Correlates of Professional Breastfeeding Perceived Role, Perceived Influence, and Confidence in Providing Lactation Support Among Registered Dietitians and Registered Nurses

Abstract

Lactation support from health professionals is a crucial social determinant of health. Registered dietitians (RDs) and registered nurses (RNs) can play an important role in supporting breastfeeding, yet most have minimal formal lactation education and training. This study seeks to explore the correlates of professional breastfeeding perceived role, perceived influence, and confidence in providing lactation support among RDs and RNs. Using a cross-sectional design, a convenience sample of 111 credentialed providers completed an online survey assessing their breastfeeding-related training, experiences, knowledge, attitudes, and practices. We also examined perceptions of social support, intentions for future breastfeeding, professional roles, and confidence in lactation support. We tested for relationships between variables using chi-square, Fisher’s exact, and Mann–Whitney U tests and identified which correlates were associated with the dependent variables using bivariate logistic regression. Respondents who were breastfed as infants were 3.4 times more likely to agree that it is their responsibility to highlight health problems associated with infant formula when giving breastfeeding advice (p = 0.009). Those agreeing that people around them support breastfeeding were 8.0 times more likely to believe they can influence a woman’s breastfeeding decision and duration (p = 0.05). Respondents working in maternal/child/family health were 14.3 times more likely to feel confident in their ability to provide lactation counseling, guidance, and recommendations (p = 0.03). Educational institutions and employers should provide all RDs and RNs with opportunities for personal reflection and lactation training while strengthening breastfeeding social norms.

1. Introduction

The World Health Organization (WHO), United Nations International Emergency Fund (UNICEF), and American Academy of Pediatrics recommend early initiation of breastfeeding within an hour of birth, exclusive breastfeeding for the first six months of life, and continued breastfeeding until at least two years of age with the introduction of solid food [1,2]. Meeting these recommendations is important for public health, given that breastfeeding is associated with short- and long-term health benefits for lactating parents and their children [2,3,4]. Yet despite significant evidence regarding breastfeeding benefits, the majority of infants in the United States (US) do not meet breastfeeding recommendations: while most (83%) infants born in 2019 started out receiving human milk, only 25% were exclusively breastfed at six months, and 36% were still receiving any human milk at 12 months [5].

Although there are medical reasons that may prevent or shorten one’s ability to breastfeed, research suggests that barriers to human milk feeding more commonly fall within the social determinants of health (SDOH). According to the WHO, the SDOH are:

The non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems [6].

From an SDOH perspective, several barriers are associated with early cessation of human milk feeding, including social norms that conflict with recommendations, poor social and family support, embarrassment due to stigmatization of breastfeeding in public, employment, and issues with health services, such as healthcare professionals who are hesitant to provide lactation support or offer inappropriate communication [7,8]. Regarding the latter, lactation support from qualified healthcare professionals is crucial, especially during the antenatal and postnatal periods [9]. In their Cochrane review, Gavine et al. [10] found that women receiving a breastfeeding support intervention were less likely to stop breastfeeding at up to six weeks. Additionally, professional or mixed support may be more effective than non-professional support when comparing professional and non-professional support for exclusive breastfeeding up to six months of age [10]. Thus, healthcare professionals working with maternal and infant populations have a unique opportunity to promote and support breastfeeding.

While patients report the provider’s advice around breastfeeding to be highly important, clinicians may underestimate the level of influence they have on breastfeeding outcomes [4]. Furthermore, the influence of healthcare providers on breastfeeding outcomes may be particularly important in addressing persistent lactation disparities, especially those that exist for Black populations [11]. Previous studies have illustrated that healthcare providers lack the information and skills to successfully support the breastfeeding needs of the African American community, contributing to inequitable lactation care [12,13].

Healthcare providers working in maternal and child health, including obstetrics, pediatrics, and family medicine, need the appropriate skills to support breastfeeding parents [14]. Registered dietitians (RDs) and registered nurses (RNs) can play an important role in supporting breastfeeding in these healthcare environments. Theurich and McCool [15] identified RDs as an untapped breastfeeding resource given their expertise in nutrition. RNs comprise the largest segment of the US healthcare workforce, with more than 5.2 million RNs in 2022 [16]. Within the perinatal context, nurses provide care to and interact frequently with postpartum individuals and their infants across many settings, including maternity units, community health centers, neonatal intensive care units, and pediatric and obstetric practices [17]. Position statements from the Academy of Nutrition and Dietetics and the Society of Pediatric Nurses have articulated the pivotal roles that these professionals have in breastfeeding promotion, support, education, and advocacy [18,19,20].

However, research shows the majority of healthcare professionals, including RDs and RNs, have minimal formal education and training in lactation due in part to a lack of requirements in accredited programs [15]. For example, one study exploring breastfeeding knowledge, attitudes, and skills among dietitians identified lack of skill, confidence, and knowledge as barriers to providing breastfeeding assistance [21]. Similar studies have found that nurses have limited knowledge in breastfeeding assessment and management and low levels of confidence in supporting breastfeeding individuals [17,22]. Degree-based and post-credential training show promise in enhancing lactation-related knowledge, attitudes, intentions, self-efficacy, and/or action competence [23,24,25,26,27].

