Exploring the Breastfeeding Experiences of African American Mothers Through a Critical Race Theory Lens

Abstract

Background:

Data from the Ohio Department of Health for Hamilton County reveal that the rate of breastfeeding steadily increased for non-Hispanic white babies from 72% initiation in 2006 to 79.8% initiation in 2018. Over the same time period, the rate of breastfeeding initiation increased from 52% to 65.7% for African American babies. Despite positive gains in breastfeeding for the African American community, significant disparities remain.

Research Aim/Question(s):

Our aim was to gain insight into the breastfeeding experiences of African American women and professionals working primarily with African American women to promote and support breastfeeding.

Methods:

In this study, a critical race theory approach was used to explore the lived experiences of African American women and health care providers who serve African American communities through the analysis of breakout conference sessions. Breakout sessions were semistructured, with questions developed in a strengths, weaknesses, opportunities, and threats analysis format aimed at obtaining information related to sociocultural factors impacting breastfeeding initiation and duration, with the goal of developing actionable community objectives to address breastfeeding disparities for African American women.

Results:

Three themes emerged stereotypes and microaggressions, representation, and provider support.

Conclusion:

Qualitative analysis of the conference proceedings reveals insights that can be developed into an action plan to address breastfeeding disparities in Hamilton County.

Background

African American mothers’ breastfeeding rates remains lower than the established guidelines, despite the proven benefits.¹ Nationally, ∼74.0% of African American mothers initiated breastfeeding, with 48.6% continuing any breastfeeding to 6 months.² Conversely, white mothers initiated at a rate of 86.6%.² Data for Hamilton county (which primarily comprised the Cincinnati metropolitan area) reveal that the rate of breastfeeding initiation steadily increased for non-Hispanic white babies from 72% in 2006 to 79.8% in 2018 (the last year for which data are available).³ Over the same time period, the rate of breastfeeding initiation for African American babies increased from 52% to 65.7%. As a result, in 2018, there was a 14.1% point disparity in breastfeeding initiation for African American babies compared to white babies in Hamilton county.³

A significant number of barriers to initiation and continued breastfeeding exist for African American mothers. Mothers frequently cite support as the primary barrier, which inhibits their ability to breastfeed. Research has identified financial/economic support, expert guidance, and social support as three subareas that impede breastfeeding.⁴ The support sought by an African American woman is underpinned by racism, due to the entrenchment of a white supremacy ideology which pervades society.⁵ The Institute of Medicine landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, showed pervasive bias and inequities within the U.S. health care.⁶ Although, not well documented in the literature, bias and discriminatory practices, similar to the rest of clinical care, manifest through covert interactions in lactation care.⁷

Due to racism, African American women receive inequitable maternal care and lactation support, which impacts breastfeeding outcomes.⁸ Thomas reported routine incidents of overt racism, bias, and structural racism from White International Board Certified Lactation Consultants (IBCLCs) directed toward nonwhite patients.⁷ Another study found differences in educational support and lactation referrals from primary health care providers.⁹ In addition, African American women received less encouragement to breastfeed and were offered formula more frequently than their white counterparts.¹⁰ DeVane-Johnson et al., recommends an approach to examine complex pathways of racial disparities in breastfeeding focusing on the link between the social, cultural, and historical which requires interrogation to discern the nuanced interplay on social support and interpersonal relationships.¹¹

Conceptual model

There is an abundance of research citing the complex interplay between social, cultural, and health behavior that recommend the integration of these constructs to better elucidate interactions between causative pathways.¹² The World Health Organization (WHO) Commission for Social Determinants of Health (CSDH) conceptual framework centers the social phenomenon as the causative agent influencing health and well-being.¹³ In the CSDH framework, the upstream factors (public policy, cultural values/societal norms, social cohesion, and social capital, class, and race/ethnicity) act on downstream factors (behavior, biological factors, and psychosocial factors) to impact health and well-being.¹⁴

While the CSDH framework incorporates culture, class, race/ethnicity, gender, and social class, the framework does not fully deconstruct the systematic way, in which each operates shaping the lived experiences of those identified as ascribing to a minoritized identity. Addressing this gap requires expanding the model to conceptualize the intersectionality of race, class, and gender to discuss hierarchical power structures, entrenched cultural narratives, and racially based psychological trauma. The field of public health must actively engage other disciplines in critical discourse to develop a new theoretical framework that is underpinned by a critical analysis of barriers and facilitators of health.

