RESEARCH

1 57
2 58
3
4
Factors That Influence Breastfeeding 59
60
5
6 Initiation Among African American 61
62
7 63
8
9
Women 64
65
10 Tyonne D. Hinson, Asheley Cockrell Skinner, Kristen Hassmiller Lich, and Diane L. Spatz Q11 66
11 67
12 68
13 Correspondence ABSTRACT 69
14 Tyonne D. Hinson, DrPH, 70
Objective: To examine cultural and socioenvironmental factors that affect breastfeeding initiation among African
15 Q1 MSN, RN, NE-BC. 71
tyonnehinson@gmail.com; American women.
16 72
thinson0210@cs.com Design: Qualitative descriptive design and conventional content analysis.
17 73
18 Keywords Setting: A large, inner-city, primary care center affiliated with a 500-bed children’s hospital within a large, North- 74
19 African American mothers eastern U.S. city. 75
barriers and facilitators
20 breastfeeding initiation Participants: Participants were 34 U.S.-born African American mothers of healthy term infants 0 to 3 months of age. 76
21 culture Methods: Six focus groups were conducted using a 16-question, scripted interview guide. 77
22 qualitative research 78
social environment Results: A number of complex issues that influenced breastfeeding initiation included certain cultural beliefs about
23 79
sexuality, the influence of family and peer networks, information sources, intentions, and a variety of other barriers and
24 80
facilitators.
25 81
Conclusion: Our findings suggest that the decision to initiate breastfeeding is not solely determined by the woman
26 82
within the African American community. Because this decision is contingent on multiple factors external to the woman,
27 83
it is important to recognize the role that partners, grandmothers, communities, information sources, and health care
28 84
providers/organizations play in women’s decisions. Implementation of multilevel strategies is critical to increase
29 85
breastfeeding initiation among African American mothers.
30 86
31 JOGNN, -, -–-; 2018. https://doi.org/10.1016/j.jogn.2018.02.007
87
32 Accepted February 2018
88
33 89
34 90
35 91
36 92
37 93
T he breastfeeding initiation rate among The short- and long-term nutritional, anti-
Tyonne D. Hinson, DrPH,
38 MSN, RN, NE-BC. women in the United States is approxi- inflammatory, and immunologic benefits of hu- 94
39 Asheley Cockrell Skinner, mately 81.1% (Centers for Disease Control and man milk are well established. Human milk 95
40 PhD, is an associate Prevention [CDC], 2016). Although this rate is decreases mortality and infectious disease 96
41 professor in the Duke
less than that of most industrialized nations (Eidelman et al., 2012; Ma & Magnus, 2012; 97
Clinical Research Institute
42 and the Department of worldwide, the U.S. breastfeeding initiation Reeves & Woods-Giscombé, 2015; Spatz & 98
43 Population Health Sciences, rate has continued to improve since 1972. Lessen, 2011). This is critically important 99
44 Duke University, Durham, However, in the United States, African Amer- because African American infants and children 100
NC.
45 ican women initiate breastfeeding at a rate of are at greater risk for the development of dis- 101
46 only 66.3% (CDC, 2016). This indicates a eases such as asthma (13.4% African American 102
47 striking disparity when compared with women vs. 7.6% White at ages < 18 years), obesity 103
48 of other races/ethnicities, particularly White (23.8% African American vs. 13.1% White at ages 104
49 and Hispanic women (84.3% and 83.0%, 6–11 years), infant mortality (2.2 times the rate 105
50 respectively; CDC, 2016). These rates indicate of White infants), and SIDS (1.9 times the rate of 106
51 that African American women are less likely to White infants). Human milk decreases the risk of 107
(Continued)
52 initiate breastfeeding, which increases the lower respiratory tract infections, asthma, otitis 108
53 risk for African American infants to experience media, gastrointestinal infections, necrotizing 109
54 infant mortality, sudden infant death syndrome enterocolitis, SIDS, and obesity (Eidelman et al., 110
The authors report no con-
55 flict of interest or relevant (SIDS), childhood morbidities, and chronic 2012; Hildebrand et al., 2014; Spatz & Lessen, 111
56 financial relationships. health conditions (Spencer & Grassley, 2013). 2011; Ware, Webb, & Levy, 2014). 112

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 RESEARCH Breastfeeding Initiation in African American Women

