WIC peer counselors’ perceptions of breastfeeding in African-American women with lower incomes

Abstract

Background

African-American women have the lowest breastfeeding rates among all racial/ethnic groups in the United States. Peer counseling is an effective intervention in improving breastfeeding in this population. However, little is known on peer counselors’ perceptions of breastfeeding in African-American women.

Objectives

As part of a larger qualitative study, the goal of this study was to understand the contextual factors influencing breastfeeding decisions of low-income African-American women from the perspective of breastfeeding peer counselors (PCs).

Methods

Three focus groups were conducted with 23 PCs from the WIC program in a Southeastern state. All focus group discussions were audio-recorded, professionally transcribed, and analyzed using thematic analysis. Bronfenbrenner’s socio-ecological model was used to group categories into themes.

Results

Of the sample, 48% were African-American, 78.2% were married, 56.5% had some college education. Five main themes emerged to describe factors at multiple-levels influencing breastfeeding in PCs’ low-income African-American clients: Individual, Microsystem, Exosystem, Macrosystem, and Chronosystem. Novel findings included 1) having breast-pumps may give African-American women a “sense of security”, 2) cultural pressures to be a “strong black woman” can impede breastfeeding support, and 3) breastfeeding “generational gaps” have resulted from American “slavery” and when formula was “a sign of wealth”.

Conclusions

As PCs described, low-income African-American women breastfeeding decisions are impacted by numerous contextual factors. Findings from this study suggest a need to broaden public health approach to breastfeeding promotion in this population by moving beyond individual characteristics to examining historical and socio-cultural factors underlying breastfeeding practices in African-American women.

Background

African-American women have the lowest breastfeeding rates in the United States of all racial/ethnic groups. For African-Americans, the breastfeeding rate is 58.9% at initiation, 30.1% at 6 months, and 12.5% at 12 months.¹ Although breastfeeding trends in the African-American community have improved significantly over the past decade, rates are substantially lower than Healthy People 2020 objectives of 81.9% at initiation, and 60.6 % and 34.1% at 6 months and at 12 months respectively.¹

One intervention shown effective in improving breastfeeding initiation and duration is peer counseling.^2–8 Given the success of peer counseling, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in the U.S. expanded its breastfeeding education to include the Breastfeeding Peer Counseling Program.⁷ A WIC Peer Counselor (PC) is a “paraprofessional support person who gives basic breastfeeding information and encouragement to WIC pregnant and breastfeeding mothers.”⁹ To be a WIC PC, a woman must have breastfed at least one child for six months or longer and be a current or previous WIC participant. Evaluation studies have reported increased breastfeeding initiation rates in WIC clinics offering peer counseling services as well as program satisfaction from both WIC participants and PCs.^10–15 This is of keen importance since WIC serves low-income women and children in the United States, of which 19.8% are African-American.¹⁶

Several studies have noted positive findings specifically with WIC peer counseling and African-American women.^17–21 In the Maryland WIC program, African-American women receiving PC support were more likely to initiate breastfeeding compared to those receiving standard care or lactation counselor support.¹⁹ A focus group study in a primarily African-American sample of WIC participants found women had positive experiences with their WIC PCs and received positive social support.²⁰ In metropolitan New York, an ethnographic study of WIC clinics found African-American women viewed WIC as a supportive environment, a “trusted source of assistance”, where WIC providers were sensitive and attentive to women’s individual needs.²¹

Despite these positive findings, a recent literature review on breastfeeding in African-American women revealed that they are met with discrimination from healthcare providers who may assume they do not intend to breastfeed.²² In a survey of WIC clients in Brooklyn, NY, African–American women received less breastfeeding information from their physicians and also WIC nutrition counselors than White women.²³ Although African-American women report positive experiences with their WIC PCs, there is a gap in the literature regarding WIC PCs’ attitudes and perspectives on breastfeeding practices of their African-American clients. In one study, community health workers (CHWs) providing peer support to African-American mothers were able to describe multiple barriers to breastfeeding in their African-American clients.²⁴ However, the CHWs differ from WIC PCs in that they have not received extensive training in breastfeeding support nor were hired based on their history of successfully breastfeeding.

As part of a larger qualitative study exploring the long-term breastfeeding experiences of low-income African-American women,²⁵ we sought the perspective of WIC PCs who serve this population. Not only do WIC PCs professionally support low-income, breastfeeding African-American women in their communities, but they also serve as “peers” who breastfed their own children. Therefore, it was believed they can share dual perspectives on the facilitators and barriers to breastfeeding during their care for low-income African-American women. The aim of this study was to understand the breastfeeding norms and behaviors of low-income African-American women and the larger context influencing their breastfeeding decisions through the perspective of WIC PCs.

Methods

A focus group design was employed for this study because it allowed researchers to gain perspective of multiple PCs who have had various experiences supporting African-American women to breastfeed.²⁶ During June-July 2013, focus groups were conducted with WIC PCs at three health departments in a Southeastern state.