In the case of exploring the experiences of low-income African American mothers and breastfeeding, Critical Race Theory (CRT) should be used to elucidate these lived realities.¹⁵ Through the process of interrogation and deconstruction, health inequities can be examined in a social, historical, cultural, and race-based trauma context with the power dynamics that link and intersect these domains. Regarding low breastfeeding rates and duration among African American women, a CRT uses meaning-making to construct a theory that makes sense out of how race might operate within health behaviors. Numerous efforts have been used in health promotion theory to address the individual, community, and policy level for African Americans; however, disparities remain.¹⁶ Thus, it would seem that a new approach is warranted.¹¹

The incorporation of critical scholarship in psychology and education has provided researchers a way to view the whole of a problem and then break it down into its parts focusing on power and action for a just society.¹⁷ These disciplines approach problems of inequity from a space that interrogates and challenges the status quo, examining the dialectic between the individual and social structures with emphasis on the operation of power.¹⁷ The incorporation of a CRT framework in health promotion research is the new direction needed to begin developing a better understanding of the nuances of race and health.

Research Aim/Question

It is the aim of this article to conduct a preliminary exploration of how the lived experiences of African American women leads to breastfeeding disparities using a CRT lens.

Methods

Design

This is a qualitative study using the theoretical framework of CRT to elucidate the lived experiences of African American women and health care providers who serve African American communities. CRT was first developed to address the inability of critical legal studies to center race as an important component of the judicial system. CRT aims to expose the way in which race and racism shapes the legal system and, in addition, to show how race is informed by the structure of the system.¹⁵

The framework of CRT, proposes four assumptions: racism is embedded in the fabric of America and thus is not readily visible to those in the dominant reference group; experiential knowledge of Black, Indigenous, People of Color (BIPOC) is critical for the understanding of racism; narratives promoting color blindness and/or race neutrality perpetuate the self-interest of the dominant group; and interdisciplinary work is needed to challenge, affirm, and further develop the CRT framework.¹⁵ CRT is vital to understanding disparities as it makes racism a central component of its cause and BIPOC experiences and knowledge central to its redress.

The incorporation of CRT into health foregrounds race and racism as root causes of health disparities by challenging the separate discourses on race, gender, and class; looking at the social, political, and economic inequity among these groups, and demonstrating how race intersects with the other characteristics and how this intersection impacts BIPOC through institutional and structural racism. It is through this context that CRT allows for a more nuanced understanding of health disparities, focusing on the ability of race to inform health and the health care system due to the centrality of racism as an ingrained ideology.

Setting

This investigation is based on qualitative data collected during the “Second Annual Conference to Eliminate Disparities in Breastfeeding and Infant Mortality.” The conference was held on an urban college campus located in a Midwestern city.

Researcher characteristics and reflexivity

W.E.B. Dubois often spoke of the double conscious experience that African Americans were forced to navigate. The construction of a double consciousness creates a binary opposition, establishing a consciousness of acceptability and one of intolerability. For African Americans this means assimilating to the “White” aesthetic for acceptance, which in turns means “Blackness” is deemed unacceptable and thus is marginalized. African American women are positioned as such to be doublly marginalized, due to experiencing two identities which face marginalization.¹⁸

As the primary investigator/first author, I as an African American woman, have had to negotiate numerous tepid and hostile spaces. My experience has been one that has led to a great deal of introspection. My social positionality based on my visible double-minoritized status means that my life experiences are informed and limited by Eurocentric ideological perspectives, which relegates me and others with our shared experience to marginal positions. Our collective marginality allows for the devaluation and the silencing of our voices, which means our stories are discounted or not heard. This erasure of the “Black Female” voice to provide a counter-narrative to the hegemonic narrative of our experiences has continued to perpetuate inequalities throughout society, which are manifested within the health care system.

I knew that for transformative change to occur, I could not be silent about injustice. I would need to be a voice advocating for all experiencing marginalization. In addition, I decided that I would have to build bridges through empathetic reflexivity, as the work of social justice is not merely the work of the marginalized. This work requires intentional thought and action, which I have dedicated myself to for approximately the last 25 years.

Context

A coalition of community and health care stakeholders joined forces to hold the Second Annual Conference to Eliminate Disparities in Breastfeeding and Infant Mortality on May 3, 2017. The 2017 conference built upon the first conference sponsored by Cincinnati Children's Hospital in 2016. A major objective of the second conference was to unpack the biases that perpetuate breastfeeding disparities in the region and produce a Call to Action that articulates the action steps identified in breakout sessions.

