The Work of Breastfeeding Among Women of Low Socioeconomic Status: A Qualitative Metasynthesis

Abstract

A theory-generating qualitative metasynthesis was used to explore the questions: (a) How do mothers of low socioeconomic status in the United States express their attitudes and beliefs on breastfeeding? (b) How do mothers of low socioeconomic status in the United States describe the types of support received related to breastfeeding? Databases were searched from January 2000 to June 2022. Eleven qualitative studies were evaluated, and six themes were identified. A model was developed illustrating how the themes impact a mother’s decision to breastfeed. Positive factors included shared narratives, knowledge of breastfeeding physiology, and social network. However, more negative influences were heard such as opinions passed on from family and friends, lack of teaching and anticipatory guidance, limited support and follow up, and the perception of conflicting messages from health care professionals. This model identifies constructs that can be used as starting points for interventions, policy development and/or health promotion education.

Socioeconomic status (SES) is one of the major social determinants of health associated with poor health status in the United States (Shavers, 2007). Low SES and poor health behaviors in parents can significantly impact the future health behaviors of their children (Poulain et al., 2020). Additionally, there is speculation that childhood health experiences, influenced by parental health behaviors, might impact future health and behavioral actions with lasting effects into adulthood (Poulain et al., 2020). Children from low SES families might exhibit higher instances of multiple risk exposure as compared to middle-income children and have worse health outcomes overall (Evans & English, 2002). It is known that there are positive and long-lasting health benefits for mothers and their children when breastfed (Kirkegaard et al., 2018; Oddy, 2017; Thompson et al., 2017), but women of low SES are less likely to breastfeed their infants (Centers for Disease Control and Prevention [CDC], 2020; Yourkavitch et al., 2018). There is a need for interventional programs for parents of low SES to increase breastfeeding rates and ultimately to improve health outcomes. The purpose of this qualitative metasynthesis was to gain insight into the breastfeeding experiences of low-income women to ultimately design tailored interventions to improve breastfeeding rates among this population.

Background

Impact of Breastfeeding

Breastfeeding is considered an essential preventive health measure (American Public Health Association [APHA], 2007) and The American Academy of Pediatrics (2012) recommends exclusive breastfeeding (i.e., breastmilk only) for the first 6 months of age and continued breastfeeding, with the introduction of solids, for at least up to 1 year of age. Breastfeeding provides both short- and long-term benefits to both the infant and mother. Breastmilk is produced naturally within the body to provide complete nutrition that is easily digestible for infants and can reduce rates of sudden infant death syndrome, asthma, and allergies in children (CDC, 2021; Oddy, 2017; Thompson et al., 2017). Exclusive breastfeeding in the postpartum period could benefit the overall health of the mother by reducing postpartum weight retention better than formula or combination (breastmilk and formula) feeding (Barker et al., 2008; Hatsu et al., 2008). Additionally, breastfeeding is associated with protective cardiac factors in mothers, such as lowered risk for hypertension and cardiovascular disease, years after breastfeeding is discontinued (Kirkegaard et al., 2018). Breastfeeding also benefits the family financially. In addition to saving money spent on formula, breastfeeding contributes to decreased health costs related to fewer ear infections, diarrhea, and pneumonia in infants and reduced rates of ovarian cancer, breast cancer, and type II diabetes for mothers (Hatsu et al., 2008). The Surgeon General’s call to action states that parents following optimal breastfeeding practices can save up to $1,200 to $1,500 in just their baby’s first year alone (U.S. Department of Health and Human Services [USDHHS], 2011). Furthermore, if 90% of mothers in the United States were to breastfeed their infants for 6 months, the total savings would equal around $13 billion dollars/year and facilitate the prevention of emergency conditions often causing infant deaths (Bartick & Reinhold, 2010). The Surgeon General advocates for increased funding for breastfeeding research and to support better tracking of factors affecting breastfeeding rates (USDHHS, 2011). Nonetheless, many mothers still do not initiate and continue breastfeeding their infants as recommended by health professionals.

Breastfeeding Disparities Among Economically Disadvantaged Mothers

The US Women, Infants, and Children Special Supplemental Nutrition Program serves to safeguard the health of low-income pregnant, postpartum, and breastfeeding women, infants, and children up to age 5 years who are at nutritional risk by providing nutritious foods to supplement diets of the pregnant or lactating women, information on healthy eating including breastfeeding promotion and support, and referrals to health care. For women who chose to use formula, the Women, Infants, and Children Special Supplemental Nutrition Program provides this nutrition for the infant. The results of the United States National Immunization Survey (CDC, 2018) revealed that infants in the Women, Infants, and Children Special Supplemental Nutrition Program are less likely to have ever received breastmilk compared to infants ineligible for this service, even though the program strongly encourages breastfeeding. In 2014, the United States Department of Agriculture (USDA) reviewed the Women, Infants, and Children Special Supplemental Nutrition Program updated food packages (food for the mother or formula for the infant) and found comparable results. Infants receiving benefits from the nutrition program were less likely to be breastfed than higher-income infants (thus ineligible for services) (45% vs. 74% for 0–5.9 months of age, respectively) (Guthrie et al., 2018). Results from a qualitative study of 53 health care professionals indicated that many felt that as long as the baby is well cared for and healthy, the method of feeding is not a top priority, and they do not want to make a woman feel guilt or feel shame if she chooses to formula-feed her infant (Radzyminski & Callister, 2015).