Sample selection and recruitment

Purposive sampling was used to allow selection of participants “whose input will illuminate the questions under study.”²⁷ Breastfeeding coordinators for the WIC program in local health districts were contacted via e-mail to introduce the study and invite PCs to participate. Not every WIC office in this state had the Peer Counseling program. Four breastfeeding coordinators from three health districts expressed interest in the study and provided study information to the PCs under their supervision. Recruited focus group participants were women currently employed as a WIC PC, who had African-American mothers on their caseload, and had been a PC for ≥1 year. This study was approved by the University of Georgia Institutional Review Board.

Focus group facilitation

Three focus groups were held with 23 WIC PCs. Each focus group had 7–8 participants.¹⁴ Focus group 1 (FG1) was held in a rural district, focus group 2 (FG2) was held in a more suburban district, and the last was held in a (FG3) metropolitan district of a large city. Each focus group was facilitated by the principal investigator (PI) and a research assistant (RA) (both African-American women). The PI moderated the focus groups and the RA observed group discussions and took notes. The focus group guide was first reviewed by three experts who have worked with WIC on breastfeeding. Then a mock focus group was conducted with female public health graduate students to pilot test focus group protocol. Each focus group lasted approximately 90 minutes. As a scheduling convenience for PCs, each focus group was conducted immediately following a prescheduled WIC staff meeting at their respective health departments. Upon obtaining informed consent from each participant, the focus group commenced and was audio-recorded and transcribed within 48 hours by a professional transcription company. At the end of the focus groups, each participant completed a brief demographic form and received a $20 gift card to a local retailer as an incentive for participation.

Data analysis

Data saturation occurred after the third focus group when no new patterns emerged, and therefore, data collection ended. Thematic analysis was used to deductively analyze the focus group transcripts.²⁸ The PI and RA familiarized themselves with the data by reviewing audio files and notes from the focus groups. Mind maps were also created to help draw connections between ideas expressed by participants.²⁹ Transcripts were double-checked for accuracy with the audio-file. After preliminary analysis of the FG1 transcript, the PI created a codebook for initial coding of the transcripts. Brief memos were used to explain why each passage was considered important to the research objective to aid in building categories.³⁰ After independently coding the transcripts, the PI and RA met weekly to compare coded transcripts and reach agreement about the categories. Bronfenbrenner’s socio-ecological model was used to group categories into themes.³¹ Trustworthiness was established through the following methods: expert review and pilot testing of focus group protocol, triangulation of focus groups from different regions, monthly peer debriefings with co-authors, maintaining a research reflexivity journal, member checking with several PCs following data collection, and having two data analysts.³²

Results

Twenty-three women participated in the focus groups, with half being African-American. Median age was 34 years and the median length of employment as a WIC PC was 3.5 years (Table 1). The racial composition varied between focus groups, which help provide a variety of perspectives: FG1–50.0% African-American, 25.0% White, 12.5% Hispanic, 12.5% Other; FQ2–50% White, 37.5% African-American, 12.5% Hispanic; FG3–57.1% African-American, 28.6% Hispanic, 14.3% Other. Five themes emerged using the socio-ecological model: Individual-knowledge and attitudes; Microsystem-interpersonal relationships; Exosystem-community environment; Macrosystem-cultural norms; and Chronosystem-historical context (Tables 2–6). Themes are described using quotes with participants’ pseudonyms, focus group, and race.

Table 1.

Characteristics of Participants (Footnote: FG1 n=8, for FG2 n=8, and FG3 n=7)

Variable	Peer Counselors Sample (n=23)
Age (median)	34.0 years     IQR: 8.0
Race  Black  White  Hispanic/Latino  Other	47.8% 26.1% 17.4%   8.7%
Relationship Status  Married  Cohabiting  Single  Divorced	78.2 %   4.3% 13.0%   4.3%
Education level  High school diploma  Some college  College degree	8.7% 56.5% 30.4%
Number of children (median)	3.0 children    IQR: 2.0
Length of BF (median)	15.0 months      IQR: 11.4
Length of employment as PC (median)	3.5 years      IQR: 4.3

Table 2.

