Breastfeeding Among High-Risk Inner-City African-American Mothers: A Risky Choice?

Study design

The study used a series of focus groups in an approach called “broad involvement design” that includes both the target audience (mothers) and other audiences (family members, Community Health Workers). ¹² We partnered with the Cleveland (Ohio) Department of Public Health's MomsFirst™ Project, a federally funded Healthy Start initiative, to identify and recruit participants. We report here the results of the mothers' focus groups. The University Hospitals Case Medical Center Institutional Review Board approved the study.

Study population and recruitment

The target population was expectant and delivered low-income high-risk Cleveland mothers. Inclusion criteria were as follows: (1) current involvement in or eligibility for MomsFirst and (2) currently pregnant or have a child under age 2 years. Expectant women are eligible for MomsFirst if they reside within Cleveland and meet one of 12 elevated high-risk criteria or two of 19 standard high-risk criteria. Examples of elevated high-risk criteria are domestic violence or history of an infant who died before the age of 1 year, and examples of standard high-risk criteria are social isolation, lack of personal supports, or first pregnancy. Most women are non-Hispanic African-American, and most are enrolled in WIC. Potential participants were recruited using hand-delivered Institutional Review Board–approved fliers, word-of-mouth outreach, and client lists, and each received a copy of the consent document to preview as part of recruitment. Focus groups were “over-recruited” with the goal of having six to eight participants per group. Potential participants gave contact information to a designated administrative person or to their Community Health Worker and received reminder mailings 1 week prior to the session and reminder calls 1 day prior. Participant sociodemographic factors, obstetrical data, and infant feeding experience were not obtained, in a specific effort to protect confidentiality and encourage participation.

Study procedures

The focus groups were conducted at a local health center in June and July 2009. Written informed consent was obtained from each participant, and all groups were audiotaped while an assistant took notes throughout the session. A lactation consultant (International Board Certified Lactation Consultant) with experience serving inner-city mothers moderated the groups with a script (available on request). A pizza meal was served at the beginning of the focus group, free childcare and a round trip bus ticket were available to all participants, and each received a $10 gift card at the conclusion of the session.

Data analysis

The audiotapes of the sessions and the notes taken by the assistant constituted the focus group raw data. The principal investigator (L.M.F.) created an abbreviated transcript from the audiotape, and the research assistants (E.C.B. and A.B.N.) independently each created detailed notes-based transcripts composed of comments and quotes from the audiotapes. We photocopied the transcripts and cut them into comment/statement fragments for classification, retaining an original copy to recheck context as needed. Each comment was assessed for relevance (was a research question addressed or answered), specific detail, emotional content (perceived emotional weight), and extensiveness (how many different people addressed the same issue). The research assistants assigned participant comments to domains and subdomains and achieved near-complete agreement. A secondary coding review was performed in collaboration with the principal investigator, and full consensus was reached for all comments after discussion, including triangulation with relevant literature.

We derived the analytic structure from a focus group analysis plan for a low-income high-risk population human immunodeficiency virus intervention. ¹³ Called “Factors Influencing Beliefs” (FIBs), this model was selected because of the similarities of process, content, and target population. Domains and subdomains were redefined to apply to breastfeeding health concerns while retaining the architecture of the original human immunodeficiency virus referenced study. New subdomains were created as needed, and nonapplicable domains were dropped. Subdomains were assigned inclusion and exclusion criteria relevant to breastfeeding, and example quotes were pulled. We included all topic-relevant comments even if the respondent did not directly answer a moderator query. Topic saturation was achieved within these focus groups as confirmed by review of a follow-up group with same-population mothers who met subsequently to review the proposed intervention.

