Factors influencing African American mothers to breastfeed their infants: African American breastfeeding
Aikin, Shirley Coleman
Factors influencing the choice of method of infant feeding are explored with a population of African American mothers who receive care from a WIC Clinic. Focus groups were used to obtain data to determine the factors that influenced decisions about breastfeeding. The project was funded by a USDA grant to a local university in partnership with a local WIC agency. Implications are that role models, including nurses and other health care providers, should be from the same ethnic background or cultural environment as the client, whenever possible. Additional, provision of accurate information and support for breastfeeding is essential and can have a positive influence on the method of feeding selected. The anticipated result is an increase in the number of African Americans and others who receive this early childhood life benefit, as well as address the issue of cost effective health care. KEY WORDS: African American; Breastfeeding.
Participation in breastfeeding of infants has risen and fallen in popularity over the years among new mothers of all socioeconomic and ethnic backgrounds. Research findings identified many physiological and psychological benefits for the infants and for the mothers themselves (Mohrbacher, 1993). Additionally, a number of financial benefits are evident for these families and for the health care system (Montgomery & Splett, 1996). Questions continually arise as to what factors contribute to mothers choosing to breastfeed as well as what can be done to encourage and support that choice. Additional information also is needed regarding how ethnicity and cultural practices influence the decision.
Nurses play a significant role in the decision-making process of young mothers (Grassley & Davis, 1978; Dix, 1991). Peer counselors for women during the time they are selecting and/or attempting the breastfeeding process can increase their decision to choose breastfeeding as their infant feeding method (Locklin, 1995). Peer counselor support also can influence the length of time breastfeeding is continued (Gross, et at., 1998). Nurses and other health care providers must recognize and capitalize on that influence if they are to provide competent care, relevant education, and appropriate support. The purpose of this paper, therefore, is to explore the relationship of breastfeeding and culture based on the responses of African American women participating in several focus groups. Also identified are the implications for nurses and other health care providers.
Breastmilk is universally accepted as the best method of feeding for an infant. It is nutritious, satisfying, and fulfills all the daily requirements for vitamins. It is always available at exactly the right temperature, in the right quantities; and needs no storage, preparation, refrigeration. or packaging (Cramer, 1994). Human milk is biochemically unique and contains over two hundred recognized constituents (Blanc, 1982; Jelliffee and Jelliffee, 1978). Also,. the mother’s prolactin levels increase during breastfeeding, a factor which has been reported to positively influence mothering (Gulick, 1982; Janke, 1991).
The physiological impact of breastfeeding is significant for both mothers and their newborns (Mohrbacher, 1993). Dix (1991) indicated that infants benefit from breastfeeding by demonstrating lower rates of gastrointestinal disease, illness, and hospitalization than infants who are bottle-fed. One of the major advantages of breastfeeding is its role in preventing diarrhea. An estimated 16.5 million children under age five experience diarrhea each year. Five hundred die in the United States alone. In developing countries, a bottle fed baby is fourteen times more likely to die from diarrhea than a breastfed infant (Palmer, 1988-, Huffman & Combest, 1990).
In addition to the physical benefits of breastfeeding, there are emotional rewards as well. Mohrbacher (1993) indicated that breastfeeding helped mothers form a special bond with their babies due to the additional holding and touching which occurs during feeding. For the mother, there is a sense of love and satisfaction; for the infant, a sense of security and comfort. This bonding is the first significant communication whereby the dyad begin to know each other and develop a pattern of satisfying interactions (Cramer, 1994). The implications of those interactions are evident in childhood development and maternal confidence building.
There also is a substantial economic benefit to breastfeeding when compared to formula feeding an infant. Data gathered from the state and federally funded WIC Program (Women, Wants and Children) revealed that approximately $478 per infant is saved in the first 6 months of the infant’s life, after consideration of the formula manufacturer’s rebate (Montgomery & Splett, 1996). The average total (woman/infant) breastfeeding WIC food package, after applying the formula manufacturer’s rebate, was approximately $ 10 per month less than for formula feeding infants. As modest as $ 10 per month may seem, when applied to the 17.5 percent of infants breastfed for 6 months in Colorado, close to $26,000 a month was realized. Approximately 9.3 million dollars per month would be saved by the WIC Program nationwide with an increase in the number of mothers breastfeeding ( Montgomery & Splett, 1996).