Self-efficacy in providing breastfeeding support is beneficial for healthcare providers working in maternal and child health. Studies show that personal experience with breastfeeding, breastfeeding knowledge, and age are associated with healthcare providers’ lactation practices and self-efficacy or confidence in offering support [21,28,29,30,31]. However, few studies have quantitatively investigated the relationships among these and other potential correlates to determine which factors are most influential. Therefore, the aims of this study are to (1) explore the correlates of professional breastfeeding perceived role, perceived influence, and confidence in providing lactation support among a sample of RDs and RNs; and (2) examine which correlates are the most strongly related to RDs’ and RNs’ perceived role, perceived influence, and confidence in providing lactation support.

2. Materials and Methods

2.1. Design

Between May and June 2019, we distributed a cross-sectional, online open survey to a convenience sample of RDs and RNs practicing in the US. Before starting the survey, we provided participants with a prospective agreement form detailing the purpose of the study, investigator names and contact information, approximate length of the survey, and that data would be collected using the Internet. We conducted this research in accordance with the Declaration of Helsinki, and the Institutional Review Board of Montclair State University approved the study (FY18-19-1347, approved 10 May 2019).

2.2. Setting and Data Collection

We recruited participants via social media (i.e., Instagram, LinkedIn, and Facebook) and by e-mail to RD and RN forums, listservs, and direct contacts. Outreach spanned local (e.g., specific medical centers and schools), state (e.g., the New Jersey Academy of Nutrition and Dietetics and the New Jersey Association of Public Health Nurses), and national (e.g., the Registered Dietitian Net group via LinkedIn and the Tribe-RN Nurses group via Facebook) levels. In the recruitment posts and e-mails, we asked participants to voluntarily complete a 15 min online survey via Qualtrics XM (Qualtrics, 2019) and informed participants of their eligibility to enter a raffle for one of five USD 10 Amazon gift cards upon survey completion. The survey was anonymous; no identifying information or IP address was collected. We collected e-mail addresses for the raffle separately without linkage to survey responses.

2.3. Participants

To be eligible for the study, participants must have met all inclusion criteria: (1) 18 years of age or older; (2) hold the credential of RD or RN; (3) currently practicing in the US; and (4) be able to read English. Based on the available industry data at the time of the study, there were 73,381 RDs in 2016 [32] and 3,245,080 RNs in 2018 [33] working in their respective fields. Given the total population size of 3,318,398, a confidence level of 95%, and a 10% margin of error, the sample size needed was 97. In the current study, 111 respondents consented to the survey, and 106 respondents submitted the last survey page, for a completion rate of 95%. We did not use cookies or log files to identify duplicate entries.

2.4. Measures

The survey included 56 items over 14 pages, with an average of four items per page (range 1–12). We asked questions in the same order for all participants, and we used skip logic to reduce the number of unrelated questions asked per respondent. A back button was available, allowing participants to review and change their answers. Participants were notified if any questions were unanswered before moving on to the next page. Two researchers tested the survey before recruitment for usability and technical functionality.

The survey comprised seven sections to measure demographic data: professional training in breastfeeding; personal breastfeeding experience; breastfeeding knowledge; breastfeeding attitudes; perception of social support for breastfeeding; self-assessment of breastfeeding intention and support; and professional breastfeeding perceived role, perceived influence, and confidence in providing lactation support. Wherever possible, we derived or adapted questions from validated survey tools. Each survey section is outlined below.

2.4.1. Demographic Data

We asked respondents to report their age in years, gender, race and ethnicity, marital status, total household income, highest level of education completed, parental status, and the number of children they had. Profession-related questions asked respondents to report which credential they held (i.e., RD, RN), US state of practice, primary practice setting, primary position, primary practice specialty, and the year they were credentialed.

2.4.2. Professional Training in Breastfeeding

We asked respondents to indicate which, if any, types of professional training in breastfeeding they had received: part of their academic program; employment; continuing education; through a professional certification (e.g., Certified Lactation Counselor—CLC, Certified Lactation Educator—CLE, International Board-Certified Lactation Consultant—IBCLC); or other (specify). We created a breastfeeding training scale by summing the number of professional training types reported by each respondent (possible range 0–5).

2.4.3. Personal Breastfeeding Experience

We asked respondents whether they or their partner had ever breastfed a child. If respondents answered in the affirmative, we then asked them to rate their overall breastfeeding experience [34,35], indicate whether they or their partner met their personal breastfeeding goals, and report which, if any, breastfeeding challenges they experienced from a list of 12 options derived from previous research [8,36,37]. We created a breastfeeding challenges scale by summing the number of challenges reported by each respondent (possible range 0–12). We also asked respondents whether they or someone they know ever breastfed in public and if they were breastfed as children [38].

2.4.4. Breastfeeding Knowledge

We assessed respondents’ breastfeeding knowledge using a series of 12 true/false questions [35,38,39,40,41]. We created a breastfeeding knowledge scale by summing the number of correct responses (possible range 0–12), whereby a higher score indicates more breastfeeding knowledge.

2.4.5. Breastfeeding Attitudes

We asked respondents their level of agreement (1 = strongly disagree, 5 = strongly agree) to 14 statements. Six statements measured attitudes regarding breastfeeding in the workplace [40,42], and the remaining eight measured attitudes about breastfeeding and infant formula more generally [35,38,39,41]. After reverse coding the negatively worded statements, we created a breastfeeding attitudes scale by averaging the response scores across all statements (possible range 1–5). The higher the score, the more favorable a respondent’s attitudes were towards breastfeeding.

2.4.6. Perception of Social Support for Breastfeeding

We asked respondents their level of agreement (1 = strongly disagree, 5 = strongly agree) with the statement, “People around me support breastfeeding” [38].