Risk Appraisal Domain

This domain included multiple factors that interfered with the choice to initiate or continue breastfeeding. Although mothers knew that breastfeeding was optimal and were aware of its benefits, lack of information, misinformation, and the perception of pain while breastfeeding made formula feeding seem a better choice. Women expressed fear of pain, both as a personal experience and as a deterrent reported by others. Fear of suffocating the baby was frequently expressed, as well as worry about not knowing if the baby would be adequately fed. Other misconceptions mentioned by multiple participants included concerns that smoking or an unhealthy diet with “spicy” foods prohibited breastfeeding and worry that the nipple could not be adequately sanitized. Inadequate understanding of breastfeeding basics such as feeding frequency and good latch was expressed. Overall, women articulated understanding of the benefits of breastfeeding, yet noted challenges and did not verbalize solutions.

Self Perception Domain

Women tentatively expressed interest in “trying” or at least initiating breastfeeding but were clear that just knowing breastfeeding is “healthy” does not mean a woman will choose to breastfeed. Lack of self-efficacy was a major self-described barrier, with limited comments expressing positive self-efficacy. Only one participant described breastfeeding (four children) without difficulty and was able to articulate overcoming obstacles. Worries that others would not be able to share care of the infant and fear of social isolation were expressed frequently. Several women who had successfully breastfed highlighted the joy of breastfeeding and said the experience gave them a sense of self-worth and self-fulfillment.

Emotion and Arousal Domain

No comments were directly relevant to this domain.

Relationship Issues/Social Support Domain

Women compared the value they placed on the opinions of their own mother and their partner: while the father's preference could be ignored, the maternal grandmother's mandates were viewed as nonnegotiable. Participants discussed whether breastfeeding in public or even among family members is offensive or acceptable. One mother reported being arrested for breastfeeding on the bus (“They called transit police. I got a ticket. I had to go to court.”); the moderator noted that there is now a state law permitting breastfeeding in public. Women were unsure whether they and their partners could separate sexuality from breastfeeding, and even supportive partners could be perceived of as an obstacle to breastfeeding. Women were uncertain if men were actually interested in breastfeeding information, while acknowledging that most programs were intended for mothers. There appeared to be general agreement that breastfeeding was not a societal norm for the participants, but that within one's own family there might be a different norm (“It makes it easier when there is a history of breastfeeding in the family.”); in this context, any personal support was viewed very positively.

Structural/Environmental Factors Domain

Although hospital practices and lactation support after delivery are generally expected to be a positive source of support and information, several women reported negative postpartum hospital experiences. Women were frustrated by a perceived lack of general information about breastfeeding and visited the dilemma of balancing the safety net function of WIC with its “free” formula and dominant influence in their feeding choices. Women reported there was no place for them to breastfeed away from home and did not verbalize strategies to overcome this barrier. Finally, although many women expressed negative comments about the breastfeeding support at the hospital, it seemed that coming home was even harder.

Risk appraisal

In agreement with prior research, the majority of women in this study indicated that they perceive breastfeeding as a riskier choice than formula feeding. While expressing awareness and knowledge about the benefits of breastfeeding for themselves and their infant, nipple pain and painful latch were frequently and forcefully identified as obstacles.^14–23 Mothers expressed misconceptions regarding low milk supply and contraindications to breastfeeding. They also articulated a general lack of knowledge about the process of breastfeeding in areas ranging from feeding frequency, nipple care, and good latch to building milk supply.^{16,19,20,22,24–26}

A finding unique to this study was the fear of suffocating the baby during feeding: several women thought their breasts would be too big and would suffocate the baby while nursing. A 2009 focus group study on adolescent attitudes towards breastfeeding documents a single participant stating that she felt she was "too big" to breastfeed but without further elaboration. ¹⁶ We are not aware of other studies that have documented this as a concern among nonadolescents. Several studies reported lack of time and the challenge of work/school balance as a deterrent to breastfeeding; however, only two of our participants mentioned lack of time as an obstacle.^{15,17,22,24,27} It is possible that breastfeeding was not identified in this study as a unique time management challenge if participants faced multiple other work/life/time balance issues, but no specific supporting data on this topic were obtained in the focus group.