Aims

A better understanding of the infant feeding experiences of socioeconomically disadvantaged women is needed before appropriate interventions can be developed for this population. To our knowledge, work to synthesize the barriers and facilitators to breastfeeding in low SES women that can be used in future studies or interventions for this population has not been undertaken. Seguara-Pérez et al. (2021) systematically reviewed breastfeeding interventions for minorities in the United States, however the focus was not primarily on women of low socioeconomic status. Insight into low-socioeconomic mothers’ unique experiences can be gained through a theory-generating qualitative metasynthesis to identify and synthesize their perspectives and experiences (Finfgeld-Connett, 2018).

Design

Theory-generating qualitative metasynthesis methods are routed in grounded theory and go beyond mere description of studies and an aggregation of qualitative findings. The process uses the findings of previously completed qualitative studies as raw data (Finfgeld-Connett, 2018; Sandelowski, 2015). Through the qualitative metasynthesis process of analysis and syntheses of findings over time, new findings, theoretical constructs, and relationships are identified to guide future research and inform practice (Finfgeld-Connett, 2018). The research questions guiding our qualitative metasynthesis were: (a) How do mothers of low socioeconomic status in the United States express their attitudes and beliefs on breastfeeding? (b) How do mothers of low socioeconomic status in the United States describe the types of support received related to breastfeeding?

Methods

Search Methods

After consultation with a health-sciences librarian, a search of the literature was conducted focusing on low-socioeconomic mothers’ (of any age) perceptions of and experiences with breastfeeding (of any duration and format) in the United States by author Weston. Because many national efforts to increase breastfeeding rates gained momentum in the 1990s, such as the Baby-Friendly Hospital Initiative in 1991, the Women, Infants, and Children Special Supplemental Nutrition Program’s Loving Support in 1997, and national breastfeeding work legislation in 1998 (Cadwell, 1999), only studies published in or after the year 2000 were included for review. Searches were limited to English language and from 2000 to 2022. The searches were run in September 2020 and April 2021, with the last search ending on June 25th of 2022. Because Finfgeld-Connett (2018) recommends using an expansive search method, diversified databases were utilized. The databases searched were PubMed, CINHAL, Scopus, PsychINFO, and Google Scholar (with forward and ancestry searching). See Table 1 for PubMed search strategies, keywords, and results. PRISMA systematic review guidelines were followed throughout the inclusion and exclusion process (Moher et al., 2009). See Table 2 for specific inclusion and exclusion criteria and Figure 1 for the PRISMA diagram. Reference lists of the research reports matching the inclusion criteria were evaluated for relevant reports and forward ancestry searches were conducted. Research reports describing results outside of the United States or focusing on the prediction of breastfeeding were excluded.

Table 1.

PubMed Search Strategy.

Search ID	Search terms	Search options or filters	Results
S10	S9 AND S2	All Fields, Limited from 2000 to 2022, Filtered by English	119
S9	S6 AND S7 AND S8	All Fields	283
S8	Low income	All Fields	136,694
S7	Breastfeed	All Fields	52,995
S6	Qualitative OR interview OR focus group	All Fields	642,311
S5	S1 AND S2 AND S3 AND S4	Title/Abstract, Limited from 2000 to 2022, Filtered by English	221
S4	Low income[Title/Abstract] OR poor[Title/Abstract] OR low socioeconomic[Title/Abstract] OR disadvantaged[Title/Abstract]	Title/Abstract	739,464
S3	Breastfeeding[Title/Abstract] OR breastfed[Title/Abstract]	Title/Abstract	44,225
S2	United States OR USA OR Alabama OR Alaska OR Arizona OR Arkansas OR California OR Colorado OR Connecticut OR Delaware OR Florida OR Georgia OR Hawaii OR Idaho OR Illinois OR Indiana OR Iowa OR Kansas OR Kentucky OR Louisiana OR Maine OR Maryland OR Massachusetts OR Michigan OR Minnesota OR Mississippi OR Missouri OR Montana OR Nebraska OR Nevada OR New Hampshire OR New Jersey OR New Mexico OR New York OR North Carolina OR North Dakota OR Ohio OR Oklahoma OR Oregon OR Pennsylvania OR Puerto Rico OR Rhode Island OR South Carolina OR South Dakota OR Tennessee OR Texas OR Utah OR Vermont OR Virginia OR Washington OR West Virginia OR Wisconsin OR Wyoming)	All Fields	8,451,967
S1	Qualitative OR interview OR perspective OR experience	All Fields	1,717,734

Table 2.

Qualitative Metasynthesis Inclusion and Exclusion Attributes and Rationales.

