Significance

What is already known on this subject? This research expands upon current literature on barriers and facilitators to breastfeeding among AA women by providing insight into how SEM factors influence breastfeeding.

What this study adds? The sharing of unique personal experiences among AA women increases understanding of breastfeeding support needs in this vulnerable target group. In AA womens’ own words, non-judgmental support and education on practical aspects including use of breastpumps are needed in breastfeeding promotion programs.

Introduction

Breastfeeding is recognized as the optimal feeding choice for infants because of numerous associated health benefits (Hauck et al., 2011; Lederman et al., 2004; McDowell et al., 2008). While the majority of US women initiate breastfeeding, significantly fewer continue to breastfeed exclusively for the recommended six months (Asiodu & Flaskerud, 2011; Services, 2011) especially among certain population subgroups. With only 24.9% of infants, in 2015, being exclusively breastfed through 6 months of age, The Healthy People 2030 objectives listed these rates as the baseline and set the target for 42.4% (Promotion, 2021). African American (AA) women are the least likely to initiate breastfeeding, continue to 6 months, or exclusively breastfeed (Reis-Reilly et al., 2018). These trends are in parallel to AAs having the highest rates of maternal and infant mortality and morbidity (Bartick et al., 2017; Johnson et al., 2015; Prevention, 2012). Improving maternal and infant health of AAs remains an important public health goal for the US, and may be achieved in part by targeted breastfeeding promotion and support.

Several factors are known to influence breastfeeding behavior among AAs. In addition to socio-demographics and healthcare, these include intention to breastfeed, attitudes toward infant feeding methods (Kornides & Kitsantas, 2013; Stuebe & Bonuck, 2011), lactation experiences, maternity care practices (Ahluwalia et al., 2012), limited lactation support (Reis-Reilly et al., 2018), breastfeeding self-efficacy (Thulier & Mercer, 2009), social support (Dennis, 2002; Thulier & Mercer, 2009), and non-supportive workplace and childcare environments (Grummer-Strawn & Shealy, 2009). These factors influence breastfeeding outcomes among all women, but have been shown to be higher among AAs. Additional AA-specific breastfeeding factors include cultural influences, attitudes and behaviors, stigma, lack of social support, and inconvenience, pain, and sexuality beliefs (Ramos, 2012; Reis-Reilly et al., 2018). Spencer and Grassley (2013) further identified several factors that appear to have a negative impact on breastfeeding from an integrative literature review pertaining to AA womens’ breastfeeding decisions and practices. Factors included: early return to work, short maternity leave, insufficient information about breastfeeding from healthcare providers, limited access to professional support, embarrassment with breastfeeding, and perceptions around poor milk supply.

Quantitative studies have identified factors known to influence breastfeeding in the AA population; however, qualitative studies that expand upon these findings by providing recommendations through the voices of AA merican women are limited. Their experiential knowledge and lived experiences are important considerations for professionals who want to enhance breastfeeding outcomes.

The Socio-Ecological Model (SEM) proposes a theoretical perspective for understanding the relationships and underpinnings involved with breastfeeding behavior (Sallis et al., 2008; Tiedje et al., 2002). We used the SEM as our theoretical framework for understanding group level factors that either hinder or support mothers in their ability to breastfeed within the integrated context of intrapersonal characteristics, interpersonal processes, institutional factors, community factors and public policy. Instead of focusing on the mother as the sole person responsible for infant feeding decisions, we recognized breastfeeding as a multifaceted SEM experience (Bueno-Gutierrez & Chantry, 2015).

The objectives of this qualitative study were to (1) gain insight into unique experiences and factors relative to social support and self-efficacy, which influence breastfeeding goals and behavior (duration and exclusivity) among AA women; and (2) identify new ideas or knowledge that can assist in breastfeeding support and success among AA women who want to breastfeed.

Methods

The study, approved by Michigan State University’s human research protection program, met ethical standards. This was part of a larger Randomized, controlled trial (RCT) designed to increase breastfeeding duration and decrease postpartum weight retention (R21HD085138-02, Mama Bear Feasibility Trial). For more information, this RCT was registered with ClinicalTrials.gov on 3/27/2018 (Identifier NCT03480048). We tested the feasibility and acceptability of one to one randomization for a combined breastfeeding support and weight management program. We did not assess the process of intervention, results are limited to follow up.

