1. Hinson, Tyonne D. DrPH, MSN, RN, NE-BC
  2. Skinner, Asheley Cockrell PhD
  3. Spatz, Diane L. PhD, RN-BC, FAAN


Although the rate of breastfeeding initiation in the United States has continued to rise since 1972, African American mothers continue to experience a significant disparity in initiation. The aim of this study was to explore the perceptions of the facilitators and barriers of breastfeeding initiation among African American mothers from the perspective of subject matter experts (SMEs). This study was part of a larger study that also involved focus group methodology with African American women. The purpose of this article is to describe the opinions, knowledge, and perceptions of SMEs who work with African American mothers. A semistructured interview guide was used to interview 7 SMEs at which point no new themes emerged from the data. SMEs highlighted the significance of modifiable factors in breastfeeding initiation decisions and validated many perceptions of African American mothers. SMEs identified many critical issues foundational to community perspective and shaping future success in raising breastfeeding initiation rates. To increase breastfeeding initiation rates among African American mothers, strategies beyond the individual level are necessary. SMEs recognize the importance of addressing fundamental issues related to historical perspectives, normalization, education, and disparities in breastfeeding as critical.


Article Content

Since 1972, the breastfeeding initiation rates in the United States have risen considerably with a current initiation rate of 83.2%.1 However, African American mothers initiate breastfeeding at a rate of only 69.4%.1,2 This persistent disparity can significantly influence the short- and long-term health outcomes of infants.3,4 Critically low rates of breastfeeding initiation among African American mothers have left African American infants at the highest risk for morbidity, chronic health conditions, and mortality.5-12


Gaps exist in the literature regarding factors influencing breastfeeding initiation among this population.4,13-19 Therefore, a multifaceted qualitative study was developed to explore the perceptions of the facilitators and barriers of breastfeeding initiation among African American mothers as well as local and national subject matter experts (SMEs). The result of the focus groups with mothers has been previously published.20


This article presents data generated through interviews with SMEs. Understanding the perspective of SMEs and comparing this to findings from the focus groups with mothers will allow us to identify the best strategies and practices to improve breastfeeding in the African American community.




This study was a qualitative research design to determine the opinions, knowledge, and experiences of SMEs with national and international exposure to policies and practices influencing African American breastfeeding initiation rates. Interviews were used to learn about SME perceptions of (1) barriers and facilitators of breastfeeding initiation among African American mothers; (2) local and national policies, legislation, and organizational breastfeeding practices critical to rates of breastfeeding initiation; and (3) obstacles critical to implementing and amending current legislation influencing rates. Data from these SME interviews were compared and contrasted to the data from the focus groups with mothers.20 Institutional review board approval was obtained.



The first author contacted potential SMEs via e-mail correspondence. A SME list was created based upon: regional and national presence in breastfeeding initiatives for minority populations; leadership in breastfeeding policy, practice, or research; multiple professional disciplines to ensure broad representation and viewpoints; and varied geographic locations. SMEs included key leaders working in the space of breastfeeding in the African American community. Electronic correspondence detailed the purpose of the study, details of study participation, and request for participation. Once each SME provided written consent, in-person or phone interviews (45-60 minutes) were conducted.



In total, 7 SMEs were interviewed. The cross-section included: PhD Breastfeeding Nurse Researcher, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program Administrators, State Breastfeeding Coordinator, Executive Director/Grassroots Advocate, International Board Certified Lactation Consultant (IBCLC)/Social Worker, and City of Philadelphia Councilman. SMEs were located throughout the Northeastern and Midwest regions of the United States (Pennsylvania, Delaware, Michigan, and Illinois) and were of varied racial/ethnic background (Caucasian, Asian, and African American). SME experience spanned from 8 to 41 years focused on breastfeeding advocacy, education, and research.



A 19-question semistructured interview guide was utilized (see the Appendix). The interview guide was developed using the Conceptual Model for Breastfeeding Behavior and the Social Ecological model.13 The Conceptual Model for Breastfeeding Behavior was specifically utilized as a framework, as it is designed to address breastfeeding intention and initiation through non-modifiable factors of demographics (race/ethnicity and nativity) and socioeconomic factors (education, employment, income, age, and birth order) that interplay with external factors. These external factors include cultural context, social environment, maternal well-being and behaviors, and infant characteristics. Questions in the semistructured interview guide represented only 2 domains: cultural context and social environment. Each interview was recorded and transcribed.


