Table 1.

Scoping Review on Breastfeeding Initiation and Continuation Support Among African Americans

Author, year, study site	Method	Sample	Trustworthiness	Findings	Gap
Robinson et al., 2019, Southeast Wisconsin	Qualitative Two focus group discussions	9 AA women, ≥18 years currently BF or breastfed 6 months before the study.	Verbatim transcription, member checking, audit trail and expert support.	The role of BF peer counselors had a positive impact on lactation. Four themes: Educating with truth, validating for confidence, countering others negativity, supporting with solutions.	Establishment of standard guidelines for BF peer counselor's intervention.
Hinson et al., 2018, Northeastern US	Qualitative Six focus group discussions	United States born—AA woman, ≥18 years, within 3 months postpartum.	Prolong engagement, transcription, field notes, member checking.	BF initiative among AA is affected by: cultural beliefs, (benefits, bonding, natural, “wet nurse” history, formula is as good as breast milk, racism); sexuality issues (breasts for nutrition, over-sexualization of AA females, sexual act); social environment (familial/network influence—self, mother, sisters, partner, friends/peers, religious community); information sources (prenatal clinics, WIC, physicians, nurses, lactation consultants, internet), BF intentions (positive, negative or ambivalent), barriers (pain, embarrassment of public exposure, lack of knowledge and support of BF in AA community, lack of information and education about BF, prenatally lack of access to equipment and resources, aversions to BF, convenience of bottle and FF independence, national policy), and facilitators (involved fathers, prior positive experience, cost and convenience of BF, peer counselors/peer support groups, supportive family environment, BFHI, WIC).	Multifactorial approach, involving mothers, partners, and community to address cultural barriers to lactation.
Schindler-Ruwisch et al., 2019, Washington, DC	Qualitative 24 Interviews	24 AA women aged ≥18 years, in WIC with infants 0–8 months.	Prolong engagement, transcription, dual coding, Kappa 0.7107.	Four themes of BF initiation: Influence of others on BF confidence and intention; benefits; pervasiveness of obstacles (pain, latch, milk supply); and importance of social support (emotional, instrumental, appraisal, informational, provider support WIC).	Reinforcement of community outreach program through social support geared toward BF.
Furman et al., 2016, Cleveland	Quantitative Pre- and post-test	66 Partners/partners, predominantly self-identified AA, aged 17–64 years.	No validity or reliability tests done.	Improved knowledge in lactation (62%) and readiness to welcome BF of next infant (85%).	Engagement of inner city and AA fathers or partners as priority in BF initiatives.
Oniwon et al., 2016, Washington, DC	Quantitative Cross-sectional	100 multiparous women in WIC, predominantly AA, aged 18–41 years.	No validity or reliability tests stated.	Women (71%) initiated BF based on education level, full-time or no job status, had one child, and was breastfed in childhood. Barriers for BF continuation at home—limited support, pain, insufficient milk perception.	Improvement in prenatal education, and reinforcement of BF exclusivity in though outpatient services.
Barbosa et al., 2017, Richmond, VA	Qualitative Seven focus group discussions	25 low-income AA women, aged ≥18 years, enrolled in WIC, with a child <2 years.	Transcription, member checking.	Positive deviance factors—BF intention, high self-efficacy and sought knowledge, value BF and understood FF disadvantage, varied interpersonal support, resist negative BF/positive FF influences, positive BF influence on others, prenatal health providers promote BF and FF products, hospital offered good BF instruction and support, postnatal staff gave limited support/advise, appreciate WIC BF help, overcame job barriers, indifferent to BF stigma and public BF.	Community engagement to promote strengths of positive deviance toward BF.
Asiodu et al., 2017, Northern California	Qualitative Ethnographic	22 AA (14 pregnant women and eight support people).	Prolong engagement triangulation	Themes related to BF decision making—best for baby; normalization/role models; social support; fluid social dynamics, resiliency; seeking support and empowerment; stress, shame, and guilt; combination feeding.	Education through identified social support person, social media platform, and combination feeding.