Sample and Recruitment

After the Mama Bear study (n = 54) ended at 20 weeks postpartum, we used convenience sampling to invite Mama Bear participants/AA women (n = 13) who were receiving medical care from a large health system in Detroit, MI, to participate in individual semi-structured qualitative interviews. Women were from recruited from both the control and intervention arm of the study. Informed verbal consent was obtained, prior to inclusion in study. Inclusion criteria included self-identification as African American. All participants were offered the option to conduct the interview by phone, video, or in person to allow flexibility and comfort. An estimated 15–20 participants were sought, based on a previous qualitative study that used semi-structured interviews (n = 17) to determine how AA women experience breastfeeding in the context of their daily lives (Spencer et al., 2015). Recruitment continued until data saturation was reached (Corbin & Strauss, 2008).

Data Collection Procedures

Interview questions were developed with SEM as the conceptual framework. Questions embodied aspects of breastfeeding social support and self-efficacy, specifically representing factors that influence breastfeeding and strategies needed to assist in improving breastfeeding outcomes. Two key informants, who worked with Mama Bear participants and AA women in the community, helped shape the relevance of questions included. Four researchers with experience in qualitative research design confirmed face validity of the questions. A one-on-one (in-person, phone or video-conference) semi-structured format was chosen to provide a more flexible conversational approach, allowing the primary researcher to establish trust with participants and elicit richer input. The Primary Investigator (PI) conducted all interviews which were between 30 and 60 min, documented via audio recordings and hand notes, and were followed with a debriefing to allow clarification and/or correction of any misunderstanding. Digital recordings were transcribed verbatim and to ensure accuracy and transcriptions were reviewed in conjunction with field notes. All digital and document files were stored on encrypted and password protected university sites.

Analysis

Theortectical (deductive) Thematic Analysis occurred utilizing six steps as described by Braun and Clark (2018). Although, thematic analysis does not require having a theoretical framework our study questions were developed with the Social Ecological Model as a conceptual framework. The PI developed coding frameowrk that aligned with the interview guide and the study’s objective. The main themes were: (1) Challenges with meeting breastfeeding goals; (2) Successes with meeting breastfeeding goals; and (3) Suggestions for Expanding Breastfeeding Support/Promotion among African American Women. For the codebook, the PI included definitions of the codes and examples of how they should be applied. The PI and author (DK) read transcripts independently and separately generated initial codes. After each coding of the transcript we held a meeting to discuss the codes, their application, and to ensure agreement. Each reviewer generated potential themes based on an initial coding schema and highlighted exemplar quotes. We also inductively identified additional codes that arose as themes from the transcripts themselves. The results were compared, and where necessary themes were combined to form an overarching theme, collapsed, or eliminated. Coding and collating was done using a combination of NVivo 12, a qualitative analysis software, and manually. Descriptive statistics were generated using Microsoft Excel 2016.

Results

Table 1 displays the characteristics of participants (n = 13) [Display Table 1]. Most were 25–34 y, multiparous, and single (69% for all). Over half (54%) had stopped breastfeeding and/or pumping at time of interview (range 12–16 months postpartum). All women described breastfeeding as being enjoyable and memorable using multiple phrases which included terms of mother and infant bonding, feelings of closeness, and eye contact. Many women remembered the initial latch of their infant. These shared moments seemed to enhance the breastfeeding experience.

Table 1 Demographic characteristics of African American participants (N = 13)
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The three overarching thematic categories for data alignment were challenges to and successes for meeting various breastfeeding goals and suggestions for expanding breastfeeding support and promotion for AA women. These are presented with subthemes and associated quotes in Tables 2, 3 and 4, respectively [Display Table 2, 3, 4].

Table 2 Challenges with not meeting breastfeeding goals
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Table 3 Successes with meeting breastfeeding goals
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Table 4 Suggestions for expanding breastfeeding support and promotion among African American women
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Challenges with not Meeting Breastfeeding Goals

  1. 1.

    Waning Confidence with Breastfeeding:

All participants described some level of “losing confidence.” Some participants lost initial confidence when they experienced breastfeeding issues that remained unresolved despite attempts for help that led to feelings of discouragement that influenced their decision to terminate breastfeeding. Associated breastfeeding issues voiced by women included concerns about infant’s weight gain, adequacy of nutritional intake, conflicts with work accommodations, inability to meet pumping schedule, and adequate milk supply.

  1. 2.

