What Do Pregnant Low-Income Women Say About Breastfeeding?

Abstract

Background:

Although low socioeconomic status and African-American race have been shown to be risk factors for low rates of breastfeeding, maternal reasons for selection of infant feeding method are not well understood in these populations.

Methods:

Healthy women ≥15 years of age receiving routine obstetrical care from nurses and nurse midwives at the outpatient clinic of MacDonald Women's Hospital, Case Medical Center, Cleveland, OH were surveyed using a questionnaire interview including Likert-scaled and open-ended questions. All responses to the six open-ended queries were transcribed. Content analysis was used to categorize these responses into three to seven descriptive themes for each question. The authors and two other clinically experienced reviewers participated in theme development, which involved categorization by individual reviewers and then by the group; a full consensus was achieved at each stage. University Hospitals Institutional Review Board approved the study.

Results:

Of 186 eligible women, 179 (96%) consented, and 176 (95%) were interviewed. Median age was 22 years (range, 15–41 years), 68 (41%) had greater than a high school education, 167 (95%) were African-American, 167 (non-identical 95%) were unmarried, and 87 (49%) were multiparous. When interviewees were asked, “What is the biggest reason you want to breastfeed?,” responses included maternal reasons, infant-related reasons, and advice of others. When women were asked, “What would stop you from breastfeeding?,” responses included lifestyle reasons, pain-related reasons, lactation process issues, hypothetical medical reasons, and maternal reluctance.

Conclusions:

Expectant low-income African-American inner-city women appear well informed about the benefits of breastfeeding. Obstacles to breastfeeding that may be susceptible to intervention include fear of pain, lifestyle issues, and lactation process concerns.

“I want to breastfeed because I don't want to get up in the middle of the night.”

“I wouldn't breastfeed if it hurt.”

“He [the father of my baby] does not want me to breastfeed because the baby might want to suck on his nipples.”

Introduction

Breastfeeding has myriad health benefits for infant and mother.¹ Although 74.2% of all women initiated breastfeeding in 2005, Centers for Disease Control and Prevention data show that low-income African-American women, as compared to all women, continue to have the lowest rates of breastfeeding initiation (61.4%) and exclusive breastfeeding at 6 months (6.5% vs. 11.9%).² This disparity mandates exploration of factors underlying low rates of breastfeeding in this population. Implementation of a breastfeeding promotion campaign called Best Start^™, designed by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), has increased rates of breastfeeding initiation among low-income African-American women, but there remains a considerable margin for improvement.³

In order to develop effective and targeted breastfeeding intervention programs, we need to understand the reasons behind infant feeding choices of low-income inner-city women. Issues that mothers consider in their feeding decisions include convenience, ease, bonding with their infants, and their general comfort with a feeding method.⁴ However, few current studies have explored the thinking that underlies decision making by low-income African-American women during pregnancy.^5–12 This study aimed to delineate and better understand these reasons in order to identify possible interventions for breastfeeding promotion specific to expectant low-income inner-city African-American mothers.

Subjects and Methods

There were two aims of this study: (1) to identify themes describing the reasons for infant feeding choice by low-income African-American pregnant women and (2) to identify themes susceptible to intervention to increase breastfeeding rates in a low-income African-American population.

Design and procedure

The study was a prospective cross-sectional survey conducted by structured interview. Following Institutional Review Board approval, consecutive pregnant women receiving obstetrical care from nurses and nurse midwives at the Women's Health Center of MacDonald Women's Hospital, University Hospitals Case Medical Center, Cleveland, OH were referred by their providers to the study and were approached for consent and interview while awaiting prenatal care visits. The Center serves a predominantly African-American, inner-city and low-income population from the urban East side of Cleveland. Approximately 80% of obstetrical patients receive care from either nurses or nurse midwives; high-risk pregnancies are referred to on-site physicians. Participants were given a copy of the questionnaire during the interview, and the researcher (A.A.) read each question aloud and documented the participants' oral responses. Our purpose was to promote questionnaire completion and minimize confounding due to low literacy levels.