2.4.7. Self-Assessment of Breastfeeding Intention and Support

We asked respondents their level of agreement (1 = strongly disagree, 5 = strongly agree) with three statements. To measure personal breastfeeding intention, we posed the statement, “If I have any children in the future, I plan to breastfeed or support my partner to breastfeed” [39]. Another statement, “I support individuals who breastfeed or express breast milk at work” [38], was included to measure workplace breastfeeding support. “In my professional capacity, I have or would recommend breastfeeding as the ideal way to feed an infant”, measured professional breastfeeding support intention.

2.4.8. Professional Breastfeeding Perceived Role, Perceived Influence, and Confidence in Providing Lactation Support

We asked respondents their level of agreement (1 = strongly disagree, 5 = strongly agree) with three statements to understand their professional breastfeeding perceived role, influence, and confidence in providing lactation support. These served as the three dependent variables in this study:

• “As a health professional, I believe it is my responsibility to highlight the health problems associated with the use of infant formula when giving advice about breastfeeding” [39].
• “In my professional capacity, I can influence both a woman’s decision to breastfeed and the duration for which she will feed” [39].
• “I feel confident in my ability to provide lactation counseling, guidance, and recommendations if asked by the population I serve”.

2.5. Analysis

We exported survey data from Qualtrics into SPSS, version 15 (IBM Corporation, Armonk, NY, USA, 2021). Due to small numbers, we recoded categorical variables as dichotomous dummy variables (i.e., yes/no) and Likert scale responses as dichotomous variables of explicitly expressed agreement, where an original response of somewhat agree (4) and strongly agree (5) were considered explicitly expressed agreement, and all others were not explicitly expressed agreement.

We used descriptive statistics to describe the sample and report as means (standard deviations, SD) and frequencies. We did not use statistical corrections (e.g., weighting of items, propensity scores). Since dietetics and nursing are distinct healthcare professions, we wanted to determine if RDs and RNs differed on measured variables before utilizing inferential statistics. To compare RDs and RNs in the sample, we used the chi-square test of independence or Fisher’s exact test for categorical variables and the Mann–Whitney U test for continuous variables.

To determine the strength and statistical significance of relationships between independent and dependent variables, we used the chi-square test of independence or Fisher’s exact test for categorical variables and the Mann–Whitney U test for continuous variables. After checking for multicollinearity, we entered all independent variables significantly related to a dependent variable into a bivariate logistic regression model. We ran three models—one for each dependent variable—to determine which independent variable(s) remained statistically related to the dependent variables when controlling for all others. All tests were two-tailed, and we defined significance as p < 0.05.

Six respondents had missing data for one or more variables in the regression models and were excluded from regression analysis. To determine if we introduced self-selection bias, we compared the six missing respondents to the rest of the sample using the same methods described above. No significant differences existed on any of the demographic or dependent variables, with two exceptions: compared to the rest of the sample, the six respondents with missing data were significantly more likely to have received breastfeeding training through a professional certification (8% vs. 50%, p = 0.04) and have a lower mean breastfeeding training scale (1.7 vs. 1.0, p < 0.001).

3. Results

3.1. Sample Description

Of the 111 respondents who completed the survey, 47% (n = 52) were RDs and 53% (n = 59) were RNs. The average age of respondents was 42.3 years (SD 13.4). The sample was overwhelmingly female (98%), white (91%), non-Hispanic (94%), married or in a domestic partnership (76%), with a household income of more than USD 96,000 (61%), and a bachelor’s degree or higher (92%). Although respondents represented various geographic regions, practice settings, and practice specialties, a plurality were from the Northeast (59%), worked in direct patient care (56%), and specialized in something other than maternal/child/family health (83%). About three-fourths (73%) of the sample received breastfeeding training during their academic program, and only 9% held a lactation certification or credential. Significantly more RNs worked in maternal/child/family health (p < 0.001), while significantly more RDs had received breastfeeding training via continuing education (p < 0.001). On average, respondents received breastfeeding training via 1.6 (SD 0.93) method types (

Table 1. Sample characteristics: overall and by credential (N = 111).

