706361

research-article2017
JHLXXX10.1177/0890334417706361Journal of Human LactationGrubesic and Durbin

Original Research
Journal of Human Lactation

Breastfeeding Support: A Geographic

1­–11
© The Author(s) 2017
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DOI: 10.1177/0890334417706361
https://doi.org/10.1177/0890334417706361
journals.sagepub.com/home/jhl

Tony H. Grubesic, PhD1 and Kelly M. Durbin, MEd2,3

Abstract
Background: Clinical lactation professionals, breastfeeding peer counseling, and mother-to-mother support are important
sources of information and guidance for helping mothers initiate and maintain breastfeeding in the early weeks, months, and
years postpartum. However, there is limited information concerning the geographic barriers that mothers face when seeking
this support.
Research aim: This study aimed to identify the geographic barriers to breastfeeding support, delineate gaps in access,
assess inequities in the distribution of local support, and highlight the underlying differences in access and equity for different
demographic and socioeconomic groups.
Methods: The locations of formal breastfeeding support resources were collected for the state of Ohio for 2016 and
were combined with demographic and socioeconomic estimates and derived transportation catchment areas to conduct an
analysis of spatial access and equity.
Results: Significant geographic gaps in formal breastfeeding support exist within the state of Ohio. Although urban areas
benefit from a higher density of support options, including a wide variety of clinical experts and mother-to-mother support
groups, inequities in exurban and rural areas were more strongly aligned with socioeconomic status than geography.
In particular, the Special Supplemental Nutrition Program for Women, Infants, and Children offices in rural Ohio offer
breastfeeding support to income-qualifying mothers but cannot address the needs of mothers who do not qualify.
Conclusion: Spatial analytical approaches facilitate a more nuanced view of access and equity to breastfeeding support
options, helping to both decompose important structural differences in the state of Ohio and identify locations that could
benefit from additional breastfeeding support resources.

Keywords
breastfeeding, breastfeeding support, health services research, lactation counseling, La Leche League International, social support