The questionnaire (available on request) included 12 questions about sociodemographic factors and 33 questions about breastfeeding knowledge and attitudes. Information related to factors associated with breastfeeding intent and duration was gathered; this included age, race, marital status, and educational level, as well as obstetrical information including parity, prenatal body mass index, and timing of first obstetrical visit. Questions were divided into six conceptual domains, including knowledge and attitudes about breastfeeding, planning/abstract thinking, maternal concerns, influence of family and friends, use of resources, and body image.^13,14 Question format included yes/no, Likert-scaled, and free response questions. Free response questions, i.e., open-ended questions, focused on why the mother would or would not breastfeed, the input of the father and of girlfriends, how breastfeeding feels, and how it might change a woman's body. This article reports only the analysis of the free response questions.

Sample

During the study period June 1–July 31, 2007, 186 eligible consecutive women were approached for participation, and 179 (96%) consented, of whom 176 (95%) were interviewed. Eligible participants included all healthy women receiving obstetrical care from nurses or nurse midwives at the Women's Health Center. The sole exclusion criterion was maternal age ≤14 years.

Analysis

Responses were categorized using content analysis.¹⁵ The researchers participating in the content analysis included the co-authors (L.F. is a pediatrician, D.D. is a nurse researcher and educator, and A.A. is a medical student) and two neonatal nurse practitioner students (Megan N. Nadzam and Margaret Stofcho). Responses to each question were transcribed onto index cards and coded with study number and feeding intent. Many women offered more than one answer to a question, and each response was transcribed separately. The consensus procedure for final response categories was as follows. Working together, A.A. and L.F. sorted response cards by question and identified preliminary descriptive themes. Then, working individually, M.N. and M.S. sorted responses by question and created their own descriptive themes. Next, L.F., M.N., and M.S. worked together to combine the three preliminary lists into a single comprehensive set of descriptive themes for each question. Last, A.A., L.F., and D.D. worked together and finalized the set of descriptive themes for each question. Each group discussion used a back and forth collaborative process that sought commonalities and distinctions between the responses and then compared themes for inclusiveness, avoidance of overlap, and clarity. We decided that identifying three to seven descriptive themes per question was appropriate for the complexity of the questions and would prevent the themes from becoming either too broad or too detailed.^15,16 A full consensus was achieved at each stage of theme development.

Results

Sample

The population was 95% African-American, a non-identical 95% unmarried, and WIC-eligible.¹⁷ Participants ranged in age from 15 to 41 years (mean 23 years, SD 4.5 years), and the sample included 46 teens (26%), defined as ≤19 years of age. Eighty-nine (51%) were primiparous. Regarding feeding intentions, 107 (61%) planned to breastfeed at all (of whom 40 [23%] planned to breastfeed exclusively), 37 (21%) planned to formula feed, and 32 (18%) were unsure. The median gestational age at interview was 27 weeks (range, 6–39 weeks), and 148 women (84%) had their first prenatal visit in the first trimester.

Questions

What is the biggest reason you want to breastfeed?

Each participant, regardless of feeding intent, was asked why she would want to breastfeed. Responses were categorized into seven themes: Globally healthy, Infant health, Maternal health, Convenience, Influence of others, Bonding, and Maternal uncertainty. Most responses were described within globally healthy and infant health (Table 1). Globally healthy included very general responses such as “natural” and “healthier” and “best.” Infant health encompassed responses with explicitly identified health outcomes, most frequently the immune benefits of breastfeeding, with a minority of responses related to improved cognitive development, milk nutrients, decreased allergies and other outcomes. Within Maternal health, participants cited both general and specific health benefits. Breastfeeding to facilitate maternal weight loss was a prominent idea; a majority said breastfeeding would help them lose weight more quickly and get their shape back. Main ideas expressed within maternal Convenience included the cost of breastfeeding (“it's free”), freedom from bottles and formula, and less night awakening. Influence of others included health recommendations from mothers, friends, WIC dieticians, and doctors. The Bonding theme described responses focused on the maternal–infant relationship: mothers used the words “quality time,” “closeness,” “connection,” “bonding,” and “nurture” in describing this benefit of breastfeeding. The category identified as Maternal uncertainty included responses that appeared to reveal maternal ambivalence about the breastfeeding choice and included the concepts that breastfeeding is novel and different and appears interesting.

Table 1.

“What Is the Biggest Reason You Want to Breastfeed?”