Individual Level of Influence

Knowledge and Attitudes
Knowledge	A lot of them are not educated … our paperwork has to be on a 6th grade reading level. (Ryan-Nai, FG1, Multiracial) A lot of them don’t understand that formula’s not the same (Keke, FG1, African-American) What I find, a lot of them just don’t know there is a difference between breast milk and formula… I mean it’s a lot that stuff they don’t know. (Sha’Rondah, FG1, White) I decided to start asking them “What are the benefits of formula” instead of just talking about breastfeeding… So, educating them more about the FORMULA seems to open their eyes (Eve, FG2, African-American) It’s important to educate them on how the body makes the milk and how everything works when it comes to breastfeeding. (Buttefly, FG3, Hispanic.) They don’t realize how great [breastfeeding] is for them and – it’s really the duration that gets the great benefits for them (Faith, FG3, African-American)
Confidence	You also have those moms who come in with these horror stories and they’re just like, “Oh, maybe I can’t do it.” (LaKeysha, FG1, African-American) I don’t see a lot of moms that have that determination, “Come hell or high water, I’m gonna do this.” “If it gets a little bit difficult, I’m done.” (Sha’Rondah, FG1, White) It comes down to their confidence level. If they’ve got all of these barriers, it’s going to bring down their confidence (Angela FG2, African-American) You have to give them a way around all of the obstacles. Then once they can see it and fit it into their schedule, then they’re more than willing to go through… some of these hard areas in breastfeeding (Lola, FG2, African-American) Pumping Well, she just KNEW in her mind she needed one. And she called me every day SINCE then, “I’ve GOT to have this pump.” So that’s why yesterday I agreed to get her a hand pump because regardless of protocol, if it’s an African-American woman, I’m going to get her that pump. ’Cause that’s the only way I know I’ll be able to keep her. (Ivy, FG2, White) Even if the thing with the pump. How would you HEAR about a pump? WHO told you about a pump? But, you come in automatically knowing NOTHING… about breastfeeding [laughter]…but you know you need to get that pump … (Eve, FG2, African-American)
Body Image	The thought of a baby being on their nipples, their breast, really disgusts them and they think it’s [breastfeeding] nasty…but I think a lot of it is like a negative self-image, a body image. (Candi, FG1, White) So they use it [breasts] for sex and not nutrition. (Keke, FG1, African-American) They are taught to not touch their breast. They don’t do self-exams. They don’t know about doing any of that. They’re uncomfortable with seeing their selves, even seeing their selves naked or something like that. So, to have a child on them would be a problem. (Ryan-Nai, FG1, Multiracial) When we look at African-American women and you look at a Hispanic woman, and … a Caucasian woman and you just look at her physical appearance, we’re usually very full-figured women. Like, we’re not small…“I can’t breastfeed because my breasts are too big.” And then sometimes it is a thing where their breasts were too small, their nipples are too small. (Faith, FG3, African-American) I think the African-American woman views her body very different. I think the media, it’s more of a sexual object. Just ask any young African-American woman that comes into the WIC office….Sometimes you can even tell by the way we dress. (Eve, FG2, African-American) The more people see mothers breastfeeding in public, those mindsets are going to be falling down, that breastfeeding is something that needs to be done in private. (Victory, FG3, Hispanic) Molestation/Abuse And I also think that because of the lifestyle that they live, a lot of them get…raped. (Mulata, FG1, Hispanic) Some of the mothers could have been molested and they probably look at it being negative as if somebody touch their breasts that they probably feel like they’re gonna basically molest their child. (Queen, FG3, African-American) Lots of women, African-American especially…experience abuse and so… back to that word nasty….You always have to wonder or be mindful that it could be the case. (Angela, FG2, African-American)

Table 6.

Chronosystem Level of Influence

Historical Context

Slavery & Generational Gaps

Because like African-American women we breastfed, we use to even wet nurse back in slavery. So it’s not something that is abnormal to our culture, our ancestry should I say, but it’s abnormal to our culture NOW. (Faith, FG3, African-American) My mom talks about how, although she breastfed, she wanted to be in and use formula because it was kind of a sign of wealth if you could because if you couldn’t afford to do formula you breastfeed. So, it was almost like, okay you’re poor. So, you have to. But moms who could afford to buy formula, they were wealthy and in fact, you can give your baby a bottle. So, it was kind of a status thing for the ladies in my mom’s generation. (LaKeysha, FG1, African-American) And it [breastfeeding] is certainly something that we lost HOLD of or lost a grasp of whether it’s from not seeing it over the generations or seeing it on TV or not being expected of us… Or maybe that was expected of us and we went AGAINST that. I don’t know. (Angela, FG2, African-Amerian) With my own personal experience that my mom didn’t breastfeed. My sisters didn’t breastfeed. So… there are a lot of generational gaps that not only … I think when the woman says, “I don’t want to breastfeed and I have all these things going on, ” If you dig a little bit DEEPER, then you’ll kind of find some history behind that. And it’s more than just the JOB and just the BOYFRIEND or the DAD. It’s some stuff that runs REAL deep that still is passed through generations. (Eve, FG2, African-Amerian) Most of the people that were on WIC were the lower level African American families, some middle class African American families. But the African American families seemed like they were always on WIC. You have your low class, Caucasian, and Hispanics…but it’s like African Americans have always been on WIC and so they figure because of their socioeconomic status this is part of the norm. And so then they make their decision about how to feed their babies off of WIC and they learn the system. (Faith, FG3, African-American) We have the highest rates in high blood pressure, highest rates of diabetes. We have the highest…I mean lowest high school graduate rates, the highest… And yet still, you’re wanting to feed your child something that’s going to make them dumber. (Keke, FG1, African-American) Us just as African American people, we deal with a lot more high-risk for anything from diabetes, to breast cancer, to all these other health issues that may come about…It really is NECESSARY to give these parents for the future generation to try and promote, and maybe lower the risk for eliminating it altogether because that’s their best health care right there. (Ms. Determined, FG3, African-American)

