Breastfeeding Social Support Among African American Women in the United States

A Meta-Ethnography

Abstract

Background: 

In the United States, there are racial disparities in 6 months of exclusive breastfeeding. Only, 25.8% of American infants were breastfed for the first 180 days of life, with African American infants least (19.8%) exclusively breastfed in 2018.

Purpose: 

The meta-ethnography explored the breastfeeding support for African American women in the United States.

Data Sources: 

The online databases of American Psychological Association, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Scopus were searched with key words, and the search was not limited by the year of publication.

Study Selection: 

The inclusion criteria for the study selection entailed all qualitative studies conducted on breastfeeding support among self-identified African American women in the United States, written in English language, peer reviewed, or dissertation. The initial search produced 905 articles of which 8 met the eligibility criteria.

Data Extraction: 

Data extraction and analysis were guided by Noblit and Hare's (1988) meta-ethnography approach. The analysis process was completed by a team of researchers, inclusive of breastfeeding experts.

Results: 

Five overarching themes emerged including trustworthy information; early postpartum support by key influencers; maternal culture; tangible resources, and Black mothers' empowerment.

Implications for Practice and Research: 

Social support is a major determinant for the initiation and continuation of breastfeeding among African American women in the United States. Future longitudinal studies are warranted to explore the social support of breastfeeding among African American women in the United States.

Only 44% of infants in the world and 25.8% of infants in the United States are breastfed exclusively for the first 6 months of life.^1,2 Breastfeeding (BF) benefits transcend health benefits for infants and women to economic savings for the world.³ For instance, global gross expenditure of $341.3 billion and $114.97 billion in the North America region is saved beside decreased risks for health conditions such as postpartum depression, diabetes, breast and ovarian cancers in women, and physiological jaundice, diarrhea, allergies, and obesity in infants.^4,5

There is racial disparity in BF in the United States, and African American (AA) infants are least likely to be exclusively breastfed (19.8%) at 6 months.¹ African American women report the need for support during the postnatal period to meet and sustain BF goals despite robust collaborative initiatives such as “The Healthy People 2030” campaign and the implementation of the ecological model.^6–9 The ecological model of BF recognizes the significance of support in maternal BF efforts. The rigorous adherence to the aforementioned initiatives acts as pacesetters in addressing the systemic racism in BF.

Pregnant AA women in the United States, like many women, usually make their BF decisions in consultation with their family and peers based on several socioeconomic, health, political, cultural, and religious factors.^8–10 For instance, partners (fathers) who obtained increased knowledge in lactation during an experimental study showed readiness to support maternal BF efforts.⁹ In a related study,¹⁰ most mothers (71%) reported the need for improvement in prenatal education and reinforcement of BF exclusivity through outpatient services.¹⁰ Furthermore, the implementation of outpatient services such as the Communities and Hospitals Advancing Maternity Practices (CHAMPS) initiative from 2014 to 2017 for AA women led to improvement in BF.¹¹

In addition, all women benefit from a collaboration between a local health facility and the community they live in to support BF.^12–14 African American women also benefit from collaboration that is sensitivity to their community and maternal culture to be an effective model to promote BF. For instance, during the CHAMPS longitudinal study set in the Southern United States, hospitals collaborated with communities to initiate advanced maternity practice for BF, which increased BF initiation and exclusivity among AA infants, from 46% to 63% (P < .05) and from 19% to 31% (P < .05), respectively.¹¹ Moreover, 39% of AA women who received BF knowledge from peers breastfed the infants for more than 6 months.¹⁵ Some of such women actively participate in online support groups for BF AA women.¹⁶

Yet, even with increased BF intention, all women face barriers with BF. For first time, BF AA women in the study by Kim et al¹⁷ reported that BF is a biological process that should be completed with ease. Participants obtained high scores for their BF attitude (70) and self-efficacy (62) using the Iowa Infant Feeding Attitude Scale and BF Self-Efficacy Scale—Short Form, respectively. However, their BF efforts were thwarted by prevalent systemic racism and discrimination from hospitals, schools, workplaces, and communities.^17–21

Therefore, the purpose of this meta-ethnography was to synthesize the qualitative literature on the BF social support of AA women in the United States. Study findings may help improve BF duration and exclusivity practice among AA women and other women globally.