Theme (number of responses)	Participants' responses (examples)
Globally healthy (87)	“Natural,” “best for your baby,” “healthy for baby”
Infant health (82)	“Fewer illnesses and allergies,” “helps baby's immune system,” “makes baby smarter”
Maternal health (27)	“Helps you lose weight quicker,” “healthier for mom,” “prevents breast and ovarian cancer”
Convenient (19)	“Easier on me at night,” “free,” “Poops and spit-ups won't stink”
Advice of others (14)	“My mom and WIC say it's the best kind of milk to give your baby,” “They say it makes them smarter”
Bonding (11)	“Helps mom and baby bond,” “Nurture my baby”
Maternal uncertainty (9)	“To try something different,” “I guess you're supposed to. I don't know,” “It looks interesting”

What would stop you from breastfeeding?

Each participant, regardless of feeding intent, was also asked why she would not want to breastfeed. Barriers to breastfeeding were characterized by five themes, including Lifestyle, Pain, Process of lactation, Maternal reluctance, and Medical reasons (Table 2). Within Lifestyle, concerns about smoking, caffeine intake, and the perceived need for a healthier diet were mentioned, as well as concerns about the time commitment breastfeeding would require, creating difficulty with school and work arrangements, and a lack of personal freedom. The Pain theme included multiple succinct comments such as “pain,” “teeth,” and “it hurts,” as well as anecdotes from personal experience that described damage to the breast and nipple that had not been brought to medical attention. Process of lactation included general as well as specific concerns about latching, milk sufficiency, and infant aversion to breastfeeding. Worry that the infant would not latch on, that “the milk won't come out,” that the baby would not like breastfeeding, and that the process was too complex were prominent. Maternal reluctance included blanket statements that breastfeeding was unappealing or aversive (“nasty”), as well as specific reasons mothers felt uncomfortable, such as concern about body changes related to the breasts. Medical reasons detailed maternal and infant health issues, as well as intent to follow the advice of healthcare practitioners. Answers ranged from concern about the infant's growth or the effect of necessary maternal medications, to less likely possibilities, for example, the mother getting a chest tumor.

Table 2.

“What Would Stop You from Breastfeeding?”

Theme (number of responses)	Participants' responses (examples)
Lifestyle (53)	“It's too time consuming,” “smoking,” “work,” “I want freedom from the kids,” “caffeine withdrawal,” “They eat too much”
Pain (45)	“Teeth,” “It hurts,” “I'm scared. My friend's nipple was hanging off as a result of breastfeeding,” “I tried with my first child and it really hurt”
Process of lactation (35)	“If it doesn't work right,” “if I couldn't produce enough milk,” “if the baby doesn't like it,” “if the baby doesn't latch”
Maternal reluctance (25)	“It's just nasty,” “I just don't want to,” “I'd just rather have a bottle”
Medical reasons (25)	“If I had to take medications that would interfere,” “if my baby gets sick from it”

If the father of your baby does not want you to breastfeed, what did he say about it?

This question yielded only 18 answers because nine participants responded only if they had stated that the father would be involved in the infant's care and the father had said he did not support breastfeeding. Responses were described by four themes including Just said no (n = 7), Bad for baby (n = 5), Paternal role (n = 4), and Concern for mother (n = 2). Responses classified in Just said no included “I don't know why not,” “just told me not to,” and the more ominous “you don't want to know.” Bad for baby described responses such as “boy will be a sissy” and “baby will be spoiled.” Paternal role responses mainly expressed the fathers' desire to be involved in child care: “He wants the baby to be attached to him,” “He wants to participate in feeding the baby,” and “He knows I love it, but he can't help as much then so it's less convenient for him,” but one participant reported the father of her baby worried that “the baby might want to suck on his nipples.” Only two responses expressed Concern for the mother: “worried I'd be afraid to do it in public” and “doesn't want me to keep pumping because he knows I have to go to school.”

What do your girlfriends say to you about breastfeeding?

All participants were asked what their girlfriends have said about breastfeeding, generating 177 responses characterized by seven themes: We don't talk about it, generally positive, Pain, Negative other, Specifically positive, Mixed message, and Up to you (Table 3). Many participants denied talking with girlfriends about breastfeeding, with the remaining responses almost equally divided between positive and negative. Generally Positive included comments such as “I should do it” and “It's a good idea,” which were supportive of breastfeeding but not specific about its benefits. Specifically positive included reasons to breastfeed that focused on the infant's health, growth, and immune system and on maternal–infant bonding. Pain described cautionary responses that ranged from simply “It's going to hurt” to the horror stories of both personal experience and friends. Other negative included a variety of discouraging and disparaging comments that focused on anticipated loss of personal freedom, the perceived extreme time demands of breastfeeding, and the idea that breastfeeding spoils the baby so no one can babysit him or her. Mixed message responses included ambivalent comments in which the mother summarized her friends' positions, presenting both their positive and negative messages side by side within the same phrase, as in “Some say do and some say don't.” This theme was distinguished from Up to you, which included comments with an almost dismissive tone that appeared to query the mother rather than providing either positive or negative input.