113 breastfeeding initiation in the African American 169

114 In African American women, the decision to initiate community. The institutional review boards of the 170
115 breastfeeding is not solely determined by the women but is University of North Carolina at Chapel Hill and the 171
116 contingent on multiple external factors. Children’s Hospital of Philadelphia approved this 172
117 study. 173
118 174
It is likely that the factors that influence the deci-
119 Sample and Setting 175
sion to initiate breastfeeding among African
120 The setting was a large, primary care facility 176
American women include internal (individual) and
121 affiliated with a 500-bed pediatric hospital within 177
external (interpersonal, organizational, commu-
122 a large Northeastern U.S. city. The facility pro- 178
nity, and public policy) factors. Examples such as
123 vides comprehensive primary care for the West 179
the conceptual model for breastfeeding behavior
124 Philadelphia community and has the capacity to 180
by Lee et al. (2009) illustrate how these elements
125 accommodate more than 45,000 outpatient visits 181
influence breastfeeding intention and initiation
126 each year. More than half of the population 182
through interactions among demographic, so-
127 receiving care at this setting self-identifies as 183
cioeconomic, and external modifiable factors
128 Black or African American, and almost 75% are 184
(Gross et al., 2014; Lee et al., 2009; Reeves &
129 enrolled in Medicaid or Medicaid/Managed Care. 185
Woods-Giscombé, 2015; Ware et al., 2014). The
130 African American mothers of infants 0 to 3 months 186
conceptual model for breastfeeding behavior was
131 of age were invited to participate. 187
specifically designed to explain breastfeeding
132 188
intention and initiation through nonmodifiable
133 We purposefully divided participants into two 189
factors of demographics (race/ethnicity and na-
134 groups: those who were breastfeeding at the time 190
tivity) and socioeconomic factors (education,
135 of enrollment and those who were not breast- 191
employment, income, age, birth order) that inter-
136 feeding. Inclusion criteria were U.S.-born African 192
play with external modifiable factors. External
137 American woman; English speaking (primary 193
factors include cultural context, social environ-
138 language); mother of a healthy term infant within 194
ment, maternal well-being and behaviors, and
139 the past 3 months; and at least 18 years of age. 195
infant characteristics (Gross et al., 2014; Lee
140 Consent was obtained from a total of 61 women 196
et al., 2009; Reeves & Woods-Giscombé, 2015;
141 because of anticipated high no-show rates for the 197
Ware et al., 2014).
142 focus groups; focus groups were discontinued 198
143 after 34 African American mothers participated. 199
Lee et al. (2009) provided a detailed examination
144 Additional focus groups were not deemed 200
of breastfeeding practices and modifiable factors
145 necessary because saturation of themes was 201
among primarily minority (64% African American),
146 reached. Participants included a diverse sample 202
inner-city women in Philadelphia, PA. They re-
147 of African American mothers with various de- 203
ported that cultural and social–environmental
148 mographic characteristics. 204
factors played a central role in the decision to
149 205
initiate breastfeeding. To understand and
150 Data Collection 206
address low rates of initiation among African
151 The first author actively recruited eligible women 207
Kristen Hassmiller Lich, American women, these issues must be investi-
152 for focus groups on weekdays at the primary care 208
PhD, is an assistant gated further through focused research and
153 center during their infants’ scheduled medical 209
professor in the Department analysis (Reeves & Woods-Giscombé, 2015).
154 of Health Policy and visits. Each eligible woman was approached by a 210
Therefore, the purpose of our study was to
155 Management, Gillings nurse or medical assistant at the center regarding 211
School of Global Public explore perceptions of the facilitators of and
156 the woman’s interest in participation in the study. 212
Health, University of North barriers to breastfeeding initiation among African
157 Carolina at Chapel Hill, Interested women remained in their examination 213
American women with a specific focus on cultural
158 Chapel Hill, NC. rooms to discuss the purpose of the research, 214
and social–environmental factors.
159 requirements of participation, incentives for 215
Diane L. Spatz, PhD,
160 RN-BC, FAAN, is a participation, and interest in enrollment with the 216
161 professor of perinatal Methods researcher via a standardized script. Interested 217
162 nursing and Helen M. We used a qualitative research design to uncover women were informed that they would be asked 218
Shearer Term Professor of
163 Nutrition, University of factors that influence opinion, behavior, and to voluntarily share their personal experiences 219
164 Pennsylvania School of motivation about breastfeeding and to explore the about cultural, social, and environmental factors 220
165 Nursing, and Director of the social issues associated with breastfeeding initi- that influenced their decisions to breastfeed their 221
166 Lactation Program, 222
ation among African American women. Focus infants in a one-time group session. After they
Children’s Hospital of
167 Philadelphia, Philadelphia, groups were used to gain women’s perspectives provided informed consent, enrollees were given 223
168 PA. on beliefs, practices, facilitators, and barriers to information about future scheduled focus groups 224

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 Hinson, T. D., Skinner, A. C., Lich, K. H., and Spatz, D. L. RESEARCH