Self-perceptions

We are not aware of other studies that have reported lack of self-efficacy as a self-identified barrier to breastfeeding. Potentially relevant comments have been expressed in earlier studies, for example, “My biggest fear is that the baby won't gain weight. Am I doing this the right way? Am I feeding him right?” ^16,17 The issue of self-efficacy as related to breastfeeding outcomes has been extensively explored, but this appears to be the first study to categorize relevant interview or focus group comments as pertaining to this domain. ²⁸ A single participant in our study was an “outlier” with regard to positive self-efficacy, and her breastfeeding advocacy served to highlight the lack of self-efficacy most women endorsed.

We are also not aware of other studies that have documented self-esteem as a motivation for breastfeeding. Others have reported that women identified the joy of bonding with their babies as a motivating factor for breastfeeding, with comments that the bond gave them a sense of self-worth and personal fulfillment as a parent; the feeling of “doing the right thing for the baby” heightened this perception.^17,22,25,27 These comments were categorized as pertaining to “benefits of breastfeeding.” We believe, however, that the emotional weight and context of the comments are highly meaningful, especially in comparison with pragmatic statements about breastfeeding benefits, such as an expectation of fewer ear infections, and therefore assigned “bonding” comments to the self-esteem subdomain.

On the other hand, women in this study expressed a fear of social isolation and, as reported by others, were apprehensive about having to “sit alone” with the baby or be the only one able to care for the baby.^25,29 The concern that breastfeeding would establish an undesired dependency of the infant on the mother has been reported in earlier studies.^15,16,19 This theme was not reflected in our focus groups, likely because of differences in study population and method. Hannon et al. ¹⁹ and Nelson ¹⁶ exclusively examined teenage populations, and Cricco-Lizza ¹⁵ used in-depth longitudinal interviews; the “dependency” theme may be unique to adolescents or alternately may represent a more private concern not shared in the group setting.

Relationship issues and social support

In agreement with earlier studies, cultural/societal norms about breastfeeding significantly influenced feeding choice: mothers reported that breastfeeding was not the norm in their community and that most friends and family did not breastfeed or discuss breastfeeding.^19,24,25,29 As has been widely reported, concerns about breastfeeding in public due to the perceived sexuality of breastfeeding were cited, with specific concern about offending others or attracting unwanted attention.^{16,19,25,29,30} Anxiety about public breastfeeding extended into the home, with several women expressing the need for modesty while breastfeeding so as to avoid offending family members. The only prior studies identifying this concern were a 2006 focus group study conducted in the United Kingdom ²⁵ and a focus group study with Hispanic mothers ³¹ ; ours appears to be the first study among high-risk inner-city African-Americans to concur.

Especially notable were our participants' perceptions of the father's opinions regarding the sexuality of breastfeeding. Women reported their partner's discomfort with breastfeeding in public because of how other men might react. Even more poignant were women's statements about their partner's beliefs regarding the sexual implications of breastfeeding: one partner called breastfeeding “freaky,” and another partner accused the mother of being “gay” with her daughter by breastfeeding her. Two focus group studies^29,30 of men and women from a wide spectrum of socioeconomic backgrounds reported that men were uncomfortable with public breastfeeding, but the only other study with such extreme comments pertaining to sexuality is Alexander et al. ²⁰

The opinion of the baby's father is well recognized as an important influence in a mother's choice to breastfeed across all socioeconomic groups.^16,20,25,29 Several women in this study perceived the father's attitude to breastfeeding as negative but did not let his opinion deter them from breastfeeding. This is in accord with recent studies reporting that mothers make their feeding choice independent of the father and that fathers defer to the mother.^16,20,29 Avery and Magnus ²⁹ reported that the men in their study had positive attitudes about breastfeeding but that this was not communicated to or perceived by the mothers. We did not interview fathers, but our findings do not dispute this view, and we speculate that lack of communication between fathers and mothers may result in mothers verbalizing a negative perception of fathers' opinions toward breastfeeding.