Table 3.

“What Do Your Girlfriends Say About Breastfeeding?”

Theme (number of responses)	Participants' responses (examples)
We don't talk about it (64)	“Nothing,” “We don't talk about it”
Generally positive (31)	“It's a good thing,” “I should do it,” “nothing negative”
Painful (26)	“It's going to hurt,” “She stopped because the baby's suction was too hard and it split her nipple”
Other negative (25)	“Too time consuming,” “My baby will be spoiled,” “I'll have no freedom”
Specifically positive (23)	“Good, convenient, better bond with baby, healthier,” “less sickness for baby”
Mixed message (10)	“Some say it's good, some say it will ruin your figure,” “Some say do it, some say don't”
Up to me (7)	“They ask me why I want to do it,” if that's what you want,” “They don't care either way”

If you think breastfeeding will change your body, how do you think your body will change?

One hundred sixteen (66%) women responded “yes” to the question “Do you think breastfeeding will change your body?” and offered 177 ideas characterized by three themes, including General body changes (n = 123), Breast changes (n = 40), and Other (n = 8). The predominant idea within general body changes (107 responses) was that breastfeeding promotes weight loss and helps the mother return to her prepregnancy shape. The remaining general body changes mentioned included the ideas that breastfeeding “helps contract the uterus,” helps the mother heal, is generally healthier, and forces the mother to eat better. The Breast changes theme responses described a variety of alterations in size, shape, and function, including “my breasts will get small and sag,” “get bigger,” “get lopsided,” “be leaky,” “sore”, “not as perky or young looking,” or “not firm.” This theme also described more frightening consequences, including “my nipples could be chipped” and “may have to get implants.” Other responses (n = 8) included “period doesn't come,” “emotional changes,” and “I don't really know.”

How do you think breastfeeding feels?

Participants were asked if they had ever been told how breastfeeding feels for the mother, and those who responded “no” were asked for their own idea about how breastfeeding feels. Both multiparous and primiparous mothers were free to respond, and 79 mothers (49 multiparous women, of whom 31 had breastfeeding experience, and 30 primiparous women ) provided 97 responses, described by five themes, including Painful all the time, Painful initially, then better, Positive, Uncertain, and Other (Table 4). The theme with the most responses was Painful all the time. Multiparous mothers with breastfeeding experience (n = 18), multiparous women who had never breastfed (n = 8), and primiparous women (n = 4) specifically said breastfeeding is “painful” and “hurts a lot” and included the experiences or anticipated experiences of nursing, uterine contractions, and weaning (“drying up”) in their responses. The Painful initially then better theme included responses from multiparous women with (n = 10) and without (n = 2) breastfeeding experience. Their responses acknowledged initial pain or discomfort but incorporated the concept that this was temporary, for example, “uncomfortable but tolerable after you have a routine.” The Positive theme included responses from multiparous women with breastfeeding experience (n = 17) and primparous women (n = 8). Few responses included superlatives, with the majority describing breastfeeding with comments such as “OK—not that bad” and “alright.” The Other theme included responses without any positive tone in which mothers used words such as “weird,” “different,” and “funny,” and the Uncertain theme included “I don't know/not sure” responses. The majority of comments from multiparous women with breastfeeding experience (18 of 31) indicated that breastfeeding is painful all the time. None of the multiparous women without breastfeeding experience thought breastfeeding would feel good.

Table 4.

“How Do You Think Breastfeeding Feels?”

