African American Mothers’ Decision to Discontinue Breastfeeding and Switch to Formula

Abstract

After initiating breastfeeding, some African American mothers find adjusting to the demands challenging and discontinue breastfeeding. To learn about decisions switching to formula, we conducted a secondary analysis of qualitative interviews with African American mothers ≥ 18 years old. Data were analyzed using thematic analysis guided by the social cognitive theory. We identified four key themes that reflect personal, behavioral, and environmental factors: (1) simplicity of formula, (2) diverse support networks, (3) early breastfeeding is most important, and (4) lack of access to breastfeeding support resources. To increase breastfeeding duration among African American mothers, it is essential for interventions to be comprehensive including various strategies such as education regarding the physical aspects of breastfeeding, exposure to African American breastfeeding mothers, and active involvement of support persons. More research among African American mothers is needed to identify effective opportunities for change in cultural, social, and structural systems that impede successful breastfeeding.

For optimal growth and development, the American Academy of Pediatrics (AAP) recommends that all infants are exclusively breastfed for 6 months before adding complementary foods with continued breastfeeding for 12 months or longer if preferred (AAP Section on Breastfeeding, 2012). While many women (84%) in the United States initiate breastfeeding at birth, countless women do not continue exclusive breastfeeding through 6 months of age, with only 25% successfully meeting the AAP recommendations (Centers for Disease Control & Prevention [CDC], 2020). This low rate of exclusive breastfeeding at 6 months is far from the Healthy People 2030 target of 42% (Office of Disease Prevention & Health Promotion, n.d). It is essential to improve breastfeeding duration and surpass the healthy people target to see a meaningful impact on both infant and maternal health outcomes. Longer durations of exclusive breastfeeding provide the greatest protective effect for infants with a significantly reduced risk of severe respiratory infections, otitis media, necrotizing enterocolitis, and sudden infant death syndrome (AAP Section on Breastfeeding, 2012). Additionally, the low breastfeeding rates in 2014 contributed a total medical cost of $3 billion with 79% related to maternal diseases. The greatest impact on health occurs for mothers due to significantly more deaths associated with diabetes, breast cancer, and myocardial infarctions (Bartick, Schwarz, et al., 2017). Therefore, a close look at factors that impact breastfeeding and formula feeding decisions is necessary.

Breastfeeding among African American Mothers

While breastfeeding initiation rates among African American mothers has increased from 63% in 2010 to 74% in 2017, they continue to lag behind other racial groups with Asian (90%) and White (87%) mothers having the highest rates. Only 21% of African American mothers continued exclusive breastfeeding at 6 months of age in 2017, compared to 27% Asian and 29% White mothers showing a significant drop in breastfeeding duration for all racial groups (CDC, 2020). However, African American mothers and infants are affected most by adverse health outcomes. Higher rates of diabetes, obesity, and cardiovascular death occur for African Americans compared to Asian and White Americans (CDC, 2019). African American infants are also three times more likely to have necrotizing enterocolitis and two times more likely to die from sudden infant death syndrome than White infants (Bartick, Jegier, et al., 2017). The persistent disparity in breastfeeding and disproportionate health outcomes is troubling given the significant impact breast milk has on maternal and infant health.

Research has shown social determinants of health play an important role in whether African American mothers continue exclusive breastfeeding. Mothers with lower incomes often lack sufficient personal and social support as well as experience adverse life events and chronic exposure to stressors that impact prolonged breastfeeding. Furthermore, African American mothers are more likely to return to work within 8 weeks after birth to demanding environments unsupportive of breastfeeding needs, lack access to professional breastfeeding services, and experience racially biased care. While these barriers to breastfeeding are not distinctive to only African American mothers, they are experienced more often at disparate rates compared to other racial groups (Anstey et al., 2017; Johnson et al., 2015). Nonetheless, more African American mothers have initiated breastfeeding than ever before but many supplement or switch to formula when breastfeeding challenges are faced (Asiodu et al., 2017; Jefferson et al., 2021). More research is needed to hear the voices of those struggling the most to overcome challenges and successfully reach breastfeeding goals.