    Discouragement from Issues Associated with Breastfeeding:

While breastfeeding was new for several women and something they wanted to do for the health benefits, some participants described experiencing specific breastfeeding issues which they could not overcome that led to them giving up. The most common challenges described by participants, also mentioned above, were uncertainty about whether their infant was getting enough, latching, pumping, lack of comfort with breastfeeding in public (family and others), and work constraints.

Success with Meeting Breastfeeding Goals

  1. 1.

    Dual Benefit for Infant and Mother:

Participants described the decision to exclusively breastfeed their infant as primarily due to receiving education and understanding general benefits for both mother and infant. Most mothers mentioned receiving this information from their healthcare providers, which included but was not limited to their physician, midwife, and Women Infants and Children (WIC) counselor.

  1. 2.

    Increased Confidence After Positive Experiences:

Some women who said that they lacked confidence early on showed an increase/boost in their confidence as they experienced indicators that breastfeeding was “going right” and the infant was doing well.

  1. 3.

    Perseverance, Commitment, and Self-Motivation:

Participants consistently expressed their awareness around the importance of breastfeeding and also described perseverance with breastfeeding despite experiencing some challenges. Many participants described self-determination in making the commitment to at least initiate breastfeeding and trying to be successful. Self-motivation was noted as a subtheme that helped many mothers continue breastfeeding. Participants described instances in which they were building up their “own confidence” and expressed moments where they provided themselves with their own positive affirmations.

Ability and Success with Pumping:

The ability to pump was mentioned several times as an important component of meeting breastfeeding goals. This was especially important both with regard to going back to work and at home when their milk supply was perceived to be over and above the infant’s needs.

  1. 4.

    Encouragement, Help and Support from Social Support Networks:

Outside encouragement/support from support networks was identified for meeting breastfeeding goals. Some women sought out help and asked questions from known social support sources including their peers who were breastfeeding. Women indicated that they sought and received the right amount of support from their support systems within the community. People/organizations most often mentioned were WIC, Mama Bear research study counselor, social worker, and online resources (mother blogs). Most of the help women described was emotional (encouragement and positive affirmations/reinforcement) and informational support (tips, advice). Participants utilized and appreciated community programs that provided items for their infant. However, very few participants mentioned receiving hands-on breastfeeding technical help while in the hospital and at home. Many participants were very positive and encouraged to breastfeed while receiveing some level of support, which enhanced their breastfeeding experience.

Suggestions for Expanding Breastfeeding Support/Promotion among African American Women

  1. 1.

    Tangible, Immediate, Proactive Support:

Study participants were asked about the type of help that would be beneficial to encourage AA women to undertake and continue breastfeeding. Women mentioned the importance of knowing the health and infant bonding value of breastfeeding. They expressed a need for readily available and tangible assistance from healthcare professionals. Acknowledging their issues with breastfeeding at various times throughout their experience women felt that it would be beneficial to have a knowledgeable person readily available to communicate with to help in identifying and resolving breastfeeding issues before they become problems.

  • 2.Positive Non-Judgmental Support (Professional and Personal):

Regarding breastfeeding promotion, participants described the need for AA women to receive positive, non-judgmental support from all people within their social support network, including family members and reinforcement from health care professionals. Many participants mentioned that they were willing to accept encouragement from nearly anyone. Participants said they needed to feel comfortable with expressing challenges authentically. They specifically described the need for breastfeeding to be normalized for women in order for them to feel comfortable not only asking questions, but also feeling comfortable with breastfeeding in public or at work and to receive more encouragement around this health promoting practice.

  1. 3.

    Understanding About “Milk Supply” and “Use of Pump”:

Having readily available and accessible information and support from health care professionals with expertise in breastfeeding, especially when a mother new to breastfeeding needs help or has questions was important to participants. The majority of participants mentioned that education should be available preconception, prenatally, and postpartum. The participants also described the need to have lessons and a good understanding focused on healthy eating while breastfeeding. Many participants expressed uncertainty and clarified a need for education about perceived fluctuations in their milk supply, which could be measured if comfortable with using the pump. They did not connect, however, the possibility of one influencing the other. While particpants mentioned pumping often, they lacked an understanding about how and when to use the pump.

  1. 4.

    Self-Motivation, Willpower, Perseverance:

Many women described the need for AA women to have the inherent “willpower” to breastfeed, which they felt would limit or reduce feeling discouraged. Many women acknowledged their own challenges with breastfeeding but described the importance of not giving up dispite difficulties. They also described the self-gratification perceived from completing what they sought out to do.