Theme (number of responses)	Participants' responses (examples)
Painfull all the time (30)	“It would hurt probably with a baby biting on you,” “Personal experience was really painful,” “really hurt a lot”
Positive (25)	“Not a bad feeling”
I don't know (23)	“Not sure,” “I really have no idea”
Painful initially, then better (12)	“Probably would hurt for a minute until you get used to it,” “uncomfortable but tolerable after you have a routine”
Other (7)	“Different than what I'm used to,” “funny, will take some getting used to,” “will feel weird”

Discussion

We used free response questions within a structured interview to explore breastfeeding knowledge and attitudes in an urban, low-income, predominantly African-American population that includes both pregnant teens and adults. It is well appreciated that low rates of breastfeeding in this sociodemographic population represent a concerning and continuing health disparity, and despite a decade of breastfeeding promotion efforts, progress is limited.^17,18 Other studies have also used qualitative methods to examine breastfeeding attitudes of low-income mothers, but most prior work is 10 or more years old and includes populations with either only teens, no teens, a rural rather than urban setting, a small sample size, or a different ethnic group.^4,10–12 In comparison to older studies, we found that the majority of low-income inner-city African-American women whom we interviewed were very well informed about the benefits of breastfeeding and that few were deterred by concerns raised in prior studies, such as breastfeeding in public. However, lack of good knowledge about the actual process of breastfeeding was still a major impediment. These insights may contribute to design of effective interventions targeted toward women at high risk for not breastfeeding: rather than additional broad educational marketing campaigns promoting breastfeeding, it appears that access to one-on-one postpartum lactation support is needed.

Our results showed that women most frequently offered mother-centered reasons for not breastfeeding, such as lifestyle issues or maternal discomfort.²⁰ Conversely, mothers wanted to breastfeed for a mix of mother-centered and infant-centered reasons, such as convenience and maternal and infant health benefits. Mothers appeared to be well informed about the infant health benefits of breastfeeding. Analysis regarding thoughts of fathers and girlfriends suggested that pregnant women may have limited personal support for breastfeeding. Reported paternal attitudes towards breastfeeding were concerning and included responses that could be described as controlling and father-centered, with only two expressing concern for the mother. We recognize that because of the structure of the interview these responses may not be representative. Responses regarding girlfriends' opinions were a mix of positive and negative comments with an overall tenor of ambivalence, suggesting a potential lack of support for breastfeeding. Incorrect beliefs and poor general knowledge predominated in responses about how breastfeeding would feel and how it would change the woman's body. Many believed that breastfeeding would help them lose weight or would permanently change the shape, size, and attractiveness of their breasts. The majority of women either believed breastfeeding would hurt all the time or were unsure about how it would feel. Women identified pain, lifestyle issues, and process of lactation concerns as the main obstacles to breastfeeding. Thus, although pregnant women appeared knowledgeable about infant health benefits, knowledge about maternal health effects and knowledge about the experience of breastfeeding were often inaccurate, and support from peers and fathers may be limited. It is also noteworthy that mothers with breastfeeding experience identified pain as an obstacle. This suggests that individualized lactation support and personal coaching should be considered as potential interventions.

Only three current studies included free response questions and focused on a low-income, African-American population, and all supported our finding that fear of pain is a common concern and major impediment to breastfeeding initiation in this population.^6,20,21 However, pain with nursing was neither mentioned nor discussed in a focus group study of low-income WIC participants who were “successfully breastfeeding in communities where nursing was uncommon” (p. 253).²² It is possible that multiparous mothers with painful or negative breastfeeding experiences self-select formula feeding with a subsequent infant and would benefit from focused and individualized prepartum interview combined with postpartum assistance. The free response questionnaire studies noted above supported our findings that women believe return to work, process of lactation concerns such as milk supply and nipple aversion, lifestyle issues, such as diet and smoking, and lack of freedom are also barriers to breastfeeding.^6,20,21 Interestingly, only one participant in our study said that discomfort with breastfeeding in public would stop her from breastfeeding, whereas each of the other studies identified this as a major barrier. Our studies were in agreement that health benefits of breastfeeding are a major incentive to breastfeed; however, some women who choose to formula feed are not convinced about these benefits.^6,20 Establishing a closer maternal–infant relationship is one reason women give for wanting to breastfeed, although in an extended ethnographic study Cricco-Lizza⁶ concluded that the low-income African American women she interviewed viewed the potential of a close bond with their infants as a barrier to breastfeeding. This author speculated that lack of maternal social support might explain an expressed desire for “freedom,” “infant independence,” and hence bottle feeding. Limitations of these three comparison studies included small sample size (11 and 14 participants, respectively [Wambach and Koehn²⁰ and Cricco-Lizza⁶]) and query with only two free response questions, both regarding breastfeeding barriers (Hurley et al.²¹).