Background of maternal–child healthcare, rapidly moved breastfeeding

Breastfeeding is a complex physical and emotional endeavor
for a new mother. Meeting a newborn’s nutrition demands is
fundamental to this process, but equally valuable is the devel-
opment of a strong emotional bond between a mother and her
infant (Hofmeyr, Nikodem, Wolman, Chalmers, & Kramer,
1991; Johnson, 2013; Klaus, 1998), as well as the myriad of
other benefits that mothers and infants accrue from breast-
feeding (Gartner et al., 2005; León-Cava, Lutter, Ross, &
Martin, 2002). Historically, new mothers and their breast-
feeding efforts were supported by a large network of experi-
enced mothers, relatives, and friends (Renfrew, McCormick,
Wade, Quinn, & Dowswell, 2012), but this varies by culture
and location (Rooks, 1997). For example, until the early 20th
century, breastfeeding was the primary means of nourishing a
baby in the United States (Riordan & Wambach, 2010), but a
range of social changes, including greater family mobility, the
commercialization of infant formula, and the medicalization
out of mainstream practice (Rossman, 2007; Victora et al.,
2016).
Recent trends in U.S. breastfeeding rates indicate prog-
ress, with 81.1% of all infants born in the United States being
breastfed at least once, and 44.4% and 22.3% being breastfed
exclusively at 3 months and 6 months, respectively (Centers
1
Center for Spatial Reasoning & Policy Analytics, College of Public Service
& Community Solutions, Arizona State University, Phoenix, AZ, USA
2
Childbirth International, Singapore
3
LaLeche League International, Schaumburg, IL, USA
Date submitted: December 9, 2016; Date accepted: March 28, 2017.
Corresponding Author:
Tony H. Grubesic, PhD, Center for Spatial Reasoning & Policy Analytics,
College of Public Service & Community Solutions, Arizona State
University, 411 N Central Ave #600, Phoenix, AZ 85004, USA.
Email: grubesic@asu.edu
2 Journal of Human Lactation 00(0)
for Disease Control and Prevention [CDC], 2016). Although
these rates fall short of the Healthy People 2020 (2016) goals
of 81.9% (at least once), 46.2% (exclusively at 3 months),
and 25.5% (exclusively at 6 months), significant progress
has been made, but more work is needed to improve duration
and exclusivity metrics.
It is also important to acknowledge that national bench-
marks and aggregate U.S. statistics obfuscate significant
regional and local variation in breastfeeding practices. For
example, in the state of Mississippi, the CDC National
Immunization Survey indicates that only 52% of the children
born in 2013 were ever breastfed, and 21.4% and 9.3% were
breastfed exclusively at 3 and 6 months, respectively (CDC,
2016). In Oregon, 92.5% of children have been breastfed at
least once, with 52.9% and 30.6% breastfed exclusively at 3
and 6 months, respectively. These geographic variations in
breastfeeding rates are fueled by differences in socioeco-
nomic status, ethnicity, culture, hospital practices, and partici-
pation in the Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC) (Gill, 2009; Hurley,
Black, Papas, & Quigg, 2008; Ludington-Hoe, McDonald, &
Satyshur, 2002; Nommsen-Rivers, Chantry, Cohen, & Dewey,
2010; Ryan & Zhou, 2006; Sparks, 2011). Location also plays
a role, with differences in breastfeeding rates manifesting
between rural and urban communities (Allen, Perrine, &
Scanlon, 2015; Flower, Willoughby, Cadigan, Perrin, &
Randolph, 2008; Grubesic & Durbin, 2016; Sparks, 2010).
Breastfeeding support takes many forms but generally
falls within the following categories: (a) lactation profes-
sionals; (b) breastfeeding counselors and educators; and (c)
volunteer-based, mother-to-mother support organizations.
Lactation professionals, specifically International Board
Certified Lactation Consultants (IBCLCs), offer expertise in
the clinical management of breastfeeding and often work in
a variety of settings (e.g., hospitals, doctor’s offices, inde-
pendently, etc.) to help improve breastfeeding outcomes.
This often includes practical assistance and support with the
physical mechanics of breastfeeding such as latching and the
proper positioning of the child (Genna, 2016; Rossman,
2007). Breastfeeding counselors and educators fill an impor-
tant niche for a community and are charged with educating
mothers on the benefits of breastfeeding, troubleshooting
low-level challenges with breastfeeding mechanics, and
counseling on mother–child comfort and the sociocultural
challenges that often accompany breastfeeding efforts. Last,
volunteer-based mother-to-mother support groups such as La
Leche League International (LLL) and Breastfeeding USA
(BUSA) provide mothers with evidence-based breastfeeding
information, including information on the benefits of human
milk for babies as well as promoting breastfeeding as the
biological and cultural norm.
Fundamental to all forms of peer breastfeeding support is
shared experience (Cohen, Underwood, & Gottlieb, 2000).
Thus, although breastfeeding peer support may come from
sources that are not part of a mother’s immediate family or
Key Messages
•• Breastfeeding rates in rural communities in the
United States lag behind national averages, and
these rates are often stratified by race and
income, but little is known about the geo-
graphic divide in access to breastfeeding sup-
port resources between urban and rural locales.
•• Mothers living in urban areas benefit from a
density, a diversity, and a geographic ease of
access to breastfeeding support resources.
•• Rural mothers are often geographically depen-
dent on the Special Supplemental Nutrition
Program for Women, Infants, and Children for
breastfeeding support, which can exclude
women who do not meet the requisite income
guidelines.
•• This research provides insight into the spatial
structure of the breastfeeding support divide
and provides a framework for better identify-
ing locations that could benefit from additional
breastfeeding support resources.
social network, peer counselors often share a similar ethnic
background, socioeconomic status, and other overlapping
cultural and/or geodemographic traits (Arlotti, Cottrell, Lee,
& Curtin, 1998; Dennis, 2003; Hannula, Kaunonen, &
Tarkka, 2008; Jones, Power, Queenan, & Schulkin, 2015).
All three of the breastfeeding support options detailed
above function as formal extensions of the traditional net-
work of family and friends who help mothers after childbirth
(Rossman, 2007). Specifically, aside from the clinical and
educational expertise offered through these formal channels,
the ability to provide mothers with “expressions of caring,
compassion, encouragement, reassurance, reflection, and
attentive listening” (p. 632) can help improve the breastfeed-
ing experience for both mother and child, facilitating success
and duration.
The problem with this model of community breastfeeding
support is that, for any given region, there may be a significant
spatial mismatch between the location of mothers in need of
support and the people who can provide it. Although this is
well-trodden ground within the context of patients and primary
healthcare services (Guagliardo, Ronzio, Cheung, Chacko, &
Joseph, 2004; Hine & Kamruzzaman, 2012; Khan, 1992;
Rosero-Bixby, 2004; Schuurman, Berube, & Crooks, 2010),
much less is known about access to breastfeeding support,
especially when considering the diversity of support resources
and their associated locations. For example, although clinical
lactation support often mirrors existing healthcare outlets,