Prevalence of Feeding Method
The number of mothers who breastfeed their infants has varied over the years, based on the data sources and populations surveyed, results of studies are inconsistent. During some periods, there have been high rates of breastfeeding, while at other times, the rate seems to have been quite low. This disparity of results causes inconsistency of information disseminated and inconsistent support for the effort of breastfeeding. In the 1940s, approximately 38% of mothers breastfed their newborns (Arafat, Allen, and Fox, 1981). However, other reports show that late in the 1960s and early 1970s the majority (80%) of mothers in the United States were bottle feeding their newborns (Nelson, 1969; Filer, 1971). In addition, from 1971 to 1979, the number of women who breastfed doubled (Hawkins, Nichols & Tanner, 1987). During the 1980s, breastfeeding was reported to he less popular as a result of an increase in prepared infant formulas being offered to postpartum mothers in hospital settings (Kurinij & Shiono, 1991). Concomitantly, the initiation of breastfeeding also was reported as was quite popular in the early 1980s with over 60% of mothers selecting breastfeeding as the infant feeding choice and less popular at the end of the 1980s, indicated by a 10% decrease in breastfeeding by mothers in the United States (Ryan, Rush, Kreiger,& Lewandowski, 1991).
In the early 1900s, breastfeeding began to decline, reaching a low of 22 111o in 1972. A steady and dramatic increase began in 1973 and by 1982, the incidence had peaked at 61.0 percent (Janke, 1993). By 1985, the incidence of breastfeeding was 58 percent; in 1987, it decreased to 55.6 percent, and by 1988, only 54.3 percent of women were breastfeeding at the time of hospital discharge. Interestingly, around 1989, two infant formula companies began direct advertising. Based on marketing trends, the overall sale of infant formula increased and revenue reached $2.1 billion by 1992 (Huffman, 1991 ).
Ethnicity and Culture
The ethnic background or cultural environment of mothers appear to be factors in the decision to breastfeed. Underwood, Pridham, Brown and Limbo (1997) indicated that any woman’s beliefs and values relative to infant feeding method and preparation of infant formula were developed and learned primarily within the context of their cultural group. Many factors act as important barriers to successful breastfeeding, including: cultural beliefs, mothering roles, and past experiences with breastfeeding (Andrews and Boyle, 1995). The rate of initiation and the duration of breastfeeding seems to be lowest in African American mothers. Findings of one study, based on data collected from a multiethnic, heterogeneous sample (n=41 1), revealed that mothers who recorded their ethnic identity as African American (33%) were significantly less likely to breastfeed their infants than White (55%) or Hispanic (67%) mothers (Arafat, et al., 1981). The researchers concluded that breastfeeding should be considered a social act that is influenced by social and cultural forces.
Racial differences in relation to breastfeeding are even more pronounced in some studies. A 1992 survey revealed that 58% of white mothers, 48% of Hispanic mothers, and 23% of African American mothers breastfed their children (United States Department of Agriculture, 1993). In the study by Gross, et all (1998), where all subjects (n=273) were African-American, 116 (48%) reported putting their baby to the breast during the first 7 to 10 days. All groups breastfed for a shorter duration than in previous years.
The sample (n= 198) for one recent study was composed of African-American and Caucasian women who were receiving WIC benefits and completed prenatal and postpartum interviews (Gielen, Faden, O’Campo, & Paige, 1992). Findings showed that only 27% of the sample selected breastfeeding as the method for infant feeding. In addition, significantly fewer African-American women (15%) chose to initiate breastfeeding when compared to Caucasian women (35%, p=.001) who participated in the study. That finding is consistent with those reported by Rassin and colleagues (1984) and MacGowan, and associates (1991).
A recent survey by Serdula (1991) reveals that, of immigrants from Southeast Asia now living in the midwest, 93% of those born in their native land had been breastfed compared with 10% of those born in the United States. In their eagerness to acculturate, mothers may turn away from their cultural heritage of breastfeeding. Consider the impact, on new immigrant mothers, relative to selection of breastfeeding, when they receive a formula discharge pack from the hospital as well as free formula through WIC in the land where babies don’t die (Riordan & Auerbach, 1993).
Rates of breastfeeding among low-income women also are significantly low. Only 38% of women with incomes less than $25,000 ever breastfeed, with only 11% continuing to breastfeed at six months (Ross Laboratories, 1992).
Health objectives for the United States specify that, by the year 2000, the proportion of women who initiate breastfeeding should be increased to 75 %, and that at least 50 % should be breastfeeding when the infants are 5-6 months of age (Healthy People 2000, 1990). If this national objective is to be met, nurses and other health providers who care for women must recognize all the factors related to breastfeeding and understand the impact of each.
