Understanding the Racialized Breastfeeding Experiences Among Black Millennials

Abstract

Introduction:

The World Health Organization recommends 6 months of exclusive breastfeeding for infants. Racial disparities exist, where only 27.9% of black women exclusively breastfeed at 6 months compared to 45.1% of white mothers. Previous research suggests that these disparities are due to a variety of factors, including poor paid leave policies, racism, and bias, but few studies have looked specifically at the experience of black millennial mothers.

Methods:

This qualitative study aimed to understand the racialized experiences of breastfeeding among black millennials and whether or not there are factors to mitigate the effects of racism. Three focus groups were conducted (N = 15) with black millennial mothers. Participants were recruited through social media sites, emails to breastfeeding/black maternal health organizations, and local partnerships. Inclusion criteria included self-identification as a black/African American woman, born between 1981 and 1996, and having at least one child 5 years or younger.

Results:

Five major themes emerged from the analysis as follows: (1) institutional racism and barriers, (2) challenges to motherhood, (3) black experiences, (4) breastfeeding in the millennial age, and (5) hopes for the community. Results showed that black millennial mothers expressed being treated differently and poorly due to race. While participants reported supporting each other through their breastfeeding journey, this was not specifically a strategy to impact racism/bias.

Discussion:

Results also showed that black millennials feel a desire to succeed in breastfeeding to change the narrative about past generations. Further research should explore differences between the breastfeeding experiences and perceptions of black millennials in comparison to that of previous generations.

Introduction

Breastfeeding is an important behavior in the mother-infant dyad around the world. Breast milk provides specific developmental needs for babies due to the inclusion of antibodies and proteins necessary for a healthy brain and to fight off disease.¹ However, black mothers in the United States initiate breastfeeding and exclusively breastfeed at rates that are significantly less than any other racial/ethnic group.

The Centers for Disease Control and Prevention (CDC) recognizes a magnitude of black-white disparities in breastfeeding initiation, exclusivity, and continuation. Among all infants born in 2017, rates for exclusive breastfeeding at 3 months were 28.7% for black infants and 52.4% for white infants, while at 6 months, the exclusivity rates were 21.2% and 38.7%, respectively.² There are potential generational differences in breastfeeding outcomes and experiences between millennials and older generations. One study of black women who chose not to breastfeed found that most participants older than 51 years were more likely to cite sociohistorical influences on choosing not to breastfeed; these influences were the slavery-era mammy stereotype and wet nursing.³

Previous research points to historical trauma of being forced to serve as wet nurses during slavery, lack of representation, structural and systemic barriers to breastfeeding, and racism as potential causes of the racial gap.^4,5 Theories about the impact of racism on breastfeeding play out in multiple ways from interpersonal experiences of discrimination from health care providers to institutional barriers for black international board-certified lactation consultants (IBCLCs) who comprise less than 2% of the population of lactation consultants.^6,7 Beyond experiencing racism and discrimination directly with health care providers, experiences of racism outside of health care settings also show potential to impact breastfeeding.⁸ A study of experiences of racism on first-time African American mothers found that women who experienced acts of racism and discrimination in their workplace had lower odds of breastfeeding at or past 3–5 months postpartum.⁸

Generational differences between Baby Boomers, Generation X, and millennials impact perceptions of health care and breastfeeding. One study found that those in Generation X, born between 1965 and 1980, are more likely to trust information that is evidence based and comes directly from a health care provider versus millennials. Millennials, born between 1981 and 1996, are more technologically savvy, health conscious, and most likely to gather health information from the internet and social media.⁹ Another study found that Baby Boomers, born between 1946 and 1964, are most likely to use the internet for their preventative health care needs.¹⁰ Generational differences in breastfeeding perceptions among black women are a current gap in the research literature; however, some studies on this subject have been recently published. One study looking at intergenerational perceptions of breastfeeding in black family dynamics found that older family members such as grandmothers were supportive of breastfeeding, but more likely to express reservations. The researchers also found that younger generations of mothers were most likely to breastfeed if their mother and grandmother also had experience breastfeeding.¹¹

While there have been studies about racism and breastfeeding, none to our knowledge has specifically focused on how black millennial mothers are experiencing racism and breastfeeding. This study seeks to better understand the current status of breastfeeding among black millennial mothers and how racism impacts their experiences.