Discussion

This less common, person-focused experiential approach to capture the voices of AA women helps to elucidate their perspectives on challenges and facilitators of breastfeeding. Further, this research reveals womens’ recommendations on how challenges to breastfeeding can be addressed, including key factors of addressing waning breastfeeding confidence, breastfeeding-related discouragement issues, and boosting mother and infant benefits, perseverance/commitment/self-motivation, pumping strategies, and social support.

Despite complex factors within different levels of the SEM either reinforcing or discouraging breastfeeding initiation and maintenance among AA women that contribute to disparities (Jones et al., 2015), at the individual level, participants consistently expressed their own awareness surrounding the importance of breastfeeding. Contrary to what some may think, many were knowledgeable about breastfeeding benefits for both them and their infants. Self-motivation, self-determination and commitment, named as common factors for successful breastfeeding experiences (Spencer et al., 2015), were also mentioned by participants as influential for initiation and continued breastfeeding. Named challenges are consistent with barriers that have been reported as impeding AA women from breastfeeding (Services, 2011). While many participants wanted to continue breastfeeding, some challenges were especially discouraging, and resulted in waning confidence and intentions over time.

Key recommendations based on study findings include tangible, immediate, and proactive help, positive non-judgmental support, “milk supply” and “use of pump” education, and methods to build self-motivation/willpower/perseverance.

Suggestions to Facilitate Breastfeeding

Participant suggestions for facilitating and improving breastfeeding outcomes within the SEM framework indicated that the inner sphere encourages AA women to recognize and utilize their own willpower and promotes self-determination. For the middle and outer spheres, factors identified included tangible, immediate, and proactive help, positive, non-judgmental support, and education about their milk supply and use of the pump. Therefore AA womens’ responses were centered on encompassing multiple levels of the SEM, consistent with the study by Tiedje et al. (2002), where authors suggested that breastfeeding promotion should occur at several levels reflective of the SEM.

At the intrapersonal level, a theme emerged on willpower and self-determination as two important factors needed for reinforcing breastfeeding. Noted as an important attribute of AA women, the willpower and determination to breastfeed was consistent among the participants. External community was also influential in impeding breastfeeding, similar to other studies (Dattilo et al., 2020; Johnson et al., 2015). Participants mentioned the need for support to be normalizing, genuine and positive, to help make them feel comfortable not only with the act of breastfeeding, but also with asking questions and participating in open discussions centered around breastfeeding. At the community level participants consistently mentioned that assistance in the form of education, resources, or actual technical help should be readily accessible and available. Research confirms these suggestions that mothers need continuity in care using a multi systems approach to address social and personal barriers to breastfeeding (Gross et al., 2017; Johnson et al., 2015; Parker et al., 2018).

Tailoring Breastfeeding Education

Overall, study participants were very knowledgeable and had been provided with some form of education around the benefits of breastfeeding. The key sources of information consistently mentioned by participants were WIC, lactation consultants, physicians, and breastfeeding groups. However, many participants were unsure of how to handle “technical issues” associated with breastfeeding. Breastfeeding education is best accepted when tailored to the individual and her stage of breastfeeding knowledge (Schapira et al., 2017). While women should be educated on the benefits of breastfeeding, our resuls indicated the need for more topical education on breastfeeding. A systematic review by Dattilo et al. (2020) indicated that parents desire individualized instruction regarding infant feeding, but expectations often are not met and many express mistrust with education and feeding recommendations.

With the widespread availability of portable, personal, electric breast pumps because of the mandate in the Affordable Care Act (Gurley-Calvez et al., 2018; Hawkins et al., 2015), the practice of pumping frequently or exclusively has grown, increasing unanticipated related problems for some. Participants that were pumping also complained about a fluctuation or decrease in milk supply, not recognizing that pumping may be associated with milk supply. Some women lacked information about how and when to correctly use the pump (Eglash & Malloy, 2015). Education was also needed about the fluctuation in the volume of milk supply between each breast and between feedings (Daly et al., 1992; Kent et al., 2006).

