FACTS Spotlight: National Breastfeeding Month
Enhancing Breastfeeding Rates Among African American Women: A Systematic Review
By: Stephanie E. Nonawzki, DO
Editor’s Note: As part of our series during National Breastfeeding month, we continue to highlight benefits of breastfeeding. Stephanie Nonawzki, a former FACTS elective student and recent medical school graduate, summarized a 2015 study called Enhancing Breastfeeding Rates Among African American Women, a systematic review of current psychosocial interventions. The review utilizes the terms “African American” and “black” interchangeably to refer to the same population of women. Considering first the barriers and facilitators particular to breastfeeding among African American women, researchers Johnson et al. then discuss published breastfeeding interventions for this group.
Introduction
Breastfeeding is positively correlated with nutritional, psychological, and developmental benefits for both mothers and infants, when compared to bottle feeding. [1] As research continues to emerge in support of breastfeeding, the United States has seen an uptick in overall breastfeeding rates, likely supported by legislative changes in health, economics, employment, and welfare policies and practices. However, despite these interventions, African American mothers continue to have the lowest breastfeeding rates. This can lead to poorer postnatal outcomes and other possible health disparities. When compared to white women, black women have higher rates of poor perinatal health outcomes, chronic illnesses, stress, depression, and PTSD and often experience lower incomes and systemic discrimination. Black women of low socioeconomic status with fewer personal and professional supports, less flexible employment, and shorter maternity leaves are also less likely to receive the physical, emotional, and social support and resources they need. Overall, established risk factors associated with lower breastfeeding rates are more prevalent among African American women, thus contributing to lower rates of breastfeeding and breastfeeding self-efficacy.
Methodology
The researchers followed Whittemore and Knafl’s five-stage qualitative literature review process, which includes identification of the problem, followed by a literature review, data evaluation and analysis, and concludes with presentation of results. Researchers conducted an electronic search of articles published from 1995-2013 for common phrases and words related to breastfeeding and black mothers. The goal was to identify interventions and strategies to improve breastfeeding initiation and duration among black mothers. In total, 23 studies met the inclusion criteria, which included at least a 30% African American mother representation.
Breastfeeding interventions were organized using an adapted social ecological framework using a multilevel systems approach within a socio-historical context. Four levels function both independently and in conjunction with components of social structure: the outermost macrosystem level includes policy, legislation, and institutions related to breastfeeding; the local exosystem level refers to clinically-trained healthcare practitioners, including physicians and lactation consultants; the interpersonal microsystem includes friends and family; and the innermost individual level includes the mother–infant dyad and the mother’s breastfeeding attitude, knowledge, and self-efficacy. Interventions target different levels, but all remain within the overarching socio-historical context that considers racial discrimination and biases.
Figure 1. The social-ecological model
Results
None of the studies exclusively addressed macrolevel policy and social systems specific to African American women, despite being part of a high-risk group. However, a few studies combined both macrolevel and community-level interventions, studying hospital-led initiatives derived from national policies such as the Baby-Friendly Hospital Initiative (BFHI).
Several studies only addressed local community-level interventions, focusing on available breastfeeding education and support from hospitals, medical professionals, and lactation consultants. Community-level interventions found statistically significant correlations between home visits by lactation consultants postpartum and improved rates of breastfeeding. A study exploring institutional level differences in care through Women, Infants and Children (WIC) interventions found that African American women were more likely than white women to report being advised to bottle feed instead of breastfeed. Both African American women and white women demonstrated higher rates of breastfeeding when reporting that their healthcare practitioner advised breastfeeding versus bottle feeding (39.9% vs. 15.1%; p<0.001).
“Both African American women and white women demonstrated higher rates of breastfeeding when reporting that their healthcare practitioner advised breastfeeding versus bottle feeding.”
Additional studies assessed the interpersonal level of psycho-emotional support, education from a breastfeeding peer or mom, and individual level markers of perceived breastfeeding self-efficacy, personal attitudes, and perseverance. In several urban hospitals and clinics where interpersonal studies were conducted to target either expectant mothers and fathers with peer-led prenatal support and education on breastfeeding, studies observed higher breastfeeding initiation rates. Compared to control groups, mothers with prenatal breastfeeding education started breastfeeding at a rate of 67% to 55% [p<0.001] and 74% to 41% [p<0.02] for expectant fathers.
The literature also highlighted the importance of familial role models, such as mothers, grandmothers, or sisters. Previous personal or family breastfeeding experience was found to be a strong predictor of breastfeeding in a sample of low-income African American women. Two more strong predictors of breastfeeding initiation and duration are maternal breastfeeding self-efficacy and perseverance. Boosting a mother’s confidence and her ability to persevere if she encounters difficulties are essential to increasing breastfeeding rates.