Individual

Knowledge

Overall, PCs described that their African-American clients have both low educational attainment and knowledge deficits regarding why “formula’s not the same” as breastmilk, how mothers’ bodies produce breastmilk, and how breastfeeding benefits are connected to longer durations.

Confidence

PCs agreed in recent years, more African-American mothers are interested in breastfeeding and desire more education. However, PCs acknowledged if African-American clients feel they have too many barriers to breastfeeding, “it’s going to bring down their confidence.” In FG2, there was an interesting discussion around breastfeeding confidence and pumping since WIC offers free breast-pumps.

If I have a relationship with an African-American woman, I know that the pump is going to be a big deal. And it will solidify the fact of whether she is going to breastfeed at all, let alone long-term. (Ivy, FG2, White)

The pump IS a lifesaver for them. It’s a backup plan in case that it just doesn’t flow like it’s supposed to, and a lot of times it doesn’t. Because I’ve seen more premature babies. I see more moms that have to go back to work. So why transition over to a bottle…from the breast…They don’t want any more hurdles then they have to. So I don’t frown upon them if they do get the pump because this is their sense of security right now until they get that confidence in what they’re doing. (Lola, FG2, African-American)

Body Image & Sexuality

PCs discussed their African-American client’s attitudes related to a negative body image with breasts seen as objects “for sex and not nutrition” and commonly called “titties.” Breastfeeding is often viewed as “nasty”. Relating to the finding on breast-pumps and confidence, a PC shared this example:

She was uncomfortable putting the baby on her breast and didn’t want to…I said, “I’ll work with you however you want to do this.” We talked about pumps, we talked about shields – just not putting the baby on her breast. (Candi, FG1, White)

Several African-American PCs linked negative body image to how African-American women are more “full-figured” and how the media portrays their bodies as a “sexual object”. In each of the three focus groups, PCs mentioned that a history of molestation or abuse can also underlie why African-American clients may not want to breastfeed. PCs explained that these attitudes around breasts and breastfeeding lead African-American mothers to believe “breastfeeding…needs to be done in private”.

Microsystem

Family

When asked, what enables mothers to breastfeed for six months or longer, PCs echoed “support.” PCs viewed grandmothers and infants’ fathers as the most influential persons to support or discourage an African-American woman in breastfeeding. For single-mothers and teen mothers, PCs emphasized that a grandmother “sometimes…plays a bigger part than the dad does.” Examples were shared of African-American clients who encountered positive or negative family support. PCs discussed that negative family support in many African-American families is due to lack of exposure to and experience with breastfeeding compared to formula feeding.

Peer Counselors

PCs shared their African-American clients have often said “you’re the only support I have” to breastfeed. Their role in supporting clients, who often have limited support, was described as “crucial”. As peers, PCs’ support often included support for non-breastfeeding issues. In terms of serving African-American clients, PCs described how they center personal breastfeeding goals on their clients’ lifestyles. In turn, this means PCs may encourage any breastfeeding over recommendations for exclusive breastfeeding or longer breastfeeding durations.

I try to give moms permission and let them know, “It’s okay. You can breastfeed and give formula.”…because they will ask, “How long should I breastfeed?” And, then if you say what the American Pediatrics recommends…It’s a wrap. They’re like, “Oh, well I can’t breastfeed…I’m not going to even do that.” But, letting them know it’s not all or nothing. (Eve, FG2, African-American)

When PCs did discuss exclusive breastfeeding or long-term breastfeeding, these were seen in African-American clients as “rare” cases.

Exosystem

WIC

WIC was viewed by PCs as the primary and often only source of breastfeeding education for their African-American clients. Given that WIC targets families with low socioeconomic status, “free resources”, such as WIC’s breastfeeding classes, peer counseling services, and breast-pumps, were seen as especially important to African-American clients.

Healthcare System

PCs felt African-American clients were not being supported enough by healthcare providers to breastfeed. If African-American mothers don’t initiate a conversation about breastfeeding, then PCs felt that their healthcare providers will not either. One PC believed race played a factor.

