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. Author manuscript; available in PMC: 2015 Aug 1.
Published in final edited form as: J Hum Lact. 2015 Feb 24;31(3):425–433. doi: 10.1177/0890334415573001

Overcoming Workplace Barriers: A Focus Group Study Exploring African American Mothers' Needs for Workplace Breastfeeding Support

Angela Marie Johnson 1, Rosalind Kirk 2, Maria Muzik 2
PMCID: PMC4506723  NIHMSID: NIHMS663237  PMID: 25714345

Abstract

Background

Persistent racial disparities in breastfeeding show that African American women breastfeed at the lowest rates. Return to work is a critical breastfeeding barrier for African American women who return to work sooner than other ethnic groups and more often encounter unsupportive work environments. They also face psychosocial burdens that make breastfeeding at work uniquely challenging. Participants share personal struggles with combining paid employment and breastfeeding and suggest workplace and personal support strategies that they believe will help continue breastfeeding after a return to work.

Objective

To explore current perspectives on ways to support African American mothers' workplace breastfeeding behavior.

Methods

Pregnant African American women (n = 8), African American mothers of infants (n = 21), and lactation support providers (n = 9) participated in 1 of 6 focus groups in the Greater Detroit area. Each focus group audiotape was transcribed verbatim. Thematic analysis was used to inductively analyze focus group transcripts and field notes. Focus groups explored thoughts, perceptions, and behavior on interventions to support African American women's breastfeeding.

Results

Participants indicate that they generally believed breastfeeding was a healthy option for the baby; however, paid employment is a critical barrier to successful breastfeeding for which mothers receive little help. Participants felt breastfeeding interventions that support working African American mothers should include education and training for health care professionals, regulation and enforcement of workplace breastfeeding support policies, and support from peers who act as breastfeeding role models.

Conclusion

Culturally appropriate interventions are needed to support breastfeeding among working African American women.

Keywords: African American, breastfeeding, disparities, employment

Background

Breastfeeding rates are lowest among African American mothers.1 In 2008, 59% of African American women initiated breastfeeding, compared to 75% of white women and 80% of Hispanic women. In 2007, only 8% of African American infants breastfed exclusively at 6 months compared to 14% of white infants.2

African American mothers are more likely to hold jobs with shorter maternity leave and have less flexible work hours3 and less social support to breastfeed.4,5 Length of maternity leave is positively associated with breastfeeding initiation6,7 and duration.8,9 Mothers who return to work within 12 weeks or work full-time are less likely to exclusively breastfeed in postpartum.10 African American women return to work on average 2 weeks earlier than women from other racial and ethnic groups.11,12 African American women are less likely to have flexible hours because they are more often working in jobs without breastfeeding protections.11-13,14 Insufficient break times15 and demanding work schedules16,17 make pumping difficult. African American women are also disproportionately represented in low-income, nonmanagerial positions with high workplace stress18 void of flextime, job sharing, and part-time schedules.19

The objectives of this study are to further investigate African American mothers' perceived needs for work-related breastfeeding support and interventions.

Methods

We applied qualitative focus group methodology to explore knowledge, experience, perceptions, attitudes, and motivations to breastfeeding among disenfranchised mothers.20 We utilized a standardized approach by using a focus group guide based on the literature and views of those with expertise in breastfeeding and maternal and infant health.21

Sample Selection and Recruitment

Participants were mothers or expectant mothers who breastfed or planned to do so, those who did or chose not to breastfeed, and lactation professionals. All were recruited between June and November 2013 through materials posted at local public health departments, nonprofit agencies, schools, child care centers, housing sites, community churches, or hair salons. Inclusion criteria were self-identification as African American woman, pregnant, or with a child <3 years, and residency in southeast Michigan. A group of lactation professionals (lactation consultants, peer breastfeeding counselors, midwives, or other health professionals supporting black mothers) were also recruited.

Participants attended 1 of 3 focus groups: for professionals, for women breastfeeding or planning to breastfeed, or for women not breastfeeding or planning to breastfeed. We held 2 groups in each category. Breastfeeding was defined as a baby receiving any breast milk. To maximize attendance we provided onsite child care and food and held groups in convenient locations. Participants received a gift card ($30 for mother and $20 for professionals) for their time.