“Boosting a mother’s confidence and her ability to persevere if she encounters difficulties are essential to increasing breastfeeding rates.”
Some studies examined peer counseling, healthcare professionals and staff behaviors, and support — with a focus on perceptions, attitudes, and ideas. Results included positive correlations with healthcare policies, staff training, breastfeeding assistance shortly after birth, continued demonstration and education for mothers, and 24-hour mother-child rooming. However, many of these studies fail to account for ecological factors, including demographics and other social influences. Black mothers received little breastfeeding education and support and expressed distrust, anxiety, and dissatisfaction with nurses and physicians.
Discussion
A number of ecological studies found positive outcomes following breastfeeding interventions, but an integrative approach is needed to address the many factors and barriers affecting black women regarding breastfeeding initiation and duration. There is room for education and improvement across all levels of intervention. National, state, and local policies may be needed. On a community and institutional level, there needs to be more education for healthcare professionals — from practical strategies and teaching practices to the benefits of breastfeeding, which includes better health outcomes for mom and baby and effective postpartum family planning with the Lactational Amenorrhea Method. Research indicates that even the phrasing of questions about breastfeeding matters. Asking“What do you know about breastfeeding?” instead of “Are you going to breastfeed or bottle feed?” doubled the rate of breastfeeding initiation. [2] Educated professionals can take the onus on themselves to inform women and advocate for better public health infrastructure, protected workplace flexibility and accommodations, and ongoing interventions from prenatal to postpartum periods. Interpersonal and individual factors are also critical to positive breastfeeding self-efficacy and consistency.
“Research indicates that even the phrasing of questions about breastfeeding matters. Asking “What do you know about breastfeeding?” instead of “Are you going to breastfeed or bottle feed?” doubled the rate of breastfeeding initiation.”
As we seek new and effective strategies to better serve women, it is valuable to consider the role of systemic racism to address these issues, at every level. The complicated relationship between race and cultural norms must also be addressed when it comes to breastfeeding. Racism presents a barrier to a black woman’s opportunity to achieve optimal health for herself and her baby, and there’s a need for improved training to provide culturally-appropriate care and avoid racial bias. Furthermore, despite the inclusion of research on institutional, community-level interventions by hospitals and healthcare professionals, none of the studies discussed employer-led interventions targeting African American women specifically. These women have a higher risk of breastfeeding cessation after returning to work, and yet there were no targeted support programs identified. Systemic racism affects all levels and all institutions, so effective interventions may have to adopt a multi-level approach to create lasting change and racially equitable care.
Improving access to both social and economic resources on multiple levels is another fundamental step. Despite psychosocial risks to breastfeeding success — such as stress, mental health problems, and chronic illness — psychological and social support interventions have not adequately addressed these risk factors.
To address more macro-level questions of economic status, income, and social class, further studies are needed. Many studies are not socioeconomically diverse and tend to target one income range (often low-income), introducing confounding factors and making the data less generalizable. Without studies that adequately sample women across socioeconomic status, it remains a challenge to tease out socioeconomic status from race. In addition, since mothers use social media and the internet for support and research, encouraging positive associations with breastfeeding within these mediums would be beneficial.
There are many questions remaining regarding how to create interventions and strategies that increase breastfeeding among black women. Firsthand feedback and information from the mothers or healthcare workers about their experiences could advise future research, as would targeted research on breastfeeding duration.
Sources
[1] Johnson A, Kirk R, Rosenblum KL, Muzik M. Enhancing breastfeeding rates among African American women: a systematic review of current psychosocial interventions. Breastfeed Med. 2015;10(1):45-62. doi:10.1089/bfm.2014.0023
[2] Hartley BM, O’Connor ME. Evaluation of the ‘Best Start’ breast-feeding education program. Arch Pediatr Adolesc Med. 1996;150(8):868–871. doi:10.1001/archpedi.1996.02170330094016
ABOUT THE AUTHOR
Stephanie E. Nonawzki, DO
Stephanie E. Nonawzki, DO, a graduate of the New England College of Osteopathic Medicine, has a passion for social justice and advocacy work. She spearheaded the start of the University of New England’s Equity and Diversity Advancement Committee and served as the Council of Osteopathic Student Government President’s Diversity Representative. She began her pediatric residency at the University of Rochester Golisano Children’s Hospital in June 2021, where she intends to continue her diversity, equity, inclusion, and advocacy work.