METHODS

Design

We conducted a meta-ethnography, which is a form of meta-synthesis.^22,23 The Noblit and Hare²² meta-ethnography approach was used to synthesize various forms of cross-disciplinary qualitative studies on social support of BF among AA. All studies were analyzed to yield different interpretations and conceptualizations after iterative comparisons and integration.²³

Data Collection: Meta-Ethnography Article Selection Process

Online databases of American Psychological Association, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Scopus were searched with key words. The key words used were breastfeeding, BF, lactation, AA, Black, support, assistance, qualitative, and help. The inclusion criteria for the study selection entailed all qualitative studies conducted on BF support among self-identified AA women in the United States irrespective of the year of publication, written in English language, full text, peer reviewed, or dissertation. Exclusion criteria were all quantitative research and other qualitative studies on BF among AA. Initially, 905 reports were retrieved, after removing duplicates and screening the titles and abstracts, 69 full-text records were screened for eligibility, 61 records were excluded with reason, and 8 full-text peer-reviewed articles remained for the meta-ethnography (Figure 1).

FIGURE 1: PRISMA flowchart for identification of studies via databases for the meta-ethnography.

Data Analysis

The Noblit and Hare²² 7-phase meta-ethnography method was used. A meta-ethnography combines the findings of multiple qualitative studies to create a figurative meaning of the identified themes resulting in a new understanding of AA women's BF experiences. An ethnographical approach aids description of cultures and norms of a defined population. The first phase of the meta-ethnography marked the commencement of the research process. The meta-ethnographers identified an area of interest following the review of the literature of diverse types of qualitative studies. In the second phase, the researchers decided on which of the reviewed qualitative data sources were of relevance to the initial interest for the meta-ethnography. The third phase involved an iterative reading of the various qualitative studies to identify the key metaphors, themes, or concepts. Such metaphors were a word or a phrase. Afterward, the meta-ethnographers proceeded to the fourth phase where a determination was made about how the studies were related. A list was made to compare the key themes, metaphors, or concepts previously identified for each qualitative study. The identified key themes, metaphors, or concepts were related as reciprocal, directly comparable, and not refutational opposition to each other or in lines of argument. In phase 5, the studies were translated into one another (ie, the concepts, metaphors, and themes were compared with those in other studies; the concepts, metaphors, and themes of each study in their relation to other metaphors or concepts in the same study and with other studies in the meta-ethnography). During the sixth phase, the translations were synthesized to make a whole from the individual parts. The final phase focused on expression of the synthesis as a document and dissemination.

RESULTS

Sample Characteristics

The studies were conducted between 2010 and 2020. Study participants were sampled conveniently, purposefully, or through snowball techniques. The qualitative designs used were descriptive qualitative design (5), grounded theory (2), and ethnography (1). Data were collected through interviews, field observations, surveys, and focused group discussions. Thematic analysis was the choice of data analysis for all the studies. The study participants in the articles were self-identified AA women mostly from Southeast Michigan, Illinois, and Southern United States. A total sample size of 156 women from the 8 studies had a history of BF (direct BF and/or pumping). Participants were currently BF the infants, pregnant, or support persons (grandmother or healthcare professional) aged 18 to 61 years. Most of the study participants received some form of BF support. Data on employment were not specified except for 16 women who mentioned their work status. In terms of marital status, there were nearly equal scores between married/partner (71) and single (77) (Table 1).

TABLE 1. - Demographic Characteristics of Participants of the Individual Studies Included in the Meta-Ethnography

Study	Sample Size	State	Age Range, y	Support Person	Employed	Marital Status	N
Kim et al17 (2017)	Breastfeeding mothers: 15	Illinois	18-24	Yes	Not specified	Married/partner Single	12 3
Johnson et al24 (2016)	Pregnant women: 8 Lactating mothers: 21 Lactation support providers: 9	Southeast Michigan	22-44	Yes	Not specified	Married/partner Single N/A	4 25 9
Lutenbacher et al25 (2016)	16 women (3 pregnant, 3 breastfeeding)	Not specified	21-46	Not specified	9	Married	>50%
Peritore26 (2016)	Mother group (16) Grandmother (12)	Not specified	18-36 41-61	Not specified	Not specified	Married/partner Single Married/partner Single	11 5 2 10
Johnson et al27 (2015)	Same as for Johnson et al (2016)24	Southeast Michigan	22-44	Yes	Not specified	Married/partner Single N/A	4 25 9
Lewallen and Street28 (2010)	Mother who breastfeed:15	Southern United States	18-38	Yes	Not specified	Not specified
Asiodu et al (2017)29	Pregnant women:14 Support persons: 8	Northern California	21-36	Yes	7	Married/partner N/A	11 11
Robinson et al (2019)30	22	Not specified	26-34	Not specified	Not specified	Married/partner Single/separated	13 9

Abbreviation: N/A, not applicable.