Focus Group and Interview Guide

Informed by grounded theory,22 focus group guides were developed by our research team to enable consistency across groups.21 Guides were designed to elicit information on needed support during maternity leave and return to paid work.20 (See Table 1 for focus group guide.) Mothers were assigned to a focus group based on their planned or current breastfeeding.

Table 1.

Focus Group Guide and Sample Questions.

Topic Prompt or Question
1. Group introductions and infant feeding general thoughts

  1. As we go around to each of you, please clearly state your name, age of your child(ren), or when your baby is due if you are pregnant.

  2. What influences decisions to breastfeed babies? (Probe for specific examples that may influence mothers' breastfeeding decision: personal ideas, family, friends, media, personal experience, breastfeeding, educational material, etc.)

  3. What is needed to support breastfeeding? (Probe for examples of things necessary for a mother to breastfeed: help from family, experience, education, support at work, etc.)
2. Maternity leave and return to work

  1. For mothers who are in paid employment, how does maternity leave time and returning to work influence infant feeding plans, infant feeding practices, or infant feeding interests?

  2. How should this topic be approached in ways that best support breastfeeding mothers? (Probe for examples of strategies and ideas for addressing breastfeeding, maternity leave, and return to work: planning return to work, requesting more maternity leave, talking with work manager or boss, space and time to pump at work, etc.)

  3. Who should be involved?

  4. (If not mentioned ask) Should health professionals, family, friends or baby's father have input?

  5. How can each of these people help support breastfeeding? (Probe for examples of others who should be involved: baby's father, baby's grandmother, friend, health care professional including lactation consultant, peer counselor, obstetrician, midwife, pediatrician, primary care doctor, nurse, etc.)
3. Logistics of a breastfeeding support intervention program

  1. If we were to design a program that effectively helps African American mothers start and continue breastfeeding, describe what it might look like.

  2. How would we go about it? (Probe for examples of the type of program that would work: group, individual counseling, telephone, Internet, blogs, etc.)

  3. When would it be best to offer this to mothers? (If not mentioned, probe for examples of best times: evenings, daytime, before baby is born, after birth?)

  4. Who might attend? (Probe for examples of who should be invited to attend: other moms with breastfeeding experience, fathers, children, lactation consultant, etc.)

  5. Where is the best location?

  6. What are other practical concerns? (Probe for examples of things that program participants may need: child care, transportation, electronic reminders, Internet access, etc.)
4. Social support

  1. Social support is thought to be important by some people. Others think that it can be unhelpful.

  2. Is there anything special or unique about support in the African American community that affects breastfeeding or bottle choices?

  3. What type of support is most needed by African American women and their families in order to breastfeed? (Probe for examples of types of practical or other support: listening, advice, information, pumping space at work, break time to pump at work, space to pump in stores or restaurants, etc.)

  4. From whom should the support come? (Probe for examples of formal or informal support: health professional, baby's father, family, friends, etc.)

  5. If not mentioned, prompt with: Should health professionals, family, friends, or baby's father have input? (Remind participants that examples of health professionals might include lactation consultant, breastfeeding peer counselor, obstetrician, midwife, pediatrician, primary care doctor, nurse, etc.)

  6. How can each of these people help support breastfeeding?
5. Additional topics

  1. Again, the purpose of this focus group is to gather information that could be used to develop and test an intervention that addresses the barriers to breastfeeding for African American mothers.

  2. Are there any other topics or concerns we should address?

  3. Is there anything we should have talked about but didn't?

  4. (If no specific examples given, prompt with) What issues or topics have we missed?

  5. Once we have compiled findings, we'd like to have some participant volunteers to help us confirm findings. Please let us know if you might be interested before you leave.
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Focus groups were facilitated by the study principal investigator (PI; an African American woman) and a research assistant (RA). The PI led the focus group by opening each session, explaining the purpose of the focus group, and using the open-ended focus group guide to elicit discussion in the group. The RA supported focus group sessions by taking reflective handwritten notes of verbal and nonverbal responses and prompting further elaboration on points made. Every attempt was made to achieve topic saturation23 by guiding semi-structured discussions within each focus group.24,25 Focus group discussions were audiotaped. The PI and RA met immediately after each session to develop additional field notes.