emergent clinical options are a relatively recent development,
and not all hospitals or doctor’s offices provide such resources.
Furthermore, most mother-to-mother support organizations
Grubesic and Durbin
and breastfeeding counselors/educators will have a more
diverse range of meeting locations (i.e., not hospitals or doc-
tor’s offices), affecting support access for mothers. A related
concern is that of distributional (i.e., spatial) equity as it relates
to location. The fundamental premise of spatial equity is a sim-
ple one. Within any region, goods and services should be
equally available to all members of society, regardless of race,
economic status, place of residence, or culture. If inequities
exist, there may be inefficiencies in the economic order or effi-
ciency goals of the system (Morrill & Symons, 1977). Spatial
inequities are especially acute between urban and rural areas.
Rural areas simply do not have the population density or yield
a large enough potential return on investment to support certain
services. In short, issues of access and equity are important
considerations when evaluating the landscape of breastfeeding
support for any region. This is especially true when one consid-
ers the large geographic variations in breastfeeding initiation
rates and duration throughout the United States (Allen et al.,
2015; Sparks, 2010, 2011).
For the purposes of this article, we focus on the state of
Ohio where approximately 22% of its residents live in rural
areas and approximately 15.8% live in poverty—both above
the national averages of 19% and 14.8%, respectively (U.S.
Census Bureau, 2014, 2015a). Ohio also provides a good
case study because the breastfeeding rates for children born
during 2013 lag behind national averages (CDC, 2016). For
example, 77.7% (81.1% nationally) of children in Ohio were
breastfed at least once, 39.6% (44.4% nationally) were
breastfed exclusively at 3 months, and 22.3% (22.3% nation-
ally) at 6 months (CDC, 2016). A woman’s right to breast-
feed is protected under Ohio law. Specifically, Ohio Revised
Code (2016a, 2016b) states that “a mother is entitled to
breastfeed her baby in any location of a place of public
accommodation wherein the mother otherwise is permitted,”
but there is no enforcement provision in Ohio.
Given this background information, there are three goals
for this research. In general, this work seeks to identify the
geographic barriers to formal breastfeeding support. The first
facet of this analysis will delineate gaps in spatial access
using a suite of geocomputational approaches. Second, this
work will simultaneously assess whether or not the distribu-
tion of local support is spatially equitable in Ohio through
the examination of support resources. Last, this work will
highlight the underlying differences in access and equity for
different demographic and socioeconomic groups through-
out the state and provide some basic strategies for achieving
improved access and equity for breastfeeding support
resources throughout the state.
Methods
Design
This study was designed as an exploratory spatial analysis of
breastfeeding support resources, access, and spatial equity
for the state of Ohio.
3
Setting
The state of Ohio (see Figure 1) provides a particularly inter-
esting region for exploring issues of locational access and
equity for breastfeeding support. Ohio is a complex mixture
of rural and urban settlements. With a population of approxi-
mately 11.6 million (U.S. Census Bureau, 2015a), approxi-
mately 15.8% of Ohioans are living in poverty and 2.3
million of Ohio’s residents live within rural areas. The
Interstate 71 corridor functions as the core axis of Ohio’s
population, including the large metropolitan areas of
Cleveland, Columbus, and Cincinnati. Southeastern Ohio,
also known as Appalachian Ohio, consists of 32 primarily
rural counties. The Appalachian Regional Commission
(2015) has designated 12 of these counties either economi-
cally “distressed” or “at risk” during 2015. This is an area
that is often targeted by federal and state government part-
nerships seeking to improve economic development,
strengthen healthcare services, and build local and regional
capacity (Appalachian Regional Commission, 2010). The
racial composition of Ohio is 82.7% White, 12.7% African
American, 2.1% Asian, and 3.6% Hispanic/Latino (U.S.
Census Bureau, 2015b).
Data Collection
The breastfeeding resource database is multifaceted. First, we
obtained a list of all Baby-Friendly hospitals in the state of
Ohio (n = 11) (Baby-Friendly Hospitals, 2016). Baby-
Friendly hospitals are part of a global initiative to “encourage
and recognize birthing centers that offer an optimal level of
care for infant feeding and mother/baby bonding” (Baby-
Friendly Hospital Initiative, 2017). These hospitals provide
enhanced lactation support and education for mothers initiat-
ing and continuing breastfeeding with their infants (Ferrarello,
2012). Second, we obtained information on all IBCLCs and
their locations for the state of Ohio from the International
Lactation Consultant Association (2016). Third, we obtained
the meeting locations for all active LLL (n = 52) and BUSA
(n = 6) groups in Ohio (Breastfeeding USA, 2016; La Leche
League International, 2016). Fourth, we obtained the loca-
tions of all WIC offices in the state (n = 199) (U.S. Department
of Agriculture, 2016). Last, geographic base files for all coun-
ties in the state of Ohio (n = 88) as well as a comprehensive
street network and block group-level demographic and socio-
economic data were obtained from the U.S. Census Bureau
(2015b). Table 1 details the basic descriptive statistics for
these block group data and associated measures. The use of
these publicly available data did not require ethical approval.
Data Analysis
All of the hospital, IBCLC, LLL, and BUSA addresses were
geocoded and transformed into latitude and longitude coordi-
nates for subsequent analysis. Catchment areas for each sup-
port resource were calculated using a suite of geocomputational
4 Journal of Human Lactation 00(0)
Figure 1. The state of Ohio.
procedures in ArcGIS (Environmental Systems Research
Institute, 2016). As detailed by Schuurman, Fiedler,
Grzybowski, and Grund (2006), catchments are geographical
areas around an institution or business that help describe the
level of access that a surrounding community has to an insti-
tution’s goods or services. Although catchment areas can be
derived using distance metrics (e.g., 5 kilometers), a more
intuitive and meaningful approach leverages drive-time
catchments (e.g., 10 minutes) along street networks. For
example, these are often used by retailers to deepen their
understanding of local market demographics and target pro-
motional efforts toward potential consumers (Clarkson,
Clarke-Hill, & Robinson, 1996; Dennis, Marsland, & Cockett,
2002). When considering demand for breastfeeding support
services, travel times are an excellent indicator of local access
to these important resources. Moreover, extended travel times
can be considered a significant barrier because infants rarely
cooperate on long drives but also because mothers are strongly
affected by the perception of support levels and associated
resources. For example, a mother might be willing to take a
longer trip for clinical support (e.g., IBCLC) than she would
for lower level peer support from LLL. Empirical analysis
suggests that a reasonable drive time for primary care is
approximately 30 minutes (Lee, 1991), and this is
Grubesic and Durbin 5