Data analysis

Following transcription all data were analyzed utilizing qualitative analysis software, Atlas.ti, 7.0, and conventional qualitative content analysis. Independent reading and individual coding of transcripts by the lead researcher and an experienced pediatric PhD-prepared nurse researcher with formal education in qualitative research design, methods, and analysis assisted in ensuring coding accuracy and consistency regarding themes and preservation of meaning/sentiments. Independent analyses by the researchers were then compared to reconcile differences regarding codes and approve primary themes and subthemes. Methodological rigor was enhanced by the use of sequential prescripted questions for the conduct of all key informant interviews, double coding of transcripts to ensure consistency of the data and preservation of expressions by SMEs, and administration of all interviews by the lead researcher.


Data from the SME interviews were examined to provide critical insight regarding facilitators, barriers, and programmatic/policy challenges informing the current rate of breastfeeding initiation among African American mothers. All SME interview comments were de-identified in documentation and reported anonymou-sly in aggregate to ensure protection of professional identity.



Primary themes from key informant interviews were analogous to many factors of 2 modifiable domains in the Conceptual Model for Breastfeeding Behavior, cultural context and social environment factors.13 Overall, a total of 7 primary themes and 28 subthemes were identified during key informant interviews. All themes and subthemes are noted in Table 1 with the most salient themes detailed in this article.

Table 1 - Click to enlarge in new windowTable 1. Primary themes and subthemes

Cultural context domain

The cultural context themes, beliefs about breastfeeding and issues of sexuality, provide background knowledge regarding the prevailing perceptions about breastfeeding among African American mothers, their families, and the community.


Beliefs about breastfeeding

Benefit to baby and mom's health. SMEs recognized the important role of breastfeeding in infant nutrition and protection from illness, as well as mother's ability to return to prepregnancy weight.


I think that we have become too bougie, so that we're concerned about the way we look and whether this is going to affect how we look, and we're not as concerned about the nutrition for our ... for our child. And if everyone understands truly what the importance of breastfeeding, it's important for the mom. It's one of the best ways to get yourself back to normal after birth.


Increased bonding. SMEs emphasized a belief in a heightened connection between the mother and her child, ultimately changing the maternal-infant experience.


We've had moms who, you know, come in and they're like, oh no, I'm not going to breastfeed or, okay, maybe I'll pump for a little bit and then the next thing you know they've gotten this bonding experience with their baby 'cause they did try it and they love it and now they're a year out and they're like, nope, I'm stopping when my baby is ready to stop.


Historic cultural events have influenced beliefs, exposure, and perceptions of breastfeeding. The historic evolution of breastfeeding in African American culture was a perspective shared by many SMEs. They particularly highlighted the critical historical influence of slavery on the perceptions of infant independence, spoiling, and breastfeeding.


But then there's the whole ... historical thing, like what's the trauma that's going on with black families and black moms ... that ... has led us here ... we can link the historical, societal, and social barriers together .... That' doesn't mean that you don't love your child, right? That just means that you love your child so much that you understand this world is harsh to black folk and they got to be independent and strong early-on.


Racism/disparities. Racism and disparities were 2 prominent issues raised by 2 SMEs. The following quote illustrates the inequity in care that African American women may experience:


I think there is this ... oh you know, this mother's never gonna want to breastfeed, so why am I spending this time ... And I do think you see that more with low income, young, urban, African-American mothers ... and I do think that's a type of racism.


Issues of sexuality

Oversexualization of African American females. SMEs also acknowledged that female breasts are oversexualized within the African American community.


And then the whole sexualized ... you know how breasts are sexualized, and then images of women ... Black women and their bodies.


Social environment domain

The social environment domain themes, familial/network influence and informational sources, highlight the power and influence of individuals and the environment surrounding African American mothers during pregnancy and postdelivery on the final breastfeeding decision.


Familial/network influence

Matriarchal influence. SMEs specifically called out the lack of support for breastfeeding and concern with interference in lifestyle of breastfeeding daughters found among "younger" grandmothers.


So, I think the occasional grandmother, we have some issues with because I think the grandmother always is gonna look out first and foremost for the daughter. So, if the daughter is interrupting ... you know, if she thinks there will be an interruption in school or work or something that breastfeeding would make that more complicated, I think sometimes then we see discouragement.


Partner influence. SMEs also recognized the importance of involving male partners in the breastfeeding discussion early, as fathers are critical influencers in final breastfeeding decisions and behaviors.


... The men are always like, yeah, if it's the healthiest thing then, yeah, you know? And I feel that's a really huge part in...will play a really huge part in mom's initiation and longevity with breastfeeding, too, so ... especially if he says no, don't do it, right? And then that also plays a part as well.


Friend/peer network influence. SMEs discussed the critical issue related to a lack of friend and network support while attempting to overcome the social barrier of initiating breastfeeding in the African American community.