Inclusion	Rationale	Exclusion	Rationale
Qualitative or mixed methods studies published in or after the year 2000	Only qualitative findings are included in a QMS; BF programs and BF promotion gained momentum in late 1990sa	Outside of the U.S.	Focusing on description of the low-income American mother experience.
Low- income/socioeconomic experience with BF or pumping	Focus of QMS is to explain BF experience for low-socioeconomic mothers in general, including pumping, storing, childcare, return to work, etc.	Studies only focusing on BF intention, initiation duration, or cessation	Focus is on mothers who actually breastfed and their experience
Mother’s description of experience with BF and/or support received	Explains moms’ experience in how they decided to feed their infants	At-risk mom or infants (e.g., premature babies, obese mothers; incarcerated mothers)	Less likely to BF‡
Studies that described a WIC peer counselor or HCP support from mom’s perspective	Focused on moms’ experience with WIC or health care practitioner support offered for BF mothers	Studies specific to WIC operation/improvement areas; Intervention research reports	Focus of QMS is not on WIC services nor intervention programs
Mothers’ perspective	Focus is on mothers’ perspective, not that of family members and friends
At least 50% of participants have attempted BF at least once	Want to focus on both the experience and barriers and facilitators of BF

Note. BF = breastfeed, breastfeeding; WIC = women, infants, and children special supplemental nutrition program; QMS = qualitative metasynthesis.

Figure 1.

PRISMA flow diagram summarizing screening process.

Search Outcomes

More than 500 titles were reviewed and a total of 54 abstracts were read for inclusion in this synthesis. After excluding 23 abstracts for inclusion, 31 research reports were read in their entirety and another 20 research reports were excluded due to exclusion criteria (13 had the wrong study focus, five had viewpoints other than mothers, and two had subjects located outside of the United States). To reduce publication bias (Finfgeld-Connett, 2018), gray literature was included and evaluated in this search process, however no results were found to meet the specific inclusion criteria. A total of 11 research reports were found to match the inclusion criteria and are included in this qualitative metasynthesis. See Figure 1.

Quality Appraisal

To appraise the quality, esthetics, and transferability of the included research reports, the Critical Appraisal Skills Program (CASP, 2019) checklist for qualitative studies was used to evaluate each of the included research reports. The CASP checklist is recommended by both Cochrane and the World Health Organization. It remains as one of the most widely used tools for quality assessment in qualitative evidence synthesis (Long et al., 2020). A document was created noting the CASP criteria, strengths, and potential weaknesses of each research report. The CASP ratings of the research reports were strong, with research questions aligning with methods and analysis, along with clear statements of findings. No research report had any critical issue with quality warranting its exclusion from the synthesis. Therefore, no research report was excluded from the analysis if it met the criteria for inclusion (Finfgeld-Connett, 2018; Sandelowski, 2015).

Data Extraction and Synthesis

Characteristics of each included research report were documented in a table of attributes to provide a summary of the included research reports. Column labels of this table included the article citation, study purpose, methods, state/region, sample size/breakdown, rural or urban population focus, and how low socioeconomic status was defined (see Table 2). Each research report was first carefully read in its entirety. The theory-generating qualitative metasynthesis analysis process uses the findings of primary qualitative studies as raw data; thus, participants’ direct quotes or exemplar excerpts of interview transcripts were not included for analysis (Finfgeld-Connett, 2018; Sandelowski, 2015). Line by line, the findings (now our raw data) were highlighted, and preliminary codes were noted in the margins. Memoing was used to retain ideas, articulate, and expand concepts, and remain transparent in the research process (Birks et al., 2008; Finfgeld-Connett, 2018). Codes and categories were then transferred into an Excel document for review with the research team. At this time, codes were discussed and combined when appropriate to avoid any repeated or unnecessarily similar codes. This was an iterative process, with coding and reflexive memos being repeatedly evaluated to ensure the meaning of the data was reflected (Finfgeld-Connett, 2018). As themes and subthemes started to arise, a hand-drawn diagram was developed to clarify and illustrate ideas. Once we developed a more cohesive understanding of the findings, we used PowerPoint to develop a diagram representing our findings.

Validity

Validity is an important aspect in assuring trustworthiness in findings, but also the credibility of the subsequent theory or model (Finfgeld-Connett, 2018). Validity was safeguarded throughout the research process through several methods such as exploring literature through cited references, maintaining clear search criteria and cutoff dates, and relying on reflexivity during coding, categorizing, diagramming, and memoing (Finfgeld-Connett, 2018). The first round of coding used traditional theory-generating qualitative metasynthesis analysis techniques, staying close to the data. Throughout this process, coding was reviewed by and discussed by the research team. The team met frequently to confirm interim and final thematic findings and then to flesh out details and features of the relationships, theoretical constructs, and corresponding diagram to provide triangulation of the qualitative metasynthesis process and findings (Finfgeld-Connett, 2018).

