Lactation Experiences of Black Mothers Who Breastfed a Child Beyond Age One

Research team

The research team comprised two researchers: a predoctoral nursing student and a PhD-prepared, established nurse scientist in the field of human milk and lactation. This study was reviewed and deemed exempt by the University of Pennsylvania Institutional Review Board.

Methodological framework

The specific aim for this study was “to understand the needs and experiences of Black/African American mothers and infants who breastfeed beyond one year of the infant(s) life.” We use the terms “long-term breastfeeding” and “breastfeeding beyond infancy” interchangeably to refer to any breastfeeding that lasts for a year (12 months) or more of the child's life.

Because there is little research on long-term breastfeeding, particularly in the Black community, conventional qualitative content analysis was deemed best suited for and used in this study. In addition, this report is structured according to the Consolidated Criteria for Reporting Qualitative Research. ⁹

Study design and data collection

The researchers developed a semistructured interview guide based on existing research in this area (Table 1).^10–13 Following informed consent, interviews were conducted online through a secure meeting platform, and participants were requested to keep cameras on to facilitate the researchers' abilities to read facial and body language cues during the sessions. With participants' permission, sessions were audio recorded and transcribed verbatim using Trint artificial intelligence transcription software. Transcripts were reviewed and edited for accuracy by the first author. Participants completed a short demographic survey deployed by REDCap^®. ¹⁴

Participant recruitment

Participants were recruited through a variety of organizations that serve Black breastfeeding mothers, including, but not limited to listservs and offices of the Children's Hospital of Philadelphia and a online breastfeeding support group for Black families called “Black Families Do Breastfeed.” Mothers were eligible for participation if they identified as Black/African American, were currently breastfeeding a child who was 12 months old or older, or had weaned a child who was 12 months old or older at the time they weaned (within the past 5 years). Mothers were excluded if they planned to, but had not yet breastfed a child for at least 12 months and/or did not identify as African American.

Data analysis

Data from transcripts were analyzed in a cyclical, iterative manner with transcripts being coded, re-coded, and analyzed on an on-going basis. The researchers developed a code book using in vivo codes, created second-level codes, and then organized the coded data into categories. Categories were reviewed until themes emerged. The researchers met together regularly in person to review individual coding, create categories, and eventually review themes. When repetition (“saturation”) was noted, data collection ended. Once themes well represented the data, researchers conducted two-member check interviews to assess the validity the identified themes. In total, 18 interviews were completed.

Theme 1: Need for effective education/information about breastfeeding

This theme describes both the usefulness of practical, hands-on breastfeeding education as well as mothers' feelings of being underprepared for the actual process of breastfeeding. Participant 15 shared, “I thought it was just put the boob in the baby mouth and call it a day. That was not the case once I actually did it. So that was a shocker for me.”

Other mothers shared how, compared to experiences with prior children where they stopped breastfeeding sooner than they would have liked, having better breastfeeding education with subsequent children provided the confidence and assurance to make it through the early days of wondering if the child was getting enough. Participant 18 shared, “[This time] I'm older and wiser, so, you know, I was very firm on my decision and I was more educated on breastfeeding. So I knew the ins and outs of breastfeeding… that their stomach is but so big. So if they get the colostrum, they're fine… [chuckles] I was like, ‘…Don't even bring that formula over here.”

Similarly, Participant 4 described using her breastfeeding knowledge from past experiences when faced with negative support from health care providers:

“the second time around, I was much more confident in, you know, knowing what to expect. [The nurses] said, ‘are you sure you have enough milk?’ Let me see, a bunch of them tried to tell me I needed to wean my older child and even brought a pediatrician to tell me. And I was pretty confident… I have a newborn. Obviously, he's gonna get priority, I'm not gonna let him stop while I feed the toddler. And they would ask me, ‘you sure you have milk?’ I'm like, ‘yes. Look, you want to see?’ And I had to like squirt milk and show them [laughs]. Like literally, it's crazy. [My second born] lost weight too, which is supposed to be because they loose [weight from] their birth weight, and the pediatrician that we usually saw was out of town. So we saw another doctor at the practice and she was trying to get him to use formula. And I was showing her the growth charts. And I just—tell her that, look, you know, he has lost weight, but he's losing less and less. So technically, the weight that he lost is declining. So he's going to gain weight and I was able to fight for it. So he never had formula, whereas my [older child], she did.”

Theme 2: Initiating breastfeeding

Mothers described how persevering through the challenges of initiating and maintaining a breastfeeding relationship in the early days, weeks, and months of the child's life was the first step to setting and reaching long-term breastfeeding goals. Many, like Participant 13, described feeling like hospital staff were not strongly committed to helping them learn to breastfeed and pushed formula over breastfeeding:

“I was like, you know, I want my baby to be breastfed and they was like, ‘Oh, honey, you know, a lot of people don't do that. Like, we'll bring you some formula’. They brought like you know, little ready made bottles. And I was like, ‘No, I don't want that… she's going to breastfeed. So like, if I'm going to be here four five days and you come in all the time, I need you to be able to tell me like, what am I doing?’ And they were like, ‘Well, we really don't know. We really—’ and I'm like… It doesn't make sense. Like, you a lactation specialist in the hospital! How you gon’ tell me you don't know what to do? Like?”

A quote from Participant 17 helps further articulate the importance of early breastfeeding support from health care providers who are committed to helping mothers meet their goal to breastfeed:

“what I experienced is that you have some people that support [breastfeeding] even when you're in labor and delivery, and most do. But then you also have a big presence of people that support the formula, which—it's nothing wrong with formula, but if a person has a desire and that's something that they want to do, then they need everything that you can think of to help them get to that point. Because our bodies are designed for that, but if we have all these external factors, all these stress factors, medication—it doesn't matter. All that works against us. So I, I've learned that when I'm in a environment that is relaxing, I'm positive, I can feel love, release love, it helps me produce more milk.”