Several women indicated that their own mother breastfed, and studies have identified the maternal grandmother as very influential in a mother's choice to breastfeed. Unique to this study, however, is that three participants stated they were actually coerced into breastfeeding by their mothers.^16,19,25 Without specific follow-up information, we do not know whether this approach ultimately had a positive or negative impact on the mothers' breastfeeding experiences.

Structural and environmental factors

Others have reported that “systems, policies, and practices” do not support breastfeeding, causing women to view formula feeding as more convenient than breastfeeding. ²⁶ Negative influences on breastfeeding initiation reported by us and others include a lack of places for women to breastfeed in public, lack of information or support from healthcare professionals, and negative experiences with hospital personnel postpartum.^16,21,24,25 Although these concerns seem intuitive, ours appears to be the first U.S. study to identify breastfeeding difficulties at home after hospital discharge as a barrier. Participants expressed the notion of everything “working” in the hospital but not knowing what to do or how to get help after returning home. A United Kingdom study is the only other report in this high-risk inner-city non-Hispanic subpopulation to articulate difficulties after hospital discharge as a breastfeeding barrier. ²⁵ Finally, also unique to our study is participants' vigorous advocacy for more public information about breastfeeding such as billboards and school health classes.

Strengths and limitations

This study has several identifiable strengths. The methodological choice of target population focus groups that use open-ended questions and permit participant interaction is well suited to identification of new themes and the corroboration and exploration of previously identified themes. The raw data suggest that the focus group discussions were energetic and that women felt comfortable sharing opinions. The absence of a verbatim transcript is a study limitation. However, data analysis with the notes-based approach permitted incorporation and appreciation of the nuances and emotional impact of comments, and the simultaneous independent transcription by two research assistants minimized the possibility of missing any participant statements. The use of the FIBs analytic framework added precision, fresh perspective, and rigor to the analytic process. An additional limitation is the lack of sociodemographic information about the participants, such as age, breastfeeding experience, parity, and educational level. These data were not requested from participants in an effort to promote recruitment and attendance but would have benefitted the analysis. Other study limitations are inherent to focus group methodology, for example, mothers who chose to participate may have been more interested in breastfeeding than women who chose not to participate, making results less generalizable. Results may also be less generalizable to other subpopulations and groups because of the race and ethnicity of the study participants, who were high-risk inner-city non-Hispanic non-immigrant African-Americans. Finally, it was not possible to determine if the group dynamic influenced the participants' comments, and each focus group had a limited number of participants per appropriate methodology, which has potential to limit the diversity of opinions.

Implications

The FIBs analytic framework, as modified for breastfeeding concerns, creates a context for future analysis and comparison of related studies that use focus group or interview methodology. Currently, comparison of studies is challenged by the need to integrate each investigator's unique approach. The FIBs methodology can serve as a common framework with which to organize, compare, and sort themes regarding breastfeeding attitudes and barriers, potentially furthering the understanding of obstacles and interventions for breastfeeding among high-risk inner-city non-Hispanic African-American mothers.

We also used the FIBs framework to create an intervention curriculum, Breast for Success, which incorporates the themes identified in this study (available on request from the corresponding author). Each module corresponds to several of the FIBs subdomains. Additional study will be needed to evaluate the efficacy of the curriculum.

We found that the opinions of maternal grandmothers seemed to play a major role in the mother's decision to breastfeed, which suggests that future studies and programs should focus on how to harness their experience and knowledge into support for their daughters. We also found that the fathers'/partners' opinions were not highly valued, with apparent miscommunication between mothers and fathers about feeding choice; this suggests that future programming could target ways to include fathers and to strengthen the fathers' and mothers' relationships. We reported on one very highly motivated mother who succeeded in her breastfeeding goals and who did not articulate experiencing the same barriers as other mothers, despite having the same high-risk background. Future study using structured and unstructured interview of such extraordinary women could potentially reveal generalizable information about what makes them so successful as compared with their peers. Finally, further focus groups with WIC-eligible and WIC-participating mothers, as well as with WIC peer helpers, will be needed to continue to identify opportunities and barriers to breastfeeding promotion among all WIC recipients.