Variable	Total (N = 111) % (n)	RD (n = 52) % (n)	RN (n = 59) % (n)	p-Value a
Gender				1.00 b
Female	98.2 (109)	98.1 (51)	98.3 (58)
Male	1.8 (2)	1.9 (1)	1.7 (1)
Race				0.02 * b
White	91.0 (101)	98.1 (51)	84.7 (50)
Non-White	9.0 (10)	1.9 (1)	15.3 (9)
Ethnicity				0.01 * b
Non-Hispanic	93.7 (104)	100 (52)	88.1 (52)
Hispanic	6.3 (7)	0 (0)	11.9 (7)
Marital Status				0.04 *
Married/domestic partnership	75.7 (84)	84.6 (44)	67.8 (40)
Single/divorced/widowed	24.3 (27)	15.4 (8)	32.2 (19)
Household Income				0.20
≤USD 96,000	28.8 (32)	25.0 (13)	32.2 (19)
>USD 96,000	61.3 (68)	69.2 (36)	54.2 (32)
Prefer not to answer	9.9 (11)	5.8 (3)	13.6 (8)
Highest Level of Education				0.003 ** b
Diploma program/associate’s	8.1 (9)	0 (0)	15.3 (9)
Bachelor’s/master’s/doctorate	91.9 (102)	100 (52)	84.7 (50)
Parent (n = 109)				0.29
Yes	75.2 (82)	70.6 (36)	79.3 (46)
No	24.8 (27)	29.4 (15)	20.7 (12)
Geographic Practice Area				0.05
Northeast	58.6 (65)	46.2 (24)	69.5 (41)
Midwest	10.8 (12)	17.3 (9)	5.1 (3)
South	18.0 (20)	23.1 (12)	13.6 (8)
West	12.6 (14)	13.5 (7)	11.9 (7)
Primary Practice Setting (n = 110)				<0.001 ***
Direct patient care	55.5 (61)	32.7 (17)	75.9 (44)
Academic	30.0 (33)	44.2 (23)	17.2 (10)
Public health/community	7.3 (8)	11.5 (6)	3.4 (2)
Other	7.3 (8)	11.5 (6)	3.4 (2)
Primary Position/Role (n = 110)				<0.001 ***
Education	33.6 (37)	44.2 (23)	24.1 (14)
Clinical provider	30.9 (34)	13.5 (7)	46.6 (27)
Administration/supervisor	18.2 (20)	15.4 (8)	20.7 (12)
Other	17.3 (19)	26.9 (14)	8.6 (5)
Primary Practice Specialty (n = 109)				<0.001 ***
Maternal, child, family health	17.4 (19)	3.9 (2)	29.3 (17)
Community health, public health, general practice, primary care, other	82.6 (90)	96.1 (49)	70.7 (41)
Year Credentialed (n = 110)				0.81
2015 or later	20.0 (22)	21.2 (11)	19.0 (11)
2005–2014	36.4 (40)	34.6 (18)	37.9 (22)
1995–2004	18.2 (20)	21.2 (11)	15.5 (9)
1985–1994	14.5 (16)	15.4 (8)	13.8 (8)
Before 1985	10.9 (12)	7.7 (4)	13.8 (8)
Breastfeeding Training Method Received (n = 109)
Academic program	72.5 (79)	64.7 (33)	79.3 (46)	0.09
Employment-based	23.9 (26)	21.6 (11)	25.9 (15)	0.60
Continuing education	37.6 (41)	56.9 (29)	20.7 (12)	<0.001 ***
Certification (e.g., CLC, CLE, or IBCLC)	9.2 (10)	13.7 (7)	5.2 (3)	0.18 b
Other	20.2 (22)	21.6 (11)	19.0 (11)	0.74
Had Experience Breastfeeding a Child (n = 109)				0.53
Yes	71.6 (78)	68.6 (35)	74.1 (43)
No	28.4 (31)	31.4 (16)	25.9 (15)
Had Positive Breastfeeding Experience (n = 108)				0.93
Yes	55.6 (60)	56.0 (28)	55.2 (32)
No (negative/neutral/no experience)	44.4 (48)	44.0 (22)	44.8 (26)
Met Personal Breastfeeding Goals c (n = 79)				0.30
Yes	73.4 (58)	79.4 (27)	68.9 (31)
No	26.6 (21)	20.6 (7)	31.1 (14)
Breastfeeding Challenges Experienced c (n = 80)
Lack of support from family	9.9 (8)	11.4 (4)	8.7 (4)	0.72 b
Lack of support from friends	2.5 (2)	0 (0)	4.3 (2)	0.50 b
Lack of support from co-workers	9.9 (8)	11.4 (4)	8.7 (4)	0.72 b
Lack of support from supervisors	4.9 (4)	8.6 (3)	2.2 (1)	0.31 b
Inadequate maternity leave	16.0 (13)	17.1 (6)	15.2 (7)	0.85
Lack of break time during workday	29.6 (24)	25.7 (9)	32.6 (15)	0.46
Lack of facilities at work	18.5 (15)	17.1 (6)	19.6 (9)	0.75
Inflexible or difficult work schedule	23.5 (19)	22.9 (8)	23.9 (11)	0.87
Difficulty carrying/storing pump at work	6.2 (5)	8.6 (3)	4.3 (2)	0.65 b
Lack of knowledge regarding breastfeeding	12.3 (10)	5.7 (2)	17.4 (8)	0.17 b
Lack of support from childcare provider	7.4 (6)	8.6 (3)	6.5 (3)	1.00 b
Lack of support/access to lactation professional	13.6 (11)	17.1 (6)	10.9 (5)	0.52 b
Were You Breastfed as an Infant? (n = 108)				0.04 *
Yes	59.3 (64)	70.0 (35)	50.0 (29)
No/don’t know	40.7 (44)	30.0 (15)	50.0 (29)
Have You/Someone You Know Breastfed in Public? (n = 108)				0.73
Yes No	88.9 (96)	90.0 (45)	87.9 (51)
	11.1 (12)	10.0 (5)	12.1 (7)
	Mean (SD)	Mean (SD)	Mean (SD)	p-Value d
Age (years)	42.3 (13.4)	40.9 (12.1)	43.5 (14.5)	0.38
Number of children (n = 109)	1.6 (1.22)	1.4 (1.12)	1.7 (1.30)	0.30
Breastfeeding training scale e (n = 109)	1.6 (0.93)	1.8 (0.97)	1.5 (0.88)	0.08
Breastfeeding challenges scale f (n = 81)	1.5 (1.48)	1.5 (1.75)	1.5 (1.24)	0.46
Breastfeeding knowledge scale g (n = 107)	9.7 (1.87)	10.1 (1.68)	9.33 (1.95)	0.03 *
Breastfeeding attitudes scale h (n = 106)	4.1 (0.45)	4.2 (0.35)	4.0 (0.49)	0.04 *