Materials and Methods

Sample and setting

Focus group participants were recruited through social media platforms and partnerships with community organizations. Selection criteria for participation were self-identity as black/African American, age between 24 and 39, and having at least one child 5 years old or younger. Three focus group interviews were held (n = 15) of a duration of ∼2 hours each. Initially, 22 women completed the research interview interest form provided through 10 different maternal and child health organizations and connections. The participants wgo were interviewed ranged in age from 26 to 37 at the time of the interview. Further demographic information was collected of the participants following the interviews (n = 13, 2 not available). Regarding level of education, seven participants had a master's degree, one had Trade/Vocational training, and five had obtained a bachelor's degree. Regarding birth setting, 10 participants gave birth in a hospital and three gave birth in a birth center. Breastfeeding outcomes of participants' infants ranged from continuation that ended at 1 week of age to 2½ years of age. Focus group interviews were held in Raleigh and Durham, North Carolina. Focus group participants self-selected the locations and dates/times of availability provided by the researchers. Participants were then contacted to schedule focus groups based on availability. Focus group discussion was facilitated by the researchers using a semistructured focus group guide.

Study design

This study utilized a qualitative, grounded theory approach.¹² The focus group guide was semistructured and covered topics such as breastfeeding journey, experience with racism, and implications for future generations. Social media use was explored as well, but not included in this article as it was not a salient theme during the focus group discussions. In addition to focus group questions, each participant was provided with a page that included definitions of interpersonal, internalized, and institutional racism as described by Dr. Camara Jones.¹³ Participants described their experiences of institutional racism based on their interpretations of Dr. Jones' definition. The research project was approved by Elon University's IRB.

Data collection

Focus groups were held over a 3-week period. To accommodate participants, childcare services, refreshments, and compensation in the form of $40 gift cards were provided at each focus group interview site. Before arrival, each participant received a digital copy of a consent form. A hard copy was provided and signed upon arrival to each focus group session.

Analytic approach

Focus group interviews were audio recorded and uploaded to a transcription service. Responses were analyzed using thematic analysis. The Sort and Sift, Think, and Shift method of analysis, created by Research Talk, Inc., was heavily utilized.¹⁴ This process allows the researcher to dive into data to understand its content and dimensions, and then step back to bridge findings with current conversations in their field. First, highlights from each focus group interview were noted and a reflection sheet was created that summarized main points. Each focus group recording was transcribed using Rev transcription service, read thoroughly, and annotated for shifts in tone and topic. Second, quotation identification was utilized for each transcript, finding powerful quotes. Through quotation identification, data were reduced from the transcripts to analyze the most meaningful or relevant data. Next, a quotation inventory was created, which collected powerful data segments of each collection episode. Categories were created for the various quotes in the three transcripts by creating overarching main themes and several subtopics beneath them. As analysis continued, the themes/topics were monitored and revised to best fit the data. Researcher Y.I.L. listened to audio recordings and described initial themes; themes were then revised and correlated by researcher S.B. The definition of institutional racism as described by Dr. Camara Jones was utilized in the thematic development.¹³ Finally, a visual profile, in the form of a Microsoft PowerPoint, was created, which bridged connections between the episode profiles.

Results

Five major themes were identified, including (1) Institutional Racism and Barriers, (2) Challenges to Motherhood, (3) Black Experiences, (4) Breastfeeding in the Millennial Age, and (5) Hopes for the Community. A more complete collection of illustrative quotations is provided in Table 1, while a few are included in the Results section as well.

Table 1.