A lot of doctors, that are other races, an Indian or African-American…those are the ones that usually lean more towards…having their…patients breastfeed. Whereas, the Caucasian doctors with the African-American moms don’t really talk about it. (Ryan-Nai, FG1, Multiracial)

PCs were adamant that African-American clients received hospital support that contradicted breastfeeding, such as limited or no visits by lactation staff, “6 pack of formula” samples, and infant formula supplementation. Moving toward Baby-Friendly hospital practices, PCs agreed would improve clients’ breastfeeding rates. PCs know African-American women are at higher risk for adverse birth outcomes (ie. Cesarean delivery, blood transfusions), and shared that these impact breastfeeding initiation. Yet, one PC thought doctors do promote breastfeeding for premature infants.

Because they have a preemie…The doctors have been telling “If you want to take this baby home you need to do it ” … I have more African-American moms who breastfeed because of that than anything else.” (LaKeysha, FG1, African-American)

Employers

Workplace support was pinpointed by PCs as important for continued breastfeeding for African-American clients.

Out of all of the cultures African-American women probably more than likely are the ones that are at the top that go back to work the soonest. (Lady-S, FG3, African-American)

Since many of PCs’ clients work in the fast-food or retail industries earning minimum-wage pay without benefits, they return to work usually within six weeks after birth. PCs do teach clients their legal rights to breastfeed. However, PCs expressed their African-American clients are “scared to ask their employers” about breastfeeding accommodations, fearing being terminated or having their work-hours reduced.

Media/Internet

PCs critiqued the media and internet for “not doing … justice” in promoting positive images of African-American breastfeeding women. They described that clients often believe what they read online, turning to blogs and YouTube for breastfeeding information. PCs described a lack of visibility of African-American women breastfeeding in the media.

And there are no commercials on TV, NONE, that show a black woman is breastfeeding. There’s a Luvs commercial that’s on MTV…But there is no positive images of black moms breastfeeding in the media. (Sharondah, FG1, White)

Macrosystem

Breastfeeding Norms

PCs expressed their African-American clients have several negative breastfeeding attitudes. African-American clients “don’t see other black women in their community” breastfeeding and grow up normalized to formula feeding (bottle feeding). Thus, PCs said formula feeding is perceived as “normal” and a better fit with clients’ busy lifestyles.

They’re born in a community that it’s being said over and over again, “They don’t breastfeed, they don’t breastfeed.” …So they grow up thinking, “I don’t breastfeed.”…That’s the mindset because of their culture, their environment, (Victory, FG3, Hispanic)

Other breastfeeding attitudes that PCs reported hearing from African-American clients are breastfeeding is only for stay-at-home mothers and White women, and breastfeeding may “spoil the child”.

Womanhood Norms

In FG1, a conversation emerged on the “strong black women image”, meaning African-American women are taught to be strong, independent, and not display signs of weakness. PCs discussed how this image may impacts clients’ willingness to seek breastfeeding support.

I tell them in my classes sometimes…“I have to call you ‘cause you’re not gonna to call me.” A Black woman will rarely reach out for help. She got to be down with a nipple falling off her body before she can reach out. And IF she calls you…She would just rather go to formula and keep it moving. So, pride is our enemy. (Cleopatra, FG1, African-American)

The worst nipple cases I’ve ever helped were all Black. Yup. That’s probably one of the reasons. (Sha’Rondah, FG1, White)

Similar comments were described from PCs in FG2 around breastfeeding, vulnerability and African-American women. African-American clients were said to have “grand and great” responsibilities outside of motherhood which PCs believe make breastfeeding challenging.

I feel SHE, an African-American woman, never gets to just BE. I feel like everything is expected of her. She has that baby and instantly [snaps fingers], she got to be in control …everybody’s watching her…She NEVER even got her down time. She just had this baby. She never even got A moment’s peace. (Ivy, FG2, White)

Wanting to prove that you can be a model woman…There’s all kinds of cultural changes that breastfeeding went through, but to be vulnerable…is NOT the norm…It’s not allowed for…most women, but certainly in African-American culture. And you ARE vulnerable when you are breastfeeding. (Angela, FG2, African-American)

Chronosystem

Slavery& Generational Gaps

African-American PCs, particularly in the FG1, shed light on the unique historical context of breastfeeding in African-American women. Their comments traced breastfeeding stigma to American slavery when African slaves served as wet-nurses, or mammies, to their owners’ children.

Slavery! And to be honest I do because a lot of black women… use it as an excuse…“I don’t want to be seen as a mammy, ”… It’s sad and this is the South… they still think that way. And a lot of Black women, their grandparents chose to formula feed simply because, “Well, my grand mama said, she got tired of being this White woman’s mammy.” …They started formula feeding simply because they could do it. And that’s what I hear. (Keke, FG1, African-American)

Comments also described when formula was “a sign of wealth… because if you couldn’t afford… you breastfed.” One PC in FG3 added that historically, whether lower or middle class “African-Americans have always been on WIC, ” which is known for providing supplemental formula. These historical events have led to “generational barriers,” with PCs reporting that few clients have seen someone breastfeed. In turn, PCs shared that breastfeeding is now viewed as “abnormal” in African-American culture. African-American PCs stressed the importance of improving breastfeeding in their communities to combat their disproportionate burden of health disparities.

