹ linking the strong cultural protective factor for this population. However, they initiate formula supplementation due to early return to work.³⁹ These cultural factors imply that certain racial/ethnic groups have unique burdens and experiences for early breastfeeding discontinuation.

It is interesting to know that one study showed the differences of breastfeeding continuation between rural and urban were not significantly different in the multivariate analysis.¹⁷ Furthermore, problems with latching, sore nipples, actual/perceived low milk supply, and use of a nipple shield were identified as common problems among rural dyads.^34,37 The results of these studies indicate that regardless of where mothers live, either in urban or rural, they have difficulty in establishing and continuing breastfeeding. This might better explain that, while urban-rural breastfeeding disparities exist, they are also significantly influenced by other protective factors such as individual factors (e.g., infant feeding attitudes,^33,35 skills to interpret infant behavior,^49,50 breastfeeding confidence^49–51) and interpersonal factors (e.g., supportive family member¹⁹).

Poor quality of care is prevalent due to health care professionals' limited perceived roles, lack of experiences in providing breastfeeding care, time constraints, and a lack of knowledge and practical skills to demonstrate a clear guidance to breastfeeding dyads.^{17,25,26,30,38} Knowledge about breastfeeding is best known among health care professionals, but specifics are missing.⁵² This contributes to confusion and creates vulnerability for rural mothers. Encouraging direct breastfeeding at nighttime will increase breast milk production and meet both mother and infant physiological needs such as sleep.⁵³ Health care professionals can encourage this practice because the method is simple, affordable, and easy to carry out with less effort than other feeding methods and will likely promote a longer duration of exclusive breastfeeding.

A brief hospital stay and discontinuation of breastfeeding support after being discharged from the hospital, in addition to transportation barriers and limited access to affordable care, make it difficult for rural dyads to establish and sustain breastfeeding at home. There is one study that improved breastfeeding initiation and continuation by using the community-based prenatal education program, composed of education website, prenatal chat groups, and community support teams delivered to First Nations pregnant women in Canada.³⁹ The intervention did not have a control condition, which requires further evaluation. However, this study reinforced the importance of building community partnerships that can guide researchers to explore ways in which programs can be initiated or adopted into existing professionals' systems and community resources. Valuing community-based partnerships can build trust among its members and the research itself can support communities. There is a possibility that such interventions enable equitable access to care and ultimately positive health outcomes for rural breastfeeding dyads.

Policy change was identified as modifiable; however, it may take time to accomplish. The surge of the COVID-19 pandemic required a different mode of health care delivery, such as digital health. Expanding digital health, such as telehealth, is one of the prioritized strategies for WHO since 2020.⁵⁴ Therefore, federal/state/local governments can step up the efforts to improve resource allocation. The broadband infrastructure may increase access to evidence-based practice, which can in turn reduce breastfeeding disparities in the rural areas. The results from patient-centered technology-based interventions will help to demonstrate how technology can reduce traveling, improve access to high-quality care in rural areas, and improve future studies.

Our findings should be viewed with caution because this scoping study addressed the broad research question about determinants of breastfeeding in rural breastfeeding dyads and did not evaluate evidence quality. Selection bias might be an issue based on review of only studies written in English and the elimination of gray literature. The majority of the studies that were reviewed were conducted in the United States. Therefore, the findings may not be applicable to other high-income countries or low/middle-income countries. Breastfeeding behaviors for underrepresented minority groups (e.g., indigenous people, multiethnic, multiracial groups) were not reported. However, this preliminary investigation mapped breastfeeding disparities in rural areas and identified the range of gaps that exist in the literature.

Conclusions

Low breastfeeding initiation and duration are prevalent in rural breastfeeding dyads. Although breastfeeding disparities are prevalent in rural dyads, the basic challenges mothers face when breastfeeding are universal, despite geographical locations in high-income countries. Health care professionals need to acquire more specific knowledge and skills to resolve breastfeeding problems mothers face in real-life situations. While policies are identified as modifiable factors, attempts to make substantial change can be difficult. However, resource allocation needs to be improved to increase density of resources, education, and support for breastfeeding dyads. Patient-centered technology interventions, specifically focused on modifiable causes of the problem, may compensate for breastfeeding barriers in rural areas and increase access to evidence-based practices. Interventions that reduce breastfeeding disparities in rural communities warrant further investigation.

Footnotes

Acknowledgments

The first author expresses appreciation to Dr. Ka'imi Sinclair, who guided health disparities research, and Dr. Kathleen R. Helfrich-Miller for the assistance of article preparation.

