Understanding Black Matriarchal Role Models in the U.S. Attitudes and Beliefs About Breastfeeding

Abstract

Introduction:

Despite the tremendous health benefits for both mother and infant, black women (including African Americans and those who self-identify as black) have lower rates of breastfeeding than all other racial groups. Historically, matriarchal role models have been essential within the black family structure. The purpose of this study was to explore matriarchal role models' attitudes and beliefs about breastfeeding.

Methods:

Thirty-eight black women between the ages of 46–82 years were surveyed regarding their perceptions of breastfeeding.

Results:

Our results revealed that 44.1% of the participants believed that breastfeeding is a better infant feeding method. However, 52.6% of the participants did not demonstrate confidence in their ability to breastfeed overall.

Conclusions:

These findings suggest that while black matriarchal role models have positive attitudes about breastfeeding behaviors, they may need to be educated along with postpartum and/or prenatal women about breastfeeding benefits and techniques to better support and improve black women's initiation and continuation of breastfeeding.

Introduction

Black women have lower rates of breastfeeding than all other racial/ethnic groups in the United States.¹ Black women's breastfeeding initiation and continuation rates are well below the Healthy People 2020 goals for breastfeeding,² with disparities in breastfeeding rates between black and white women widening in recent years.³ Previous research has shown that social support can significantly affect black women's decisions to initiate and continue breastfeeding. The cultural context of breastfeeding among black women is important to acknowledge. In the black community, matriarchal role models (i.e., mothers and grandmothers) are fundamental to the culture. These matriarchal role models play an integral role in helping to raise children. Grandmothers have been described as guardians of the generation,⁴ preservers of extended families, keepers and sharers of history, wisdom, and folk beliefs, sources and communicators of values and ideals,⁵ and the protector of grandchildren.⁶ Mothering and grandmothering in the black community have also been described as “other-mothering” or “community mothering” because black women from multiple generations often share the responsibility for raising children.^7,8 In addition to this communal form of mothering, extensive research shows that family support (e.g., pregnant woman's mother), social support,^9–11 and social modeling of breastfeeding (e.g., a family member who breastfed) are significant predictors of breastfeeding intention, continuation, and duration among black women.¹²

Matriarchal role models who do not understand the health benefits of breastfeeding, especially if they did not breastfeed, may be resistant (and sometimes in conflict with) to providing support to their daughters, granddaughters, nieces, and so on who want to breastfeed. For example, one study found that when attempting to make lifestyle changes that would impact both their cancer risk (e.g., breastfeeding) and their family's cancer risk (e.g., using bisphenol A free plastic), they encountered “generational resistance” and found themselves challenging “relational norms” in their dynamics with their mothers and mothers-in-law.¹³

Despite the evidence suggesting that social support can greatly influence black women's breastfeeding, black women receive the least amount of breastfeeding support. One study found that black mothers were the least likely racial/ethnic group to receive breastfeeding support from their mothers, partners, friends, and health care providers.¹⁴ A second study found that black mothers were the least likely to receive instructional support from health care workers, less likely to be provided breastfeeding support resources, and less likely to have their babies in their hospital rooms (a public policy initiative to encourage women to breastfeed).¹⁵ Furthermore, another study found that black men prefer their babies to be bottle-fed rather than breastfed.¹⁶ Given the key role of social support in black women's breastfeeding, it is critical to improve black women's social support to help encourage breastfeeding, and ultimately reduce their risk of triple negative breast cancer (TNBC). Moreover, several studies have reported that black women indicate receiving little or no prenatal educational advice from a health care provider about breastfeeding compared with white women.^17–19

Methods

Thirty-eight black women between the ages of 46–82 years were recruited to participate in a short survey about their attitudes and beliefs about breastfeeding. We used convenience sampling to recruit participants from community-based organizations in New York City and Western New York to obtain our sample. Institutional Review Board approval was received, and all participants provided informed consent and completed the survey either in person or over the phone. Participants received $40 for completing the survey.

The survey included demographic questions (i.e., age, marital status, level of education) as well as questions about their childbearing history (e.g., how many children do you have?) and breastfeeding behaviors for each child (e.g., did you breastfeed your child and how long did you breastfeed?). The survey also included open-ended questions that asked participants to list some of the advantages of breastfeeding for babies and for mothers. We also asked participants to describe what made them decide to breastfeed or not breastfeed themselves. We assessed participants' normative beliefs about breastfeeding, breastfeeding knowledge, infant feeding attitudes, medical mistrust, and social support using adapted versions of the following scales.

Normative beliefs about breastfeeding scale

This scale comprises three 1–5 Likert subscales: the importance of breastfeeding for the mother, the opinions of her familial/professional support systems, and the influence their opinions had on her decision to breastfeed.²⁰ If a woman did not have a family member or professional for a specific question, that response was made missing. Scores ranged from 5 to 25, 7 to 28, and 5 to 20 for each of the subscales, respectively. Higher scores indicated more belief in the importance of breastfeeding, greater breastfeeding preference among her familial/professional support network, and greater importance of familial/professional involvement.