225 (time and date) and transportation fare for their pediatric PhD-prepared nurse researcher with 281
226 sessions; they received follow-up reminder calls formal education in qualitative research design, 282
227 24 to 48 hours before the sessions. Focus groups methods, and analysis independently read and 283
228 were held in a conference room at the ambulatory coded transcripts to ensure coding accuracy and 284
229 center location. At the completion of the focus consistency. Independent analyses were 285
230 group, participants were given a meal, return compared to reconcile differences regarding 286
231 transportation fare, and a $25 gift card. codes and to approve primary themes and sub- 287
232 themes. The use of sequential, prescripted 288
233 Focus groups were conducted with the use of a questions for all focus groups and double coding 289
234 16-question, open-ended script. These pre- of transcripts enhanced methodologic rigor. 290
235 scripted questions were developed on the basis 291
236 of a review of the literature and prior research to 292
237 broadly elicit participants’ perceptions of the fa- Results 293
238 cilitators and barriers of breastfeeding initiation Six focus groups were conducted with a total of 294
239 among African American women with a specific 34 participants. Focus groups ranged in size, and 295
240 focus on cultural and socioenvironmental factors three to nine women participated in each session. 296
241 and the modifiable factors of the conceptual A total of 22 participants were breastfeeding at 297
242 model of breastfeeding behavior (Lee, Elo, the time of the study, and 12 participants were not 298
243 McCollum, & Culhane, 2009). The interview (see Table 1). 299
244 questions were pilot-tested by three African 300
245 American women of different demographic The primary themes that emerged from focus 301
246 backgrounds who met study inclusion criteria groups were analogous to most factors of the two 302
247 (see Supplemental Table S1). The focus group central modifiable factors of the conceptual 303
248 interview script included probes to encourage model for breastfeeding behavior, Cultural 304
249 additional description or clarifiers to ensure that Context and Social Environment Factors, and the 305
250 each focus group had a consistent approach, external domain Breastfeeding Intention. Key 306
251 regardless of diversity among participants in perceived facilitators and barriers were high- 307
252 each group or breastfeeding decision. Each lighted in the primary themes. In total, we identi- 308
253 focus group was audiorecorded. A co-facilitator fied 7 primary themes and 40 subthemes. 309
254 took field notes to capture impressions, ideas, Although it is not feasible to address all 40 sub- 310
255 gestures, and key words during each session. themes in this article, they are listed in Table 2. 311
256 The focus group facilitator and co-facilitator were The two primary themes in the Cultural Context 312
257 African American women. domain were Beliefs About Breastfeeding and 313
258 Issues of Sexuality. 314
259 Each focus group lasted approximately 120 mi- 315
260 nutes. Questions focused specifically on personal Cultural Context: Beliefs About 316
261 and familial beliefs about breastfeeding, relevant Breastfeeding 317
262 issues of sexuality, social network interactions, 318
Benefits to Baby and Mom’s Health. Participants
263 social support, social influence, and information 319
in the breastfeeding and non-breastfeeding focus
264 sources. To protect confidentiality, participants 320
groups frequently mentioned benefits to the infant
265 were able to select pseudonyms instead of using 321
and mother as a prevailing belief about breast-
266 their first names during the recorded session, but 322
feeding. Although some participants cited bene-
267 none opted to do so. Data collection was 323
fits to the infant (e.g., intellect, protection from
268 completed in 2016. 324
illness) as being most important in breastfeeding,
269 325
other participants cited maternal benefits (e.g.,
270 Data Analysis return to pre-pregnancy weight, illness protec-
326
271 After transcription, all data were analyzed using 327
tion) as critical reasons to breastfeed.
272 Atlas.ti 7.0 qualitative software and conventional 328
273 qualitative content analysis to elucidate experi- 329
274 ences, facilitators, and barriers and to preserve Increased Bonding. The phenomenon of 330
275 intended meanings. We inductively developed a increased bonding among breastfeeding 331
276 codebook from the primary results as transcripts mothers and infants was highlighted several 332
277 were reviewed. Additions and revisions to the times by participants in both focus groups. 333
278 codebook and coding process were made itera- Despite not breastfeeding, non-breastfeeding 334
279 tively as new themes and subcategories focus group participants also identified the act 335
280 emerged. The first author and an experienced of breastfeeding as a positive exchange between 336