Thomson et al., 2017, Mississippi	Quantitative Experimental	82 AA	Randomization No blinding High attrition rate.	BF knowledge increased in both groups, 39% participants BF infant for ≥6 months. Pre-pregnancy weight and BF intent were significant for BF initiation.	Using peer counselors with BF experience and inclusion of male partners in education.
Robinson et al., 2018	Quantitative Systematic review and meta-analysis	Four identified	PRISMA guidelines	AA pregnant women who participated in Centering Pregnancy Models had a 71% probability of BF observed.	Outcomes of Centering Pregnancy model for AA women
Merewood et al., 2019, Southern US	Quantitative Longitudinal (2014–2017)	Hospitals enrolled in Communities and Hospitals Advancing Maternity Practices	Validity and reliability tests not stated. No blinding	BF initiation and exclusivity among AA infants increased from 46% to 63% (p < 0.05) and from 19% to 31% (p < 0.05), respectively.	None stated.
Kim et al., 2017, Illinois	Mixed method Interviews and questionnaire	15 first-time AA mothers enrolled in WIC.	Validated instrument used (IIFAS and BFSE-SF) data saturation reached, transcription, member checking.	BF facilitators and barriers—Themes: Normative infant behavior in sociocultural context; cultural beliefs on maternal nutrition and BF; time and cost associated with BF; managing and integrating BF while maintaining a social life; necessity of social support from significant others and female role models; suboptimal support from institutions (hospitals, school, work place and community). Positive attitude to BF (70%) and high self-efficacy (62%).	Interventions focusing on social support (emotional, tangible, informational, and encouragement).
Robinson et al., 2019, Internet	Qualitative Four focus group discussions	22 AA women, aged ≥18 years, participating in BF support groups on Facebook.	Transcription, peer debriefing, member checking, expert input, triangulation.	Themes: Creating a community for Black mothers; online interactions and level of engagement; empowerment of self and others; shifts in BF perceptions and beliefs.	None stated
Robinson et al., 2019, Online	Quantitative Online cross-sectional survey	277 AA women	Validated instruments used (IIFAS and BFSE-SF)	Average BF intention duration was 19 months, due to Facebook support. Self-efficacy and BF attitudes remained significant predictors of intended BF duration.	Impact of Facebook support on prolonged BF durations in AA women.
Spencer et al., 2015	Qualitative Sequential-Consensual Qualitative Design	Stage 1: Four AA key informants Stage 2: 17 AA mothers BF infant for ≥4weeks Stage 3: 7 AA women	Prolonged engagement, transcription, peer debriefing	Stage 2 themes: Self-determination; spirituality and BF; and empowerment Stage 3 themes: Engaging spheres of influence; sparking BF; activism; and addressing images of the sexual breast versus the nurturing breast.	Engaging supportive network; pediatricians' and obstetricians' view on BF attitude and knowledge; culturally sensitive educational interventions and initiatives (mother's time, activities).
Obeng et al., 2015, Midwest	Qualitative Focus group discussion	20 AA women, aged 20–40 years	Prolonged engagement, verbatim transcription	Themes identified on AA women BF perceptions and experiences: Health benefits, lack of information, negative perceptions of BF by others, organizational support, unforeseen circumstances of BF.	Explore ways to increase BF initiation and duration among AA women based on their experiences, desires, and needs.
Johnson et al., 2016, Detroit	Qualitative Focus group discussion	38 Pregnant and lactating AA women and racial diverse health professionals	Transcription,	Health workers not always supportive of BF, lacked adequate information and skill to educate AA women on BF, so women lost confidence in them and relied more on relatives and peers.	None stated
Jefferson, 2017	Quantitative Cross-sectional survey	696 AA and Caucasian college students, aged ≤45	Validated instrument used, IIFAS	Favorable attitude to BF but FF was viewed as much easier; odds of experiencing BF exposure and positive BF attitudes were thrice higher for Caucasian students than for AA students.	Further studies to identify strategies to improve BF exposure and attitudes among AA students.