RD, registered dietitian; RN, registered nurse; CLC, certified lactation counselor; CLE, certified lactation educator; IBCLC, international board-certified lactation consultant; SD, standard deviation. ^a Based on chi-square test of independence, two-tailed. ^b Based on Fisher’s exact test, two-tailed. ^c Question only asked of respondents who reported affirmatively to being a parent (n = 82). ^d Based on Mann–Whitney U test, two-tailed. ^e Scale created by summing the number of types of professional training reported by each respondent, for a possible range of 0 to 5. ^f Scale created by summing the number of challenges reported by each respondent, for a possible range of 0 to 12. ^g Scale created by summing the number of correct answers reported by each respondent, for a possible range of 0 to 12. ^h Scale created by averaging response scores across all statements after negatively worded items reverse coded, where 1 = strongly disagree and 5 = strongly agree, for a possible range of 1 to 5. * p < 0.05; ** p < 0.01; *** p < 0.001.

).

Three-quarters of respondents were parents, with an average of 1.6 (SD 1.22) children. Seventy-two percent of the sample had breastfed a child, and 56% reported having a positive breastfeeding experience. Among parents, 73% met their breastfeeding goals and reported an average of 1.5 (SD 1.48) breastfeeding challenges, with the most frequently reported challenges being lack of break time during the workday (30%), inflexible or difficult work schedule (24%), and lack of facilities at work (e.g., no private space for pumping, no access to refrigeration) (19%). Most respondents (89%) reported breastfeeding in public or knowing someone who had, and 59% were breastfed as infants (Table 1).

Supplementary Table S1 lists the frequencies of correct responses to the individual breastfeeding knowledge questions. Respondents correctly answered an average of 9.7 (SD 1.87) out of 12 questions, or 81%. Questions related to dietary intake were more frequently answered correctly by RDs compared to RNs, which contributed to RDs’ higher mean score on the breastfeeding knowledge scale (U = 1082.500, p = 0.03) (Table 1).

Responses to attitudinal questions are outlined in Supplementary Table S2. The highest explicitly expressed agreement levels were for employment-related protections, such as access to a private space for pumping or milk expression at work (96%), the right to pump at work (93%), paid break time to breastfeed or express breast milk (91%), and family leave (90%). Over half the sample (57%) agreed that hospitals should supply infant formula to babies even if formula feeding is not medically warranted, and more than a third (37%) felt that individuals who breastfeed in public should cover themselves. The average breastfeeding attitudes scale score was 4.1 (SD 0.45) out of 5, indicating favorable attitudes towards breastfeeding. RDs had a slightly higher average compared to RNs (4.2 vs. 4.0, U = 1074.500, p = 0.04) (Table 1).

Most respondents (88%) agreed that people around them support breastfeeding, and nearly all (95%) supported other people who breastfeed or express breast milk at work. Overall, 80% planned to breastfeed or support a partner in breastfeeding if having a child in the future, though significantly more RDs agreed with this statement compared to RNs (p = 0.03). Additionally, 91% had or would recommend breastfeeding as the ideal way to feed an infant. There was less explicitly expressed agreement in the three dependent variables: 54% believed it was their responsibility to highlight the health problems associated with using infant formula when giving breastfeeding advice; 71% felt that they could influence a woman’s decision to breastfeed and the duration for which she will feed; and 59% felt confident in their ability to provide lactation counseling, guidance, and recommendations if asked by the population they serve. There were no significant differences in explicitly expressed agreement between RDs and RNs with any dependent variable (

Table 2. Frequency of explicitly expressed agreement to statements relating to social support, breastfeeding intention, personal support, perceived role, professional influence, and confidence in providing lactation support: overall and by credential (N = 107).

Statement	Total (N = 107) % (n)	RD (n = 50) % (n)	RN (n = 57) % (n)	p-Value a
People around me support breastfeeding.	87.9 (94)	92.0 (46)	84.2 (48)	0.22
I support individuals who breastfeed or express breast milk at work.	95.3 (102)	98.0 (49)	93.0 (53)	0.37 b
If I have any children in the future, I plan to breastfeed or support my partner to breastfeed. (n = 106)	80.2 (85)	89.8 (44)	71.9 (41)	0.03 *
In my professional capacity, I have or would recommend breastfeeding as the ideal way to feed an infant.	90.7 (97)	92.0 (46)	89.5 (51)	0.75 b
As a health professional, I believe it is my responsibility to highlight the health problems associated with the use of infant formula when giving advice about breastfeeding.	54.2 (58)	56.0 (28)	52.6 (30)	0.73
In my professional capacity, I can influence both a woman’s decision to breastfeed and the duration for which she will feed.	71.0 (76)	76.0 (38)	66.7 (38)	0.29
I feel confident in my ability to provide lactation counseling, guidance, and recommendations if asked by the population I serve.	58.9 (63)	56.0 (28)	61.4 (35)	0.57

RD, registered dietitian; RN, registered nurse. ^a Based on chi-square test of independence, two-tailed. ^b Based on Fisher’s exact test, two-tailed. * p < 0.05.

).