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337 393
338 Table 1: Demographics of Focus Group Participants 394
339 395
Breastfeeding Group (n ¼ 22) Non-breastfeeding Group (n ¼ 12)
340 396
Demographic Variable n (%) n (%)
341 397
342 Age in years mean ¼ 26.5 mean ¼ 24.7 398
343 18–21 4 (18.2) 4 (33.3) 399
344 22–25 6 (27.3) 2 (16.7)
400
345 401
26–29 5 (22.7) 4 (33.3)
346 402
347 30–35 6 (27.3) 2 (16.7) 403
348 36–40 1 (4.5) 0 (0) 404
349 405
Number of children
350 406
351 1 10 (45.5) 7 (58.3) 407
352 2 4 (18.2) 1 (8.3) 408
353 409
3 3 (13.6) 2 (16.7)
354 410
355 4 4 (18.2) 1 (8.3) 411
356 5þ 1 (4.5) 1 (8.3) 412
357 413
Previous breastfeeding experience 11 (50) 2 (16.7)
358 414
Initiation of breastfeeding with this infant 22 (100) 7 (58.3)
359 415
360 Employment status 416
361 Working 0–20 hours per week 0 (0) 2 (16.7) Q8 417
362 418
Working 21–40þ hours per week 13 (59.1) 5 (41.6)
363 419
364 Not working 9 (40.9) 5 (41.6) 420
365 Monthly income 421
366 422
$0–$833 12 (54.5) 8 (66.7)
367 423
368 $834–$1,666 5 (22.7) 2 (16.7) 424
369 $1,667–$2,449 2 (9.1) 0 (0) 425
370 426
Not disclosed 3 (13.6) 2 (16.7)
371 427
372 School status 428
373 Enrolled 6 (27.3) 2 (16.7) 429
374 Not enrolled 16 (72.7) 10 (83.3)
430
375 431
Highest level of education
376 432
377 Some high school 3 (13.6) 2 (16.7) 433
378 High school graduate/high school equivalency 6 (27.3) 6 (50) 434
379 435
Some college/vocational school/associate’s degree 9 (40.9) 4 (33.3)
380 436
381 Bachelor’s degree 1 (4.5) 0 (0) 437
382 Other (master’s degree) 3 (13.6) 0 (0) 438
383 439
Enrolled in WIC 19 (86.4) 12 (100)
384 440
385 Note. WIC ¼ Special Supplemental Nutrition Program for Women, Infants, and Children. 441
386 442
387 443
388 a mother and her child through more skin-to-skin some, the reference to the word natural was 444
389 contact and enhanced connection. focused on the connection to spirituality and a 445
390 divine design by God. Although other partici- 446
391 It’s Natural. Many breastfeeding participants pants in both groups did not reference the spiri- 447
392 referred to breastfeeding as being “natural.” For tual connection, they did mention the perfect 448

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449 505
450 Table 2: Primary Themes and Subthemes 506
451 507
Primary Themes Subthemes
452 508
Cultural Context (Factors)
453 509
454 Beliefs About Benefits to Baby and Mom’s Health 510
455 Breastfeeding Increased Bonding 511
456 512
It’s Natural
457 513
458 Historic Cultural Events Have Influenced Beliefs, Exposure and Perceptions of Breastfeeding 514
459 (Non-Normalized) 515
460 Formula Is as Good as Breast Milk 516
461 517
Racism/Community Disparities Supporting African American Maternal Breastfeeding
462 518
463 Issues of Sexuality Breasts for Both Nutrition and Sexuality 519
464 Breastfeeding for Sexuality/Sexual Act Q9 520
465 521
Oversexualization of African American Females
466 522
467 Social Environment (Factors) 523
468 Familial/Network Influence Self-Influence 524
469 525
Matriarchal Influence
470 526
Partner Influence
471 527
472 Sister Influence 528
473 Friend/Peer Network Influence 529
474 530
Religious Community Influence
475 531
476 Informational Sources Prenatal Clinics 532
477 WIC 533
478 534
Physicians
479 535
480 Nurses 536
481 Lactation Consultants 537
482 538
Internet Sources
483 539
484 Breastfeeding Intention 540
485 Intention Positive Intention 541
486 Negative Intention/Ambivalence
542
487 543
Barriers and Facilitators
488 544
489 Barriers Competing Priorities 545
490 Pain 546
491 547
Embarrassment of Public Exposure
492 548
Lack of Knowledge and Support of Breastfeeding in African American Community and Home Q10
493 549
494 Lack of Information and Education About Breastfeeding Prenatally 550
495 551
Lack of Access to Equipment and Resources
496 552
497 Aversions to Breastfeeding 553
498 Convenience of Formula and Bottle-Feeding 554
499 555
Independence
500 556
National Policy
501 557
502 (Continued) 558
503 559
504 560