Results

Characteristics of Included Studies

The perceptions and experiences of approximately 599 low socioeconomic status mothers were included in this qualitative metasynthesis with no detectible overlap among samples. A summary of the 11 research reports included in this qualitative metasynthesis can be found in Table 3. Data obtained from the mothers were mainly from focus groups and interviews. One mixed methods study met inclusion criteria (Guttman & Zimmerman, 2000), however only the qualitative findings were included in the analysis. Authors of the included research reports used a data analysis spiral (Barbosa et al., 2017), two groups used a grounded theory approach (Deubel et al., 2019; Hardison-Moody et al., 2018), four included content or thematic analysis (Gross et al., 2017; Hohl et al., 2016; Raisler, 2000; Robinson et al., 2016), one used a narrative analysis approach (Pounds et al., 2017), and three author groups did not specify their approach (Cross-Barnet et al., 2012; Guttman & Zimmerman, 2000; Heinig et al., 2009). Only three reports included a discussion of the model or framework driving their investigation. An integrative model was reported in one study (Barbosa et al., 2017), whereas one group of authors used an applied medical anthropology framework (Deubel et al., 2019), and another used a positive deviance framework (Pounds et al., 2017). The included studies were conducted in various locations across the United States including Richmond, Virginia, Maryland, Florida, Georgia, northern California, eastern Washington, Nebraska, western Iowa, Wisconsin, southeast Michigan, and North Carolina. One study did not list a specific location in the United States (Guttman & Zimmerman, 2000). Two author groups designated their location as urban (Deubel et al., 2019; Hardison-Moody et al., 2018), three used both rural and urban locations (Cross-Barnet et al., 2012; Hardison-Moody et al., 2018; Raisler, 2000), one used only rural participants (Hohl et al., 2016), and five did not specify urbanicity/rurality (Guttman & Zimmerman, 2000; Gross et al., 2017; Heinig et al., 2009; Pounds et al., 2017; Robinson et al., 2016). Of the 11 research reports, only one (Pounds et al., 2017) included exclusive breastfeeding as an inclusion criterion. Five author groups delineated their number of mixed versus exclusive breastfeeders (Deubel et al., 2019; Hardison-Moody et al., 2018; Hohl et al., 2016; Pounds et al., 2017; Raisler, 2000). Four author groups described the length in months of breastfeeding among participants (Gross et al., 2017; Hardison-Moody et al., 2018; Heinig et al., 2009; Robinson et al., 2016), while two author groups only detailed participants with history of ever initiating breastfeeding (Cross-Barnet et al., 2012; Guttman & Zimmerman, 2000).

Table 3.

Sample Attributes From Articles Included in Qualitative Metasynthesis.

First author	Study purpose, participant characteristics	Methods	State/region, urbanicity	How low-socioeconomic status defined
Barbosa et al. (2017)	Examine infant-feeding attitudes and experiences of Latina and African American women, N = 25, at least 1 biological child <2 years old	Mini focus groups	Richmond, VA, urban	Recipients of public assistance, WIC, or lived in public housing complex
Cross-Barnet et al. (2012)	Explore infant-feeding education and support experiences of mothers in WIC peer counseling program, N = 75, black or white clients (no Latinas or Asians)	In-depth interviews	Maryland, 1 urban, 1 suburban, 1 semi-rural	WIC participants
Deubel et al. (2019)	Investigate perceptions and practices of infant feeding among African American women, and attitudes toward prenatal BF education and postpartum support available to them, identify key factors motivating infant-feeding decisions, N = 20, received prenatal care at Oasis and delivered baby at associated hospital, ≥18 years old, baby <3 months postpartum	Semistructured interviews	Tampa, Florida, urban	Received prenatal care at publicly funded clinic “Oasis”
Guttman (2000)	Create a typology of mothers’ feelings about their infant feeding method is developed, N = 154, Low-income health center, and WIC clinic	Mixed-method, structured interviews	United States/no state or region specified	Publicly funded agencies: by mandate serve low-income populations and/or must meet low-income guidelines for WIC
Gross et al. (2017)	Explore long-term breastfeeding experiences of African American women, N = 11, 18 years or older, currently or previously BF one of their children for at least 6 months (and the BF child had to be ≤2 years old)	Semistructured, in-depth interviews	Georgia, urbanicity not specified	Current or previous WIC participant
Hardison-Moody et al. (2018)	To understand factors that inhibit or facilitate breastfeeding practices of low-income mothers, N = 138, Primary caregiver or mother of at least 1 child between ages 2–8 years old	In-depth, semistructured qualitative interviews	North Carolina 2 rural counties and 1 urban county	≤200% of federal poverty line (self-reported)
Heinig et al. (2009)	To identify sources and quality of infant feeding advice among WIC participants, N = 65, had intended to BF, had 4–12-month-old infant, English or Spanish speaking	Focus groups	3 counties in northern California, urbanicity not specified	WIC participants
Hohl et al. (2016)	To explore experiences, and perceptions toward BF in Latina women, N = 20, Identify as Hispanic or Latina, ages 21–45, and reside in Lower Yakima Valley, and had at least 1 child >5 years old	Face-to-face-qualitative interview	Rural Washington State	High-poverty area, little education, and low rates of insurance in area
Pounds et al. (2017)	To understand the experience of low-income women balancing full-time work and breastfeeding, N = 12, Aged 19–45, English speaking, worked at least 32 hours outside the home, fed breastmilk and no formula, and consistently BF while infant was >1 year old	In-person or phone interviews	Nebraska and western Iowa, urbanicity not stated	WIC participants
Raisler (2000)	Asked low-income mothers about their experiences of breastfeeding care in the health system and about integrating breastfeeding into their daily lives. N = 42, Ages = 16–39, Nursing mothers who participated in WIC and were assisted by breastfeeding peer counselors	Focus groups	Southeast Michigan Rural and urban areas	Low-income because participants participated in WIC services
Robinson et al. (2016)	To examine influence of BF peer counselors on BF experiences of African American mothers participating in WIC, N = 9, at least 18 years old, currently BF or had BF during previous 6 months, English speaking	Focus groups	Southeast Wisconsin, urbanicity not specified	WIC participants

Note. BF = breastfeeding, breastfeed; WIC = women, infants, and children special supplemental nutrition program.