Conceptual Framework

The social cognitive theory guided this study as we focused on human behavior regarding infant feeding of African American mothers. Bandura’s social cognitive theory is rooted in the belief that people have the capability to transcend social influences in their direct environment and intentionally produce outcomes by their actions as human agents (Bandura, 2018). The interaction of personal, behavioral, and environmental factors determines human functioning. These determinants are central variables to the social cognitive theory that include intrapersonal effects, the behavior people participate in, and the environmental influences that impact their lives. Key properties regarding the variables that produce human agency encompass forethought, self-reactiveness, and self-reflectiveness (Bandura, 2018).

People guide their lives in forethought by developing goals and picturing potential outcomes for behavior. For self-reactiveness, people evaluate their performances based on adopted standards. While regulating behavior, people also self-reflect at a higher level addressing their efficacy, challenges, and conflicts of different courses of action to make decisions about what to do (Bandura, 2018). The social cognitive theory has been demonstrated to be a useful framework to study breastfeeding behavior in African American mothers. Eastin and Sharma (2015) found self-efficacy in the ability to breastfeed and overcoming barriers as significant predictors of breastfeeding intent. Findings also demonstrate social support from others can impact the course of action regarding breastfeeding goals as well as the confidence to breastfeed (Schindler-Ruwisch et al., 2019). This evidence supports the concept that intrapersonal factors, such as self-efficacy motivate and regulate behavior. Furthermore, the social cognitive theory recognizes behavior is socially positioned and discriminatively considered (Bandura, 2018). Social situations and structural systems affect many people’s daily lives presenting conditions they have no explicit control over. How people live their lives is also affected by a collective lifestyle or the cultural group they belong to (Bandura, 2018). The social cognitive theory conceptualizes the contribution of individual and societal processes a person uses for daily activity and how culture shapes experience making it a useful framework for exploring African American mothers’ infant feeding behavior.

Purpose

It is essential to understand the breastfeeding perspectives of African American mothers as they have unique life events and stressors that should be considered (Asiodu & Flaskerud, 2011). Being aware of specific challenges will help develop effective interventions to address the racial disparity in breastfeeding and improve health outcomes. It is also important to consider the specific factors that influence decision-making regarding formula feeding. Therefore, the aim of this study was to identify the social and cultural factors that influence African American mother’s formula feeding decisions. We explored the question: What personal, behavioral, and environmental factors affect African American mothers’ decision to switch from breastfeeding to formula feeding?

Methods

Design and Sample

This is a secondary analysis of a cross-sectional qualitative study that explored determinants of infant feeding decisions among African American mothers (Jefferson et al., 2021). A descriptive qualitative design was used to identify infant feeding exposure, experiences, psychosocial beliefs, and cultural views regarding breastfeeding and formula feeding. Mothers self-identifying as an African American woman ≥18 years of age with an infant 1–6 months of age participated in the primary study. Mothers were not required to have initiated breastfeeding but having an infant or maternal conditions that complicate breastfeeding (i.e., infant diagnosed with a congenital anomaly or currently in the hospital) were exclusion criteria for the primary study. Approval to conduct human research was obtained from the appropriate Institutional Review Board. A convenience sample of 30 breastfeeding and formula feeding African American mothers were recruited from local businesses in central Missouri during February 2015–July 2016. For this secondary analysis, the sample only included participants formula feeding their infants at the time of the interview (N = 14).

Data Collection in the Primary Study

Prior to data collection, written consent was obtained from each participant. A self-administered demographic questionnaire was used to collect data regarding social, prenatal, and birth history. An interview guide regarding infant feeding exposure, experiences, psychosocial beliefs, and cultural views was used to collect data by individual face-to-face interviews. Interviews were conducted in an accessible location selected by participants and lasted approximately 1 h. At the end of the interview, participants received a $35 Wal-Mart gift card for taking time to share their infant feeding experiences and beliefs. Data collection continued until no new information was received from mothers. All interviews were audio-recorded and transcribed verbatim by a trained research assistant. No identifying information was recorded on demographic questionnaires or transcripts. All data were stored on a password-protected secure computer server. Formula feeding participant interview transcripts were obtained for the secondary analysis.