Study Themes and Quotes

Theme	Theme description	Illustrative quote
Institutional racism and its barriers	The structural barriers and negative experiences within social	“That's one of the things that we're realizing is that the birth working industry as a whole is a business. Unless you have thousands of dollars to keep training upon training, more people are running online because there's really no information or community out there… I just cannot pay $142 to speak to a lactation consultant every time I have a question or concern.”
		“Just the type of information that you're able to receive, even the type of care and the types of clinics that you're allowed to go to all formulate down to either race or class. It's very limited options when you don't come from a background that is financially secure. Most of the time it seems like women that are of color are pushed more towards formula feeding within the first 48 hours and they are encouraged to breastfeed.”
		“A whole bunch of stuff that I do think had to do not only because I'm Black, but I was poor and was Black. I'm going through [health facility name] and stuff like that trying to get healthcare because I don't have health insurance. They just have a total disregard. No, I'm telling you something's wrong. I can't even drink water. I'm puking every day. I done lost 15 pounds. What is it? What's up? It was traumatic.”
Challenges to motherhood	Self-reflection on both positive and negative experiences during the motherhood journeys	“At the time, I was pumping and so he was doing bottle and everything fine, but I think that outside of the U.S., the assumption is that you breastfeed and if you don't, there's actually questions. I would actually get questions. They're like, ‘What's your baby doing right now?’ Literally. People were actually very concerned around my breasts and my child getting nourishment in other countries. It was more like, ‘Oh, she is coming. Don't worry. We kicked out the leader of the project so you can have a pumping room,’ as opposed to having me be here in the States and having to be like, ‘So, is there a pumping room?’”
Black experiences	Represents times when women directly reflected on needs and experiences as a function of their race	“We feel that, that familial comfort was able to shine through with the Black providers whereas White providers, it's just professional…I do feel that some of the White providers, it felt a little more rushed. You could tell they had 15 minutes for your appointment. It was like check these boxes, okay, bye. Like I'm washing, yeah, we're having a conversation, but I'm washing my hands and taking off my gloves and getting ready for my next visit. I felt that way. I could tell they didn't have time for me, for my questions, for my concerns. There was no time for it.”
Breastfeeding in the millennial age	Any experience specific to the age demographic and in contrast with previous generations	“They're baby boomers. Like you said, in the generation it was all about the struggle and working hard, and lots of things got cut out. If it wasn't surviving, it's kind of like breastfeeding is viewed as a luxury.”
Breastfeeding in the millennial age		“I feel like we're the first generation to really be okay on a broad scale, broad spectrum, of going against what our parents did, and what was normal in their generation.”

Selected illustrative quotes.

Institutional racism and its barriers

Experiences of institutional racism were described to participants by researchers as structural barriers and negative experiences within social systems. Some of these barriers included financial barriers to affording lactation support and discrimination from health care providers about their ability to exclusively breastfeed. Regarding discrimination from health care providers, participants were asked, “Do you feel that healthcare workers and/or lactation consultants have treated you differently based on your race/ethnicity?.” Additional examples of barriers were insurance limitations on access to health care options and individual fear or mistrust of the health care system.

Financial barriers were obstacles that related directly to breastfeeding costs and were often connected to institutional racism/discrimination. For example, some mothers identified high financial costs associated with seeking out lactation support as an economic barrier. A common experience of mothers was that they felt health care professionals assumed they would not breastfeed due to national statistics:

All right, so by the next visit, when you come back, if she hasn't gained weight, you're going to have to do formula. That was like an automatic thing. It's honestly just like, racism aside, no, not racism aside, but either you're going to have the Black … you're going to have to do formula or sorry to tell you, I'm just going to tell you with a smile, but you're Black so you're not going to be successful at this anyway, okay?

Participants also stated the care they were able to receive was influenced by their socioeconomic status (SES). Access to care was affected by the financial stability of the patient, type of health insurance, and geographic location in which participants lived, all ways in which institutional racism has created differential access to resources. Participants stated that the intersectionality of identity plays a part in access to care.

The intersectionality of race and social class came up frequently in two of the three focus groups. Some participants felt that their identity as a black woman and lower SES intensified the mistreatment and discrimination they experienced. Access to health care, the availability of health insurance, and treatment by health care professionals were connected to identification of being black and the assumption or presence of lower SES. Regarding health insurance of participants at the time of the interviews they either had private insurance or Medicaid, or were uninsured (n = 13, 2 not available).

Challenges to motherhood

Challenges to motherhood included the self-reflection on both positive and negative experiences during the motherhood journeys. Participants reported social barriers to breastfeeding through their friendships and family dynamics. Some participants felt isolated from family and friends because they chose to breastfeed past 6 months and 1 year, but most women continued to breastfeed despite these barriers:

Sometimes you actually would have to fight that thing and lose a couple of good relationships with people about it because they don't realize it's not just something that I'm doing for recreational purposes. This is what my child eats. It's something I have to do. I mean, not even just employment. Like she was saying earlier, just friends understanding, “Hey, this is something I got to do.”