Identification of Themes

All the selected studies were reiteratively read, and a detailed table of metaphors and concepts was constructed from each of the 8 articles, which revealed that the meta-ethnography followed a reciprocal translation path. In following the reciprocal translation process as outlined by Noblit and Hare's steps,²² each study's metaphor was reciprocally translated into one another. Subsequently, the translations were synthesized into a whole, representative of the various study metaphors. Five overarching themes evolved.

The 5 themes reflected the perspectives of AA women in the United States on social support in BF, namely, trustworthy information, early postpartum support by key influencers, maternal culture, tangible resources, and black mothers' empowerment (see Supplemental Digital Content Table 1, available at: https://links.lww.com/ANC/A159). (1) The first theme, trustworthy information, emerged from the evidence in each of the articles that the mothers needed and wanted timely and accurate BF information from sources and stakeholders they could trust. (2) Early postpartum support by key influencers as a theme came about because of the consistent reference to reliance on key persons, identified as partners, grandmothers, health professionals, and peers. Early postpartum support covered all forms of support needed by new mothers during the first 2 weeks of puerperium to ensure maternal success at BF. An identified support person was viewed as key to the successful initiation and continuation of BF. (3) Maternal culture refers to the knowledge and beliefs a woman has about BF that she has gleaned from her background and lived experiences. This was identified as a theme because of the reported positive and negative effects a mother's cultural norms, residential environment, household arrangements, and BF role models had on BF decisions and habits. (4) Throughout the articles, there were references to a variety of resources that supported the women. The theme, tangible resources, refers to the maternal needs for material and financial resources such as free access to lactation consultants and doulas, BF pumps and storage, daycare, and paid maternity leave to support BF efforts. (5) Black women's empowerment describes the reported emotional support women gained through interaction with peers who were Black mothers and breastfed their infants.

The AA women varied in the experience of the BF social support perspectives. Some women experienced one or more at specific periods. A more detailed exploration of the 5 themes based on the meta-ethnography of the 8 qualitative studies is shared in the remaining part of this section.

Trustworthy Information

Maternal need for BF information ran across all the studies. Women stressed the need for such information to be trustworthy. The importance of accurate and evidence-based BF educational support was identified in 7 of the studies. Two studies indicated the need for the formalization of BF educational needs.^17,25 Such knowledge was to be reaffirmed throughout the pre- and postnatal periods to meet women's unique needs.^24,29

A woman suggested the period for BF information sessions in the study by Johnson et al²⁴:

I think that if the doctor could give out information, or have someone in their practice that can go ahead and talk to those women who are kind of on the fence about whether or not they are gonna breast or bottle feed. If, you know, they could do that, I think that would help, ....^(p671)

Topics for education were to focus on BF benefits, complications, how to latch the infant to the breast, use of breast pumps, and the correction of BF myths and misconceptions. Learning sessions had to be simple and concise to meet the learning needs of the attendants. For instance, in the study by Johnson et al,²⁷ a woman expressed the need for understanding from lactation classes:

You ... be available day and evenings ... make sure that education is real. Not so much textbook ... and on a daily basis. So they can grasp it and understand it ... not just professional.^(p430)

Persons to be engaged in the learning sessions were to include pregnant women; BF women; the significant others of pregnant and BF women such as the family members, friends, employers, public, and partner; and health staff.^25,29,30

Varied levels of trust were occasionally reported by women in relation to the received BF information. Usually, mothers welcomed evidence-based information but in few instances doubted messages obtained, even from health professions.^24,25 In addition to healthcare workers, family members, peers, friends, the Internet, digital versatile disc, and books were listed by the various studies as the sources of BF information. It was worthy to note that maternal access to accurate BF information was essential and partially influenced the BF decision-making process in all the studies.