Themes

Six themes were identified from this qualitative metasynthsis. The themes identified included: family and household support or lack thereof; Women, Infants, and Children Supplemental Nutrition Program and peer counselor support or lack thereof; mothers’ perceptions of breastfeeding; mothers’ perceptions of community/public opinion of breastfeeding; mothers’ experiences with breastfeeding; and interaction with health care professionals. The major themes and subthemes are detailed below.

Family and Household Support (or Lack of) and Influence

Environmental Challenges of Breastfeeding

Social support has been recognized as an important factor in both the decision to breastfeed and breastfeeding duration (Kong & Lee, 2004; Renfrew et al., 2012). The mothers identified hardships within their homes that impaired and discouraged breastfeeding behaviors. Mothers discussed that people were frequently in and out of their home (Hardison-Moody et al., 2018; Raisler, 2000) and that they had close and cramped living conditions or had to “hide” to breastfeed their infant (Barbosa et al., 2017; Hardison-Moody et al., 2018; Raisler, 2000). This made breastfeeding difficult because mothers often had no designated “place” to breastfeed their infants comfortably (Barbosa et al., 2017; Guttman & Zimmerman, 2000; Hardsion-Moody et al., 2018). Furthermore, the mothers reported discomfort with breastfeeding in front of frequent visitors, extended family members, and young children (Barbosa et al., 2017; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Raisler, 2000). In general, the mothers gave a sense that there was a lack of overall support, family knowledge to facilitate support, and encouragement from family members within the home.

Family Members Influence Breastfeeding Success

Mothers frequently cited the grandmother and father of the baby as a major influence in their infant feeding decision. Unfortunately, that influence tended to be negative and deterred support of breastfeeding (Barbosa et al., 2017; Deubel et al., 2019; Hardison-Moody et al., 2018; Heinig et al., 2009; Hohl et al., 2016; Pounds et al., 2017; Robinson et al., 2016). Mothers commonly shared that they were encouraged by grandmothers and fathers to use formula for family convenience, efficiency, or when feeding the baby while mom was away. They also voiced that the grandmothers and/or fathers lacked the knowledge on how to support them with breastfeeding in general (Gross et al., 2017, Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Hohl et al., 2016; Pounds et al., 2017; Raisler, 2000). Mothers reported that family members had the same environmental concerns as she in exposing her breasts to immediate family while breastfeeding (Barbosa et al., 2017; Guttman & Zimmerman, 2000; Raisler, 2000). In contrast, research reports that included exclusively African American or Latina mothers described primarily positive support from fathers and grandmothers with many stating that breastfeeding was the norm among their households and/or family members (Barbosa et al., 2017; Deubel et al., 2019; Gross et al., 2017; Hohl et al., 2016). In the research reports including only African American or Latina mothers, the mothers also stated that the support from fathers and/or grandmothers was central to their ability to continue to breastfeed their infants.

Women, Infants, and Children Special Supplemental Program and Peer Counselor Support and Influence

The Women, Infants, and Children Special Supplemental Nutrition Program Sends Mixed Messages

Nine research reports included mothers enrolled in the Women, Infants, and Children Special Supplemental Nutrition Program. There was no discernable consensus on the value of the support that the Women, Infants, and Children Supplemental Nutrition Program provided to the mothers in this sample. Mothers appreciated the program’s services and non-judgmental (over feeding choice) attitude overall, but they had varied feelings on the actual value of the support they were given regarding breastfeeding (Barbosa et al., 2017; Hardison-Moody et al., 2018; Heinig et al., 2009; Raisler, 2000). There were differing opinions on the Women, Infants, and Children Supplemental Nutrition Program’s encouragement of breastfeeding and formula feeding. Some mothers thought the limited amount of formula given to mothers who chose to combination feed (both breast and formula feed) forced them to ultimately choose to exclusively formula feed to acquire enough formula to feed their infants (Barbosa et al., 2017; Hardison-Moody et al., 2018; Hohl et al., 2016; Raisler, 2000). Others thought that offering supplemental formula to a breastfeeding mother was unsupportive of breastfeeding practices (Barbosa et al., 2017; Hardison-Moody et al., 2018; Hohl et al., 2016; Raisler, 2000). There was an overall sense of confusion in the message the Women, Infants, and Children Special Supplemental Nutrition Program conveyed to this group of mothers.

Peer Counselors as a Sounding Board

Despite confusion about Women, Infants, and Children Special Supplemental Nutrition Program services, there was unanimous consensus on the value and support of the peer counselors mothers were assigned to while participating in the program. Mothers described building intimate relationships with their peer counselors due to the extra time spent supporting the mothers and the personalized home visits that the peer counselors provided (Gross et al., 2017; Heinig et al., 2009; Raisler, 2000; Robinson et al., 2016). The mothers appeared to value the support of their peer counselor over that from other health professionals (Hardison-Moody et al., 2018; Heinig et al., 2009; Raisler, 2000; Robinson et al., 2016). The mothers’ responses described a confidante-type relationship with the peer counselor that made them comfortable sharing with and learning from the peer counselor as they would with a trusted girlfriend.