Hannon et al.¹⁰ conducted an ethnographic interviewing study in an overlapping but different population of teen urban Latina and African-American mothers. They also found that benefits of breastfeeding served as a strong incentive to choose breastfeeding and that pain and lifestyle issues served as deterrents. The influence of family, the father, peers, and health providers was noted but variable and was not the final determinant of the mother's feeding choice.¹⁰ Bunik et al.⁵ interviewed low-income Latina mothers in Denver, CO about infant feeding decisions. Ethnic and cultural factors and beliefs were predominant in the themes they identified, emphasizing the importance of examining infant feeding issues not just within the broad context of economic strata, but within the more specific contexts of racial and ethnic group and social environment. Our population was racially and ethnically different, and many beliefs differed from those in the latter study.

The high consent rate within an understudied population and enrollment of a large sample of pregnant women ranging in age from 15 to 41 years are strengths of our study. The use of a single interviewer ensured consistency, and face-to-face interviewing allowed insight into the nuances of vocalized responses. The collaboration of five experienced reviewers through four iterations of themes yielded a consensus-driven process of theme development. Weaknesses of the study include non-parallel phrasing of questions about the breastfeeding attitudes of fathers and girlfriends and omission of questions about other social supports. A more comprehensive understanding of paternal breastfeeding attitudes could have been attained if we had asked all participants what the fathers of their babies said about breastfeeding and had included uninvolved fathers and breastfeeding supportive fathers also. Both older and more current work has already identified the influence of the father as important to breastfeeding choice.^23,24 We did not ask a free response question about the participants' mothers, which might have provided more insight into the breastfeeding support available to women in this population. Additionally, asking about the relative value women placed on the support and opinions of their mothers, girlfriends, the fathers of their babies, and perhaps others like aunts or godmothers would have provided a context in which to interpret these responses and their impact on maternal feeding decisions. Finally, our sample is geographically limited to an inner city low-income Northern “rust belt” community, and although this sample homogeneity is a strength of the study, results cannot necessarily be generalized to other ethnically, racially, and economically similar populations elsewhere.

Implications

Low-income African-American women appear relatively well educated about the health benefits of breastfeeding but much less knowledgeable about the actual process of breastfeeding, so an important area for intervention will be education about what to expect when breastfeeding. Topics should include lifestyle changes, instruction on latch and “trouble-shooting” latch, tips on how to incorporate breastfeeding into a busy schedule, body changes, and, most importantly, how breastfeeding feels. Preparing women for the sensation of breastfeeding is essential to mitigate their fear of pain and encourage breastfeeding initiation. The availability of prompt and knowledgeable lactation support both in the hospital and after discharge will be critical to making pain-free breastfeeding a reality. “Life coaching” after the infant's birth to help the mother negotiate lifestyle challenges associated with breastfeeding, such as work/school issues, holds potential promise as an innovative area for intervention. In addition, it will be important to engage fathers in the infant-feeding dialogue, to elicit their concerns, and to prepare them for what to expect when the mother is breastfeeding. We identified some concerning paternal misconceptions about breastfeeding. Research has shown that fathers significantly influence maternal infant feeding choice, so breastfeeding education with reassurance that the father's parenting role is not compromised may enable fathers to provide the support mothers need to breastfeed successfully.^25–27 In this structured interview study that included 176 pregnant inner-city low-income predominantly African-American women, themes developed from participants' responses update our knowledge of breastfeeding attitudes in this population and identify possible avenues for intervention.

Footnotes

Acknowledgments

We gratefully acknowledge the invaluable contributions of Megan N. Nadzam and Margaret Stofcho to the data analysis process.

Disclosure Statement

No competing financial interests exist.

References

Agency for Healthcare Research and Quality. Breastfeeding and maternal and infant health outcomes in developed countries [structured abstract] http://www.ahrq.gov/clinic/tp/brfouttp.htm. 2009 February 18.

Centers for Disease Control and Prevention. Breastfeeding Among U.S. Born Children 1999–2005. CDC National Immunization Survey, 2008. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm. 2009 February 18.

Ryser

. Breastfeeding attitudes, intention, and initiation in low-income women: The effect of the best start program. J Hum Lact, 2004; 20:300–305.