Breastfeeding knowledge: advantages to baby and advantages to mother subscales

This 14-item scale measured women's knowledge about the benefits of breastfeeding using true or false questions.²¹ Incorrect responses were scored as “0” and correct responses were scored as “1”; total scores were calculated by summing these responses. Scores ranged from 0 to 14, with higher scores indicating greater knowledge. Cronbach's α for the entire questionnaire was 0.77.

Iowa Infant Feeding Attitude Scale

We adapted the Iowa Infant Feeding Attitude Scale (IIFAS) to measure our participants' attitudes toward breastfeeding using 18 items with Likert scales ranging from 1 (“strongly disagree”) to 5 (“strongly agree”).²² Scores ranged from 18 to 90, and some items were reverse-scored. Higher scores indicated greater preference toward breastfeeding. Cronbach's α ranged from 0.68 to 0.86.

Medical mistrust: suspicion subscale

Women's beliefs about how their communities interact with and are treated by health care professionals were assessed with this subscale.²³ Each question had a Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”); total scores were calculated by summing their responses on the subscale's six items. Scores ranged from 6 to 30, and higher scores indicated greater belief that her ethnic group should be suspicious of health care professional's actions and opinions. In African American populations, the scale exhibited a Cronbach's α of 0.61.

Medical outcomes survey social support scale

The medical outcomes survey social support scale (MOS) is a four-domain, 19-item instrument that evaluated the support the participants had when raising their children in infancy.²⁴ The four domains were emotional/informational support, tangible support, affectionate support, and positive social interaction. Each question was scored using a Likert scale ranging from 1 (“none of the time”) to 5 (“all of the time”). Sample questions from the MOS scale for each domain—emotional/information support: someone you can count on to listen to you when you need to talk, tangible support: someone to help you if you were confined to bed, affectionate support: someone who shows you love and affection, and positive social interaction: someone to do things with to help you get your mind off things. As a result, scores ranged from 1 to 5, with higher scores representing greater support. The overall MOS Cronbach's α was 0.97, while the subscales had α values ranging from 0.91 to 0.96.

Descriptive statistics were calculated for demographic variables as well as women's opinions about and experiences with breastfeeding. All scale and subscale total scores were calculated as described. Internal consistency was measured for each scale and subscale using Cronbach's α; the standard ≥0.70 was used as a cutoff value.²⁵ Open-ended questions were independently coded for common themes by the first author (L.O.) and a research intern (J.C.). Discrepancies were reviewed and resolved by a third coder (J.S.).

Results

Demographic results are displayed in detail in Table 1. Table 2 displays a summary of the results on all of the applied scales. According to the normative beliefs about breastfeeding scale, most participants reported that they believed in the importance of breastfeeding (mean ± standard deviation: 20.81 ± 3.64), that their familial/professional support networks had a greater preference for formula feeding (6.15 ± 5.22), and that their familial/professional support networks had a moderate influence on their decision to feed their babies (12.22 ± 5.94). With an average score of 4.82 (±2.72) on the breastfeeding knowledge scale, however, the participants indicated that they had insufficient knowledge regarding the benefits of breastfeeding.

Table 1.

Descriptive Statistics

Category	n (%)/mean (±SD)
Age	61.28 (±8.30)
Education
Less than a college degree	19 (50)
A college degree or more	19 (50)
Relationship status
Ever married	20 (52.6)
Never married	18 (47.4)
Employed
Yes	9 (23.7)
No	29 (76.3)
Annual household income
<$50,000	11 (55)
$50,000+	9 (45)
Health insurance
Yes	36 (94.7)
No	2 (5.3)
WIC assistance
Yes	6 (15.8)
No	32 (84.2)
Number of children	1.76 (±1.95)
Breastfed their children
Yes	12 (33.3)
No	24 (66.7)
Breastfeeding confidence
Little-to-no confidence	10 (52.6)
Confident	9 (47.4)
Best way to feed a baby
Breastfeeding	15 (44.1)
A mix of breast and formula feeding	12 (35.3)
Formula feeding	3 (8.8)

SD, standard deviation; WIC, Women, Infants and Children.

Table 2.

Scale Analyses

Scale	n	Mean	SD	Median	Minimum	Maximum	Cronbach's α
Normative beliefs about breastfeeding scale
Breastfeeding importance	37	20.81	3.64	20.00	14.00	28.00	—
Support network opinion	34	6.15	5.22	6.00	0.00	16.00	—
Support network importance	32	12.22	5.94	14.00	0.00	20.00	—
Breastfeeding knowledge^a	34	4.82	2.72	5.00	0.00	12.00	0.66
IIFAS	33	66.24	5.42	68.00	56.00	78.00	0.40
Medical mistrust^b	37	14.41	5.16	14.00	6.00	30.00	0.91
MOS social support	30	4.04	1.07	4.35	1.00	5.00	0.98
Emotional/informational support	30	3.84	1.12	4.06	1.00	5.00	0.97
Tangible support	30	4.13	1.15	4.38	1.00	5.00	0.96
Affectionate support	30	4.23	1.16	4.83	1.00	5.00	0.96
Positive social interaction	30	3.98	1.12	4.25	1.00	5.00	0.96

Advantages to baby and advantages to mother subscales.