Geographical/regional differences were discussed in both a national and global context in regard to views on breastfeeding. One participant described breastfeeding as more challenging in the United States than when traveling to another country where she felt more supported.

Black experiences

The theme “Black experiences” represents times when women directly reflected on needs and experiences as a function of their race, for example, seeking representation of black people in the health care setting, searching for black breastfeeding support online, and feelings of acute awareness of their black identity in different spaces. The researchers did not explicitly ask about the racial identity of the participants' health care providers. However, two of the three focus groups were asked a follow-up question regarding experiences of racism. The two groups were asked if they had specifically sought out black providers. Participants then discussed either their desire to seek out black providers or to seek out the best care regardless of racial and ethnic identity.

Although some participants sought out black health care providers, other participants did not:

…I never sought out a Black birth team. I didn't know what a doula was. Then actually, that's what got me here now that I think about it. She's a Black doula and she has a Facebook page. She stepped away for a while, and now she's back. I follow her. Then that's how I got here. It never really occurred to me. I was like, “Where?” I guess that's sad in and of itself. Where am I going to get the best care? I didn't think about us [Black people] because I've never seen us in this capacity.

Participants who did explicitly seek out black doctors, midwives, and doulas did so with hopes of feeling a stronger connection with someone who had a similar racialized experience. They felt that having a black provider would lead to better cultural empathy for their needs as black mothers. Most participants indicated they wanted the best care for themselves and their infants regardless of if that came from working with a black provider or a white provider.

Breastfeeding in the millennial age

Breastfeeding in the millennial age refers to any experience specific to the age demographic and in contrast with previous generations. For example, this theme encompassed conversations about generational differences between older generations such as Generation X and Baby Boomers. Participants stated that millennials were the generation to create a shift in breastfeeding rates and to breastfeed for longer durations to “do better” than their own mothers and grandmothers. One participant spoke to whether or not breastfeeding in the millennial generation is a trend or fad:

I think it's more accepting in this generation. I don't think it's a fad or trend, or something like that, but I think it's definitely more acceptable in the millennial generation. Younger. Because I feel like older, I don't know if it was just the time that they grew up in, and you know, my mom she always says, I had to work so I didn't breastfeed any of you all. If it was just the culture, the push away from breastfeeding when that came about, I guess, you know, more women stopped breastfeeding. It kind of was almost like a lost art, almost forgotten about.

Participants also stated that they felt older generations did not have the same ability to breastfeed due to workload, lifestyle, and necessity. In regard to shifting breastfeeding trends, one participant stated that millennials are the first generation of going against the norms of previous generations.

Hopes for the community

Hopes for the community reflect participants' hopes and dreams for younger generations of black mothers. Participants were asked to discuss advice they wish they had been given when starting their breastfeeding journey, words of encouragement for younger generations, and their hopes for the future for their own children. One participant summarized her hopes for the community as follows:

… I would hope that the narrative in culture can go in that direction. Just by the way of nature, of culture, of where we're doing things, more Black women breastfeeding and being educated about it, and then being out and about and seeing more women breastfeeding. I think that's critical if it's to continue.

Discussion

This study sought to understand the lived experiences of black millennials through qualitative research methods. Themes reflecting the qualitative data included Institutional Racism & Barriers, Challenges to Motherhood, Black Experiences, Breastfeeding in the Millennial Age, and Hopes for the Community. Black millennial mothers face both historical and institutional barriers to breastfeeding; however, they are able to successfully breastfeed at or past the WHO's recommendation of 6 months exclusive breastfeeding. These mothers breastfeed despite institutional racism and its barriers to shift the narrative of breastfeeding in the black community and bring hope to future generations of black mothers.