Authors' Contributions

N.K.W.: conceptualization, methodology, formal analysis, and writing—original draft preparation. R.A.P.: formal analysis and writing—review and editing. A.M.D.: data curation and writing—original draft preparation.

Disclosure Statement

No relationship/condition/circumstance that present potential conflict of interest exists.

Funding Information

The authors received no financial support for this study.

References

Figueiredo

, Canário

, Field

. Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychol Med, 2014; 44(5):927–936; doi: 10.1017/S0033291713001530

Rameez

, Sadana

, Kaur

, et al. Association of maternal lactation with diabetes and hypertension: A systematic review and meta-analysis. JAMA Netw Open, 2019; 2(10):e1913401; doi: 10.1001/jamanetworkopen.2019.13401

Peters

SAE

, Yang

, Guo

, et al. Breastfeeding and the risk of maternal cardiovascular disease: A prospective study of 300 000 Chinese women. J Am Heart Assoc, 2017; 6(6):e006081; doi: 10.1161/JAHA.117.006081

Chowdhury

, Sinha

, Sankar

, et al. Breastfeeding and maternal health outcomes: A systematic review and meta-analysis. Acta Paediatr, 2015; 104(S467):96–113; doi: 10.1111/apa.13102

Pan American Health Organization. Babies Should Be Breastfed Within the First Hour of Life. 2018. Available from: https://www3.paho.org/hq/index.php?option=com_content&view=article&id=14530:3-in-5-babies-not-breastfed-in-the-first-hour-of-life&Itemid=0&lang=en#gsc.tab=0 [Last accessed: December 1, 2022].

, Chung

, Raman

, et al. A summary of the agency for healthcare research and quality's evidence report on breastfeeding in developed countries. Breastfeed Med, 2009; 4(1_suppl):S17–S30; doi: 10.1089/bfm.2009.0050

Bider-Canfield

, Martinez

, Wang

, et al. Maternal obesity, gestational diabetes, breastfeeding and childhood overweight at age 2 years. Pediatr Obes, 2017; 12(2):171–178; doi: 10.1111/ijpo.12125

Pan American Health Organization. World Breastfeeding Week: Breastfed Infants Have Healthier Futures. 2016. Available from: https://www3.paho.org/hq/index.php?option=com_content&view=article&id=12343:breastfed-infants-have-healthier-futures&Itemid=0&lang=en#gsc.tab=0 [Last accessed: August 22, 2023].

American Academy of Pediatrics. American Academy of Pediatrics Calls for More Support for Breastfeeding Mothers Within Updated Policy Recommendations. 2022. Available from: https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-calls-for-more-support-for-breastfeeding-mothers-within-updated-policy-recommendations [Last accessed: August 22, 2023].

10.

World Health Organization. Breastfeeding. n.d. Available from: https://www.who.int/health-topics/breastfeeding [Last accessed: August 22, 2023].

11.

UNICEF. UNICEF Calls for the Narrowing of “Breastfeeding Gaps” Between Rich and Poor Worldwide. n.d. Available from: https://www.unicef.org/eca/press-releases/unicef-calls-narrowing-breastfeeding-gaps-between-rich-and-poor-worldwide [Last accessed: August 22, 2023].

12.

Wood

, Woods

, Blackburn

, et al. Interventions that enhance breastfeeding initiation, duration, and exclusivity: A systematic review. MCN Am J Matern Child Nurs, 2016; 41(5):299–307; doi: 10.1097/NMC.0000000000000264

13.

Buckland

, Hector

, Kolt

, et al. Interventions to promote exclusive breastfeeding among young mothers: A systematic review and meta-analysis. Int Breastfeed J, 2020; 15(1):102; doi: 10.1186/s13006-020-00340-6

14.

Dutheil

, Méchin

, Vorilhon

, et al. Breastfeeding after returning to work: A systematic review and meta-analysis. Int J Environ Res Public Health, 2021; 18(16):8631; doi: 10.3390/ijerph18168631

15.

Navarro-Rosenblatt

, Garmendia

M-L

. Maternity leave and its impact on breastfeeding: A review of the literature. Breastfeed Med, 2018; 13(9):589–597; doi: 10.1089/bfm.2018.0132

16.

Harris

, Aboueissa

A-M

, Baugh

, et al. Impact of rurality on maternal and infant health indicators and outcomes in Maine. Rural Remote Health, 2015; 15(3):1–17.

17.