Early Postpartum Support by Key Influencers

Key influencers played a critical role in maternal BF decisions and efforts. All the studies mentioned the valuable contribution of family members, partners, church members, nurses, friends, peers, pediatricians, doctors, and other health providers among women who breastfed. A few BF women recalled how strangers offered valuable input in the BF process.

The significant person's role was essential for the successful transition into motherhood, especially during the first 2 weeks postpartum. Typical family support was reported by 1 mother in the study by Asiodu et al.²⁹:

I mean, my boyfriend is supportive but I'm getting more support from my mom and dad.^(p869)

In the early days after birthing, lactating women expressed the need for home visits, lactation support, and household support for domestic chores. A new lactating woman in the study by Robinson et al¹⁶ shared the lactation support obtained through home visits:

I did have some really great support once I got home because I actually had 2 people come over and help me ... make sure I'm still on track ....^(p157)

A few women explained the valuable role of key influencers in the practice of public BF.^25,28 However, some mothers reported varying levels of support from key influencers across the studies. For instance, 1 woman shared the experience about sample formula in the hospital in the study by Johnson et al.²⁴:

I know some hospitals pretend to be baby friendly but a lot of times that's not the forefront. You see all this foreign stuff in the room, they force it on you, you might state you wanna breast feed ... (but), the baby's in the nursery and they wanna give your baby formula when you're sleep or things like that.^(p98)

Women in all the studies emphasized the importance and persistent role of key influencers in the successful initiation and continuation of BF throughout the critical transition period after birth and the first few weeks postpartum.

Maternal Culture

Maternal culture refers to the knowledge and beliefs a woman has about BF that she has gleaned from her background and lived experiences. It was evident from the studies that women's cultural norms, environment, household arrangements, and availability of BF role models had an influence on her BF decisions. Breastfeeding was not the popular infant feeding choice in most households. Women who opted to breastfeed felt isolated, discouraged, and criticized. For instance, women who initiated and continued to breastfeed the infant soon after birth reported cold reception by some family members and friends in the study by Lutenbacher et al²⁵:

they're like you're not going to do that...you're not going to breastfeed ... I was like, yes, I am ... I had more women discourage me from breastfeeding than I did that encouraged me.^(p234)

The situation got worse during family gatherings and/or outdoor activities. Some women felt embarrassed because of the expressed need to feed infants in public. A woman shared the regretful experience at a family gathering in the study by Peritore²⁶:

It was all of my future in-laws, the whole family. And I started nursing uncovered at the table ... they started laughing, ... my future father-in-law told me that I need to take the baby in the bathroom and nurse in the bathroom ... and there was a very tense stare-down ... I will never forget that feeling that this breastfeeding is not welcome.^(p66)

To promote favorable social support of BF among AA communities, a suggestion was made for the establishment of BF role models within the residential communities.^25,28,29 Such role models may be grandmothers, health workers, friends, sisters, or women with BF experiences. One woman enrolled in the study by Lewallen and Street²⁸ reported:

My mom breastfed me, so that helped me to make up my mind that I wanted to breastfeed, ... so that's the reason why I chose to do it.^(p669-670)

African American women stressed the active desensitization of the public on the oversexualization of the female breast and the promotion of the nutritional value of the breast.

Tangible Support

The readily provision of tangible BF resources in the communities of AA women was essential. This need was identified in each of the studies except in the study by Robinson et al.³⁰ Women suggested the creation of a publicly available guide on the list of lactation resources within the communities of residence. Such community resources were to include financial support to purchase BF resources such as breast pumps; childcare; and housing and lactation support from peers, consultants, and BF champions. A woman in the study by Johnson et al²⁴ shared the critical need for assistance:

I need a refrigerator. I need a bed. I am sleeping on the floor ... So you that's where I said you have to kinda have to knock down some of the barriers before you can talk about or breastfeed.^(p98)

Some single women needed support at home a few days after discharge from the hospital. Such women required the assistance of paid doulas. The doulas assisted with household chores while the woman obtained adequate rest and invested time to breastfeed their infants.