Data Analysis

Data were managed using Dedoose software version 8.2.32. We used thematic analysis as a descriptive qualitative approach to data analysis of narratives about infant feeding exposure, experiences, psychosocial beliefs, and cultural views. This structured approach allowed for a rich detailed account of common themes to emerge from the data (Vaismoradi et al., 2013) based on the central variables of the social cognitive theory. The step-by-step approach described by Nowell et al. (2017) was followed to meet the trustworthiness criteria of descriptive qualitative research. In the first phase of data analysis, we engaged with data by reading and re-reading transcripts and interviewer field notes. Each author maintained a reflexive journal throughout the analysis process documenting thoughts about potential personal, behavioral, and environmental themes. Next, we coded data independently identifying initial codes focusing on rich descriptions of social and cultural factors influencing formula feeding decisions. We met bi-weekly to discuss thoughts and compare individual codes developing a common list of codes regarding personal, behavioral, and environmental factors that influenced the discontinuation of breastfeeding and switching to formula feeding. Once all transcripts were coded, we searched the codes for emerging themes using an inductive approach giving meaning to the data. Themes were reviewed and refined to reflect a clear distinct pattern across data. Review of data continued until agreement on final themes were identified and named to reflect the overall personal, behavioral, and environmental narratives of African American mothers. A record of data analysis decisions was documented in an audit trail.

Results

Fourteen formula feeding participants age 19–36 (M = 25) were included in this secondary analysis. Most of the sample were single (71%), currently employed (57%), caring for multiple children (57%), and reported their income <$1,000 a month (79%). Among the eight participants with older children, 50% had successfully breastfed other children for a duration of 3–6 months. Education level varied from high school to completion of some college courses with most (71%) achieving a high school diploma.

Four major themes were identified that align with the social cognitive theory. Simplicity of formula and diverse support networks described personal determinants while behavioral determinants were exemplified by the theme early breastfeeding is most important. The final theme lack of access to breastfeeding support resources represented environmental determinants. To highlight participant voices, excerpts from data are included in quotation marks and additional quotes are presented in Table 1.

Table 1.

Themes and Quotes.

Themes	Participant Quotes
Personal determinants
Simplicity of formula	“What made me switch to formula all the way was cause when I got home…I was by myself and trying to clean and take care of myself and take care of him and pump my breasts and all that stuff it was just too much.” “When she wakes up in the middle of the night and she wants a bottle…my boyfriend can wake up and make her a bottle…so I can get some rest.” “I was going to work and I didn’t know how I can just pump and work and him being at the babysitter.” “I’ve seen stuff about people saying mothers shouldn’t breastfeed in public. I didn’t want to go through that, somebody rolling their eyes cause I was breastfeeding, so formula was easier” “I don’t see any difference not being any healthier than the breast milk because I mean she’s growing well, she’s still not sick or anything.” “He’s still receiving the proper nutrients that’s required for him to develop properly is all I was concerned about. I’m feeding my son formula because that’s what’s best for our lifestyle. The fact that I’m on the go, have older children…that suits us.”
Diverse support networks	“Definitely my grandmother if no one else is, she’s definitely for breastfeeding. My mom, she was just kind of like, whatever works for you… She doesn’t want to be like a burden or a stress factor.” “My friends and his daddy wanted me to keep him breastfed.” “My mom wanted me to breastfeed at first but it wasn’t working out so she supported me with formula feeding too.” “My sister, she never wanted me to breastfeed. She told me to never do it. She says you’re not going to find a sitter and breastfeeding spoils ‘em.”
Behavioral determinants
Early breastfeeding is most important	“I did want to breastfeed because of the benefits from it but the only reason why I didn’t breastfeed was because I couldn’t tolerate the pain that I had in my breasts.” “I feel like we should, as in Black women should embrace and breastfeed our baby. At least give it a try…start off with it like I did and then switch over. Just to give that baby that good milk that they need at first.” “It’s just a lot cause you have to change your diet too and I had already did that for nine long months of eaten healthy and all that and you got to continue to do it so it’s like…a year basically.”
Environmental determinants
Lack of access to breastfeeding support resources	“Formula feeding cost more but thank God we got WIC. Cause if it wasn’t for WIC, I would probably try to stick to more breastfeeding.” “The last class that I took at the WIC program, we talked about budgeting… It [breastfeeding] may be expensive with getting bags and stuff like that for the breast milk to go into.” “The only one time I saw a lactation consultant was when I went to my WIC appointments. And although she was really…helpful, and she told me, ‘if you need me at 3 o’clock in the morning you call me, it doesn’t matter’. But, you know, my mind, at the time, was just not on it.” “I’ve never really heard of anyone that’s Black who breastfed. Besides a few celebrities…I think when it comes down to infant feeding I think most Black people usually just kind of take the easy way out.” “A lot of black women do not breastfeed I’ve noticed that. They just go straight to formula…I know a lot of White people do it [breastfeeding] and I’ve noticed that a lot of Black people do not and I’ve seen it at my job too like they love it, like the White people love breastfeeding but the Black women don’t.”