Discussion

This is the first study to our knowledge to gather the unique perspectives of PCs regarding breastfeeding in the low-income African-American women they serve through the WIC program. The findings support the literature that individual level factors, such as gaps in breastfeeding knowledge, low breastfeeding confidence, and negative body image do influence African-American mothers’ decisions to breastfeed.^{22, 33–41} More importantly, there are other complex contextual factors from African-American women’s interpersonal relationships, community, culture and history also at play.^{22, 33–41} Our novel findings include breast-pumps may give African-American women a sense of security, cultural pressures to be a strong black woman can impede breastfeeding support, and cultural breastfeeding norms have been impacted from American slavery and when formula was viewed as a status symbol.

Breast-pumps- Confidence, Body Image, and Culture

PCs described the value African-American clients placed on breast-pumps as if having access to one was an indicator of whether they could successfully breastfeed. In one qualitative study specifically on pumping and milk supply concern found mothers gained “additional control over breastfeeding from pumping”⁴² African-American women may view pumping as not only as a free WIC resource to fit breastfeeding into their busy schedules, but also as a strategy to circumvent their attitudes around breasts and bodies as sexual objects with breastfeeding being nasty and culturally abnormal. PCs in our study reported on African-American women’s lack exposure to other breastfeeding women in their families and communities, cultural norms for bottle-feeding, and anxieties around breastfeeding in public are consistent with the literature.^{22, 33–41} Therefore, African-American women may see pumping breastmilk as a more culturally appropriate means to breastfeed.

Strong Black Women and Breastfeeding Support

The strong black woman image described by PCs is referred to as multiple constructs in Black Feminist literature, such as the Superwoman Schema or Sojourner Syndrome.⁴³ PCs, both African-American and of other races, described that their clients will often not reach out for breastfeeding support or accept support when offered. In an ethnographic study, being independent or “soldiering” was described as an influencer of the infant-feeding decisions of Black women enrolled in WIC.³⁷ This finding is consistent with literature describing the Superwoman role as a survival mechanism for African-American women.⁴⁴

Historical Events and Breastfeeding Stigma

African-American PCs specifically touched on breastfeeding’s journey in their unique history complicated by both race and class as women. A recent literature review on infant-feeding in African-American women confirms our findings on breastfeeding cultural beliefs stemming from slavery and how a history of aggressive formula advertising contributed to views of formula as a status symbol.³⁵

Limitations

This study was conducted with a small, non-representative sample of WIC PCs in a Southeastern state. Results may not be transferable to other populations. PCs provided their perspectives on breastfeeding behaviors of their African-American clients. If focus groups were conducted with African-American women themselves, findings may have been different. Breastfeeding exclusivity was not specifically addressed in this research. Our findings suggest that due to African-American women’s busy lifestyles, PCs focus on promoting any breastfeeding even if their clients have to supplement with formula. This study is unique in viewing WIC PCs as community experts and assessing their knowledge of the contextual factors surrounding breastfeeding decision of African-American women.

Conclusion

Although more African-American women are initiating breastfeeding, their decisions are influenced by a host of both personal and contextual factors. Research to improve their breastfeeding rates must transition from assessments of risk factors to evidence-based interventions.⁴⁵

The findings of this study present several implications for research and practice. African-American women should receive comprehensive breastfeeding education not only from WIC but also their healthcare providers. Care should be taken to ensure mothers’ individual anxieties about breastfeeding are addressed and that breastfeeding recommendations are balanced with their lifestyles. Breastfeeding education should extend to African-American women’s family members to promote positive social support. WIC PCs should receive training on cross-cultural counseling and how to advocate for African-American mothers receiving limited social support. To negate the Superwoman norm, PCs can lead support groups with African-American mothers to share ways to overcome breastfeeding challenges and to foster sisterhood and peer support.

The WIC program has the capacity to provide breastfeeding education to large numbers of African-American women, which warrants expansion of its breastfeeding programs, specifically peer counseling and breast-pump loans. Healthcare providers should be educated on the history of breastfeeding in African-American culture as well as how to provide culturally-tailored breastfeeding support. Hospitals should implement Baby-Friendly practices so that African-American mothers are certain breastfeeding is the optimal form of infant nutrition. African-American women should be informed of their legal breastfeeding rights using handouts on the Affordable Care Act and counseled on discussing workplace accommodations with their employers. The media can enhance these suggestions and combat historical stigma by promoting positive images of African-American women breastfeeding, such as those in the It’s Only Natural campaign.