Table 1 Descriptive Statistics for Demographic and The distribution of these resources has a significant effect
Socioeconomic Indicators for Ohio Block Groups on access to sources of breastfeeding support. Figure 3 dis-
Minimum Maximum M (SD) plays the results of the derived catchment areas and Table 2
provides companion statistics for each area within or not
Population 0 9,173 1,257.60 (666.42) within the catchments. For the purposes of discussion, areas
Households 0 3,527 505.4 (259.88) located outside the delineated catchments are considered part
Population age 25 0 5,499 853.08 (452.96) of the coverage “gap” within the state of Ohio. For example,
years or older
consider Figure 3a, which shows the geographic footprint of
Minority 0 5,536 253.74 (320.62)
the 30-minute catchment areas associated with all Baby-
populationa
Female population 0 4,769 641.95 (339.78)
Friendly hospitals in the state of Ohio. As detailed in Table 2,
Female population 0 3,528 238.94 (161.05) the locations and communities within 30 minutes of a Baby-
age 15-45 years Friendly hospital are home to more than 1.27 million (57.96%)
Age 25 years 0 2,097 142.67 (156.68) of the female population between the ages of 15 and 45 years
or older with in Ohio. In aggregate, the residents of these catchment areas
bachelor’s degree are more affluent (median income = $51,445), more educated
Median household 0 200,001 49,953.73 (20.34% with bachelor’s degree), and more diverse (~3×
income (24,750.30) larger minority population) than the population not residing
Note. N = 9,232. Catchment area indicators are drawn and summarized
within 30 minutes of the Baby-Friendly hospitals. Specifically,
from 2015 estimates of census block group data for the state of Ohio. All locations and communities that do not have access to a Baby-
block groups for the state have been used for this analysis. Friendly hospital within 30 minutes—regions we call the
a
Includes population that identifies as Black, Hispanic, American Indian, “hospital gap”—have a median household income of $45,436,
Asian, Pacific Islander, other, and multiple races.
only 12.14% have bachelor’s degrees, and they display a
much lower minority population.
the benchmark used for accessing clinical breastfeeding When considering access to IBCLCs (30 minutes) and
support in this article. Specifically, 30-minute catchment LLL and BUSA (20 minutes) (see Figures 3b and 3c), the
areas are generated for each hospital, WIC location, and story remains largely the same. Communities with access to
IBCLC location, whereas 20-minute catchment areas are these resources are more diverse, more affluent, and more
generated for lower level support resources such as LLL educated. However, the overall level of access to IBCLCs for
and BUSA meetings. It is important to remember that catch- women in Ohio is significantly better than both Baby-
ment areas reflect typical travel times but do not account Friendly hospitals and mother-to-mother support resources.
for high-traffic scenarios (e.g., rush hour) or inclement Specifically, 90.33% of the female population between the
weather. Thus, the catchment areas derived for analysis ages of 15 and 45 years resides within 30 minutes of an
represent relatively liberal estimations of access to support. IBCLC, whereas only 69.69% are within 20 minutes of a
Results are mapped with ArcGIS 10.3.1 (Environmental LLL or BUSA meeting. Perhaps, the most compelling result
Systems Research Institute, 2016). Finally, the derived of this analysis is that nearly all Ohio women live within 30
catchment areas (20 and 30 minute) were then used to minutes of a WIC location.
extract and aggregate local demographic and socioeconomic
measures for evaluating spatial equity.
Equity
Given the results detailed above, it is important to acknowl-
Results
edge that differences in the spatial equity of breastfeeding
Access resources are driving the variations in access to breastfeeding
support throughout the state. Women residing in urban and
Figure 2 displays the spatial distribution of breastfeeding suburban communities of Ohio have much better access to
support resources for the state of Ohio. Specifically, Figure breastfeeding support when compared to rural and remote
2a highlights Baby-Friendly hospitals, Figure 2b shows portions of the state. However, the results visualized in
IBCLCs, Figure 2c displays LLL and BUSA meeting loca- Figures 2d and 3d (for WIC) fail to illustrate the important
tions, and Figure 2d shows all WIC locations for the state. underlying differences in spatial equity for Ohio, especially
The bulk of these support resources is located in Ohio’s when communities are stratified by income. Differences in
larger urban areas (e.g., Cleveland, Akron, Columbus, income are especially salient when considering the role that
Dayton, and Cincinnati), mimicking the population distribu- WIC plays in breastfeeding support. Specifically, WIC main-
tion for the state. Again, this is not a surprising result consid- tains income thresholds that dictate which women and house-
ering that most goods and services are typically located in holds are eligible. For example, the 2015 guidelines for the
and around population centers. However, WIC locations state of Ohio dictate that families of four or fewer must have
have a much larger geographic footprint throughout the state. an income of $44,863 or less to qualify for WIC assistance
There is at least one WIC office in each county. (U.S. Department of Agriculture, 2015). Thus, although
6 Journal of Human Lactation 00(0)
Figure 2. Breastfeeding resources in Ohio.
spatial access to WIC and its associated support resources is
nearly ubiquitous for women in Ohio, questions of equity
remain because of the relatively strict income thresholds dis-
qualifying many women. Figure 4 highlights how these dif-
ferences manifest in geographic space. All WIC locations are
displayed, but additional information regarding local house-
hold distributions and income are also visualized.
Specifically, although census data are not available for the
exact cutoff point for WIC income qualification, Figure 4
uses a dot-density map to display a viable alternative—all
households within the state of Ohio that have an income of
$50,000 or more for 2015. Each dot represents 50 house-
holds. In sum, 2,299,586 of the households in Ohio do not
qualify for WIC, regardless of family size. Although census
data can support more nuanced analysis here, the broader
point is clear—spatial equity does not necessarily ensure
access to breastfeeding support resources in Ohio, especially
for WIC. There are thousands of households scattered
throughout Appalachian Ohio that are located far from Baby-
Friendly hospitals, IBCLCs, and mother-to-mother support
groups, none of which qualify for WIC (see Figures 2 and 4).
Discussion
There are three elements of the results that merit additional
discussion. First, access to breastfeeding support in the state
of Ohio is a mixed bag for local mothers. There is no doubt
that mothers living in the larger urban areas benefit from
Grubesic and Durbin
Figure 3. Catchment areas for breastfeeding resources in Ohio.
both a density and diversity of support services and breast-
feeding expertise. From multiple Baby-Friendly hospitals in
Cleveland and Cincinnati to numerous mother-to-mother
support meetings and IBCLCs, urban and suburban areas
along the I-71 corridor are more than adequately resourced.
However, it is important to acknowledge that the mere pres-
ence of breastfeeding support resources does not yield wide
(or uniform) use. For example, in the Cincinnati metropoli-
tan region, there are six active mother-to-mother support
groups (LLL and BUSA), but all of them conduct meetings
in and around neighborhoods that are primarily White and
relatively affluent. To be clear, this is not a condemnation of
these groups or their important efforts, but racial and cultural
7
divides in places like Cincinnati are real. Thus, there may be
a suite of barriers (economic, cultural, language, lack of
peers, etc.) that prohibit Black or Latina mothers from travel-
ing across the city to attend a mother-to-mother support
meeting in a primarily White neighborhood (Cohen et al.,
2000; Rossman, 2007). As a result, although metropolitan
areas of Ohio are thick with breastfeeding support resources,
the complexities of social, cultural, and economic relation-
ships that can form barriers for mothers are not accounted for
in this analysis.
Second, although the spatial equity and access to the
breastfeeding support resources at Ohio WIC locations are
good, the qualifying income restrictions for WIC likely
8 Journal of Human Lactation 00(0)