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Simplicity of Formula

Most participants (86%) reported intentions to breastfeed and initiated breastfeeding. However, they found formula feeding to be “easier than breastfeeding” and “just as healthy” as the infant gains good weight without having to “add vitamin D.” One participant explained, “as I give her formula now, she’s getting bigger.” Participants reported that the demands associated with breastfeeding were “too stressful.” Lifestyle factors were particularly important when considering the ease of formula, such as the need to go back to work quickly and caring for other children or cooking and cleaning their homes. This made breastfeeding feel like “another job” they had to do as indicated by one participant, “I’m a single mom, so I’m doing it all by myself…I’m going to do it the way that works out for me and (infant’s name).” Additionally, the reality that other members of the household can feed the infant was a key aspect in participants’ decision to formula feed their infants. Participants also described how formula feeding made it easier because they did not have to worry about “covering up” in public when breastfeeding their infant. Many described the feeling that society views “breasts as sexual objects” and expressed discomfort with breastfeeding their infants around other people. Participants expressed that choosing formula feeding allowed them the opportunity to just “pop in a bottle” as needed without the worry of stopping to find a discreet location. Despite initiating breastfeeding, personal concerns about returning to work, multiple life tasks, and breastfeeding in public led to decisions to switch to formula as the simple feeding choice which outweighed intentions to breastfeed with one participant describing, “It’s [breastfeeding] a big commitment and you don’t realize it until you’re like trying to do it and convince yourself that you want to be dedicated to it.”

Diverse Support Networks

There was a great deal of variation among participants regarding support from family and friends with some for breastfeeding and others against it. Although many participants report being from a formula-feeding family, some expressed that the emotional support from a close friend or an encouraging health care provider influenced breastfeeding initiation after birth. One participant was unsure about the reasons for varying support stating, “My mom she really didn’t like me to breastfeed the baby when I had tried it at the hospital…I don’t know why she doesn’t like it. But my grandma and my sister they’re the two for breastfeeding.” Other participants talked about emotional support or encouragement from the same sources for making the choice to feed their infant formula, especially when faced with difficulty breastfeeding. Significant others were particularly influential, with participants describing partners that were very supportive of breastfeeding and in fact disappointed when they switched to formula feeding: “At first my child’s father was upset because he wanted me to breastfeed…because it’ll be healthier for the baby.” Even with this direct emotional support from some partners for prolonged breastfeeding, participants were not able to continue. Other partners and family agreed with many of the convenience aspects described by participants related to formula and reinforced the simplicity and ease of use as well as their ability to be part of the feeding process.