There was a strong dichotomy between the three focus group interviews with women reporting either strongly negative or fairly positive experiences in the overall pregnancy journey. Negative experiences were due to discrimination faced in the hospital setting, while positive feelings were from those who birthed in a birth center setting where they found solidarity. This finding is similar to a study that found women who gave birth in a birth center with midwives were approximately twice as satisfied with their care when compared to women who gave birth in standard hospital settings.¹⁵ In this study, participants who gave birth in a birth center were also in the same in-person support group. They had a more positive outlook on their experiences and fewer shared experiences of racism. These differences suggest potential association between birth setting, social support groups, and perceived experiences of racism and discrimination that were not explicitly assessed in this study. Similarly, one study found that black women who attended in-person support groups were more than twice as likely to intend to breastfeed and have higher self-efficacy to breastfeed.¹⁶

Participants in the focus group with overall positive experiences desired black representation in their health care providers, but specifically stated that as long as they were receiving the best care, they did not mind having white providers. Patient-provider concordance is the similarity of identity between patients and health care providers.¹⁷ One literature review found that there were no significant associations between patient–provider concordance in positive health outcomes among Hispanic and black patients.¹⁷ However, another study found that patient-provider concordance resulted in higher satisfaction with health care providers among Hispanic and black patients.¹⁸ The literature contains inconsistent findings about the importance of racial concordance, but the participants in this study expressed a desire for black health care providers.

The intersectionality of race and SES was discussed at length in the focus group interviews. Intersectionality is a term coined by Kimberle Crenshaw to explain the ways in which race and gender affect the experiences of black women.¹⁹ Crenshaw's work sought to shed light on the nuances of discrimination faced by black women such as experiences of racism and sexism that were heightened by the intersections of gender and race identity. Within this study, low-income participants felt that they were specifically discriminated against due to both their racial identity and lower income. Participants felt that health care providers were biased toward black patients and made an automatic assumption that if they are black, they must also be “poor.” Those underlying beliefs based on race and presumed SES negatively affected their treatment. One study found that black women from lower SES were more likely to report experiences of unfair treatment, whereas black women with higher status reported subtler experiences of institutional racism.²⁰

Findings from this study suggest that black women are able to initiate and continue breastfeeding despite experiences of racism/discrimination. Findings also contribute to the paucity of research literature studying black millennial mothers and breastfeeding. This study describes the lived experiences of this population through discussion of overall breastfeeding journeys and experiences of institutional racism on breastfeeding outcomes.

One limitation of the study is the sample size of 15 participants among the interviews. Although relevant data were still collected from interviews, ideally more participants would have been recruited for participation in the study. Due to the small sample size, we are unable to attribute experiences that are solely unique to black millennials. However, one study found that a qualitative sample size of two or three focus groups will still capture ∼80% of relevant themes for participants from a similar population when using a semistructured focus group guide.²¹ Similarly, sampling bias was a limitation because participants were recruited through social media platforms and contact with maternal and child health organizations. It is possible that the sample population is not representative of black millennial mothers more broadly due to exposure to breastfeeding information and support from these organizations. Another limitation of the study is the lack of evaluation of breastfeeding counseling practices in the prenatal period as the researchers did not ask this during focus group interviews. The researchers asked questions regarding the postpartum period specifically.

However, this study was able to bring the voices of black millennial mothers into the broader literature regarding black mothers by making certain that generational representation is present. Previous research has studied institutional barriers to breastfeeding and racism, but has not sought to understand the racialized experiences of breastfeeding among black millennials specifically. Another strength of the study was the targeted approach of utilizing a semistructured focus group guide during interviews. The guide allowed for collecting the most meaningful data and allowing flexibility in discussion for participants.

Conclusion

While some black millennial mothers are able to successfully breastfeed past the WHO's recommendation of 6 months exclusive breastfeeding, the barriers of institutional racism and challenges of motherhood in the millennial generation place strain on breastfeeding experiences. Future research should make additional progress toward understanding generational differences in breastfeeding among black women.

Footnotes

Authors' Contributions

Y.I.L. and S.B. contributed to the design and implementation of the research, to the analysis of the results, and to the writing of the article. All authors reviewed the final article.

Acknowledgments

The researchers would like to acknowledge Mocha Moms, Inc., Ste'Keira Thompson with Triangle Doulas of Color, Janiya Williams, IBCLC with Mahogany Milk, Tonya Daniel, IBCLC, statistician Dr. Che Lena Smith, and all the participants who made this study possible.

Data Availability Statement

The datasets generated during and/or analyzed during this study are available from the corresponding author on reasonable request.

Disclosure Statement

No competing financial interests exist.

Funding Information

Funded by the Honors Fellows and Lumen Scholars programs at Elon University.

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