Table 2 Demographic and Socioeconomic Differences in Access to Breastfeeding Support Resources in Ohio: A Snapshot of Derived
Catchment Areas and Gaps

Indicator variables

Minority % Age 25 or older Median household Female population age % Female population
population with bachelor’s degree income 15-45 age 15-45
Hospital (30-minute 1,760,762 20.34 $51,445 1,278,648 57.96
catchment area)
Hospital gap 581,755 12.14 $45,436 927,398 42.03
IBCLC (30-minute 2,265,678 17.53 $50,035 1,992,720 90.32
catchment area)
IBCLC gap 76,839 9.68 $41,654 213,326 9.67
LLL and BUSA (20-minute 2,003,138 18.92 $49,714 1,530,736 69.38
catchment area)
LLL and BUSA gap 339,379 12.22 $47,641 675,310 30.61
WIC (30-minute 2,340,091 16.76 $49,053 2,193,154 99.41
catchment area)
WIC gap 2,426 10.16 $43,873 12,892 0.58

Note. Gaps refer to locations in the state of Ohio that are not within the derived catchment areas associated with breastfeeding support resources. For
example, the statistics associated with the “hospital gap” detailed above refer to all census blocks that are not within the 30-minute catchment area for
Baby-Friendly hospitals. IBCLC = International Board Certified Lactation Consultant; LLL = La Leche League International; BUSA = Breastfeeding USA;
WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