Early Breastfeeding is Most Important

All participants received prenatal care and recommendations from health care providers to breastfeed in early postpartum. Some participants indicated intentions to “only breastfeed in the hospital” while others continued breastfeeding for 2 weeks after hospital discharge. This short duration of breastfeeding was contributed to “painful and sore nipples.” Participants described problems helping their infant to achieve a proper latch, which was a “miserable” experience. Although some participants were able to achieve a proper latch and breastfeed in the hospital, they were unsuccessful at home. For some participants, attempts to pump breast milk as an alternative to direct feeding at the breast did not provide relief and was often reported to be “just as painful” as well as “time consuming.” Challenges with pain and a proper latch created uncertainty about the decision to breastfeed for some mothers while others were comfortable with their decision to switch to formula and content with their short duration of breastfeeding because their infant received the “benefits of early breastfeeding.” Some participants perceived the most beneficial and important time for breastfeeding was the first few days after birth providing the infant “that good colostrum.” Additionally, the perceived need to eat healthy and not smoke cigarettes or drink alcohol influenced decisions to only breastfeed the first few weeks after birth. One participant explained, “If I didn’t smoke, I would still be breastfeeding because I like breastfeeding and she likes it.”

Lack of Access to Breastfeeding Support Resources

For many participants, a determinant in whether they initiated and continued breastfeeding was their environment. Some participants lacked access to the resources needed to successfully breastfeed. In general, participants voiced having good support from nurses and lactation consultants at the hospital for initiating breastfeeding but needed information on where to go for support after discharge and no help at home. One participant described having “really good support [at the hospital] and here it’s just me and then (boyfriend name) would come and go…I had knowledge [of breastfeeding benefits], but I didn’t really reach out and ask questions cause I didn’t know what to ask about.” Nearly all participants also indicated they did not know any African American mothers who breastfeeds that they trust and could call for help with breastfeeding challenges. Many participants reported only seeing African American mothers formula feed their infants and never had any conversations about breastfeeding within their families. One participant discussed growing up in “foster care and didn’t have babies around.” Several participants also voiced the perception that breastfeeding was something only “white people do.”

Socioeconomic factors that inhibited breastfeeding also resonated throughout the narratives. While many participants acknowledged that breastfeeding was the cheaper method of feeding their infant, it was not without costs. They discussed the need to buy breast milk storage bags and acquire a pump if they wanted to continue breastfeeding after they returned to work. One participant realized she was not ready stating, “I wasn’t fully prepared to breastfeed. Like I didn’t get a pump or anything.” Transportation to classes and lactation support was another barrier to accessing resources as some participants discussed it was difficult to make it to all needed appointments. Only five participants attended a breastfeeding class. Nonetheless, several participants mentioned the formula support they received from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) made it easy to stop breastfeeding as they did not have to “worry about purchasing a lot of formula.” Some participants were also aware of lactation peer counselor support at WIC clinics, but many did not access this resource after birth. Additionally, participants described workplace environments that made it difficult to continue breastfeeding, including lack of places to pump or limited opportunities for breaks.

Discussion

African American mothers in our study showed good emotional support for breastfeeding but had the misconception that early breastfeeding is most important and lacked access to resources which demonstrates gaps in breastfeeding education and support that influenced their comfort in a decision to switch from breastfeeding to formula feeding. This evidence adds to existing literature regarding the continued low breastfeeding rates of African American mothers and offers strategies for change to provide equitable perinatal care. In agreement with the social cognitive theory, the interaction of personal, behavioral, and environmental factors was instrumental in formula feeding decisions. Thirteen mothers initiated breastfeeding in the hospital, but only continued for short durations highlighting the perception that only breastfeeding in the first few weeks is most important. Consistent with other findings, mothers experienced physical challenges with nipple pain as well as latch difficulties (Schindler-Ruwisch et al., 2019) and the perceived need for a healthy diet without smoking that deterred prolonged breastfeeding (Deubel et al., 2019; Kim et al., 2017; Schindler-Ruwisch et al., 2019). Thus, mothers in our study found the simplicity of formula and lack of access to breastfeeding support resources to be greater influences on infant feeding decisions despite having emotional support for breastfeeding in their personal environments.