A number of researchers (Arafat, Allen, & Fox, 1981; Gielen, Faden, O’Campo, & Paige, 1992: Janke, 1993, Locklin & Naber, 1993) have stated that, within American society, many factors strongly influence women’s decisions to bottlefeed, or to discontinue breastfeeding early in their maternal careers. Frequently cited are lack of breastfeeding models, a non-supportive social environment, maternal employment, and lack of appropriate information regarding infant feeding methods.
One important factor related to the choice of breastfeeding is the support for the mother provided by significant others and health professionals during and after the type of feeding is selected (Crowder, 1981. Lochlin, 1995. Gross, et al, 1998). Crowder indicated, however, that many nurses lack sufficient information on factors that would aid mothers’ successful adaptation to breastfeeding as well as knowledge of appropriate nursing interventions that could be implemented to support mother’s decision to breastfeed.
Locklin and Naber ( 1993) report that several factors appear to foster mothers’ success in breastfeeding. These factors include: personal commitment to breastfeed: support from family, friends, peer counselors and health care professionals; and attachment between mothers and their infants. They also suggest that the new mother can be influenced to breastfeed when the proper information and support are given
To increase the number
Dix ( 199 1) contended that there were a number of factors influencing mothers to choose breastfeeding. The majority of women who select breastfeeding make their decision before delivery and are influenced by nurses and midwives more than physicians. This suggests that nurses must be sensitive to their biases/personal opinions, and care practices which may influence mothers selection of an infant feeding method. Health care professionals are frequently unfamiliar with the most typical infant feeding practices of the clients within the communities they attempt to serve (Underwood, et al.. 1995).
It is clear that there are many influences, some of which are cultural, impacting mothers’ decisions about breastfeeding (Kurinij, Shiono, & Rhoads 1988). Recognition of these factors and influences can be used to achieve positive results when nurses and other health care professionals have accurate knowledge and understanding of those influences related to breastfeeding techniques, and the role they, as professionals, play in providing support for new mothers. Additionally, sharing accurate information and timely nursing interventions will help mothers initiate and maintain this effective and rewarding method of infant feeding.
According to Nugent (1992), the number of mothers demonstrating a need for assistance with infant feeding has increased, a trend that appears to be continuing. Data also indicate that women who participated in WIC maintained higher levels of health during pregnancy than women in comparable socioeconomic groups who do not receive WIC services. WIC, a supplemental food program, supplies foods such as eggs, peanut butter, milk and cheese in addition to infant formula to low-income women who are pregnant or have small children. For every dollar spent on programs for pregnant women through WIC, there is a $2.50 to $3.00 per person saving,s in health (Nugent. 1992).
The Expanded Food and Nutrition Education Program (EFNEP)
In an effort to promote and increase breastfeeding among African American clients, a USDA grant sponsored project was developed by a university and a new WIC center located in the Pacific Northwest. The project involved the implementation of the EFNEP modeled after a similar project-, the North Carolina Cooperative Extension (EFNEP). The major goal of this project was to encourage more African American mothers to choose breastfeeding for their infants with the intent of increasing the number who would adopt and adhere to this nutritionally sound, and cost-effective, method of infant feeding. The plan was that women who were at higher risk for poor pregnancy outcomes because of lower socioeconomic status would he encouraged to participate in the program.
The region in which the project was located had approximately 24,000 potentially eligible clients who could be entered into the WIC programs. This number included a significant number of African Americans, along with others of low income, who potentially could receive needed support services through WIC agencies (Nugent. 1992). Nutrition was one factor of concern for this group because of the relationship to breastfeeding and long term implications for the mothers as well as the infants. With WIC resources to support breastfeeding as the infant feeding method, it was anticipated that pregnancy would be a more positive event for those mothers whose pregnancies were essentially uneventful.
To gather cultural information related to breastfeeding, focus groups were used, replicating data collection of the model program. Participants consisted of African American women who attended group sessions arranged by EFNEP Counselors, who were primarily African American. Five groups were held over a I-year time frame, each of which met once and involved from 2 to 9 women. Although the majority of participants were African American, the ethnic composition of the groups was mixed.
The following questions were asked of the participants:
– What questions or concerns do you think pregnant women have about infant feeding?
– Has anyone in your immediate family or close friends encouraged or discouraged you to breastfeed your baby?
– What advantages or disadvantages do you see in breastfeeding infants?
– What do you think influences a woman’s decision to breastfeed or not breastfeed their baby?