Dowling

, Shapiro

, Burant

et al. Factors influencing feeding decisions of black and white mothers of preterm infants. J Obstet Gynecol Neonatal Nurs, 2009; 38:300–309.

Bunik

, Clark

, Zimmer

et al. Early infant feeding decisions in low-income Latinas. Breastfeed Med, 2006; 1:225–235.

Cricco-Lizza

. Infant-feeding beliefs and experiences of black women enrolled in WIC in the New York Metropolitan area. Qual Health Res, 2004; 14:1197–1210.

Rose

, Warrington

, Linder

et al. Factors influencing infant feeding method in an urban community. J Natl Med Assoc, 2004; 96:325–331 Erratum in. J Natl Med Assoc, 2004; 96:404.

Zimmerman

, Guttman

. “Breast is best”: Knowledge among low-income mothers is not enough. J Hum Lact, 2001; 17:14–19.

Holmes

, Chin

, Kaczorowski

et al. A barrier to exclusive breastfeeding for WIC enrollees: Limited use of exclusive breastfeeding food package for mothers. Breastfeed Med, 2009; 4:31–42.

10.

Hannon

, Willis

, Bishop-Townsend

et al. African-American and Latina adolescent mothers' infant feeding decisions and breastfeeding practices: A qualitative study. J Adolesc Health, 2000; 26:399–407.

11.

Raisler

. Against the odds: Breastfeeding experiences of low-income mothers. J Midwifery, 2000; 45:253–263.

12.

Bentley

, Caulfield

, Gross

et al. Sources of influence on intention to breastfeed among African-American women at entry to WIC. J Hum Lact, 1999; 15:27–34.

13.

Lazarov

, Evans

. Breastfeeding—encouraging the best for low-income women. Zero to Three, 2000; 20:15–23.

14.

Wambach

, Cole

. Breastfeeding and adolescents. J Obstet Gynecol Neonatal Nurs, 2000; 29:282–294.

15.

Neuendorf

. The Content Analysis Guidebook. Sage: Thousand Oaks, CA, 2002.

16.

Busch

, De Maret

, Flynn

et al. Content analysis. Writing@CSU. Colorado State University Department of English, 2005. http://writing.colostate.edu/guides/research/content/. 2009 August 27.

17.

Breastfeeding Rates by Socio-Demographic Factors, Among Children Born in 2005, Centers for Disease Control and Prevention National Immunization Survey. http://www.cdc.gov/breastfeeding/data/NIS_data/2005/socio-demographic_any.ht. 2009 August 23.

18.

Singh

, Kogan

. Persistent socioeconomic disparities in infant, neonatal and postneonatal mortality rates in the United States. Pediatrics, 2007; 119:e928–e939.

19.

Kum-Nji

, Mangerem

, Wells

et al. Breast-feeding initation: Predictors, attitudes, and practices among blacks and whites in rural Mississippi. South Med J, 1999; 92:1183–1188.

20.

Wambach

, Koehn

. Experiences of infant-feeding decision-making among urban economically disadvantaged pregnant adolescents. J Adv Nurs, 2004; 48:361–370.

21.

Hurley

, Black

, Papas

et al. Variation in breastfeeding behaviours, perceptions, and experiences by race/ethnicity among a low-income statewide sample of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants in the United States. Matern Child Nutr, 2008; 4:95–105.

22.

Raisler

. Against the odds: Breastfeeding experiences of low income mothers. J Midwifery Womens Health, 2000; 45:253–263.

23.

Bar-Yam

, Darby

. Fathers and breastfeeding: A review of the literature. J Hum Lact, 1997; 13:45–50.

24.

Piscane

, Continisio

, Aldinucci

et al. A controlled trial of the father's role in breastfeeding promotion. Pediatrics, 2005; 116:e494–e498.

25.

Mahoney

, James

. Predictors of anticipated breastfeeding in an urban, low-income setting. J Fam Pract, 2000; 49:529–533.

26.

Wagner

, Wagner

, Ebeling

et al. The role of personality and other factors in a mother's decision to initiate breastfeeding. J Hum Lact, 2006; 22:16–26.

27.

Hill

, Arnett

, Mauk

. Breast-feeding intentions among low-income pregnant and lactating women. Am J Health Behav, 2008; 32:125–136.