3.2. Correlates of Professional Breastfeeding Perceived Role, Perceived Influence, and Confidence in Providing Lactation Support Among RDs and RNs

3.2.1. Professional Breastfeeding Perceived Role

Six variables were significantly correlated with explicitly expressed agreement (i.e., somewhat agree, strongly agree) with the statement, “As a health professional, I believe it is my responsibility to highlight the health problems associated with the use of infant formula when giving advice about breastfeeding”: breastfed as an infant, breastfeeding attitudes scale, and explicitly expressed agreement with “People around me support breastfeeding”, “I support individuals who breastfeed or express breast milk at work”, “If I have any children in the future, I plan to breastfeed or support my partner to breastfeed”, and “In my professional capacity, I have or would recommend breastfeeding as the ideal way to feed an infant” (

Table 3. Univariate correlates and binary logistic regression of respondents’ explicitly expressed agreement to the statement, “As a Health Professional, I Believe It Is My Responsibility to Highlight the Health Problems Associated with the Use of Infant Formula When Giving Advice About Breastfeeding”.

Variable	Test of Independence		Binary Logistic Regression a
	Test Statistic	p-Value	b	SE	p-Value	Exp (b)	95% CI
							Lower	Upper
Breastfed as an infant	10.812 **	0.001 b	1.230 **	0.474	0.009	3.421	1.351	8.660
Breastfeeding attitudes scale	1071.500 *	0.04 c	0.420	0.549	0.44	1.522	0.519	4.461
People around me support breastfeeding	5.776 *	0.02 b	0.341	0.887	0.70	1.406	0.247	8.000
I support individuals who breastfeed or express breast milk at work	N/A	0.02 d	20.796	1.646 × 104	1.00	1.075 × 109	0.000	--
If I have any children in the future, I plan to breastfeed or support my partner to breastfeed	6.691 *	0.01 b	−0.359	0.731	0.62	0.698	0.167	2.928
In my professional capacity, I have or would recommend breastfeeding as the ideal way to feed an infant	N/A	0.005 d	1.480	1.304	0.26	4.393	0.341	56.638
Constant			−24.422	1.646 × 104	1.00	0.000

N/A, not applicable. ^a Model statistics: Model X²(6) = 22.09, p = 0.001; −2 Log likelihood = 123.00; Cox and Snell R² = 0.190; Nagelkerke R² = 0.253; Hosmer and Lemeshow test X² = 7.60 (DF = 7; p = 0.37); n = 105. ^b Based on chi-square test of independence, two-tailed. ^c Based on Mann–Whitney U test, two-tailed. ^d Based on Fisher’s exact test, two-tailed. * p < 0.05; ** p < 0.01.

).

The binary logistic regression model was statistically significant (X²(6) = 22.09, p = 0.001), explaining 25% (Nagelkerke R²) of the variance in professional breastfeeding perceived role and correctly classifying 66% of respondents. Respondents who were breastfed as infants were 3.4 times more likely to explicitly agree with the statement, “As a health professional, I believe it is my responsibility to highlight the health problems associated with the use of infant formula when giving advice about breastfeeding”, compared to respondents who were not breastfed as infants or did not know. No other correlates were significant (Table 3).

3.2.2. Perceived Influence on Breastfeeding Decision-Making

Nine variables were significantly correlated with explicitly expressed agreement with the statement, “In my professional capacity, I can influence both a woman’s decision to breastfeed and the duration for which she will feed”: bachelor’s degree or higher, breastfeeding training scale, breastfeeding in public or knowing someone who had breastfed as an infant, breastfeeding attitudes scale, and explicitly expressed agreement with “People around me support breastfeeding”, “I support individuals who breastfeed or express breast milk at work”, “If I have any children in the future, I plan to breastfeed or support my partner to breastfeed”, and “In my professional capacity, I have or would recommend breastfeeding as the ideal way to feed an infant” (

Table 4. Univariate correlates and binary logistic regression of respondents’ explicitly expressed agreement to the statement, “In My Professional Capacity, I Can Influence Both a Woman’s Decision to Breastfeed and the Duration for Which She Will Feed”.

Variable	Test of Independence		Binary Logistic Regression a
	Test Statistic	p-Value	b	SE	p-Value	Exp (b)	95% CI
							Lower	Upper
Bachelor’s degree or higher	N/A	0.007 b	1.618	1.097	0.14	5.044	0.588	43.272
Breastfeeding training scale	886.000 *	0.03 c	0.491	0.376	0.19	1.635	0.782	3.417
Breastfed or know someone who breastfeed in public	N/A	0.04 b	0.311	0.958	0.75	1.365	0.209	8.931
Breastfed as an infant	3.898 *	0.048 d	0.030	0.664	0.96	1.030	0.280	3.787
Breastfeeding attitudes scale	851.500 *	0.03 c	0.255	0.735	0.73	1.291	0.306	5.453
People around me support breastfeeding	N/A	<0.001 b	2.075	1.067	0.05	7.961	0.984	64.436
I support individuals who breastfeed or express breast milk at work	N/A	0.002 b	19.080	1.480 × 104	1.00	1.934 × 108	0.000	--
If I have any children in the future, I plan to breastfeed or support my partner to breastfeed	18.995 ***	<0.001 d	0.569	0.869	0.51	1.767	0.322	9.694
In my professional capacity, I have or would recommend breastfeeding as the ideal way to feed an infant	N/A	<0.001 b	20.939	1.056 × 104	1.00	1.241 × 109	0.000	--
Constant			−44.628	1.818 × 104	1.00	0.000

N/A, not applicable. ^a Model statistics: Model X² (9) = 44.85, p < 0.001; −2 Log likelihood = 80.79; Cox and Snell R² = 0.348; Nagelkerke R² = 0.498; Hosmer and Lemeshow test X² = 4.07 (DF = 8; p = 0.85); n = 105. ^b Based on Fisher’s exact test, two-tailed. ^c Based on Mann–Whitney U test, two-tailed. ^d Based on chi-square test of independence, two-tailed. * p < 0.05; *** p < 0.001.