Cincinnati is a Midwestern city in Hamilton County. The city sits on the banks of the Ohio river in the southwest corner of the state of Ohio in the United States. The child population in the city of Cincinnati is 71,974. Approximately 38.3% of these children live below the poverty level, with 68% of African American children residing in the city younger than 18 years of age living in poverty.¹⁹ Data from the last U.S. Census indicate that African American children younger than the age of six years have even higher rates of poverty.

Workshop participants

African American mothers from Hamilton County, Ohio, were encouraged to participate in the conference and preconference planning activities through snowball effect marketing of the conference to community members and health care providers who currently work with, or aspire to work with, expectant or recently postpartum African American mothers. A preconference workshop was held to provide an opportunity for parent panelist, facilitators, and content experts to meet each other and share their thoughts on how to structure the breakout sessions. The discussion focused on sharing the experiences of the parent panelists and audience reaction facilitated by trained female African American facilitators. Parents were compensated for their time and travel expenses and provided food and childcare for both the preconference planning meeting and for time spent serving on the parent panel.

Sample

Participants engaging in the above described conference breakout sessions were the source for the data used in this analysis. The conference had a total of 203 registered attendees, with 50 community attendees supported on conference scholarships. Each breakout session held ∼30 attendees with 4–6 parent panelists plus 4 conference hosting staff (facilitators/notetakers/timekeepers).

Ethical issues pertaining to human subjects

All panelists openly participated in the workshop, which was open to the general public and media. Quotes from the workshops were written down on poster-size “sticky note” paper by a note taker for real-time viewing by all audience members, but at no time were any quotes linked to individual audience members or panelists. All data analyses were conducted with these anonymous notes. As we are not using any direct quotes in our qualitative analysis, our study was determined to be nonhuman subjects research by the University of Cincinnati IRB.

Data collection

Data were obtained from the above described Second Annual Conference to Eliminate Racial Disparities in Breastfeeding and Infant Mortality. Key informants participated as parent and expert panelists in small breakout sessions. The purpose of these sessions was to gain insight into the experiences of African American women and professionals working primarily with African American women to promote and support breastfeeding.

Data collection instruments and technologies

During the actual conference, attendees selected one of three interactive breakout sessions (1) breastfeeding encouragement and support from prenatal care through delivery, (2) breastfeeding support beyond the hospital, or (3) breastfeeding support from mother's community. A fourth session, harnessing social media, was more of a “how to” workshop format and is not part of the source data for this study.

The three breakout sessions were led by skilled facilitators of crucial conversations on racism and included a panel of two content experts, three to five parents from the community, and a session chair and co-chair. Breakout sessions were semistructured, with questions developed in a strengths, weaknesses, opportunities, and threats analysis format aimed at obtaining information related to sociocultural factors impacting breastfeeding initiation and duration, with the goal of developing actionable community objectives to address breastfeeding disparities for African American women. All breakout sessions were facilitated by trained African American female moderators, who served on the conference planning committee. Responses were anonymously captured via written notes taken by a session note taker. All written materials were saved for later transcribing and content analysis.

Data analysis

Two investigators were used for triangulation, with the first investigator reading the conference transcript and taking notes on general impressions. Next, a line by line reading was performed and commonly used phrases and themes were identified. The second investigator adhered to the same process undertaken by investigator one. Data were read and reread by both investigators to identify additional emerging themes. The themes were compared, and recurring themes were clustered to develop nodes within Nvivo 12 PRO (QSR International Pty Ltd.). The qualitative analysis made use of CRT to develop themes, and then a coding query was performed to group text into the identified themes.

Results

The three main themes emerged from the experiences of the participants: stereotypes and microaggression, representation, and support.

Theme I: stereotypes and microaggression

Conference panelist representing community parents discussed being stereotyped, ignored, and transgressed against by providers during different aspects of their prenatal care, labor, delivery, and postpartum period.

One panelist described how a provider did not believe she was married. The presenter stated she immediately stopped listening to the provider, as he had lost credibility with her.

Several other panelists described not having a voice, stating that their thoughts and birthing plans were ignored. A few presenters stated that they felt alienated and bullied, and others expressed feeling ignored, where their voice was silenced, and the practitioners' voices carried weight.

Theme II: representation

The second theme to emerge was representation. Many panelists and community members described their wish to interact with a provider that was able to relate to their lived experience. Panelist discussed the inability of providers to connect due to a lack of racial concordance.