prevent many mothers from taking advantage of this local
expertise. Figure 4 illustrates these gaps, especially for
Appalachian Ohio. This is especially troubling given the
well-documented differential in breastfeeding rates between
rural and urban areas of the United States (Allen et al., 2015;
Flower et al., 2008; Grubesic & Durbin, 2016; Sparks, 2010).
It is interesting that the results presented here suggest that
poorer households in Appalachian Ohio have more options
for breastfeeding support than affluent households. As
detailed in Figure 3, there are a handful of IBCLCs and LLL
or BUSA meetings in Appalachian Ohio, but they are few
and far between. This means that women living in house-
holds with incomes greater than $44,863 would be forced to
travel significant distances to obtain breastfeeding support.
Third, although the results of the geocomputational analy-
sis suggest that significant gaps in breastfeeding support
exist in Ohio, they also reveal at least two potential strategies
for mitigating these inequities. First, for women located in
rural areas, videoconferencing may provide one avenue for
obtaining breastfeeding support (Rojjanasrirat, Nelson, &
Wambach, 2012), but this would likely be contingent on a
high-quality Internet connection, which can be a challenge in
Appalachian Ohio (Mack & Grubesic, 2014). Second, as
detailed in Table 2, 99.42% of the female population between
ages 15 and 45 years have access to a WIC location within 30
minutes of their residence. Although the qualifying income
restrictions for WIC support make sense from an economic
perspective, the potential to pursue alternate support mecha-
nisms for nonqualifying women at WIC locations might also
make sense. For example, when conducting breastfeeding
classes at WIC, it might be possible to include nonqualifying
women by charging them a fee to participate. This would
greatly enhance access to breastfeeding support and educa-
tion throughout the state, especially for nonqualifying rural
women. Moreover, the ability to offset some of the costs
associated with providing these programs at local WIC
offices may be appealing to both state and federal
administrators.
Study Limitations
Last, it is important to acknowledge a handful of limitations
to this study. By limiting our hospital data to those desig-
nated as Baby-Friendly, there is a chance that we are under-
estimating access to clinical breastfeeding support resources
in Ohio. In short, there may be other hospitals or healthcare
networks offering this type of high-level support to mothers
who were not included. However, many of these providers
likely employ IBCLCs, all of which were accounted for in
this analysis. Nevertheless, our results represent a modestly
conservative estimation of local clinical resources. A second
limitation of this analysis is that many women who are in
need of support may not have access to an automobile for
travel. Public transport options (e.g., bus) are available in
many of the urban locations in Ohio, but this may not be the
case for more rural locales. As a result, the derived catch-
ment areas represent a relatively optimistic level of access
for women without personal transportation options. Third,
Ohio is not a particularly diverse state, with more than 82%
of the population identifying as White only (61% nationally).
Considering that breastfeeding rates are often stratified by
race, this may affect the spatial distribution of support
resources. Finally, we do not make any attempt to link access
or equity to actual breastfeeding rates for Ohio. This is by
Grubesic and Durbin
Figure 4. Inequities in breastfeeding support resources: Special Supplemental Nutrition Program for Women, Infants, and Children and
income qualifications.
design. We believed it was important to provide a dedicated
forum to the concepts of spatial equity and access for the
breastfeeding community prior to connecting the results to
actual initiation or duration statistics. This will be pursued in
future research efforts.
Conclusion
The results of this study suggest that the spatial access and
equity of breastfeeding support in Ohio are varied. Urban
and suburban areas, especially along the Interstate 71 corri-
dor, display a density and diversity of both clinical and
9
mother-to-mother support resources. Rural and remote areas
of Ohio have fewer options, especially for mother-to-mother
support, but the geographic ubiquity of WIC helps offset
these gaps for rural women who qualify. The results also sug-
gest that women in Appalachian Ohio, including those who