To handle all breastfeeding issues women should: (1) know who to contact, (2) feel comfortable with contacting, and (3) have confidence in knowing that someone is readily available. The American College of Obstetricians and Gynecologists (ACOG) recommended that obstetric care providers should develop and maintain skills for supporting normal breastfeeding physiology and management of common complications of lactation during later stages of pregnancy and postpartum period so AA and other women can better conceptualize how it can fit into their daily lives (Breastfeeding et al., 2016).

Mode of Breastfeeding Support

In the face of challenges reported, many participants mentioned receiving encouragement and support from their interpersonal networks and described the importance for their breastfeeding success journey. Having social support from all people identified within their social network was important to the women, and they emphasized the strong role fathers played in facilitating breastfeeding, which has been consistently documented (Arora et al., 2000; Raj & Plichta, 1998; Services, 2011). Among AA, from a cultural perspective, fathers may not always be as actively engaged in breastfeeding support (Sihota et al., 2019).

Many participants mentioned receiving some form of “help” from healthcare providers, but many expressed the wish that they had more “hands on” or tangible help and more options to access help from healthcare providers, who focus on breastfeeding to help them through challenges experienced. This finding is similar to previous research suggesting that offering complementary support in addition to standard care can aid in continued breastfeeding (Sikorski et al., 2003).

The women were aware of sources of support at the community level with WIC being a primary mention. However, help and assistance provided from WIC varied based on location. Since the federal mandate in 1991, WIC has been known for providing breastfeeding support to mothers, but participants often noted that they received technical information, and not ‘hands on” assistance. While WIC programs assist women who want to breastfeed, it becomes important to ensure that the form of support provided (tangible, emotional, or informational) is consistent across all locations. Based on these findings, it may be important to consider assessing breastfeeding support provided across WIC locations within the state or region and determine/set clear standard guidelines for the “type” of breastfeeding support WIC participants should receive in conjunction with measurable meaningful outcomes, especially for groups such as AA women who are not meeting current guidelines.

A systematic review of support for breastfeeding mothers by Sikorski and colleagues (2003), suggested that different modes and timing of support makes a significant difference in breastfeeding outcomes. Specifically, meeting face-to-face showed a significant benefit in continued breastfeeding compared to advice received over the phone. Our participants reinforced that this mode of support/ assistance is preferred, and might hence be more effective among AA.

Multifaceted Support

Participant interviews confirmed that support should be multi-faceted. When asked about breastfeeding support, women discussed the importance of having support in all aspects of their lives (e.g., caring for children, transportation, money for groceries, time to rest). Many expressed the importance of receiving support and/or encouragement from those identified within their social support networks (significant other, parents, sibling(s), friends, work), which has been consistently identified as being a factor to assist in enhancing breastfeeding (Raj & Plichta, 1998; Sikorski et al., 2003).

Strengths and Limitations

Strengths of our study include diverse socioeconomic backgrounds of participants, providing a range of perspectives. Additionally, only four of the women interviewed were first time mothers, offering variety in perspectives based on past experiences. Our process of interviewing key informants who had familiarity and experience with the specific population (community health worker and breastfeeding peer counselor) was also a strength. Limitations of this work include targeting those who had intended to breastfeed and were willing to enroll in a RCT focused on breastfeeding support which might have increased the likelihood of biased responses. Another limitation was including women from the intervention group in the Mama Bear study, which these women identified MAMA Bear as an additional form of support and may also increase the likelihood of biased responses. Further work is warranted to gain insight from women who were not intending to breastfeed from the outset. Moreover, allowing flexibility for participants to respond by phone (instead of in person) may have led to distractions inhibiting them from fully participating and/or being explicit in their answers if they were not alone.

Conclusion for Practice

The perceived barriers and facilitators identified within our study are supported by the literature. Our study is unique in that no other published work has included suggestions from AA mothers for breastfeeding promotion in an effort to overcome barriers to successfully reach breastfeeding goals. The social ecological framework provides a useful context for discussions around factors enabling or inhibiting breastfeeding within the AA community at multiple levels. AA women from all socioeconomic backgrounds can successfully breastfeed if provided an equitable amount of mutifaceted breastfeeding support that helps or enhances their breastfeeding self-efficacy. Women interviewed within this study experienced gaps in overall breastfeeding support that inhibited breastfeeding continuity. Breastfeeding rates within the AA community will improve by employing multiple approaches to shift cultural norms and support structures at all levels. Findings described here, in AA womens’ own words, provide helpful insights for further discussion, intervention, and advocacy around increasing equity for breastfeeding among AA women.