Panelist expressed desire to have someone to talk to who they could identify with/look like them/relate to them. Many workshop participants expressed that there are no minority caregivers, and how there needs to be someone relatable (e.g., you go where you feel comfortable.)

Theme III: provider support

While many of the women felt silenced and unsupported by their health care providers due to a lack of cultural humility, there are opportunities to address this via intercultural development. Panelist discussed the need for providers to be able to listen and support their needs. The panelist believed culturally competent providers would be more supportive and offer more knowledge through spending more time to inform patients. In addition, panelist discussed needing educational resources and support groups.

For example, a panelist explained that providers cannot relate to everyone, but they must be willing to listen to meet everyone's needs. Other panelist expressed the need for more support from families, communities, and employers for breastfeeding mothers. Panelists stated the need for community education and the critical need for social media and advertising to represent positive images of black women breastfeeding.

Discussion

Data have shown consistent unequal treatment of racial and ethnic minorities in health care settings.⁶ Bias in the delivery of care is embedded within the health care system due to the societal entrenchment of racial constructs rooted in power and privilege.²⁰ Analysis of the conference proceedings revealed that African American women were experiencing similar bias in obtaining lactation support.

Many of the women indicated their preference for a BIPOC provider, as they believed they would get better care and support. Some studies of racial concordance have indicated patients sharing similar racial backgrounds to their providers report feeling more comfortable and understood.²¹ An analysis of racial concordance studies by Schnittker and Liang reports concordance has little impact on the clinical encounter, except for patients preferring concordant patient-physician relationships.²² Furthermore, patients who feel heard and accepted demonstrate better medical compliance rates, which translates to better outcomes.²²

In combating health disparities, matching patients and providers based on racial background has been touted as an easy way to improve care and reduce adverse health events. However, the percentage of ethnic minorities in medical professions will not meet the needs of the ethnic population and the interaction between the patient-provider is more complex than just skin color.

Conference panelists identified reliability as a characteristic needed in health care providers to develop trust. While many described wanting a provider to be concordant with their race, these individuals understood that the ability to find a racially concordant provider was limited, and simply wanted someone who would empathize with their experience and allow them to have a voice. The process of cultural competence assumes that the provider will work within the cultural context of the patient allowing them space to guide their care through their lived experiences.

The process of developing as a culturally competent provider is an ongoing process and requires the provider to be reflexive and empathetic, as well as a seeker of cultural knowledge. The community panelists felt that the providers they interacted with had a general lack of cultural competence and cultural humility. The providers that the panelists interacted with stereotyped the women using racial archetypes and showed very little caring. Most women experienced dismissal and coercion from the medical staff due to being racialized. The experience of racialization has been reported as a frequent experience by African American women. This qualitative study gives voice to these women's experiences and provides a learning opportunity for providers to contemplate approaches to address root causes of bias.

Limitations

As this study is a qualitative design, it is specific to the group of Midwestern African American women who participated in the data collection, which means that the results cannot be generalized. In addition, the results from this study are subjective and thus cannot be replicated. Although the participants indicated that they believed racism and cultural competence impacted their breastfeeding experience, the qualitative data do not show causality.

Conclusion

African American women continue to have disproportionately lower levels of initiation and duration of breastfeeding in the United States. Despite efforts to increase breastfeeding among this group, rates remain low. Addressing this racial disparity requires a paradigm shift, which decenters whiteness, focusing instead on structures which inform thoughts and form impediments. The identification of the themes of stereotype and microaggression, and representation from the proceedings of the conference breakout sessions, has informed plans to work toward eliminating racial disparities in breastfeeding and infant mortality via focusing on racial equity.

Footnotes

Authors' Contributions

F.A.K.-K. made substantial contributions to the conception/design of the work; the acquisition, analysis, or interpretation of data for the work; drafting the work, or revising it critically for important intellectual content; gave the final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. L.N.-R. made substantial contributions to the acquisition of data for the work, conception/design of the work, drafting the work, or revising it critically for important intellectual content; gave the final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. J.W. made substantial contributions to the acquisition of data for the work, conception/design of the work; drafting the work, or revising it critically for important intellectual content; gave the final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. C.G. made substantial contributions to the acquisition of data for the work, conception/design of the work, drafting the work, or revising it critically for important intellectual content; gave the final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. N.C. contributed to the acquisition, analysis, or interpretation of data for the work; revising it critically for important intellectual content; gave the final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors received partial financial support for the research, authorship, and/or publication of this article from the University of Cincinnati Office of Equity and Inclusion.

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