Maybe your girlfriends didn't ... nurse their children so you don't ... we're really, really, really trying to overcome that ... social barrier, where you know, you have few or no friends or few or no people in your ... earlier generation who could support you. So, I think that those things are critical ... to address when we're talking about black women and breastfeeding.


Religious community influence. Some SMEs believed that religious communities offer tremendous opportunity to support breastfeeding initiation among African American mothers.


I think, for example, the churches, if they made this an important point ... because there's many of them and there's a lot of African-American church goers ... it's a structure where seniors are together with young people, so it's not just the opinions of the peer group.


Informational sources

Prenatal clinics. SMEs validated the importance of the prenatal clinical experience in informing decisions around breastfeeding decisions, particularly in this population.


Yeah, I think it's important, especially prenatally, to educate them ... educate women so that they're making an informed decision about their choice and ... understanding.


Women, Infants, and Children Program. SMEs shared mixed feelings regarding the WIC Program as a resource for information. While some recognized the program as a positive source of information, others relayed concerns related to the WIC's association with formula (particularly in the African American community) and inconsistent messaging, programming, and resourcing.


I think WIC gives conflicting messages with their program. So while I think the breastfeeding program, peer counselor program is needed and necessary, and that breastfeeding peer counselors are like breastfeeding, breastfeeding, breastfeeding; I worry about the other staff and their ability to move that message forward, as well ...


Healthcare providers. Nurses and lactation consultants were noted to be of importance.


Nurses. SMEs raised concerns about consistent nursing care to African American mothers related to issues of cultural differences and subtle discrimination.


I feel like some of the nurses ... although definitely, you know, they support breastfeeding, sometimes can be intimidated by the patient and their presenting issues. And so if they say no, I don't want to breastfeed, or I want to ... you know, that time isn't really taken to ... at that point to discuss ... And so I don't necessarily know what happens, you know, and whether it's they need to see someone that looks like them to encourage them at that point, and/or do our nurses need just a little more cultural humility around understanding ... these moms and their experiences.


Lactation consultants. SMEs raised critical concerns related to the lack of lactation consultants of color and the hospital experience for African American women. Tremendous focus was centered on the issue of cultural competence.


There are few um ... African-American Internationally Board Certified Lactation Consultants and also, those who are IBCLC's um ... who are not black, what kind of cultural-appropriate training have they received to deal with like certain cultural nuances?


Barriers and facilitators

SMEs were asked to identify specific factors that facilitated or hindered the behavior of initiating breastfeeding based on their professional experiences and knowledge.


Barriers to breastfeeding initiation

Competing priorities. SMEs highlighted the "real-life" competing pressures on mothers attempting to initiate breastfeeding.


So, you know, maybe if you're returning to work, or you're returning to school, or you're having childcare concerns, these are some of the real life things that our peers are helping to support our moms with, so it's not just ... like societal and social barriers.


Embarrassment of public exposure. SMEs articulated significant challenges related to the topic of embarrassment of public exposure.


There's more to breastfeeding than mechanics. If I um ... am a mom and I have to take, you know, public transportation and I'm on uh ... I'm on a bus or a system that does not have a culture of breastfeeding, then you know, I might be a little concerned about nursing my child, right? So I might decide that I want to give them formula because it's just easier.


Lack of knowledge and support of breastfeeding in the African American community. SMEs highlighted the lack of knowledge, support, and exposure as another significant barrier in breastfeeding initiation for African American mothers.


That lack of ... of historical experience .... My mother breastfed me because that's what she knew to have happened in the past. With the introduction of formula, mothers were going to work and so they weren't breastfeeding. They weren't even encouraged to breastfeed, and so there were several generations where breastfeeding just wasn't the norm. And so as we are trying to ... to return to breastfeeding as the norm, we're fighting an uphill battle.


Lack of information and education about breastfeeding prenatally. SMEs supported the premise that earlier education, even prior to the prenatal period, is critical to empowering African American women to make informed choices about infant feeding.


I have learned that when a mom is pregnant, she's more open to things that relate to her baby than any other time in her life ... She'll do a lot of things because she wants what's best for that baby. So if during that period ... and sometimes that window is smaller than others 'cause we don't get to see all moms as early in the pregnancy ... but if during that period we can share with her the importance of breastfeeding, I think that she's open to it and she's listening. Once the baby's born, all bets are off.


Lack of access to equipment and resources. The lack of access to equipment and resources was recognized as a significant barrier within the African American community.