The focus groups were audiotaped by the EFNEP Counselors. The tapes were available for review in the EFNEP coordinator’s office and used to identify common themes. In addition to answering the questions posed by the group leader, the members shared vivid stories of their experiences related to the breastfeeding experience. The women’s comments supported information found in the literature (Arafat, Allen, & Fox, 1981; Dix, 1991; Riordan & Auerbach, 1993
Most of the African American mothers had positive ideas regarding the benefits of breastfeeding for their infants. Responses such as The baby will stay healthier, and I feel like I’m a good mother, were elicited when informants responded to the question that addressed the benefits of breastfeeding.
When asked what factors influenced their decisions to breastfeed, a frequent response was that the decision was related to whether or not the mother /or grandmother had breastfed.
The women who had decided to breastfeed commented that they had been given varying types of information about breastfeeding. It was apparent that mothers, sisters, and friends had significant influence on the infant feeding method selected. One respondent indicated she had been told by her mother that it would be painful to breastfeed. She stated that she was discouraged by this comment, but planned to breastfeed her infant anyway. Review of the transcriptions of the tapes revealed a number of themes. These included:
impact of mother/grandmother on decision for breastfeeding;
impact of friend/significant other on decision for breastfeeding;
impact of health care provider (nurses, midwives, doctors) on decision;
role of support groups in decision for breastfeeding particularly if participants are of similar backgrounds;
information at WIC and impact on decision for breastfeeding;
other information and impact on decision for breastfeeding.
Two factors identified most frequently as influencing participants decisions were directly related to the support available and information provided. Support and information provided influenced initiation and duration of breastfeeding.
Implications and Conclusions
The evidence indicates that cultural factors influence mothers’ decisions regarding infant feeding methods. African American mothers will select breastfeeding as the primary method of feeding for their infants when there is support for breastfeeding within their personal environments and when information about this practice is provided. The nurse, midwife, and physician have a significant role to play in helping women to select the method of infant feeding that is most appropriate for them within their lifestyles.
With low income mothers receiving WIC services, the choice of infant feeding method will be based on a number of factors including whether the mother or grandmother breastfed, the availability of formula gift packs in the hospital setting, information provided in the prenatal and delivery settings regarding breastfeeding, availability of peer counselor support and the perceived support available from and value of breastfeeding to the spouse/significant other in the family unit.
Many of the factors identified in this project related to breastfeeding are similar for any woman or population of women trying to make a decision regarding the method of infant feeding. The significant factor in this project appeared to be that the EFNEP Counselors served as role models for breastfeeding and were of the same ethnic background as the majority of mothers with whom they were working in the focus groups. This suggests that a peer counselor, lactation consultant, or knowledgeable nurse, who is able to provide accurate information and support for breastfeeding can serve as a positive role model and have a significant impact on new mothers’ decisions regarding breastfeeding. When the support person is from the same ethnic background or cultural environment as the client, the probability of success increases.
The USDA regulation PL 101-147, regarding expenditures in WIC funds includes that states be required to promote breastfeeding as part of the nutrition education program. The probability that prenatal WIC participants will choose to breastfeed more than doubles if they receive breastfeeding education (Huffman & Levine, 1990). The WIC program spends over $450 million on infant formula each year, the largest food cost within the program (USDA, 1993). A substantial financial savings could be achieved with an increased focus on breastfeeding instead of formula feeding.
The literature indicates that a number of factors (physiological, psychological, socio-economic. and educational) are important and influence mothers in selecting the method of feeding for their infant. Along with the economic implications, the positive benefits of breastfeeding are clearly apparent and provide the motivation for nurses and other health providers to support this method. Providing accurate information and support, as well as role modeling for new mothers is essential. In a diverse society, ensuring the provision of culturally competent care is vital, thus, nurses who are providing that care must carefully consider the ethnic background and cultural environment of their clients.
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ACKNOWLEDGMENTS: Funding: CSREES B IVIC, Nutrition Education Initiative, USDA Grant; Nutritional Consultants: Steven Garrett, AIS, RD., Project Coordinator Washington State University; Cooperative Extension; Debra Ahern, Ph, D., RD., St. Clare Hospital B WIC Clinic; EFNEP Counselors: Linda Cramer and Roni Mellum, Washington State University Cooperative Extension; Editorial Support: Cleo M. Pass, RN, DSN, Professor, Pacific Lutheran Universit; Taconia, Washington.
Shirley Coleman Aikin, RN, MSN, Associate Professor, Pacific Lutheran UniversitY, School of Nursing, Tacoina, VA.
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