do not qualify for WIC support, could benefit from alternate
interventions and/or strategies for delivering breastfeeding
support and education.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
10
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
References
Allen, J. A., Perrine, C. G., & Scanlon, K. S. (2015). Breastfeeding
supportive hospital practices in the US differ by county urban-
ization level. Journal of Human Lactation, 21(3), 284-288.
Appalachian Regional Commission. (2010). Moving Appalachia
forward. Retrieved from http://www.tinyurl.com/psmoxex
Appalachian Regional Commission. (2015). County economic sta-
tus and distressed areas in Appalachia. Retrieved from http://
tinyurl.com/goks4z9
Arlotti, J. P., Cottrell, B. H., Lee, S. H., & Curtin, J. J. (1998).
Breastfeeding among low-income women with and without
peer support. Journal of Community Health Nursing, 15(3),
163-178.
Baby-Friendly Hospital Initiative. (2017). Retrieved from http://
tinyurl.com/zkqjy3w
Baby-Friendly Hospitals, Ohio. (2016). Designated facilities by
state. Retrieved from http://tinyurl.com/zqov74l
Breastfeeding USA. (2016). Find a counselor. Retrieved from
http://tinyurl.com/zansk8s
Centers for Disease Control and Prevention, National Immunization
Survey. (2016). Breastfeeding among U.S. children born 2002-
2013. Retrieved from http://tinyurl.com/zqkfcrh
Clarkson, R. M., Clarke-Hill, C. M., & Robinson, T. (1996). UK
supermarket location assessment. International Journal of
Retail & Distribution Management, 24(6), 22-33.
Cohen, S., Underwood, L. G., & Gottlieb, B. H. (Eds.). (2000).
Social support measurement and intervention: A guide for
health and social scientists. Oxford, UK: Oxford University
Press.
Dennis, C. L. (2003). Peer support within a health care context:
A concept analysis. International Journal of Nursing Studies,
40(3), 321-332.
Dennis, C., Marsland, D., & Cockett, T. (2002). Central place
practice: Shopping centre attractiveness measures, hinterland
boundaries and the UK retail hierarchy. Journal of Retailing
and Consumer Services, 9(4), 185-199.
Environmental Systems Research Institute. (2016). ArcGIS.
Retrieved from http://tinyurl.com/hla65f5
Ferrarello, D. P. (2012). What is a “Baby-Friendly hospital” and
what does it mean to me? Journal of Human Lactation, 28(3),
419-420.
Flower, K. B., Willoughby, M., Cadigan, R. J., Perrin, E. M., &
Randolph, G. (2008). Understanding breastfeeding initiation
and continuation in rural communities: A combined qualita-
tive/quantitative approach. Maternal and Child Health Journal,
12(3), 402-414.
Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O’Hare,
D., Schanler, R. J., & Eidelman, A. I. (2005). Breastfeeding
and the use of human milk. Pediatrics, 115(2), 496-506.
Genna, C. W. (2016). Supporting sucking skills in breastfeeding
infants. Burlington, MA: Jones & Bartlett Learning.
Gill, S. L. (2009). Breastfeeding by Hispanic women. Journal of
Obstetric, Gynecologic, & Neonatal Nursing, 38(2), 244-252.
Grubesic, T. H., & Durbin, K. M. (2016). Community rates of
breastfeeding initiation: A geospatial analysis of Kentucky.
Journal of Human Lactation, 32(4), 601-610.
Journal of Human Lactation 00(0)
Guagliardo, M. F., Ronzio, C. R., Cheung, I., Chacko, E., & Joseph,
J. G. (2004). Physician accessibility: An urban case study of
pediatric providers. Health & Place, 10(3), 273-283.
Hannula, L., Kaunonen, M., & Tarkka, M. T. (2008). A systematic
review of professional support interventions for breastfeeding.
Journal of Clinical Nursing, 17(9), 1132-1143.
Healthy People 2020. (2016). Maternal, infant, and child health.
Retrieved from http://tinyurl.com/lvf8ane
Hine, J., & Kamruzzaman, M. (2012). Journeys to health services
in Great Britain: An analysis of changing travel patterns 1985–
2006. Health & Place, 18(2), 274-285.
Hofmeyr, G. J., Nikodem, V. C., Wolman, W. L., Chalmers, B.
E., & Kramer, T. (1991). Companionship to modify the clini-
cal birth environment: Effects on progress and perceptions of
labour, and breastfeeding. BJOG: An International Journal of
Obstetrics & Gynaecology, 98(8), 756-764.
Hurley, K. M., Black, M. M., Papas, M. A., & Quigg, A. M. (2008).
Variation in breastfeeding behaviours, perceptions, and experi-
ences by race/ethnicity among a low-income statewide sam-
ple of Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) participants in the United States.
Maternal & Child Nutrition, 4(2), 95-105.
International Lactation Consultant Association. (2016). Find a lac-
tation consultant directory. Retrieved from http://www.ilca.