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561 617
562 Table 2: Continued 618
563 619
Primary Themes Subthemes
564 620
Facilitators Engaged/Involved Fathers
565 621
566 Prior Positive Experience/Exposure 622
567 Cost and Convenience of Breastfeeding 623
568 624
Peer Counselors/Peer Support Groups
569 625
570 Supportive Family (Home) Environment 626
571 Baby-Friendly Hospital Influence 627
572 628
WIC
573 629
574 Note. WIC ¼ Special Supplemental Nutrition Program for Women, Infants, and Children. 630
575 631
576 632
577 creation and exactness of the breastfeeding there are stores that have rooms. . You know 633
578 phenomenon: “I just think God created everything that you can go in and you can nurse and 634
579 kind of perfectly. you know, it just seems like, things like that. In our community, you don’t 635
580 okay, this is what’s supposed to happen” find that at all. (Breastfeeding group) 636
581 (breastfeeding group). 637
582 638
Cultural Context: Issues of Sexuality
583 Historic Cultural Events Have Influenced Beliefs, 639
Breasts for Both Nutrition and Sexuality. Many
584 Exposure, and Perception of Breastfeeding (Non- 640
breastfeeding and non-breastfeeding focus
585 Normalized). In African American culture, the 641
group participants offered positive perspectives
586 view of breastfeeding has changed during the 642
about the dual purpose of the female breast. They
587 course of history, and this change was referenced 643
spoke about the abilities of their breasts to
588 by participants in the breastfeeding and non- 644
appropriately provide nutrition for their infants
589 breastfeeding focus groups. Participants dis- 645
and be viewed sexually by their partners during
590 cussed the implications of slavery and the lack of 646
moments of intimacy:
591 knowledge and non-normalized experience in the 647
592 Black community as significant in current day 648
I believe that it’s for both purposes, like I do
593 perceptions of African American mothers and the 649
believe that it’s for the sexual purpose for your
594 community about breastfeeding: 650
husband, but it’s also for nurturing your child
595 651
when that time comes. And um. even for me,
596 There are a lot of people in the African Amer- 652
like before I started, I even wondered myself.
597 ican community that don’t even know that 653
(Breastfeeding group)
598 much, like that we were forced to feed, you 654
599 know, our master’s children. Like well, if they 655
600 thought we were. you know, that if we were Breasts for Sexuality/Sexual Act. The beliefs that 656
601 good enough to do that, that we should be breasts are solely for the purpose of sexuality and 657
602 made to do that, then maybe it’s better that we that the act of breastfeeding is sexual in nature 658
603 do it for our kids. (Breastfeeding group) were mentioned primarily by non-breastfeeding 659
604 focus group participants. These participants 660
605 Racism/Community Disparities Supporting had reservations about the act of breastfeeding 661
606 African American Maternal Breastfeeding. The based on reactions of their partners, personal 662
607 issues of racism and disparities within African skepticism, or concerns about feeding children 663
608 American communities were mentioned in both directly from the breast: 664
609 focus groups, and participants highlighted extant 665
610 disparities in African American communities Like the reasons why I don’t breastfeed is 666
611 compared with neighboring White communities. because I do think it’s sexual and it’s just 667
612 They perceived White privilege as critical in the creepy. The fact of having to put my boob in 668
613 final decision to initiate breastfeeding: my baby’s mouth. I know it sounds like, you 669
614 know, it’s harmless, and I know that’s the way 670
615 I noticed that. stores and stuff like that in for them to eat, but I just, I can’t see me doing 671
616 White, predominately White communities, it. (Non-breastfeeding group) 672