Data Analysis

Audiotapes were transcribed verbatim by RAs trained in qualitative methods. The field notes were incorporated as needed into the transcriptions prior to coding. These reflective handwritten notes were used to incorporate additional information on verbal and nonverbal responses that further clarified and confirmed transcribed data. Focus group transcripts were analyzed by the PI and RA using a thematic analysis approach.26,27 Analysis of the data was inductive in nature, building patterns, categories, and themes by organizing the data into increasingly more abstract units of information. Two independent coders pulled textual units and assigned codes. The coders then compared these and reached consensus on code names and emerging themes.28 All transcripts were combined by topic in order to more readily compare salience of themes. Topics and questions from the focus group guide were used as a framework for developing the first stage of codes, possible themes, and to highlight relevant quotes. As a second step, coded transcript information was reviewed, reduced, and organized by category to establish patterns between and throughout focus groups. In the third and final step, salient themes were derived from established codes recurring extensively across categories.27,29 All participants were subsequently invited to review and shape the final summary of themes to ensure accuracy and interpretation.25,30,31 Two respondents provided written feedback that confirmed summarized findings. The study was approved by the University of Michigan Institutional Review Board.

Description of Sample

A total of 38 women participated in 1 of 6 focus groups. The number of participants in each group ranged from 5 to 11, and each group lasted approximately 50 to 75 minutes. Mothers' working status was not a screening or inclusion criterion. Participants' demographics are displayed in Table 2.

Table 2.

Demographics and Characteristics of Focus Group Participants.

Smaller City in Southeastern Michigan (n = 18) Larger City in Southeastern Michigan (n = 20)
Focus group Yes or planning BF No nor planning BF Professional Yes or planning BF No nor planning BF Professional
n = 5 n = 8 n = 5 n = 11 n = 5 n= 4
Pregnant Yes: 3 Yes: 0 N/A Yes: 4 Yes: 1 N/A
No: 2 No: 8 No: 7 No: 4
Race AA: 13 AA: 1 AA: 16 AA: 4
Caucasian: 0 Caucasian: 4 Caucasian: 0 Caucasian: 0
Age, y, mean 29 27 44 22 24 39
Marital status
 Single 4 8 N/A 8 5 N/A
 Married/partnered 1 0 N/A 3 0 N/A
Household annual income, range $6200-$21 000 $1875-$17 000 $24 400-$39 199 $9545-$24 817 $0-$15 000 $31 000-$45 000
Education
 < High school 0 0 0 0 2 0
 High school 2 3 0 6 1 0
 Some college 3 5 2 3 2 1
 College diploma 0 0 3 2 0 3
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Abbreviations: AA, African American; BF, breastfeed.

Results

Mothers' General Thoughts, Attitudes, and Experiences

Although group compositions varied across groups, a number of issues were voiced consistently. Participants across all groups believed that breastfeeding was a healthy option. Many mothers initiated breastfeeding but experienced work or family stress, physical and mental illness, infant mortality, and/or other personal and community issues that undermined confidence and capacity to breastfeed. Breastfeeding mothers more often described breastfeeding as easier or convenient while nonbreastfeeding counterparts saw breastfeeding as inconvenient and not possible because of physical health conditions.

I had my mastectomy … so I can't. They took all my milk away. (Formula feeding mother in smaller city)

I didn't wanna breastfeed because I didn't want to be leaking like oh, wait, I gotta go get the baby it's time to feed, no …(Formula feeding mother in larger city)

Domestic violence, homelessness, stress, and poverty were also cited as barriers to breastfeeding, particularly among the nonbreastfeeding mothers and the professionals who served them in the larger city.

Sometimes stress prevents you from breastfeeding. And it could've been that because I was very much stressed out at the time. (Formula feeding mother in the smaller city)

Lack of support was a central concern voiced across focus groups. Breastfeeding mothers discussed lack of workplace-based support more than nonbreastfeeding mothers. Nonbreastfeeding mothers more frequently discussed lack of support from health care providers or their personal community and the lack of basic resources (adequate housing, etc) as barriers to breastfeeding.

Similarly, health care professionals such as primary care doctors and nurses were perceived as important influencers, who at times gave inaccurate advice. This criticism was identified by women and breastfeeding professionals alike.