In addition, the need for tangible resources also extends to the workplace. The enforcement of workplace BF policies was noted to be vital for BF promotion among working women. Most BF women who worked were usually aware of their BF rights.^17,27 Such women from across 7 studies reaffirmed the need to provide nursing breaks, paid maternity leave, and convenient space to pump and store human milk.

Pregnant and lactating women viewed the availability of tangible BF resources as a significant form of social support toward BF initiation and continuation among AA women in the United States.

Black Women's Empowerment

Emotional support was a key component identified through all the studies except the study by Lutenbacher et al²⁵ as fundamental to the empowerment of AA women who initiated and continued BF. Mothers desired a culturally sensitive BF model.

The relevance for group affiliation with other Black peers was stressed. For instance, 1 woman in the study by Kim et al¹⁷ mentioned the relevance of shared identity:

If maybe women of color knew that other women of color were there, it would just—it's like a tunnel effect, ....^(p158)

Some social media platforms became significant means of peer support groups. The virtual groups were accessible with smartphones and other electronic devices with Internet access. Participating mothers with Internet access easily shared and obtained BF information through available virtual resources, books, posters, questions, and answers guided by the group dynamics. The social media peer Black group engagement had unlimited availability of group support, a lot of participants, and motivated several women to enroll as observed by some women in the study by Robinson et al³⁰:

It just opened my eyes to more Black women breastfeeding ... “It's like 30,000 people in this group and they're all breastfeeding and they're all Black and they're all moms,” like, it was a, it just, it blew my mind.^(p574)

... there's always somebody there, 24/7. So regardless of what time you need a question answered, or you just want to know that somebody's been through the same thing that you've been through, there's always somebody there, and it's always positive.^(p577)

Women who regularly received emotional and peer support felt empowered to initiate and sustain their BF efforts. This was echoed throughout the 7 studies. African American women noted that such emotional wellness and empowerment will be met when the emphasis was placed on the emotional support of pregnant women and mothers in BF. A woman in the study by Peritore²⁶ noted this to be true of the vision of La Leche League:

... in addition to being a source of technical breastfeeding information, La Leche League really emphasizes that the emotional wellbeing of the moms is really key to the success of the breastfeeding relationship. And so being emotionally supportive of the mom is almost as important as the technical expertise.^(p100)

All the women commended the goal of the La Leche League and confirmed the benefits of emotional empowerment from group association with other Black mothers. Two women in the study by Robinson et al³⁰ shared their experiences:

I think the group has encouraged me to venture out and sorta be a voice for the African American like women who want to breastfeed....^(p578)

I honestly wanted to start weaning her, probably a few months ago, ... the group basically built, helped build my confidence to keep going, seeing that there were other mothers who have breastfed for as long as I have, or even [laugh] years longer than what I'm doing now.^(p578)

African American women would like to initiate and continue BF and even encourage their peers to do the same, given the needed emotional support and empowerment.

DISCUSSION

African American women's expressed need for trustworthy BF information before, during, and after birth for themselves and their significant others aligns with the findings by Furman et al⁹ in which fathers became receptive to BF because of increased BF knowledge. African American women and their significant others should be provided with accurate, timely, and appropriate BF education to meet their unique needs. The needs of women to breastfeed may be beyond BF education support and also include a safe place for BF and access to an effective breast pump and refrigeration for human milk.^31–33

The identified need of AA women for support from key influencers during the early postpartum period emphasizes the value and appreciation of such individuals in the transition process as observed in previous studies.^10,11 However, unlike the earlier studies that reported only health workers and community partnerships as important influencers for social support in BF, the current study noted additional significant individuals—family members, partners, friends, peers, church members, and strangers. In addition, the social support in BF was deemed most critical in the first 2 weeks after birth. This suggests that AA women may most likely initiate and continue BF if they receive adequate BF support from key influencers during the first 2 weeks postpartum. Such support should include assistance with lactation (eg, latching, positioning, follow-up), domestic activities, childcare, and groceries.

The knowledge and beliefs Black women have about BF from their backgrounds and lived experiences influenced their efforts to breastfeed; whereas Kim et al¹⁷ reported that first-time lactating women viewed BF as a biological process to be completed with ease. This confirms the traditional roles of other women within AA communities where grandmothers, mothers-in-law, and sisters may serve as BF role models and support with infant care.^21,25,26 The need for the creation of BF role models in their communities of residence and public acceptance of the nutritional value of the female breast to promote maternal intentions to breastfeed were emphasized as an essential part of culture for AA women. Thus, the AA community must be supported through culturally sensitive BF partnerships to develop a welcoming attitude for BF and encourage women with known exclusive breastfeeding (EBF) experiences to volunteer as role models for new lactating women.