Other scholars have suggested a Black Feminist approach to research breastfeeding in African-American women.^{22, 40, 46} This approach acknowledges African-American women’s unique standpoint based on their history of intersecting oppressions by race, gender and class, and therefore, research centers around their lived experiences.⁴⁷ Studies have qualitatively examined the role of culture,^{41, 48} but few have examined the role of history. In terms of future research, our findings also suggest exploring the roles of culture and history as these factors may better explain the breastfeeding disparities seen in African-American women.

Table 3.

Microsystem Level of Influence

Interpersonal relationships
Family	When you speak about the African-American culture…our strongholds, are going to be our significant others and our moms. (Faith, FG3, African-American) I don’t think it’s employment, finances. Family has a huge, huge impact on the Black woman. (Keke, FG1, African-American) The family is watching the baby while she’s at work. And they refuse to prepare the breast milk so she just couldn’t do it… They weren’t on board with it… Even the husband was not supportive. So even though when she came in, she said she really wanted to TRY, she had no support at all. (Susan, FG2, White) I’ve actually been in a hospital setting, and this has happened to me more than once with an African-American mom. And the support people that are WITH her, the grandmothers, the aunties. They literally BASH her in front of me… They also look at her and say, “Those titties are UGLY. Nothing’s gonna NURSE off those things. Put those ugly things away. Nobody wants to see them…” Very blatant. The whole room will LAUGH heartedly about the ugly titty joke…. I was like flabbergasted standing there. (Marie, FG2, White) It’s not that the families are just out to just be negative. It’s just maybe that sometimes it’s the tone, sometimes it’s facial expressions, and sometimes it is words…They are trying to be supportive. It’s just the way that they’re doing it comes out negatively to the mom… [The dad]thought by giving her an option to give the baby formula that was his way of being supportive, but in reality what it was doing was it was turning her away from breastfeeding. (Lady-S, FG3, African-American) When couples come to the class, my African American dads, over any other culture that I’ve taught, even Hispanics and Caucasians, after I’ve given them the information that they need, they are the first ones to turn around and support their partner on breastfeeding. (Butterfly, FG3, Hispanic)
Peer Counselors	She has been calling me at all times and she tells me, “You are the only support I have, ” because everybody else is criticizing her for breastfeeding. (Victory, FG3, Hispanic) And I always tell my moms…take it day-by-day and see how far you go and don’t put a goal. (Ana, FG2, Hispanic) It’s good for us to know the law and be able to go in and speak to those moms because again, I think as peer counselors, we tend to be that voice…. “Hey, we have your back. We are here for you as a group, not just peer counselors but just as moms who breastfeed.” (LaKeysha, FG1, African-American) I think our jobs become crucial when African-American or not when there is no support. That’s really where what we do comes into play and it’s very important that we can get to talk to them because you know, we may be that person that makes it happen. (Susan, FG2, White) We would against the policy get into areas that were not quite breastfeeding, but-You CANNOT separate that from anything else. You’ve got to understand…. They have conflicts…. But it always get back ’round to breastfeeding. (Lola, FG2, African-American)

Table 4.