Mothers’ Perception of Breastfeeding

Breast is Best

Consistently, mothers reported that breastfeeding was the best infant feeding choice and healthier for both mom and baby (Barbosa et al., 2017; Cross-Barnet et al., 2012; Deubel et al., 2019; Gross et al., 2017; Guttman & Zimmerman, 2000; Heinig et al., 2009; Hohl et al., 2016; Robinson et al., 2016). Breastfeeding benefits for mothers such as postpartum weight loss and support of the healing process were discussed, and breastfeeding benefits for infants included less diarrhea and less sickness overall. It was commonly reported that breastfeeding promoted bonding between mother and infant and that breastmilk itself was “best,” suggesting that these mothers had been educated on the benefits of breastfeeding.

Breastfeeding Does Not Fit My Lifestyle

Numerous thoughts and perceptions (some correct and many false) were voiced among the sample that would make breastfeeding difficult or impossible for these women. Pain was the most frequent worry expressed in this sample (Barbosa et al., 2017; Deubel et al., 2019; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Heinig et al., 2009; Hohl et al., 2016; Pounds et al., 2017; Raisler, 2000). Mothers learned from others that breastfeeding hurts, pumping hurts, and it is something one must endure while doing it. Many mothers also believed they would not be able to breastfeed their children because of smoking habits, medications they were taking, and poor diet (Barbosa et al., 2017; Cross-Barnet et al., 2012; Gross et al., 2017; Guttman & Zimmerman, 2000; Raisler, 2000). Overall, mothers felt that breastfeeding would be too cumbersome to maintain in their lives. Negative perceptions were frequently associated with the “work” of breastfeeding, such as the difficulty in breastfeeding when returning to work or school, that breastfeeding is for wealthy, non-working mothers, and that infants prefer formula and bottle feeding over breastfeeding/breastmilk, making feeding less-difficult for the mothers (Barbosa et al., 2017; Deubel et al., 2019; Gross et al., 2017; Guttman & Zimmerman, 2000; Heinig et al., 2009; Hohl et al., 2016).

Mothers’ Perception of Community/Public Opinion on Breastfeeding

Each article reviewed described participants’ embarrassment surrounding breastfeeding in public or in front of others and the perception that breastfeeding should be done in private (Barbosa et al., 2017; Cross-Barnet et al., 2012; Deubel et al., 2019; Gross et al., 2017; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Heinig et al., 2009; Hohl et al., 2016; Pounds et al., 2017; Raisler, 2000; Robinson et al., 2016). This embarrassment came from both their assumptions that the public would dislike seeing a woman openly breastfeeding, to witnessing negative looks and comments directed at mothers breastfeeding in public. The breast was viewed as a sexualized object, with the mothers expressing that they could not breastfeed their infants in public if others would be able to view their breasts; especially men and children (Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Raisler, 2000). The impression was that public opinion was favorable of breastfeeding in and of itself, but the act of breastfeeding should be kept private. The mothers’ interpreted public opinion as “breastfeed your infant, just not in front of me.”

Mothers’ Experience with Breastfeeding

Collective Complications of Breastfeeding and/or Pumping

Many mothers reported negative experiences associated with breastfeeding and/or pumping (Barbosa et al., 2017; Cross-Barnet et al., 2012; Gross et al., 2017; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Raisler, 2000). One issue appeared to be the practicality of breastfeeding/pumping when returning to work. Mothers either expressed discomfort with the location in which they had to pump or explained that they had no designated space nor time to pump while at work. Another frequently expressed issue was pain. Most of the sample that breastfed their infants also supplemented with formula (Barbosa et al., 2017; Deubel et al., 2019; Gross et al., 2017; Raisler, 2000). The mothers that supplemented breastfeeding with formula frequently reported issues such as the baby likes the bottle or formula better, or that breastfeeding or pumping was quite painful and did not resolve, leading them to ultimately discontinue breastfeeding altogether.

Interaction with Health Care Professionals

A Little Support Can Have Lasting Effects

Although these reports were less frequent than those of negative interactions with health professionals, some women reported positive breastfeeding education and/or follow-up from nurses, midwives, and lactation consultants (Barbosa et al., 2017; Cross-Barnet et al., 2012; Raisler, 2000). Simply taking some extra time to sit with the mothers and discuss breastfeeding beyond that of “will you be breastfeeding or bottle feeding?” was appreciated by the mothers in this sample. Some mothers stated a little encouragement from nurses, such as stating they were doing a good job with latching, was enough to motivate them to continue to breastfeed.

Internalization of Discouraging Interactions

The negative interactions with health care professionals far outweighed the positive in this qualitative metasynthesis. Lack of education from both physicians and nurses was frequently reported from the mothers (Barbosa et al., 2017; Deubel et al., 2019; Gross et al., 2017; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Heinig et al., 2009; Raisler, 2000). Mothers said that it was either assumed they already knew what they were doing with breastfeeding or were handed breastfeeding pamphlets without further discussion on the topic. Mothers also reported that their infants were given formula after they had expressed their wishes to exclusively breastfeed (Gross et al., 2017; Heinig et al., 2009; Raisler, 2000). Some nurses and pediatricians also encouraged combination feeding for sick infants or for infants that had trouble initiating breastfeeding, which discouraged the mothers in their breastfeeding efforts overall (Barbosa et al., 2017; Cross-Barnet et al., 2012; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018). The mothers sensed that hospital staff assumed their breastfeeding attempts would likely be unsuccessful in the end, so they did not want to put much effort into helping them. For the mothers that were successful in initiating breastfeeding, they received limited coaching and support or follow-up once they returned home.