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673 Q2 The second external domain included two pri- So people who are, you know, who have a 729
674 mary themes: Familial/Network Influence and spirituality about them, um, it seems like they 730
675 Informational Sources. These themes captured understand better the natural order of things, 731
676 the effects of interpersonal and organizational so they accept it more and they support it 732
677 interactions on participants’ decisions regarding more, because it’s like this is what you should 733
678 breastfeeding initiation. do ’cause this is what God intended you to do. 734
679 (Breastfeeding group) 735
680 736
Social Environment: Familial/Network
681 However, other participants maintained that reli- 737
Influence
682 gion does not dictate personal choice in breast- 738
Matriarchal Influence. Matriarchal influence was
683 feeding initiation decisions. 739
identified often by participants when they referred
684 740
to the familial and network influences on de-
685 741
cisions about breastfeeding initiation. Matriarchal Social Environment: Informational
686 742
influence, which refers to the positive and nega- Sources
687 743
tive influences of the infant’s maternal or paternal Special Supplemental Nutrition Program for
688 744
grandmother/great-grandmother, was the most Women, Infants, and Children (WIC). The WIC
689 745
common type of influence identified by partici- Program, sponsored by the U.S. Department of
690 746
pants: “Because my mom and my stepmom, they Agriculture Food and Nutrition Service, is a
691 747
both done it and they. I got a lot of information federal program that was frequently mentioned as
692 748
from them and how they experienced it” (breast- a source for breastfeeding information, particu-
693 749
feeding group). “One of my most negative influ- larly during the prenatal period. Although many
694 750
encers was my mother. She just made it seem participants highlighted WIC as a consistent
695 751
like, you know, you should be bottle-feeding” source of informational support, some reported
696 752
(breastfeeding group). that they did not talk with staff or that the focus on
697 753
breastfeeding dwindled after birth: “If you ask for
698 754
Partner Influence. Participants in both groups the help, they provide it, but pretty much they like
699 755
commonly agreed that African American women you get the formula, here go your checks, you’re
700 756
are influenced by the perspectives of their part- on your way” (non-breastfeeding group).
701 757
702 ners and sometimes yield their personal desire to 758
703 breastfeed because of a partner’s reluctance: Physicians. Various health care providers were 759
704 “His dad. was reading more books than me frequently mentioned as critical resources for in- 760
705 about it and talking to more people about it, so he formation and influential in breastfeeding de- 761
706 was often like the biggest cheerleader for me cisions. For example, participants shared mixed 762
707 when I was like I can’t do it” (breastfeeding experiences they had with physicians and 763
708 group). “You know, but I think they see it for a described engaged experiences in some in- 764
709 sexual purpose, ’cause he’s like, ‘I don’t want my stances and closed-minded or absent discus- 765
710 son to be eating like that. Give him the bottle’ ” sions in others: 766
711 (non-breastfeeding group). 767
712 I think another barrier could be also, you know, 768
713 Friend/Peer Network Influence. In addition to with the doctors. Like I, you know, definitely 769
714 family members and partners, participants experienced that a lot, like they’re really not 770
715 commonly mentioned that friends influenced their open-minded. They really just like, “You need 771
716 viewpoints (positive and negative) and decisions to do this, you need to do that,” you know. 772
717 about breastfeeding initiation. Friends and co- (Non-breastfeeding group) 773
718 workers were most commonly identified as 774
719 the social network external to family that provided 775
720 Nurses. Nurses were identified as positive sour- 776
the most influence, support, and encouragement.
721 ces of information by participants in both groups. 777
722 Respondents described multiple supportive 778
723 Religious Community Influence. Spanning Chris- encounters with nurses, regardless of whether or 779
724 tian and Muslim faiths, participants discussed the not they eventually breastfed: “It was just so 780
725 influence of their religious beliefs. In several welcoming and comforting that I did not have to 781
726 comments, participants who breastfed referred to struggle and try to like do this boob thing by 782
727 breastfeeding as “created perfectly by God” and myself, ’cause I didn’t know what I was doing” 783
728 “a child’s right.” (breastfeeding group). 784

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785 Lactation Consultants. Although lactation con- three other kids to worry about, you. it’s too 841
786 sultants were seen as positive and supportive demanding. (Breastfeeding group) 842
787 sources of information for some participants, 843
788 many breastfeeding and non-breastfeeding Embarrassment of Public Exposure Participants, 844
789 participants voiced frustration about their primarily from the non-breastfeeding group, 845
790 hospital experiences. Lactation consultants were expressed a sense of embarrassment and stigma 846
791 described frequently as lacking knowledge/ associated with breastfeeding in public. They re- 847
792 information and being rushed and unavailable ported that they felt self-conscious about “bearing 848
793 during hospital stays: their body parts in public places” and discomfort in 849
794 breastfeeding in front of other people. 850
795 The lactation consultants, they may have 851
796 come. like they’d either come in there for like Lack of Knowledge and Support of Breastfeeding 852
797 five minutes, and if your baby don’t get right in the African American Community Breastfeed- 853
798 on the nipple, they’re like, “Oh well, we be ing participants highlighted the lack of knowl- 854
799 back. ” So yeah, they act like they don’t have edge, support, and exposure as another 855
800 time. (Non-breastfeeding group) significant barrier to breastfeeding initiation. 856
801 Many highlighted the tremendous challenge of 857
802 Breastfeeding Intention initiating breastfeeding in a culture in which for- 858
803 In the domain Breastfeeding Intention, partici- mula and bottle-feeding are the norm. Other 859
804 pants indicated the desire and interest to initiate participants mentioned the level of ignorance that 860
805 breastfeeding. This domain included positive currently exists within the community and 861
806 intention and negative intention. Positive Intention mentioned this as the reason for lack of openness 862
807 was most often reported by breastfeeding par- to the behavior: “I do think it’s. ignorance in the 863
808 ticipants who had prior experience or exposure to Black community because we don’t talk about 864
809 breastfeeding and felt positively empowered by breastfeeding. It’s not common in our community, 865
810 providing for their infants or “doing something and Caucasian. in the Caucasian community, 866
811 different.” Many non-breastfeeding participants it’s very common. It’s almost like normal for them” 867
812 expressed Negative Intention or ambivalence (breastfeeding group). 868
813 about breastfeeding initiation and made their 869
814 decisions long before information was shared: “I Lack of Information and Education About 870
815 knew I was going to bottle-feed. I didn’t even Breastfeeding Prenatally Lack of information and 871
816 want to think about breastfeeding” (non-breast- education about breastfeeding before birth was 872
817 feeding group). also mentioned frequently by participants. Pri- 873
818 marily, breastfeeding participants highlighted a Q3 874
819 lack of information sharing about breastfeeding 875
820 Barriers and Facilitators initiation before birth in contrast to being 876
821 Barriers and facilitators were identified as specific “swarmed” with information after birth: “I didn’t 877
822 factors that facilitated or hindered the positive get no information. While I was pregnant, they 878
823 adoption of breastfeeding based on personal or didn’t ask. I didn’t receive any information about 879
824 professional experiences and knowledge. breastfeeding” (non-breastfeeding group). 880
825 881
826 Barriers to Breastfeeding Initiation. Competing Independence Some participants discussed the 882
827 Priorities The challenge of juggling multiple re- desire for an independent infant for the purpose of 883
828 sponsibilities was one of the most commonly “mommy time,” and others focused on the impor- 884
829 mentioned barriers among participants during tance of not creating a spoiled or coddled infant 885
830 focus groups. Participants frequently mentioned who needed additional attention and support. 886
831 the demands of additional children, work, home Participants noted that family members (e.g., 887
832 schedule, school, and lack of time for breast- mothers and partners) voiced these perceptions: 888
833 feeding and pumping as rationales for this “I’d rather just. I want an independent baby, 889
834 subtheme: nothing like it’s going to be stuck to me twenty- 890
835 four–seven ’cause I might have to be like, okay, I 891
836 The time, the job, it requires a lot and some need mommy time” (non-breastfeeding group). 892
837 African American women are not able to stay 893
838 at home to do this. I mean, yeah, you can Facilitators of Breastfeeding Initiation. Engaged/ Q4 894
839 pump, but if you ain’t pumped already, you’re Involved Fathers Participants highlighted the 895
840 working a twelve-hour shift and you got two or importance of involving fathers and partners early 896