Many mothers demonstrated forethought as they expressed intentions to breastfeed their infants and had set goals to do so with the majority breastfeeding at hospital discharge. This evidence emphasizes a shift from the negative breastfeeding stereotype for African American mothers indicating they do breastfeed but struggle to continue. As mothers initiated breastfeeding, personal factors, such as discomfort with breastfeeding in public and lifestyles not suitable for continued breastfeeding, led to views that formula feeding was a better option to meet their infants’ nutritional needs. This finding differs from African American mothers in the study by Schindler-Ruwisch et al. (2019) in which mothers expressed positive attitudes and comfort with breastfeeding in public as the majority had positive exposure to other breastfeeding mothers. However, mothers in our study were often faced with multiple responsibilities related to caring for other children, household obligations, and employment needs. Like other findings (Johnson et al., 2016), some mothers may feel as though formula is the only viable choice when faced with cumulative responsibilities without positive exposure to other breastfeeding mothers. This feeling can be intensified when a mother is a single-parent, or when their workplace environment is not supportive of the need to pump breast milk to sustain milk supply, which demonstrates the structural constraints with going back to work during early infancy. Formula was also perceived to be as healthy as breast milk because it did not require any additional supplements and was easier to provide without worrying about the additional task of pumping breast milk. Mothers in our study had many competing issues demanding their attention and breastfeeding was viewed as something else they had to do. When self-reflecting on challenges and basic life functioning, breastfeeding was a difficult task that could be eliminated to make life easier.

Fathers were very influential in supporting continued breastfeeding. Even with this personal level of emotional support, mothers had very short durations of breastfeeding. This evidence accentuates that for some African American mothers’ stronger support beyond verbal encouragement is needed. Considering that the physical aspects of breastfeeding had an impact on infant feeding decisions for these mothers more support is needed dealing with latch issues and nipple pain. Evidence has demonstrated many mothers experience nipple pain as an obstacle to breastfeeding, yet some African American mothers expressed confidence in their ability to breastfeed and persevered to continue a commitment to breastfeeding (Schindler-Ruwisch et al., 2019). Nonetheless, mothers in our study expressed it was helpful to have general support for either decision to breastfeed or formula feed their infant from those closest to them. Other studies have also demonstrated the importance of this level of support from various sources (Asiodu et al., 2017), with one group of African American mothers receiving more support in the form of breastfeeding information and physical help (Schindler-Ruwisch et al., 2019).

Environmental factors that influenced infant feeding decisions were professional support and social norms. Mothers expressed having easy access to breastfeeding help in the hospital but not at home. Nurses were readily available to answer questions and help with latch issues in the hospital. After discharge home, mothers had no one they trust to call for specific help and only personally knew mothers who formula-fed their infants, similar to findings of other studies (Asiodu et al., 2017; Deubel et al., 2019). The social norm among mothers in our study was that Black mothers do not breastfeed leading to reassurance with decisions to formula feed their infants. This emphasizes the potential impact of lack of exposure to other breastfeeding African American mothers. Additionally, mothers lacked access to resources to buy breast milk bags or electric pumps needed to continue breastfeeding like other study findings (Deubel et al., 2019). Some mothers in our study spoke of only receiving a hand pump in the hospital, which they did not feel was helpful or effective. Also, as another past study has revealed (Schindler-Ruwisch et al., 2019), many mothers were aware of professional breastfeeding support at WIC but did not utilize this resource. However, in our study, mothers utilizing WIC for access to formula readily attended the necessary nutrition classes and kept appointments. In contrast, mothers wanting to exclusively breastfeed in the study by Asiodu et al. (2017) created supportive environments by seeking assistance from community resources through attending classes or support groups. This difference may be due to mothers in our study not expressing a strong desire to exclusively breastfeed their infants beyond early postpartum.