DeVane-Johnson et al., 2017, Online	Qualitative Integrative literature review	Four social science electronic databases, 47 peer-reviewed articles.	Theme validation by two independent authors	Themes for BF disparities among AA women: Social characteristics (e.g., low socioeconomic status, single); perceptions of BF; quality of BF information provided by health care providers.	Focus on sociohistorical factors that have shaped current norms of BF among AA women.
Kamoun and Spatz, 2018, West Philadelphia	Mixed methods Interview Survey	Interview: 10 leaders, 44 members and 11 leaders surveyed, ≤45-year, AA, Muslim, both sexes.	Validated instrument used, IIFAS; verbatim transcription, member checking.	No prevalence of Islamic education on BF; favorable views about BF, attitude toward BF improved through religious incorporation on BF education.	None stated
Moon et al., 2017	Quantitative Randomized controlled trial	1,194 AA women who had just delivered, aged 18–42 years.	Random selection and assignment	BF was 5.3 and 6.1 weeks for infants who room or bed-shared (p = 0.01). Exclusive BF was 3.0 and 1.6 weeks for infants bed-shared or room shared (p < 0.001). Group assignment did not affect BF duration. AA infants <6 months were mostly room shared.	Further research on factors that improve BF exclusivity and duration.
Lutenbacher et al., 2016	Qualitative Focused group discussion	16 Self-identified AA women with one birth history within 5 years.	Prolonged engagement, verbatim transcription, field notes, peer debriefing.	Factors affect BF: four themes—Balancing the influences of people, myths, and technology; being in the know; critical periods; and, supportive transitions.	None stated
Fabiyi et al., 2016, Central Ohio	Qualitative Interviews	20 Middle-class AA and African-born women	Verbatim transcript, prolonged engagement, member checking	Factors affecting BF: Persistent support and encouragement; dissuasive remarks; challenges with health, job, lactation, ambivalent BF attitude.	None stated
Deubel et al., 2019, Florida	Qualitative Interviews	20 AA women	Prolonged engagement, verbatim transcription.	BF challenges—No maternity leave, access to electric pumps, BF role models and or support network to normalize long-term BF, social pressures to initiate formula supplementation, fears that BF renders infants overly dependent on mother's care.	Monitoring the practical implementation of insurance coverage for BF pumps on rates of BF initiation and duration.
LoVerde et., 2018	Qualitative Interviews	Nine AA women with VLBW (≤1,500 g)	Prolonged engagement, point of saturation, member checking, verbatim transcription	Facilitators to BF: Being a mother; neonatal intensive care unit environment; community support; useful resources. Barriers: Maternal illness; milk expression; challenging home environment; emotional distress.	Perceived barriers to improve provision of mother's own milk and quality of lactation journey of AA women with preterm infants.
Robinson et al., 2019	Mixed methods Scoping review	MEDLINE articles (5) using PubMed, CINAHL, Cochrane Library, PsycINFO, and Sociological abstracts	Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.	AA women experience racism, bias, and discrimination affecting BF care, support, and outcomes.	Effect of racism, bias, and discrimination on BF care, support, and outcomes.
Griswold et al., 2019	Quantitative Secondary data analysis of Black Women's Health Study (1995–2005)	2,705 for BF initiation analysis, 2,172 for BF duration analysis.	Validity and reliability tests not stated.	Racism in work environments was associated with lower odds of BF duration at 3–5 months; whereas higher odds of BF initiation duration at 3–5 and 6 months were observed in study participants who had experienced racism with the police; U.S.-born AA or having one parent born in the U.S. predicted lower odds of BF initiation and duration; residence in segregated neighborhood (mainly Black residents) during childhood decreased BF initiation and duration as compared with living in predominantly White communities of residence.	Influence of different racism experiences on BF behaviors for Black women in the United States and innovative interventions.

Scoping Review Chart on Quality Assessment of Studies as Guided by the “Arksey and O'Malley Framework.”

AA, African American; BF, Breastfeeding; BFHI, Baby-Friendly Hospital Initiative; BFSE-SF, Breastfeeding Self-Efficacy Short Form; FF, formula feeding; IIFAS, Iowa Infant Feeding Attitude Scale; VLBW, very low birth-weight infants; WIC, Special Supplemental Nutrition Program for Women, Infants and Children.