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897 on in breastfeeding discussions and education 953

898 because women are significantly influenced by Normalization of the breastfeeding experience, positive 954
899 their partners. They also stressed that partner matriarchal and partner influence, and decreasing racial 955
900 involvement encourages nurturing of the child: “I disparities in African American communities are keys to 956
901 watch a lot of my girlfriends. If their boyfriends, improving rates of initiation. 957
902 baby’s father, or whatever aren’t for it, then they’re 958
903 not going to do it” (breastfeeding group). 959
media and other influences. This will assist with a
904 960
positive shift toward increased breastfeeding
905 Prior Positive Experience/Exposure Prior positive 961
initiation.
906 experience with or exposure to breastfeeding 962
907 was discussed by multiple participants as a 963
Although the barriers and facilitators of breast-
908 facilitator for breastfeeding initiation. Participants 964
feeding initiation we found were numerous and
909 with past personal experiences with breastfeed- 965
overlapped with some documented in previous
910 ing children or witnessing family members 966
literature on factors that affect women more
911 described breastfeeding as a “natural instinct” 967
broadly, many new factors particularly relevant to
912 and that it was “unthinkable” to deprive a child of 968
African American mothers were identified. These
913 the benefits of breastfeeding. 969
factors are salient when considering the almost
914 970
20% disparity in rates of breastfeeding initiation
915 Peer Counselors/Peer Support Groups Breast- 971
among African American mothers, partly
916 feeding and non-breastfeeding participants 972
because of the dearth of women available to
917 verbalized interest in hearing the perspectives of 973
serve as role models, network supporters, and
918 other African American mothers and garnering 974
change agents in the community. Fortunately,
919 support during the breastfeeding process. 975
many of these factors could be significantly
920 They voiced a desire for more interaction and 976
influenced by culturally specific education, sup-
921 discussion with other mothers versus nurses or 977
port, and normalization of breastfeeding behavior
922 clinicians who lacked personal experience: “It 978
within the African American community. Barriers
923 would have probably helped me a little better 979
such as embarrassment of public exposure, lack
924 if I could have talked to a woman about 980
of knowledge and support in the community and
925 breastfeeding instead of a nurse with no kids” 981
home, aversion to breastfeeding, and a woman’s
926 (non-breastfeeding group). 982
self-centeredness/independence are some of the
927 983
topics that could be positively influenced. Facili-
928 984
929 Discussion tators, such as engaged/involved fathers, prior
985
Regardless of whether they breastfed, most par- positive experience/exposure, and peer coun-
930 986
ticipants had beliefs consistent with the current selors/peer support may be increased. Efforts to
931 987
evidence about the benefits of breastfeeding for increase exposure, support, and positivity about
932 988
infants and mothers. Despite these known bene- breastfeeding among African American women
933 989
fits, our findings indicate that awareness of health and in the community will be invaluable in build-
934 990
information and benefits alone is likely inade- ing foundational support that encourages initia-
935 991
quate to influence breastfeeding initiation. Provi- tion and increases intention early in the prenatal
936 992
sion of health information about breastfeeding, and early postneonatal periods (Fischer & Olson,
937 993
coupled with guidance about breastfeeding 2013; Spencer & Grassley, 2013).
938 994
939 expectations and culturally appropriate, positive 995
940 support by hospital/health care providers, is Implications for Practice 996
941 critical to increasing initiation rates (Cottrell & Our findings indicate that increasing rates of 997
942 Detman, 2013; Ma & Magnus, 2012). We found breastfeeding initiation among African American 998
943 that normalization of the African American women will require comprehensive interventions 999
944 breastfeeding experience, positive matriarchal on multiple levels beyond African American 1000
945 and partner influence, and a decrease in racial mothers. Several other factors, including a 1001
946 disparities in health care and communities are mother’s family, peer network, community, and 1002
947 also necessary to improve initiation rates. A sig- health care organizations/providers, play critical 1003
948 nificant cultural shift must occur within the African roles in the decision to initiate breastfeeding. 1004
949 American community with regard to female 1005
950 bodies, breasts, and sexuality so that women in Health care clinicians, public health officials, 1006
951 this community may be empowered to breastfeed and communities must consider implementing 1007
952 without the negative connotations implied by the four critical strategies: (a) implementation or 1008