I think doctors need to be educated. A lot of times physicians give out a false information and I don't think a lot of times people understand that … they really need to be brought in to get the real information of … the good benefits of breastfeeding. (Community health navigator, larger city)

Mothers who did not breastfeed often described breastfeeding as uncomfortable or inconvenient.

And then when I was pregnant my breasts was leaking, … them little pad things [were] expensive and tissue it stinks. It was … too much. (Formula feeding mother in smaller city)

Maternity Leave and Work Environment Issues

Mothers who did not breastfeed were more likely to cite breastfeeding as overwhelming because of their work schedule.

I work 7 days a week, and um [laughs] it's the best thing not to breastfeed for me for the fact that I work all the time and I don't have time to pump … it takes too much to do. (Formula feeding mother in larger city)

Mothers often faced little opportunity to establish breastfeeding routines before financially having to return to jobs insensitive to their breastfeeding needs:

As a temporary employee, I don't get a lot of the protections that FMLA [Family Medical Leave Act] would give. I negotiated with my office for 8 weeks of leave … I can't take more and my fear is what happens if I can't establish that breastfeeding bond that I want? What happens when I have to go back to work? … It's really difficult because, I don't get paid for those 8 weeks and I'm the only person that provides for my household. (Breastfeeding mother in larger city)

Others expressed frustrations of getting the appropriate support without jeopardizing their job:

We need … nursing breaks … more break time. But it depends because some companies are not nursing friendly … the bathroom is not an option for pumping. (Breastfeeding mother in larger city)

Legal Rights

Breastfeeding professionals acknowledged the workplace as a major barrier and debated whether mothers should make use of limited maternity leave by breastfeeding as much as possible instead of negotiating with employers to enforce breastfeeding rights. Many expressed frustration with attempts to negotiate workplace breastfeeding:

We have the law printed that says … you are your own voice, when you go in, give this to your boss … this dictates that … you are required to have a place and time to pump … They can go in and advocate for themselves … But they're not always going to take it [a letter] … because sometimes they're afraid of losing their jobs. (Professional in smaller city)

Health and Safety

Negotiations with employers were sometimes tense and reflected concerns about the lack of space to pump, timing of breaks, dangerous work conditions, and fears about keeping a job:

I work in the plant. That's when you get ill, … breathe in certain … fumes and chemicals …. I go to the doctor and they … tell me it's not healthy to nurse because it's almost like you are eating it …. It's just too much in your system … they said your baby can get it. It was dangerous … I want to get this money but … the chemical stuff was so strong. (Formula feeding mother in smaller city)

Stress and Support

Formula feeding mothers described more life demands, fewer resources, and less personal support:

I didn't have help, I had to catch the bus to daycare, drop him off, then catch the bus to work … catch the bus back to daycare to pick him up … catch the bus back home. I was working, taking care of a baby and pregnant with another one and trying to help my mama all at the same time … all around the time that my mama died. (Formula feeding mother in larger city)

Workplace Breastfeeding Interventions

Participants offered the following key components to support successful return to work and breastfeeding.

Increased paid maternity leave

Paid FMLA would help because it would take a lot of stress off … I feel like I have to succeed at breastfeeding because I can't go to formula as quickly as someone else would. What if he eats more than I can afford to pay for? (Breastfeeding mother in larger city)

Peer support groups

Some participants thought that peer-based group support combined with individual support in a comfortable and convenient location would be most empowering and effective:

I think the group would be the best. Only because … I think the mothers relate to other mothers. And they can help each other. (Formula feeding mother from larger city)

Having the support groups … us being able to have someone to call and be able to see a community of … African American women, because really, that's such a big thing. (Mother from smaller city planning to breastfeed)

Individual breastfeeding support from professionals

Some professionals, particularly lactation consultants, midwives, and the WIC dietician, felt that support should be offered alongside a visit to a pediatric or other clinic to help mothers receive accurate and personalized breastfeeding encouragement as part of other health care. Professionals also felt that there was a missing personal connection in some existing services such as La Leche League and local WIC offices. African American mothers need a support program that reflects their concerns:

You gotta have food, transportation … be available day and evenings … make sure that education is real. Not so much textbook … and on a daily basis. So they can grasp it and understand it … know that you hear and understand where they are … you are not trying to force them … but let them know that it is about the … health of their child. And have real people there that are going through it, not just professional. (Professional in larger city)

Educating society

Strong emphasis was also placed on educating employers, medical professionals, the public, and the media about the importance of supporting mothers' public and workplace breastfeeding interest.