Hamilton

, Tarasenko

. Breastfeeding practices in Georgia: Rural-urban comparison and trend analyses based on 2004–2013 PRAMS data. J Rural Health, 2020; 36(1):17–26; doi: 10.1111/jrh.12382

18.

Jacobson

, Twumasi-Ankrah

, Redmond

, et al. Characteristics associated with breastfeeding behaviors among urban versus rural women enrolled in the Kansas WIC program. Matern Child Health J, 2015; 19(4):828–839; doi: 10.1007/s10995-014-1580-2

19.

Lynch

, Bethel

, Chowdhury

, et al. Rural and urban breastfeeding initiation trends in low-income women in North Carolina from 2003 to 2007. J Hum Lact, 2012; 28(2):226–232; doi: 10.1177/0890334411430086

20.

U.S. Census Bureau. Urban and Rural. n.d. Available from: https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural.html [Last accessed: August 22, 2023].

21.

The American College of Obstetricians and Gynecologists. Health Disparities in Rural Women. Committee Opinion. 2014; p. 586. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/02/health-disparities-in-rural-women [Last accessed: August 22, 2023].

22.

Arksey

, O'Malley

. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol, 2005; 8(1):19–32; doi: 10.1080/1364557032000119616

23.

Page

, Moher

, Bossuyt

, et al. PRISMA 2020 explanation and elaboration: Updated guidance and exemplars for reporting systematic reviews. BMJ, 2021; 372:n160; doi: 10.1136/bmj.n160

24.

Demirci

, Kotzias

, Bogen

, et al. Telelactation via mobile app: Perspectives of rural mothers, their care providers, and lactation consultants. Telemed J E Health, 2019; 25(9):853–858; doi: 10.1089/tmj.2018.0113

25.

Flood

. Breastfeeding supports and services in rural Hawaii: Perspectives of community healthcare workers. Nurs Res Pract, 2017; 2017:Article e6041462; doi: 10.1155/2017/6041462

26.

Goodman

, Majee

, Olsberg

, et al. Breastfeeding barriers and support in a rural setting. MCN Am J Matern Child Nurs, 2016; 41(2):98–103; doi: 10.1097/NMC.0000000000000212

27.

Hohl

, Thompson

, Escareño

, et al. Cultural norms in conflict: Breastfeeding among Hispanic immigrants in rural Washington State. Matern Child Health J, 2016; 20(7):1549–1557; doi: 10.1007/s10995-016-1954-8

28.

Johnson

, Ansley

, Doolan-Noble

, et al. Breastfeeding peer support in rural New Zealand: The views of peer supporters. J Prim Health Care, 2017; 9(2):173–177; doi: 10.1071/HC16027

29.

Majee

, Jefferson

, Goodman

, et al. Four years later: Rural mothers' and employers' perspectives on breastfeeding barriers following the passage of the Affordable Care Act. J Health Care Poor Underserved, 2016; 27(3):1110–1125; doi: 10.1353/hpu.2016.0111

30.

McKellar

, Fleet

, Dove

. It's more than just luck: A qualitative exploration of breastfeeding in rural Australia. Women Birth, 2018; 31(3):177–183; doi: 10.1016/j.wombi.2017.09.005

31.

Stevenson

. The Australian Breastfeeding Association's Breastfeeding Welcome Here program in rural South-West Victorian settings. Breastfeed Rev, 2019; 27(1):7–11.

32.

Cox

, Giglia

, Binns

. Breastfeeding beyond the big smoke: Who provides support for mothers in rural Western Australia?. Aust J Rural Health, 2017; 25(6):369–375; doi: 10.1111/ajr.12362

33.

Cox

, Giglia

, Binns

. The influence of infant feeding attitudes on breastfeeding duration: Evidence from a cohort study in rural Western Australia. Int Breastfeed J, 2015; 10:25; doi: 10.1186/s13006-015-0048-3

34.

Kapinos

, Kotzias

, Bogen

, et al. The use of and experiences with telelactation among rural breastfeeding mothers: Secondary analysis of a randomized controlled trial. J Med Internet Res, 2019; 21(9):e13967; doi: 10.2196/13967

35.

Cox

, Binns

, Giglia

. Predictors of breastfeeding duration for rural women in a high-income country: Evidence from a cohort study. Acta Paediatr, 2015; 104(8):e350–e359; doi: 10.1111/apa.12999

36.

Sjöström

, Welander

, Haines

, et al. Comparison of breastfeeding in rural areas of Sweden and Australia: A cohort study. Women Birth, 2013; 26(4):229–234; doi: 10.1016/j.wombi.2013.08.159

37.