Suspicion subscale.

IIFAS, Iowa Infant Feeding Attitudes Scale; MOS, Medical outcomes study.

Despite this, the IIFAS showed that they generally had positive opinions toward breastfeeding (66.24 ± 5.42). The average score for the sample on the medical mistrust suspicion subscale (14.41 ± 5.16) revealed that participants were moderately suspicious of doctors and health care workers. Yet, these women also reported that they felt supported in all four domains of support (emotional/informational support, tangible support, affectionate support, and positive social interaction) most of the time on the MOS (4.04 ± 1.07).

While the medical mistrust and MOS questionnaires showed excellent internal consistency (α = 0.91 and α = 0.98, respectively), the breastfeeding advantage scale showed questionable internal consistency (α = 0.66) and the IIFAS showed unacceptable internal consistency (α = 0.41).

When asked to list the advantages of breastfeeding for babies, most participants mentioned general health benefits to breastfeeding (n = 18; 46%), including “protection from illness”/“better immunity” (n = 12; 31%) and greater nutrients from breast milk (n = 6; 15%). The other most commonly mentioned advantage of breastfeeding for babies was increased bonding with the mother (n = 10; 25%).

The most common themes mentioned as an advantage to breastfeeding for mothers were increased emotional bonding with the baby (n = 14; 36%) and weight loss (n = 14; 36%), followed by general health benefits (n = 10; 26%). A few women mentioned that breastfeeding was helpful in “reducing breast fullness/tenderness” (n = 3; 8%) and helped to “contract the uterus” back to its normal size (n = 4; 11%). Only three women (8%) specifically mentioned that breastfeeding aided in reducing breast cancer risk.

Discussion

This study described the attitudes and beliefs of black matriarchal role models toward breastfeeding. The literature shows that black women experience low rates of breastfeeding^1,2 and that familial support may be beneficial in increasing breastfeeding rates.^4–6 To increase black women's breastfeeding rates, it is imperative we also take into consideration how black women's attitudes and beliefs are shaped by their support networks, including matriarchal role models. Overall, among the role models surveyed in our study, less than half thought breastfeeding was the best method to feed a baby. More than half of the participants did not demonstrate confidence in breastfeeding. These results suggest that despite knowing the importance of breastfeeding, matriarchal role models, in many cases, are not confident in their ability to breastfeed. This may indicate that women still need external support for breastfeeding and that matriarchal role models may need additional education to provide informational support around breastfeeding. Therefore, researchers must design interventions that target postpartum and prenatal women and matriarchal role models. By improving breastfeeding knowledge and self-efficacy, role models could provide more tangible support, which could help prolong breastfeeding among black women.

Our results indicated that about 50% of our participants reported positive attitudes and adequate knowledge about breastfeeding. Still, their support networks had less favorable views about breastfeeding. Our results also show that participants had insufficient knowledge regarding the benefits of breastfeeding. Participants' beliefs about breastfeeding's advantages were related to better health outcomes for the baby and mother, including increased emotional bonding and weight loss. These findings reflect the long-standing legacy of slavery seen in the present day with low breastfeeding rates among black mothers.²⁶ Structural barriers, the legacy of slavery, and lack of representation have negatively affected the black community's breastfeeding rates. The lack of support and the lack of role models lead many women feeling inadequate to breastfeed and turn to formula feeding prematurely.²⁷ Because of this, it is important that individual- and community-level interventions be developed and tested to increase knowledge about the benefits of breastfeeding and enhance breastfeeding rates among black women. A recent review of psychosocial interventions to enhance breastfeeding rates among black women supports intergenerational, community-level interventions. The authors suggested that new interventions should focus on engaging family, friends, health care providers, and policymakers in providing adequate breastfeeding support.

Although the current study presented insightful information, we recognized some limitations. Our small sample size may have yielded a preliminary empirical assessment of the data. Furthermore, the survey did not ask participants whether they were grandmothers and how they supported their daughters/children in breastfeeding. Moreover, two of the scales utilized in this study expressed very low internal consistency, which means that the items of these scales did not adequately assess the same construct and that these scales may not possess adequate validity.

Conclusions

The present investigation considered matriarchal role models' perspectives about breastfeeding to better understand what type of support they may be best suited to provide to postpartum mothers. Mothers of newborn infants need a strong support system to breastfeed successfully. Thus, while research shows significant health benefits of breastfeeding, this study demonstrated that many participants were not aware of these benefits. Future interventions must build up self-efficacy in postpartum women by improving breastfeeding knowledge and confidence, and incorporating matriarchal role models to provide support aimed at increasing breastfeeding duration.

Footnotes

Acknowledgments

The authors would like to thank Dee Johnson, The Witness Project of Buffalo and The Witness Project of Harlem for their contributions to recruitment and enrollment of study participants.

Disclosure Statement

The authors have no conflicts of interest to report.

Funding Information

This work is supported by the New York State Department of Health Patricia Brown Education Grant.

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