).

The binary logistic regression model was statistically significant (X²(9) = 44.85, p < 0.001). The model explained 50% (Nagelkerke R²) of the variance in professional breastfeeding influence and correctly classified 84% of respondents. Respondents who explicitly agreed that “People around me support breastfeeding” were 8.0 times more likely to also explicitly agree to the statement, “In my professional capacity, I can influence both a woman’s decision to breastfeed and the duration for which she will feed”, compared to respondents who disagreed or reported a neutral response, though this relationship was just above the significance threshold (p = 0.05). No other correlates were significant in the model (Table 4).

3.2.3. Confidence in Providing Lactation Support

Eleven variables were significantly correlated with explicitly expressed agreement with the statement, “I feel confident in my ability to provide lactation counseling, guidance, and recommendations if asked by the population I serve”: married, parent, number of children, maternal/child/family health practice specialty, received employment-based breastfeeding training, breastfeeding training scale, had experience breastfeeding a child, had a positive breastfeeding experience, breastfeeding knowledge scale, breastfeeding attitudes scale, and explicitly expressed agreement with “People around me support breastfeeding” (

Table 5. Univariate correlates and binary logistic regression of respondents’ explicitly expressed agreement to the statement, “I Feel Confident in My Ability to Provide Lactation Counseling, Guidance, and Recommendations If Asked by the Population I Serve”.

Variable	Test of Independence		Binary Logistic Regression a
	Test Statistic	p-Value	b	SE	p-Value	Exp (b)	95% CI
							Lower	Upper
Married	3.895 *	0.048 b	0.390	0.611	0.52	1.477	0.446	4.895
Parent	4.907 *	0.03 b
Number of children	940.500 **	0.004 c	0.170	0.248	0.49	1.185	0.729	1.926
Maternal/child/family health practice specialty	11.966 **	0.001 b	2.661 *	1.186	0.03	14.310	1.400	146.231
Received employment-based breastfeeding training	9.396 **	0.002 b	0.767	0.707	0.28	2.152	0.539	8.603
Breastfeeding training scale d	1058.000 *	0.02 c
Had experience breastfeeding a child	6.137 *	0.01 b
Had a positive breastfeeding experience	17.851 ***	<0.001 b	0.556	0.692	0.42	1.744	0.450	6.765
Breastfeeding knowledge scale	882.000 **	0.001 c	0.289	0.178	0.10	1.335	0.943	1.892
Breastfeeding attitudes scale	919.500 **	0.004 c	0.355	0.665	0.59	1.426	0.387	5.252
People around me support breastfeeding	7.834 **	0.005 b	1.106	0.794	0.16	3.023	0.637	14.337
Constant			−6.150	2.982	0.04	0.002

^a Model statistics: Model X²(8) = 37.44, p < 0.001; −2 Log likelihood = 104.66; Cox and Snell R² = 0.300; Nagelkerke R² = 0.404; Hosmer and Lemeshow test X² = 4.08 (DF = 7; p = 0.77); n = 105. ^b Based on chi-square test of independence, two-tailed. ^c Based on Mann–Whitney U test, two-tailed. ^d Breastfeeding training scale was excluded from the binary logistic regression because employment-based breastfeeding training was a component of the summative scale. * p < 0.05; ** p < 0.01; *** p < 0.001.

).

In the binary logistic regression model, we excluded the breastfeeding training scale because employment-based breastfeeding training was a component of the summative scale. Additionally, we excluded two other variables—parental status and having experience breastfeeding a child—because they were each highly correlated with having a positive breastfeeding experience. The model was statistically significant (X²(8) = 37.44, p < 0.001). The model explained 40% (Nagelkerke R²) of the variance in professional breastfeeding confidence and correctly classified 78% of respondents. Respondents whose practice specialty was maternal/child/family health were 14.3 times more likely to explicitly agree with the statement, “I feel confident in my ability to provide lactation counseling, guidance, and recommendations if asked by the population I serve”, compared to respondents who practiced in other specialties. No other correlates were significant in the model (Table 5).

4. Discussion

Lactation support and care practices provided by health professionals can influence breastfeeding initiation and duration [10,26]. We aimed to explore correlates of perceived professional role, perceived influence on lactation outcomes, and confidence in providing lactation support among RDs and RNs.

We found that respondents who were breastfed as infants were more likely to agree that it was their role to highlight the health problems associated with the use of infant formula. Researchers have previously explored the intergenerational transmission of breastfeeding behaviors [43,44]. For instance, Wagner et al. [43] found that mothers who were breastfed as infants had higher breastfeeding initiation and duration rates than non-breastfed mothers [43]. Our results suggest that these same familial norms may also influence professional perceptions. Educational activities within pre- or post-licensure curricula can be designed to encourage healthcare professionals to reflect on their personal and familial feeding norms and experiences and how they shape their professional attitudes.