Black mothers' empowerment to breastfeed through the provision of emotional support and social media engagement among AA women's groups in this study is similar to findings in earlier studies.¹⁵ Women held a positive attitude toward BF, initiated and continued with BF, and volunteered to encourage other Black women to breastfeed. Therefore, it is important to explore all avenues inclusive of virtual platforms, such as social media, to establish culturally sensitive BF groups among peers in the Black community to promote BF. Such BF communities can be supported with their expressed unique needs to help meet their BF goals.

Tangible support was a new component identified to support the BF needs of women in the AA communities for which current literature is missing. All study participants expressed the need for and importance of the availability of diverse forms of tangible BF resources to meet their unique needs. This suggests that deliberate attempts must be made by all stakeholders to enforce existing BF policies; review; and support the BF resource needs of each lactating woman on a case-by-case basis; pregnant and lactating women should be regularly informed about available BF resources in the community.

Finally, the meta-ethnography highlights the prevalent racial disparities in maternal BF efforts among AA women in the United States. Critical attention is warranted to mitigate misconceptions, discrimination, and stereotyping about BF among AA women in the United States. Such collaboration and inclusivity will facilitate social support of BF and promote EBF rates.

Limitations

The limitations of the study were the dearth of literature directly related to BF social support among AA women in the United States. In addition, this meta-ethnography was limited to published articles discoverable by database searches, which may have omitted relevant sources of information. Furthermore, the reviewed literature for the meta-ethnography was not explicit on the type of qualitative study design and analysis.

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What we know:	In the African American community in the United States, significant disparities exist in breastfeeding initiation, exclusivity, and duration.
What needs to be studied:	Future longitudinal studies are warranted to explore the social support of breastfeeding among African American women in the United States. The role of religion in breastfeeding promotion should also be explored in future research.
What can we do today:	Health professionals' role during the prenatal, intranatal, and postnatal periods should provide enhanced interventions to promote and protect breastfeeding among African American women in the United States: Seek additional training to provide trustworthy and nondiscriminatory breastfeeding education. Include family members who influence breastfeeding decisions in all breastfeeding education and interventions. Consider the use of doulas who have been shown to improve breastfeeding initiation in at-risk populations. The first 2 weeks are a critical time point to establish milk supply; thus, lactation support, follow-up, and emotional support should be prioritized. Provide information on available resources in the community to support maternal breastfeeding initiation and continuation efforts.

IMPLICATION FOR CLINICAL PRACTICE AND RESEARCH

Healthcare workers must continuously upgrade their knowledge on BF to be well positioned to meet the trustworthy BF educational needs of pregnant women, lactating women, significant others, and the public. In addition, health professionals must appreciate the fact that mothers within the AA community value and acknowledge them as key influencers in their BF decision-making process. Therefore, health professionals must put in the necessary efforts and be available to discuss issues of BF in a culturally sensitive manner as part of the birth plan. The BF birth plan of the woman must be made in collaboration with other significant persons as may be suggested by the woman. The woman's healthcare team must discuss, document, and implement details about practical ways to support the woman's BF efforts especially, during the first 2 weeks postpartum. Furthermore, available peer support groups and resources in the community must be shared with the woman. Finally, the healthcare team must always seek the best ways to provide the necessary emotional support to the pregnant woman and lactating women within the AA communities to promote maternal empowerment in BF initiation and continuation.

Future longitudinal studies are warranted to explore the social support of BF among AA women in the United States. In addition, the role of church members in BF promotion may be researched.

CONCLUSIONS

The outcome of this meta-ethnography underscores the relevance of social support as a key determinant of BF among AA women in the United States.^8,34 African American women in the United States may breastfeed if the reported BF social support needs are recognized and fully met. Provision of expressed BF social support needs will favorably contribute toward the achievement of the Healthy People's 2030 goal (42.4% 6 months of EBF target for all American infants) and World Health Organization's 6 months of EBF target of at least 50% by 2030.