One mother felt that mothers, once armed with their workplace breastfeeding rights and policy, should confidently request pumping space and accommodations from their employer for when they return to work:

I'm gonna breastfeed … and I'm not going in the bathroom, that's gotta be the nastiest place … when you do go back to work, … explaining it sometimes to the boss ahead of time, so that you know they'll have that understanding too, … so what's gonna be the plan when I get back … for where I'm gonna be able to pump …. ′Cause you know what the law is right? And that's getting more confident and bold like that. (Breastfeeding mother in smaller city)

Discussion

Results from the focus groups reveal African American mothers: (1) perceive workplace as nonsupportive of breastfeeding and feel that (2) paid maternity leave would decrease stress associated with breastfeeding and a return to work, (3) interventions should educate and train physicians and (non–lactation consultant) nurses on communication skills that better support breastfeeding, (4) more workplace education and protections are needed to effectively support breastfeeding among working African American mothers, and (5) peer support groups can help support working African American mothers interested in breastfeeding. Perspectives shared by participants reinforce current knowledge and offer additional evidence to support national recommendations to strengthen workplace breastfeeding support through a comprehensive set of strategies aimed at enhancing education and policy provisions among employers and providers.32 Insights from focus groups highlight the critical need for creative workplace-based plans for low-income mothers to allow for breastfeeding at work. In addition, feedback suggests programs that encourage breastfeeding role models in the workforce and more active involvement of African American breastfeeding health professionals and supporters.

Perceptions about Paid Work and Breastfeeding

Consistent with previous findings in other populations are perceptions of overwhelming conflict between work and breastfeeding in ways that limit breastfeeding duration.15,33,34

African American women's employment is often unstable3,35 and compensated at lower levels,36 so therefore there may be additional hesitation to breastfeed at all.6 This has crucial importance for African American mothers who are also disproportionately more likely to have poor perinatal health outcomes37,38; suffer from chronic illness,39,40 stress,41,42 depression,43 or posttraumatic stress disorder44; and return to work sooner than their counterparts, all of which are known risks associated with lower breastfeeding rates.45

Breastfeeding Interventions African American Mothers Want

Train and educate health care professionals

Labbok46 and Bentley et al47 point out the critical need for including more breastfeeding support skills in all clinical skills training.46 Similarly, in this study, mothers expressed clear need for training and education of physicians and (non–lactation consultant) nurses who they felt lacked important technical information and the sincere willingness to support them. Trust seemed to be an issue as well. A number of mothers questioned the accuracy of information from some lactation support professionals. Some participants, including a breastfeeding peer counselor and community maternal health navigators, indicated that while important, the information was too “textbook” and not relatable. Information needs to be delivered in plain language and/or in a culturally appropriate manner. Some professionals, particularly those who had nonclinical roles, felt that clinic-based lactation professionals were not in tune with African American women's breastfeeding needs. For example, these lactation consultants tended to emphasize more efficient use of maternity leave before return to work (eg, establishing milk supply, pumping and storing milk, etc) as opposed to supporting breastfeeding once returned to work.

Regulate and enforce workplace protections

Data from the National Health and Examination Survey 2003-201014 show that African American infants were only half as likely to be breastfed for 6 months relative to whites even in states with laws requiring break time from work, private space to pump at work, education and awareness programming and laws that enforce breastfeeding pumping rights.14 This suggests that African American women may be apprehensive to enforce their rights for breastfeeding possibly because they perceive themselves as vulnerable in often part-time, temporary, or low-wage jobs.