Previous research suggests that health practitioners’ personal experiences with breastfeeding their children may affect their professional support practices [17,30,31]. In our study, having had a positive experience with breastfeeding was significantly correlated with feeling confident in one’s ability to provide lactation counseling and support to others. Yet practice specialty in maternal/child/family health was a stronger correlate. It is not surprising that individuals who work in this specialty are more likely to feel confident in their ability to provide lactation counseling, guidance, and recommendations. While healthcare providers from other specialties may not need to regularly provide lactation support, they may encounter lactating persons who present for other forms of medical care. For example, a nurse working in the emergency department may need to treat a lactating patient for an acute injury. The advice and care given may either support or disrupt the maintenance of breastfeeding [45]. Consistent with the recommendation of the United States Breastfeeding Committee, all health professionals, regardless of their practice specialty, should demonstrate knowledge, skills, and attitudes identified as breastfeeding core competencies [46]. Our results align with this recommendation and suggest that additional training and increased exposure to lactation may be needed to increase confidence.

Similarly, research shows that lactation-related training enhances breastfeeding knowledge, attitudes, and adherence to evidence-based practices [23]. Notably, only 9% of our sample held a lactation credential, and 17% worked in maternal/child/family health. Yet, 59% of the sample were confident in their ability to provide lactation counseling, guidance, and recommendations. Despite practice specialty being most related (likely due to the repeated professional experiences with lactation), it seems that confidence can also be developed through training in the academic and professional environment, especially for those working in other specialties. Of course, training should be up-to-date, aligned with hospital policies, and consistent across providers [47]. However, it is unclear from our study whether higher confidence translates to better quality lactation support. To be sure, different types of lactation support are needed to enhance breastfeeding outcomes. For instance, psychological and emotional support might be necessary to instill confidence in new parents, while practical and technical support is needed at times to troubleshoot breastfeeding challenges. Future research is warranted to examine the various types of support and explore factors that impact each.

A strength of our study is the inclusion of both RDs and RNs. Many studies have focused on the role of physicians in parental decision-making around breastfeeding [10,26,28,34,35,48]. Yet less is known about the role of dietitians and nurses in this realm. Additionally, studies exploring factors that influence lactation support provided by health professionals have mainly been qualitative in design [3,4,12,26]. The present study contributes to the body of knowledge by examining relationships quantitatively. Furthermore, the breastfeeding ecosystem within healthcare is complex and requires interprofessional collaboration. This understanding has led to calls to action to enhance interdisciplinary lactation research that builds awareness and integration among health practitioners [49]. Another strength of this study was that the survey collected demographic and geographic variables, which allowed for more robust models to be analyzed. Finally, where possible, we used or adapted validated survey questions.

4.1. Limitations

We must note several study limitations. The sample was relatively small and largely homogenous, with limited racial/ethnic and geographic variability. Respondents were predominantly parents, most of whom initiated breastfeeding. Thus, the findings may not be generalizable to the broader, diverse dietetics and nursing professions. Second, we did not ask respondents about organizational characteristics of the healthcare workplace that may be influential in our study outcomes. For instance, we did not inquire about employment in a Baby-Friendly designated facility [50]. Additionally, we focused on RDs’ and RNs’ perceptions and self-assessments and did not assess the quality of care and level of support provided in practice by these professionals. The primary practice setting variable, which was significantly associated with confidence in our regression model, was not specific enough to assess the duration of employment in that setting, number of employment hours, or exact specialty. Likewise, while we evaluated the number of lactation training methods completed by respondents, we did not explore the dosage or quality of those trainings. We also did not measure the degree of interaction respondents had with lactating persons in their regular professional practice. Finally, while the regression models accounted for a portion of the variance in the explicitly expressed agreement of the dependent variables, other factors that influence agreement remain unknown. Future research is needed to identify additional factors that influence perceived role, perceived influence, and confidence in providing lactation support. However, the findings presented suggest the necessity of increasing confidence among dietetics and nursing professionals providing lactation support, which could promote and improve breastfeeding rates among US children.

4.2. Implications

Pregnant and postpartum individuals consider the advice of clinicians to be highly influential in their decision to breastfeed, yet clinicians often underestimate their level of influence [4,25]. While we found that knowledge and attitudes correlated with RDs’ and RNs’ perceived level of influence, one’s perception of social norms exhibited the strongest association. Thus, continuing to shift social and professional norms around breastfeeding—particularly in healthcare settings—may contribute to health professionals’ perception that their lactation-related support and practices meaningfully impact breastfeeding outcomes. Within hospitals, further support of the Ten Steps to Successful Breastfeeding as part of the larger Baby-Friendly Hospital Initiative [51] can be a key strategy towards this aim. Furthermore, local, state, and community-level breastfeeding initiatives occurring in other settings like college campuses, workplaces, and medical practices strengthen the broader social and community norms within a social-ecological framework and may interplay with the healthcare context. Collectively, these interventions create a robust infant feeding ecosystem where all parties have a responsibility to promote and support breastfeeding and facilitate continuity of care.

5. Conclusions

Results of this study suggest that RDs’ and RNs’ breastfeeding perceived roles can be strengthened through opportunities to discuss personal and familial breastfeeding experiences and how those may influence professional beliefs and responsibilities. Likewise, improving professionals’ knowledge that others around them—such as managers, peers, and co-workers—support breastfeeding may enhance RDs’ and RNs’ perceived influence on a woman’s decision to breastfeed and her breastfeeding duration. Finally, confidence in providing lactation support among RDs and RNs can be enhanced via increased exposure to lactation in the professional environment.