The themes simplicity of formula, diverse support networks, early breastfeeding is most important, and lack of access to breastfeeding support resources implicates the importance of improved perinatal care that includes comprehensive breastfeeding education and support. There is a need for actively including personal support persons in breastfeeding interventions that educate on strategies for dealing with the physical challenges of establishing breastfeeding. This education should also include how support persons can help with daily activities around the house to allow mothers to focus on exclusive breastfeeding. Comprehensive breastfeeding interventions should focus on additional strategies that influence personal and environmental factors, such as free access to breastfeeding supplies, exposure to African American breastfeeding mothers, and parenting skills regarding time management and breastfeeding organization, in addition to education on the benefits of exclusive breastfeeding through 6 months of age and beyond. Detailed education on the benefits of breastfeeding is important to dispel misconceptions that a perfect diet is required and smoking or alcoholic drinks must be avoided in order to breastfeed. Mothers should be counseled on enjoying a balanced diet with specific food preferences in moderation, calorie needs to sustain milk production, occasional intake of alcoholic drinks, and strategies to help quit smoking with the understanding that the benefits of breastfeeding outweigh the risk of nicotine exposure and consumption of junk food (AAP Section on Breastfeeding, 2012). It is essential not to overemphasize the benefits of early breastfeeding to prevent giving the impression that providing nutrient-rich colostrum the first few days after birth is most important in achieving the health benefits of breastfeeding. Mothers should be aware the greatest benefits for both mother and infant are related to the amount and duration of exclusive breastfeeding with the most benefit for mothers seen with more than 6 months breastfeeding duration (AAP Section on Breastfeeding, 2012). We should make breastfeeding appealing and help African American mothers find ways to fit breastfeeding into their lifestyle as there are some benefits for any amount of human milk provided compared to none.

More research is vital to eliminate the racial disparity in breastfeeding. Quantitative research among African American mothers and support persons is needed to understand perceptions of good support, best education practices to improve breastfeeding knowledge, and perceptions of involvement of personal support persons, as well as reasons for missed opportunities to seek available professional breastfeeding support. Additional research is also necessary regarding the impact of exposure to African American breastfeeding mothers on infant feeding outcomes and social norms. This will help to identify effective interventions for change in cultural, social, and structural systems that affect daily life impeding successful breastfeeding.

Although findings from our study give insight into decisions regarding discontinuation of breastfeeding and switching to formula feeding, there are limitations to consider. This is a secondary analysis of data from a larger study and participants were not asked directly about personal, behavioral, or environmental factors that impact infant feeding decisions. Narratives about these factors were only present if the participant discussed them while sharing their breastfeeding experiences. Data were also collected from a Midwest community in the United States and infant feeding decisions of mothers in other regions may differ. Prospective research is needed with African American mothers to directly assess determinants for discontinuing breastfeeding and switching to formula. Nonetheless, our findings offer a closer look at how African American mothers who initiated breastfeeding were not able to overcome barriers to breastfeeding that result from social and cultural influences in their direct environment.

Findings indicate that multiple factors influence infant feeding decisions. Although mothers presented forethought with breastfeeding intentions, self-reflecting on their efficacy and challenges faced during breastfeeding prompted decisions to switch to formula feeding. Evaluating breastfeeding based on its ease or difficulty and social norms encouraged greater comfort with formula feeding. Breastfeeding for these mothers was socially positioned with situations and systems in their direct environments they had no control over, such as individual responses to breastfeeding in public or access to breastfeeding support resources after hospital discharge. While many mothers discussed available breastfeeding support at WIC, no one discussed community resources for breastfeeding mothers not participating in the WIC program. This evidence demonstrates effective, comprehensive breastfeeding interventions are not yet widespread reaching the mothers who need them most. There is a great need for structural policies and healthcare providers to help African American mothers rise above the social determinants of health that impede breastfeeding in efforts to eliminate racial disparities in breastfeeding.