Theme 3: Decision to continue breastfeeding beyond 12 months

Not all participants had initially planned to breastfeed beyond infancy. Participant 18 described that after reaching her initial breastfeeding goal of 1 year, “[her daughter] wasn't letting up so. [laughs] She was not. Imagine me take her boobies away from her? Absolutely not. Excuse me what? Oh, no, that's not mine—those are not mine anymore, those are hers. So I didn't really have a choice.”

Participant 11 highlighted the struggle to balance her child's desire to continue breastfeeding with her own desire to stop. She shared, “to be continuing to breastfeed now at 18 months, I think it's just at that point where it's just like, we're just going to go until he says he doesn't want it anymore or until it's just too much. But I think every day, every couple of days, I kind of start to rethink it like am I ready to wean and my—because he's not ready to wean, but am I?”

Participant 5 discussed the shifting primary indication for breastfeeding from nutrition to comfort, sharing that at 14 months, “[her daughter] doesn't seem like she's ready to stop. I'm pretty much indifferent to it. She doesn't nurse long. It's more of a comfort thing. Like to know it's still there. And then she's good.”

Theme 4: Pressure to stop breastfeeding

Participants described external pressures to stop breastfeeding. Participant 4 shared about an experience with a primary care provider, “[the pediatrician] made a comment that really [sighs] she said she asked me, ‘so how much milk is [your] daughter drinking?’ And I think she was three at the time. So I said, ‘I don't know, she just drinks the breast milk. And she's like, she said, ‘Oh, so you give her from the boob.’ I said, ‘yes’. And then she said, ‘we usually wean at one.’ So I said, ‘Who is we?’ And then she thought I said ‘wean’. And she tried to describe what weaning was and I'm like, ‘no, no, no. You said ‘we wean at one’. Who is we?’ And then my husband took over the conversation… he kind of he put his hand on my leg and was like, ‘OK, enough’, and her took over the questions. [laughing]. And that was the last time I saw them. I didn't fancy (them).”

Participant 5 described how she felt pressure to wean from her daughter's day care providers, sharing “I so quickly learned that, a common thing with daycare is after the child turns one that they encourage parents not to bring in breast milk anymore, they considered it a bodily fluid. They make it seem as though for the child to advance into the next stage at the daycare that they can't have bodily fluids with them and they want [them] on cow's milk, so that was definitely an opportunity to, you know, really continue, you know, advocating for her and for us.”

Theme 5: Support to continue breastfeeding/facilitators of continued breastfeeding

Participant 5 shared that she was able to lean on her daughter's pediatrician when their daycare began discouraging them from breastfeeding:

“I was very apprehensive about approaching them again about, you know, letting her have breast milk after one. It was very hard for me to do so because I felt like I don't want to be the Black mom causing trouble. And that's how I felt. And so for our pediatrician to say, ‘how much is tuition?’ that's what she said. She said, ‘how much is tuition?’ I said, ‘Well, it's this amount.’ And she said, ‘OK, so take that amount and tell them what you want as a mom.’ She said, ‘because in the same way the doctors and lawyers and nurses that come and say this is what they need for their child because they pay this amount, you deserve the same thing’. That's like, that was my motivation. Motivation to say, you know, she's right. This is what my daughter deserves. This is essentially what we pay for. I even offered to pack her additional sippy cups where they didn't have to, you know, interfere with her milk. They didn't have to prep anything, [I] labeled everything. So that was definitely a trying time after she turned one.”

Participant 17 shared that other Black breastfeeding moms were a major source of support for her, despite only having met and interacted with them virtually, “When I think about a support system now when it comes to breastfeeding, I will wholeheartedly have to say the number one support system that I came into contact with that was uh lifesaving was the online platform for Black moms. That was huge.”

Theme 6: Struggles

Participants faced cultural and intergenerational struggles in their long-term breastfeeding journeys. Participant 18 described how it can be difficult to re-educate older generations about infant feeding when they believe strongly that they know best, “Me and my aunt got into it, we stopped talking for almost a year because she was watching [my son] and we told her do not give my baby cereal. [My aunt said] ‘Ah the baby needs it’. She kept pressing and pressing, I'm like, ‘no’. She snuck and gave that baby cereal. You know how [I knew]? Because when you breastfeed a baby their poop, you know their poop you know it's smell. I looked in that diaper and it had like little remnants… I took a picture of it… It had a different smell. I said she gave that baby—!”

Participant 6 described the counter-cultural feeling associated with being a Black mother breastfeeding a child beyond infancy: “I'm well, I do kind of feel like, like a unicorn, sometimes… I will say sometimes I do kind of feel, out of the norm, especially with Black people, because, you know, most of my Black associates, you know, they they don't either they didn't breastfeed or they didn't [breastfeed] that long. So um, yeah… I feel like I'm a little bit different, you know? You know, something abnormal to them. But I wouldn't change it for the world.”

Limitations

This study was conducted during the COVID pandemic, which could have influenced participants' behaviors and/or beliefs. Many mothers in the study cited working from home and therefore being around their child more, which allowed them to directly breastfeed, possibly for longer than they would have, had they not been working from home. Our sample was older and educated, elucidating that the disparities in breastfeeding rates in Black families are likely not due to race/ethnicity, but more impacted by poverty and resources.

Implications for practice

Participants recommended the following practice implications: improved prenatal breastfeeding education, improved in-hospital lactation support, and the importance of strong support networks. If limited time is a barrier for providers, they should consider compiling a list of local and online culturally relevant resources that families can access on their own time.