Breastfeeding Experience and Support Model for Low-Income Women

Per theory-generating qualitative metasynthesis methods, the themes and subthemes identified and discussed here informed the development of the Breastfeeding Experience and Support Model for Low-Income Women (see Figure 2). The Model illustrates the support and experiences voiced by participants in the 11 included studies. As aforementioned, most of the themes land along a negative-positive continuum and this is reiterated in the model. The left side of the model houses more negative influences and the right side of the model depicts more positive (similar to a number line with point zero being the oval of “Decision to Breastfeed”). The two concentric dotted ovals surrounding the inner oval “the Decision to Breastfeed” depict the influencing factors contributing to low SES mothers’ breastfeeding decisions. The outermost oval depicts outside support (or lack thereof) from groups such as Women, Infants, and Children, health care practitioners, and the general public in the community. The middle, gold oval depicts the lived breastfeeding experience of mothers in this sample, including breastfeeding perceptions, the experience of breastfeeding, and family/household support of breastfeeding. The support and experiences depicted in the outer and middle ovals would shape how mothers ultimately view breastfeeding and make the decision to breastfeed or not. The most common types of support and experiences were illustrated as boxes pointing to (or influencing) the final decision of “Decision to Breastfeed.” Negative influencers are shaded red whereas positive influencers are shaded green. The model depicts a trend of negative perceptions and experiences among women of low SES. Note that Women, Infants, and Children Supplemental Nutrition Program’s influence is situated in the middle, depicted as both positive and negative, because of the mixed messages sent to these mothers on breastfeeding and formula feeding practices. Despite the overwhelmingly negative perceptions and experiences surrounding breastfeeding, positive influencers (located on the right side of the model) such as peer counselor support and anticipatory guidance and follow-up from nurses, midwives, and lactation consultants strengthened these mothers’ desire to initiate and continue breastfeeding. The opinion that breastfeeding was the better or best infant feeding choice was consistently reported throughout these studies (Barbosa et al., 2017; Cross-Barnet et al., 2012; Deubel et al., 2019; Gross et al., 2017; Guttman & Zimmerman, 2000; Hardison-Moody et al., 2018; Heinig et al., 2009; Hohl et al., 2016; Raisler, 2000; Robinson et al., 2016).

Figure 2.

The breastfeeding experience and support model for low-income women.

Note. “WIC sends mixed messages” is depicted as both positive and negative.

Discussion

From our theory-generating qualitative metasynthesis of 11 qualitative studies, we developed the Breastfeeding Experience and Support Model for Low-Income Women to inform and be tested in future research studies and to help guide practice initiatives led by nurses, physicians, and peer supporters as they work with women from low socioeconomic backgrounds. We believe the model identifies constructs that can be used as starting points for interventions (e.g., peer support interventions), policy development (e.g., clear and non-conflicting messages, baby-friendly hospitals, accessible lactation consultants) and/or health promotion education (e.g., breastfeeding education that targets family support systems and not just the mother). The CDC has compiled a comprehensive guide to breastfeeding interventions (Shealy et al., 2005) that can be used to address each of the themes we identified. The CDC guide includes evidence-based interventions such as educating mothers at the individual level to improve breastfeeding success; interventions targeted for promoting breastfeeding at the organizational level, such as intervening in hospitals and workplace settings; as well as targeting the public at the community level with media and social marketing. All interventions in the guide were reviewed by the Cochrane Collaboration providing evidence of their effectiveness.

The findings from our study of low-income women’s perceptions of the pros and cons of breastfeeding support previous studies, as well as identifying gaps that can be addressed in practice and future research studies. Through the qualitative metasynthesis process, we found that there were more negative expectations and experiences associated with breastfeeding than there were positive facilitators. Of importance to nurses working with pregnant women, is the finding that many of the perceptions and experiences described by the women were either preventable or resolvable with evidence-based interventions. Changing the narrative from the negative to more positive motivation to breastfeed would be huge step in improving the health disparities that exist in this vulnerable population.

Accounting for inaccurate or negative perceptions and/or expectations could facilitate changes in clinical practice and improve breastfeeding outcomes. For instance, pain was the most voiced negative perception and experience associated with breastfeeding. The words “pain” or “hurt” were mentioned 39 times throughout the studies in this review. The experience of pain while breastfeeding could be mitigated through easily accessible and appropriate breastfeeding resources, and nurses are in an ideal position in helping women obtain those resources. Tactics such as medical evaluation of infant anatomy (palate) and support with proper positioning techniques can alleviate many common causes of nipple pain (Gianni et al., 2019; Westerfield et al., 2018). Furthermore, the belief that one must endure pain in order to breastfeed can be avoided with thorough, individualized guidance. Specially trained nurses and/or lactation consultants can council women on the physiology of engorgement, lactation, and infant nutritional requirements through early and continued follow up regarding any breastfeeding issues during routine post-partum and pediatrician visits (Gianni et al., 2019; Sinusas & Gagliardi, 2001; Westerfield et al., 2018). However, nurses need to be educated on all issues regarding breastfeeding and not shy away from asking women about any difficulties they may be experiencing (Radzyminski & Callister, 2015). The CDC Breastfeeding guide (Shealy et al., 2005) outlines 10 steps that hospitals and/or clinics can take in improving breastfeeding rates, including having a written breastfeeding policy that is routinely communicated to staff, educating staff in breastfeeding skills, rooming-in for mothers and babies, and giving newborn infants no food or drink other than breastmilk unless medically indicated.