Flood

. Breastfeeding patterns in the rural community of Hilo, Hawai'i: An exploration of existing data sets. Hawaii J Med Public Health, 2013; 72(3):81–86.

38.

Dumphy

, Thompson

, Clark

. A breastfeeding quality improvement project in rural primary care. J Hum Lact, 2016; 32(4):633–641; doi: 10.1177/0890334416662240

39.

Hui

, Philips-Beck

, Campbell

, et al. Impact of remote prenatal education on program participation and breastfeeding of women in rural and remote Indigenous communities. EClinicalMedicine, 2021; 35:Article 100851; doi: 10.1016/j.eclinm.2021.100851

40.

Joshi

, Wilhelm

, Aguirre

, et al. An interactive, bilingual touch screen program to promote breastfeeding among Hispanic rural women: Usability study. JMIR Res Protoc, 2013; 2(2):Article e47; doi: 10.2196/resprot.2872

41.

Wheaton

, Lenehan

, Amir

. Evaluation of a breastfeeding app in rural Australia: Prospective cohort study. J Hum Lact, 2018; 34(4):711–720; doi: 10.1177/0890334418794181

42.

Wilhelm

, Aguirre

, Koehler

, et al. Evaluating motivational interviewing to promote breastfeeding by rural Mexican-American mothers: The challenge of attrition. Issues Compr Pediatr Nurs, 2015; 38(1):7–21; doi: 10.3109/01460862.2014.971977

43.

Joshi

, Amadi

, Meza

, et al. Evaluation of a computer-based bilingual breastfeeding educational program on breastfeeding knowledge, self-efficacy and intent to breastfeed among rural Hispanic women. Int J Med Inf, 2016; 91:10–19; doi: 10.1016/j.ijmedinf.2016.04.001

44.

Uscher-Pines

, Kapinos

, Demirci

, et al. Use of virtual breastfeeding support among underserved, rural mothers. Pediatrics, 2019; 144(2):Abstract 275; doi: 10.1542/peds.144.2-MeetingAbstract.275

45.

Vanguri

, Rogers-McQuade

, Sriraman

, et al. ABM clinical protocol #14: Breastfeeding-friendly physician's office—Optimizing care for infants and children. Breastfeed Med, 2021; 16(3):175–184; doi: 10.1089/bfm.2021.29175.sjv

46.

Phelan

, Link

, Tehranifar

. Social conditions as fundamental causes of health inequalities: Theory, evidence, and policy implications. J Health Soc Behav, 2010; 51(Suppl):S28–S40; doi: 10.1177/0022146510383498

47.

Jones

, Power

, Queenan

, et al. Racial and ethnic disparities in breastfeeding. Breastfeed Med, 2015; 10(4):186–196; doi: 10.1089/bfm.2014.0152

48.

Petit

, Smart

, Sattler

, et al. Examination of factors that contribute to breastfeeding disparities and inequities for black women in the US. J Nutr Educ Behav, 2021; 53(11):977–986; doi: 10.1016/j.jneb.2021.08.013

49.

Wood

, Sanders

, Lewis

, et al. Pilot test of a home-based program to prevent perceived insufficient milk. Women Birth, 2017; 30(6):472–480; doi: 10.1016/j.wombi.2017.04.006

50.

Wood

, Sanders

. Mothers with perceived insufficient milk: Preliminary evidence of home interventions to boost mother–infant interactions. West J Nurs Res, 2018; 40(8):1184–1202; doi: 10.1177/0193945916687552

51.

Wood

, Barbosa-Leiker

, Odom-Maryon

. Determinants of exclusive direct breastfeeding using constructs from the breastfeeding relationship scale. J Reprod Infant Psychol, 2023; 1–15; doi: 10.1080/02646838.2023.2191113

52.

Dozier

. Community engagement and dissemination of effective breastfeeding programs. Breastfeed Med, 2010; 5(5):215–216; doi: 10.1089/bfm.2010.0051

53.

Zimmerman

, Bartick

, Feldman-Winter

, et al. ABM clinical protocol #37: Physiological infant care—Managing nighttime breastfeeding in young infants. Breastfeed Med, 2023; 18(3):159–168; doi: 10.1089/bfm.2023.29236.abm

54.

World Health Organization. Digital Health. n.d. Available from: https://www.who.int/health-topics/digital-health [Last accessed: August 22, 2023].

55.

Page

, McKenzie

, Bossuyt

, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 2021; 372:n71; doi: 10.1136/bmj.n71