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1009 to capture multiple viewpoints with a diversity of 1065

1010 Increasing African American women’s rates of perceptions, an individual viewpoint or commen- 1066
1011 breastfeeding initiation requires multilevel strategies tary may have been influenced or altered by that 1067
1012 involving families, communities, and providers to address of a fellow focus group participant. 1068
1013 beliefs, perceptions, and practices that impede 1069
1014 breastfeeding. Conclusion 1070
1015 Despite the known benefits of human milk, criti- 1071
1016 cally low rates of breastfeeding initiation among 1072
enhancement of statewide peer counseling pro-
1017 African American mothers have left African 1073
grams through standard adoption of peer support
1018 American infants at greatest risk for developing 1074
programming across WIC and satellite offices
1019 diseases, chronic conditions, morbidities, and 1075
(individual level); (b) creation and deployment of
1020 even death. Although an overwhelming majority 1076
breastfeeding health promotion programs in
1021 of participants in our study had some basic 1077
trusted, nontraditional cultural institutions of the
1022 knowledge of breastfeeding and recognized the 1078
African American community (e.g., beauty salons
1023 critical health benefits associated with this prac- 1079
and churches; interpersonal and community
1024 tice for their infants and themselves, this did not 1080
level); (c) engagement of African American faith-
1025 necessarily result in breastfeeding initiation. Our 1081
based leaders in breastfeeding promotion and
1026 results indicate that a number of elements influ- 1082
community education efforts (community level);
1027 ence the state of breastfeeding initiation among 1083
and (d) adoption and implementation of tailored
1028 African American mothers. In future studies, re- 1084
health care provider training among maternity
1029 searchers should engage mothers, partners, and 1085
and community health professionals (organiza-
1030 communities in research and strategies to further 1086
tional level; Spatz, Froh, Flynn-Roth, & Barton,
1031 explore cultural perceptions and beliefs 1087
2015; U.S. Breastfeeding Committee, 2010).
1032 regarding breastfeeding to increase knowledge 1088
1033 and implement multilevel, culturally relevant 1089
1034 Implications for Research strategies and care essential to a positive 1090
1035 The U.S. Surgeon General’s Call to Action to Sup- breastfeeding experience in the African American 1091
1036 port Breastfeeding highlighted the need for community. 1092
1037 research and surveillance to provide more infor- 1093
1038 mation about reducing disparities in breastfeeding 1094
rates associated with race/ethnicity, income, and
Acknowledgment
1039 1095
preterm birth (U.S. Department of Health and The authors thank Dr. Diane Rowley and Mr.
1040 1096
Human Services, 2011). Without timely initiation Steven Wilmot for assistance with manuscript
1041 1097
of studies to validate the findings of this research development as part of the lead author’s disser-
1042 1098
and explore the effectiveness of recommended tation committee.
1043 1099
1044 multilevel strategies for mothers and members of 1100
1045 the African American community, the gap in 1101
1046 breastfeeding initiation rates between African Supplementary Material 1102
1047 American and other women will not diminish. Note: To access the supplementary material that 1103
1048 Health care clinicians, researchers, and public accompanies this article, visit the online version 1104
1049 health officials must also explore the beliefs and of the Journal of Obstetric, Gynecologic, & 1105
1050 perceptions of breastfeeding initiation and sexu- Neonatal Nursing at http://jognn.org and at 1106
1051 ality with African American males as a critical topic https://doi.org/10.1016/j.jogn.2018.02.007. 1107
1052 in transforming rates of initiation on the basis of this 1108
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