Our results also show that support from family, peers such as other women who have breastfed, professionals, and one’s community are instrumental in breastfeeding success and could improve health equity among women of low SES. The input from these individuals, described by the women in the included studies, was overwhelmingly negative and/or absent. Many research studies have shown the importance of a supportive social environment in encouraging any positive health behavior change. For example, Child et al. (2017) found that among a group of low SES adults, having a close contact who is physically active significantly increases an individual’s likelihood of exercising. This idea of positive community and peer involvement could translate into pro-breastfeeding behaviors among new mothers, but from our findings could be particularly important for women of low SES. Carlin et al. (2019) found that normative infant feeding practices observed in mothers’ social networks had a significant impact on their breastfeeding practices. Having someone with breastfeeding experience within their social network was an important factor in their ability to continue to breastfeed. That said, the context of work, work demands, and the potential inflexibility of employers of women of low SES who choose to breastfeed is an area warranting future investigation as employment and a mother’s social network may be closely related. Improving community education and support of breastfeeding practices such as peer-teaching and establishment of breastfeeding-friendly communities could impact equity efforts among this group and potentially increase breastfeeding rates among women of low SES. La Leche League International is one such community organization that has been in existence for decades and uses mothers who have breastfed as their leaders. However, organizations such as this may be of limited use for low SES women who work or lack child-care and/or transportation to attend meetings. The CDC (2005) Breastfeeding guide suggests that potential action steps that would assist further in increasing health equity could include state level funding for peer counseling services for Women, Infants, and Children Supplemental Nutrition Program participants and improving the quality of existing peer counseling in this program through additional training of the counselors.

Even if interventions are implemented, increasing the rates of breastfeeding may never be realized until the public’s image of breasts as only sexual objects is overcome. In our qualitative metasynthesis there was a strong perception that breastfeeding was not viewed by the public, and even the women, as simply a normal way to feed infants. The CDC (2005) Breastfeeding guide recommends media and social marketing to strengthen a community’s perception that breastfeeding is a normal activity. However, the guide could not provide any current evidence-based interventions to use to increase the public’s acceptance of this activity. Potential action steps they could recommended would be to elicit support from local experts or breastfeeding mothers to highlight and educate the public on the benefits of breastfeeding. Other activities suggested included running public service announcements to encourage breastfeeding, working with state policy makers to draft legislation to ensure women’s rights to breastfeed in public places, and/or creating mothers’ lounges that are not part of restroom facilities to allow breastfeeding in private.

Limitations

Due to the specific inclusion and exclusion criteria listed, only 11 research reports were found to meet the search criteria. Despite this limitation, the findings from these studies helped construct a representation of the experiences of low-income women from diverse backgrounds across the United States. Another limitation of this study is that although the CASP checklist was used to evaluate the quality of each research report, the different analysis techniques and approaches used make it difficult to fully interpret the transferability of our findings. However, our model can be used to guide future studies, both qualitative and quantitative, to further parse out the barriers and facilitators that low-income women experience in their attempts to breastfeed their infants. Our findings are not intended to represent all American women of low SES but should be taken as an opportunity for further investigation on this topic. Furthermore, limited recent research on this topic indicates a need for further research in this area. The better we understand women’s experiences of breastfeeding in the context of poverty and the structural and systemic factors that contribute to disparities in support for breastfeeding, the better we can help women make informed and healthy decisions about infant feeding.

Conclusion

The Breastfeeding Experience and Support Model for Low-Income Women was created to depict the shared breastfeeding experiences of low-income women across the United States Shared narratives from members of one’s social network and knowledge of breastfeeding physiology are important factors in influencing breastfeeding behaviors, or lack of, among mothers of low SES in the United States. Lack of education and preparation from health care professionals, along with limited support and follow up can negatively influence a mother’s decision to breastfeed and her ability to continue breastfeeding in the future. Additional research is needed on the specific types of education and guidance as well as community and peer support that would most benefit breastfeeding practices among this population. The Breastfeeding Experience and Support Model for Low-Income Women can provide a starting point for informing future programs in health clinics and for future studies.

Author Biographies

Karry Weston, MSN, RN, is a PhD Candidate at the University of Missouri Sinclair School of Nursing, Columbia, MO, USA.

Allison Brandt Anbari, PhD, RN, CLT, is an Assistant Professor at the University of Missouri, Sinclair School of Nursing, Columbia, MO, USA.

Linda Bullock, PhD, RN, FAAN, is an Adjunct Professor and Professor Emerita at the University of Missouri, Sinclair School of Nursing, Columbia, MO, USA.