The recent passage of the Patient Protection and Affordable Care Act only requires that employers provide unpaid, reasonable break time for an employee and a private space to express breast milk within the first year postpartum.48 Employers with less than 50 employees, temporary, and part-time employees are excluded, leaving many unprotected. The US remains the only industrialized nation without paid postpartum family leave.46

Furthermore, most breastfeeding laws in the US are enacted at the state level.49 By 2009 only 23 states had enacted laws to encourage support for breastfeeding in the workplace, and most did not have enforcement provisions.50 Most importantly, laws designed to support breastfeeding duration are less helpful for African American women relative to white women, in part because racial segregation across occupations finds African American women often concentrated in jobs without breastfeeding protections.14

Few published studies highlight interventions that address the unique breastfeeding support needs of African American women in workforce.51-59

Provide paid maternity leave

Providing paid maternity leave for employed mothers helps ensure breastfeeding suc cess.32,59 Participants, especially mothers who initiated breastfeeding, shared deep frustrations about having limited, unpaid time to establish breastfeeding and milk supply before returning to inflexible work environments that were not breastfeeding friendly.

Establish and support peer groups

Previous work established the benefits of peer-based breastfeeding support.60-63 Similarly, most of this study's participants, both mothers as well as lactation professionals, expressed that support from peers (ie, other African American breastfeeding mothers) helps to enhance breastfeeding efficacy and increase likelihood after returning to work.

Lactation Consultants Are Not African American

Although efforts were made to do so, we were unable to enroll African American lactation consultants for this study. This is not surprising given that there are currently few African American certified lactation consultants located in the State of Michigan although efforts are underway to ameliorate this problem.64 While African American professionals in this study were able to provide great insight about breastfeeding interventions based on their work with African American women, none of the professionals served as lactation consultants. Integrating more African American lactation consultants may help reinforce culturally relevant beliefs and practices that increase breastfeeding behavior in African American women.64

Limitations

There are several limitations to generalizability and design. This is a qualitative and exploratory study with a small sample, and participants were primarily low-income African American women in an urban Midwestern setting, thus, results are not generalizable to all populations of African American mothers and lactation professionals. Focus group methodology is also based on individuals' perspectives and personal experiences, thus dependent on participant selection.27 As previously stated, no African American lactation consultants participated in our study, which highlights the lack of appropriate African American breastfeeding supporters and role models. However, this absence may have limited voiced perspectives on culturally appropriate breastfeeding supports.

Conclusion

African American women face unique challenges in employment and health status that appear to contribute to the persistent racial gap in breastfeeding initiation and duration.53 Similar to previous work, we found that African American mothers are interested in breastfeeding after returning to work.40,53 However, African American mothers face increased risk for early breastfeeding cessation and need workplace breastfeeding supports to overcome social, environmental, and economic barriers to breastfeeding.

Employed African American mothers, especially low-income ones, would likely benefit from practical, comprehensive, and creative multisystems approaches to workplace breastfeeding programs such as paid maternity leave (similar to other Western industrialized countries) and breastfeeding at workplace support during early postpartum as suggested by the U.S. Surgeon General's Call to Action to Support Breastfeeding59 and the Business Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite.65 While some model programs exist, more research and work is needed to encourage employers' role in establishing evidenced-based workplace interventions that recognize the return on investment that breastfeeding is.65

African American mothers also need social, psychological, and educational support across the perinatal spectrum to successfully breastfeed.53 Critical components include early prenatal breastfeeding counseling to promote breastfeeding66; culturally sensitive community-based peer and professional support that counters historical misconceptions and inspires continued breastfeeding60-63; educational campaigns that foster mothers' family support66; public media campaigns that promote attitudinal change67 by diffusing the sexualization of breastfeeding68; and the use of trusted community-based organizations who are aware of the barriers that women face, know the customs and the culture, and can find workable solutions to support them.59,63

Well Established

Recommendations are that mothers exclusively breastfeed to 6 months. However, fewer mothers continue breastfeeding after they return to work. Working African American mothers have, on average, higher risk for breastfeeding cessation and experience unsupportive work environments as a barrier to breastfeeding.

Newly Expressed

Results of this study reveal that mothers experience workplace stress, uncertainty, and perceived danger as barriers to breastfeeding. Mothers felt they needed a number of interventions to help support breastfeeding once they return to work, including education and training for health care professionals, regulation and enforcement of workplace breastfeeding support policies, and peer support from breastfeeding mothers.

Acknowledgments

We extend our deep gratitude to the many women, children, and others who made this work possible.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grant number 2UL1TR000433 from the National Center for Advancing Translational Sciences (NCATS). The content is solely the responsibility of the authors and does not necessarily represent the official views of NCATS or the National Institutes of Health.

Footnotes

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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