Exosystem Level of Influence

Community Environment
WIC	Most of the moms that we help…this [WIC] is the only education that they get about breastfeeding (Candi, FG1, White) It’s kind of rare that you find a free breastfeeding class (Summer, FG1, African-American) Free resources, that’s what I meant to add. (Faith, FG3, African-American) Free information, free support…Free resources. (Butterfly, FG3, Hispanic) It [free resources] makes a big difference. (Ms.Determined, FG3, African-American) Now we do have a lot of brochures. We have a lot of peer counselors and a lot of programs out there. (Destiny, FG3, Indian)
Healthcare System	With a lot of African-American mothers, they will not go ahead and talk to the doctor about wanting to breastfeed or thinking about breastfeeding. And if the doctor does not mention it at the hospital during the labor or right after the delivery, they don’t mention it either. And they’ll just go ahead and let them give the baby a bottle (Ryan-Nai, FG1, Multiracial) She said NO ONE had said anything to her about breastfeeding. They didn’t. (Angela, FG2, African-American) As soon as you have your baby, you get a 6 pack of formula, just in case. So it’s like they plant this seed on your head telling you, “Oh, you’re not making enough milk for your baby. (Butterfly, FG3, Hispanic) Also it’s good that the hospitals are going toward the baby friendly and all those things, but there’s a lot of things that need to be done still. (Victory, FG3, Hispanic) They’re a VERY baby friendly hospital. But I think that’s a HUGE thing. I think that if more hospitals could put that into play, it would be easier…It might be easier to initiate breastfeeding. (Susan, FG2, White)
Work	Because they’re like, “Yeah, BUT…I got to go back to work.” (Marie, FG2, White) The only jobs left in our counties are working in the food industry, working at McDonald’s, Burger King, at Wendy’s, working at Wal-mart. Working at all of these places, they don’t get the time off. They can’t. they’re teenagers and they are single parents…they have to go back to work… Either they are going to lose their job and they’re not going to get bills paid… It’s like they just don’t have a choice. (Ryan-Nai, FG1, Multiracial) The moms that I deal with. They have retail jobs and they’re scared to ask their employers. (Candi, FG1, White) Our moms are scared to talk to their employers about pumping at work. (Sha’Rondah, FG1, White) She works a long job…can’t pump doing the job. But… therefore had several episodes of mastitis (Lola, FG2, African-American) I think if you can be a stay-at-home mom, or if you have a job that allows it to be a little bit easier (LaKeysha, FG1, African-American) If a mom can stay home longer, then her commitment to breastfeeding will increase. It’s really just that simple. And unfortunately, our country doesn’t support a mom in that. (Cleopatra, FG1, African-American)
Media/Internet	I called this generation…Googler. Everything we talk about, I’ll tell or I’ll ask, “Go ahead and Google it so you see what I’m saying is not a lie”. (Mulata, FG1, Hispanic) That will be a definite big influence if the MEDIA, social media, would just promote breastfeeding. (Eve, FG2, African-American) They think blogs are facts. Blogs are not facts. (Sha’Rondah, FG1, White) In most cases the blogs and all the information you’re seeing on the Internet are coming from White women and you don’t have that relate-ability to where… There aren’t many black sites where you see a black mom telling another black mom to do it. (LaKeysha, FG1, African-American) Or you [Google search] come up with someone from Africa that…not someone that looks like you. (Candi, FG1, White) I had some younger moms and they were talking about breastfeeding and how You Tube tells you to do it…. And it’s all about if they have questions about their pregnancy or breastfeeding… Google it. (Ana, FG2, Hispanic) The YouTube video about how to use a pump. I hear that a lot from EVERY race, black, white. I think that’s interesting ‘cause I would never know to look on You Tube how to use a breast pump. (Luci, FG2, White) The internet they have access to good and bad information about breastfeeding. (Victory, FG3, Hispanic) It’s pretty much normal for people to see something about breastfeeding on Facebook, or on YouTube, (Butterfly, FG3, Hispanic)

Table 5.

Macrosystem Level of Influence

Cultural Norms
Breastfeeding Norms	And I wanted the best for my child. But I remember thinking before that, that it was a Caucasian thing, that only White people did it. Because I didn’t see my mom or my grandmother do it. And then when I came around them they looked at me like I was a DISGUST. (Summer, FG1, African-American) I’ve had a lot of…African American clients, that just tell me that their moms couldn’t make enough milk, or the moms tell them that in their family women don’t breastfeed. (Butterfly, FG3, Hispanic) I don’t know if it’s more in our culture [African-American]. But they don’t want to spoil the child by always having them close to them when they’re up on them. (Lola, FG2, African-American) Most of the times when I have classes, I’ll just ask people, “Raise your hand if you’ve SEEN a women live in person breastfeeding?” And most times, you won’t get an African-American woman to raise her hand. (Eve, FG2, African-American) Even with African American culture there’s so many like subcultures within that… It’s different from an African American culture that’s from the South as opposed to an African American woman that’s nursing up in the North or even on the West Coast. They have different barriers and different things. (Faith, FG3, African-American)
Womanhood Norms	A lot of times they don’t want to call for help. (Queen, FG3, African-American) But I thinking “I’m going to do it because I’m a Black woman and I’m strong and I can do this. I’m not going to fall back and get help.” And so I end up having to stop breastfeeding totally. Have my nipples re-attached, because they were hanging off. (LaKeysha, FG1, African -American) I have lots of …African-American moms who want to but their responsibilities outside of motherhood are GRAND and great. And… I think that a lot of them see it as maybe an impossibility. And that’s really hard to sort of overcome. (Marie, FG2, White) But I think when you kind of dig back, that’s a part of that generation you’ve got to be strong, hardcore, callous, …wandering with the baby on the back of the field, breastfeeding your baby. (Eve, FG2, African-American) That was her reasoning for breastfeeding is her family was already all putting her down and she wanted to try to do it just to prove them wrong that she could do it. She was strong and she could do it (Candi, FG1, White) That goes back to us being Black women teaching our own children to be empowered, teaching them to think for themselves…you’ve got to empower your own children to do and think for themselves no matter what nine million other people are doing, if this is the right choice and this is what you’re supposed to do then. (Keke, FG1, African-American)

Well Established

Although breastfeeding trends in African-American women have improved in the past decade, current rates do not meet Healthy People 2020 objectives. Peer counseling interventions, such as those provided by WIC, have been effective in improving breastfeeding in African-American women.

Newly Expressed

WIC peer counselors expressed numerous factors influencing their African-American clients’ decisions to breastfeed, ranging from the individual to the cultural and historical context. Findings suggest that breastfeeding support interventions need to consider African-American women’s unique life experiences, culture and history.