org/why-ibclc/falc
Johnson, K. (2013). Maternal-infant bonding: A review of litera-
ture. International Journal of Childbirth Education, 28(3), 17-
22.
Jones, K. M., Power, M. L., Queenan, J. T., & Schulkin, J. (2015).
Racial and ethnic disparities in breastfeeding. Breastfeeding
Medicine, 10(4), 186-196.
Khan, A. A. (1992). An integrated approach to measuring potential
spatial access to health care services. Socio-economic Planning
Sciences, 26(4), 275-287.
Klaus, M. (1998). Mother and infant: Early emotional ties.
Pediatrics, 102(Suppl. E1), 1244-1246.
La Leche League International. (2016). Find a meeting. Retrieved
from http://www.llli.org/webus.html
Lee, R. C. (1991). Current approaches to shortage area designation.
The Journal of Rural Health, 7(4), 437-450.
León-Cava, N., Lutter, C., Ross, J., & Martin, L. (2002). Quantifying
the benefits of breastfeeding: A summary of the evidence.
Washington, DC: Pan American Health Organization.
Ludington-Hoe, S. M., McDonald, P. E., & Satyshur, R. (2002).
Breastfeeding in African-American women. Journal of the
National Black Nurses Association, 13(1), 56-64.
Mack, E. A., & Grubesic, T. H. (2014). US broadband policy and
the spatio-temporal evolution of broadband markets. Regional
Science Policy & Practice, 6(3), 291-308.
Morrill, R. L., & Symons, J. (1977). Efficiency and equity aspects
of optimum location. Geographical Analysis, 9(3), 215-225.
Nommsen-Rivers, L. A., Chantry, C. J., Cohen, R. J., & Dewey,
K. G. (2010). Comfort with the idea of formula feeding helps
explain ethnic disparity in breastfeeding intentions among
expectant first-time mothers. Breastfeeding Medicine, 5(1),
25-33.
Ohio Revised Code. (2016a). 3781.55: Breast-feeding in places of
public accommodation. Retrieved from http://codes.ohio.gov/
orc/3781.55
Ohio Revised Code. (2016b). 4112.01: Civil rights commission
definitions. Retrieved from http://codes.ohio.gov/orc/4112.01
Grubesic and Durbin
Renfrew, M. J., McCormick, F. M., Wade, A., Quinn, B., &
Dowswell, T. (2012). Support for healthy breastfeeding moth-
ers with healthy term babies. Cochrane Database of Systematic
Reviews, (5), CD001141.
Riordan, J., & Wambach, K. (2010). Breastfeeding and human lac-
tation. Burlington, MA: Jones & Bartlett Learning.
Rojjanasrirat, W., Nelson, E. L., & Wambach, K. A. (2012). A pilot
study of home-based videoconferencing for breastfeeding sup-
port. Journal of Human Lactation, 28(4), 464-467.
Rooks, J. P. (1997). Midwifery and childbirth in America.
Philadelphia, PA: Temple University Press.
Rosero-Bixby, L. (2004). Spatial access to health care in Costa Rica
and its equity: A GIS-based study. Social Science & Medicine,
58(7), 1271-1284.
Rossman, B. (2007). Breastfeeding peer counselors in the United
States: Helping to build a culture and tradition of breastfeed-
ing. Journal of Midwifery & Women’s Health, 52(6), 631-637.
Ryan, A. S., & Zhou, W. (2006). Lower breastfeeding rates per-
sist among the Special Supplemental Nutrition Program
for Women, Infants, and Children participants, 1978-2003.
Pediatrics, 117(4), 1136-1146.
Schuurman, N., Berube, M., & Crooks, V. A. (2010). Measuring
potential spatial access to primary health care physicians using
a modified gravity model. The Canadian Geographer/Le
Geographe Canadien, 54(1), 29-45.
11
Schuurman, N., Fiedler, R. S., Grzybowski, S. C., & Grund, D.
(2006). Defining rational hospital catchments for non-urban
areas based on travel-time. International Journal of Health
Geographics, 5(1), 43.
Sparks, P. J. (2010). Rural-urban differences in breastfeeding initia-
tion in the United States. Journal of Human Lactation, 26(2),
118-129.
Sparks, P. J. (2011). Racial/ethnic differences in breastfeed-
ing duration among WIC-eligible families. Women’s Health
Issues, 21(5), 374-382.
U.S. Census Bureau. (2014). Income, poverty and health insurance
coverage in the United States: 2014. Retrieved from http://
tinyurl.com/oextcnb
U.S. Census Bureau. (2015a). Ohio quick facts. Retrieved from
http://tinyurl.com/j483ef8
U.S. Census Bureau. (2015b). Selected demographic and socioeco-
nomic data. Retrieved from http://tinyurl.com/kyno38j
U.S. Department of Agriculture. (2015). Ohio WIC program eligi-
bility. Retrieved from http://tinyurl.com/zrk5q34
U.S. Department of Agriculture. (2016). Ohio WIC locations.
Retrieved from http://tinyurl.com/zzyw87j
Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S.,
Krasevec, J., & . . .Rollins, N. C. (2016). Breastfeeding in the
21st century: Epidemiology, mechanisms, and lifelong effect.
The Lancet, 387(10017), 475-490.