The women who participated in this study are comparable in terms of age and marital status to a larger group of over 4,000 Quebec women who gave birth in 2005 . However, they appear to be more educated than Quebec mothers on average, with 55% holding university degrees compared to 35% at the provincial level. Family income was also higher, with 70% having a family income exceeding $50,000 compared to 47% for Quebec households in general .
The major breastfeeding difficulties experienced by women, such as breast and nipple pain, low milk supply, latching problems, and so on, were similar to those mentioned in a study conducted in the Greater Quebec City area in the late 1990s . In addition, in our study, the reasons for ceasing breastfeeding coincided with the difficulties experienced by other women. These reasons, along with the others mentioned (return to work or school, infant health problems), are comparable to the ones found in other studies in Canada , the province of Quebec [39, 40], and the Greater Quebec City area .
Intentions and attitudes regarding breastfeeding appear to be significant factors influencing the experience. In fact, firm intentions to breastfeed gave women the motivation they needed to face difficulties. According to different studies, prenatal breastfeeding intention is an important determinant of both breastfeeding initiation and duration [33, 41–44]. The moment the decision is made, intentions regarding duration seem to be linked with breastfeeding duration [41–43]. Positive attitudes toward breastfeeding have also been associated with the initiation and longer duration of breastfeeding [33, 41]. Moreover, these elements correspond to certain concepts from our conceptual framework (Figure 1), which holds that attitudes toward a behavior are predictive of intentions to adopt the behavior, and that those intentions are in turn predictive of actual adoption, i.e., breastfeeding continuation. In addition, determination and perseverance to overcome breastfeeding challenges and difficulties are other notions that have been addressed in other studies .
With the exception of the clinicians at the breastfeeding clinic, the sources of social support mentioned by women in this study were similar to those mentioned by women in other studies included in a meta-analysis of qualitative studies  and by women in the Greater Quebec City area . These sources include partners, nurses from local community services centers, mothers, friends and hospital nurses. Moreover, a study conducted in the province of Quebec found that women's entourages influenced their decision to breastfeed, and that women generally perceived their entourage as being in favor of breastfeeding . In addition, informal sources of support (partner, family, friends, peers) and formal sources (lactation consultants, nurses, physicians) have been shown to affect both initiation and continuation of breastfeeding [39, 41, 46].
Unfortunately, as mentioned by some participants in this study, health care professionals can sometimes be a negative influence when they provide women with inconsistent, inaccurate, inadequate, or conflicting breastfeeding information and recommendations [41, 45, 47–49]. It is therefore important to ensure that health professionals are properly trained with respect to breastfeeding and that women have access to optimal services consistent with the Baby Friendly Hospital Initiative and with The Baby Friendly Initiative in the Community recommendations [50, 51].
Sources of social support and the way they influence the breastfeeding experience are analogous with some of the items of the conceptual framework (Figure 1). In fact, positive support from family and health professionals is similar to the perceived subjective norm influencing intentions to initiate and continue breastfeeding. Advice and interventions provided by a woman's entourage and by health professionals, as well as help with housework, are other facilitating factors, while encouragement and reassurance are reinforcing factors.
The influence of social pressure on the breastfeeding experience was alluded to by three women. In other studies, women have reported feeling pressure both to start and continue breastfeeding against their own wishes . In a qualitative study conducted in England, women also described feeling unprepared for the realities of breastfeeding and said they would have liked to have had more information about the possible inconveniences . Greiner considers that priority should be given to protective and supportive strategies for breastfeeding, rather than to promotion strategies. In fact, he notes that in general, "protective programs put pressure on government and industry, supportive strategies put pressure on the health care system, on networks of women and on employers, while promotion strategies [. . .] can [not easily] avoid putting pressure directly on women themselves" . Because of this, some women in our study may have felt obligated to breastfeed and hesitated to stop. In addition, some women felt guilty for stopping breastfeeding sooner than they planned and perceived this cessation as a failure, as was the case elsewhere . Similarly, an Australian qualitative study found that women may feel confusion, self-doubt and guilt when confronted with incompatible expectations between themselves and other people .
Satisfaction rates for the Quebec City Breastfeeding Clinic indicate that over 80% of women in our study were satisfied or highly satisfied with the clinic's staff and services and felt it had helped them increase their satisfaction with their breastfeeding experience. The high satisfaction rates were similar to those recorded for women attending other breastfeeding clinics. At one Canadian breastfeeding clinic in Ontario, over 90% of the 164 respondents reported satisfaction ratings of good or excellent . The clinic helped them feel more confident and positive with regards to their breastfeeding experience, enhance their knowledge of breastfeeding, and prevent or overcome difficulties. Over 70% of the respondents also believed that the clinic had helped them to breastfeed for a longer period . At another Canadian breastfeeding clinic in Saskatchewan, 100% of the 43 respondents were satisfied with the interpersonal aspects of the center and over 90% with the information and support they received. Respondents attributed their satisfaction to the advice given, the participative approach, the quality of information provided, the support, encouragement and reassurance received, and the knowledgeable staff . Similarly, mothers using a breastfeeding clinic in British Columbia, Canada, gave the facility an average rating of 8.7 out of 10 (10 = extremely satisfied) . In an Australian clinic, satisfaction survey showed that most respondents were satisfied with the clinic and felt that the service quality was better than expected . They also responded the staff were professional and knowledgeable in their field of work .
A considerable number of women also said that the Quebec City Clinic allowed them to reach or surpass their breastfeeding objectives. They gave the same reasons as those mentioned in other studies [10, 11, 13–15] to explain the influence of the clinic on the breastfeeding experience, namely, the identification of problems, the solutions found, and the encouragement and reassurance received.
However, it is important to point out that the Quebec City Breastfeeding Clinic does not operate entirely the same way as the majority of the other clinics studied. For example, these clinics employ IBCLC and nurses [10, 11, 14] or midwives [13, 15] while the Quebec City Clinic employs IBCLC and physicians. Also, at the other clinics [10, 11, 15], women are free to use the services as they wish, while at the Quebec City clinic, women are referred by field workers. Although there are other clinics in Canada that operate in similar ways to the one in Quebec, no scientific papers on their services have been published yet.
One limitation of this study is the small number of participants. Indeed, the number of semi-structured interviews conducted did not allow us to reach content saturation. Another possible limitation is the voluntary interview participation, which may have biased the results in a positive way. The telephone questionnaire and semi-structured interviews used for the study are both retrospective tools that relied on participants' memories. Participants may have forgotten information, which could have biased the results. Furthermore, the two research tools were tested, but not validated.
More research is needed to better understand the breastfeeding experience of women grappling with major difficulties and to better understand why some are able to overcome these difficulties while others are not. It would also be relevant to study how social pressure may positively and/or negatively affect the breastfeeding experience. In addition, more qualitative and quantitative research is needed on women's experience at breastfeeding clinics throughout Canada and in other industrialized countries to better understand the influence of these clinics on breastfeeding issues such as duration and satisfaction.