It's a special barrier for moms ... and many of the women I've work with ... and not all, certainly, but the vast majority here in the city I work with are urban, poor, young, African-American mothers. They're not in jobs with a corner office where they can go and pump. You know, they are hotel maintenance, gambling casino operators ... they work in bars.


National policy. SMEs primarily highlighted the gap in national policy and practices within our country as a significant barrier for initiation of breastfeeding among African American women.


It's great if you can afford to take off work without pay ... but unfortunately, many people can't afford to take off work without pay and so that affects the mothers' ... willingness or ability to ... breastfeed, because you kind of sometimes have to go back to work at an earlier time and we don't have any federal policies in place ... for extending the time periods.


Facilitators of breastfeeding initiation

Engaged/involved fathers. SMEs stressed the importance of involving fathers and partners early on in breastfeeding discussions, education, and decision-making. African American partners must be exposed during prenatal care.


There's definitely still a good portion that are not into it ... but not many like it used to be, like no, she's not doing that; I don't care. I think them hearing the message at the same time with mom and me making sure that I elicit mom's goals and her feelings about it and having them hear that part of it. And then also asking them what their thoughts were ...


Prior positive experience/exposure. SMEs highlighted the importance of prior exposure in positive breastfeeding initiation decision-making, recognizing that many African American women may not have experienced exposure to breastfeeding in their past.


And so a lot of times many women say no, or my girlfriend tried it, she hated it. And then some women say yeah, my aunt did it, you know, and that's why I want to do it. But I think most women really don't have that.


Peer support groups/peer counselors. SMEs recognized the presence of peer counselors and peer support for African American women as critically important in increasing initiation. All SMEs viewed the presence of peer support and/or peer counseling programs as foundational to modeling and influencing behaviors.


Where are the socially, culturally, and relevant, and appropriate breastfeeding support groups for black moms. And I think that that's really important when you're talking about peer-to-peer support because your lifestyle may be quite different than mine. So if I come talking about something that's specific to my culture or like my way of life maybe I could ... say that I have to work and then I go to a group of moms who mostly don't have to return to work, then how can they help me make that work for my lifestyle?


Supportive family/home environment. SMEs affirmed the critical importance of supportive family and positive affirmations about breastfeeding. They identified family as key influencers in the decision to breastfeed and overcoming low breastfeeding initiation rates.


Yeah, and I think, you know, along with that, so if you are poor, if you do not have a good home situation and if you don't have many of these things; but there are influences around you, such as your friends and family members all breastfeed and ... or say they know it's a good idea to breastfeed or give you positive feedback, like good for you, you're breastfeeding.


Baby-friendly hospital influence. SMEs highlighted the important role that this initiative has played in increasing breastfeeding, however noted that health equity concerns remain.


So I think initially for a large part it [baby-friendly] was not necessarily a good thing. A lot of the hospitals that were coming onboard with baby-friendly weren't in the areas where African-American women were delivering. And I think just because we have policies in place doesn't necessarily mean that we're going to change the culture in how we care for our women of color. We know that often times at the bedside that care is going to look different for a woman of color versus someone who's not.



While African American mothers in the overall research possessed similar beliefs about the benefits of breastfeeding, peer counselors, bonding, and the influence of historic cultural events on breastfeeding, several topics deviated from significant areas described by SMEs. These differences included WIC, independence, quality of formula versus human milk, and aversion to breastfeeding. Most notably, key informants verbalized skepticism consistent with findings in the literature regarding the WIC Program, related to a lower incidence of breastfeeding initiation, the association of formula within the African American community, and inconsistent programming and messaging for breastfeeding mothers.


In this study, SMEs significantly stressed the importance of addressing fundamental issues related to disparities in breastfeeding. Provider stereotyping, judgment, racism, and equity concerns were salient throughout the findings. Key informants highlighted the realities of racism within healthcare organizations, among providers, and within communities concerning breastfeeding initiation among African American mothers. Despite the "call to action" to support breastfeeding initiation in African American women, accounts from key informants provided evidence regarding the continued presence of stereotyping, disparities in approaches to care based on culture, and lack of access/resources in specific communities and locations.9 Therefore, consistent, comprehensive, and culturally relevant care practices for African American mothers by all providers that span antepartum to intrapartum to postpartum are critical.


Interventions focused on education and exposure for mothers, grandmothers, and fathers within the African American community are also essential. Community and public health leaders must create more opportunities for peer networks and support groups among young African American women and their partners facing breastfeeding decisions. They must all address the lack of a paid maternity leave, as it has a direct influence on the willingness and perceived ability of African American mothers to initiate breastfeeding, due to concerns of low-income African American mothers working in blue collar industries with little leverage in negotiating shifts and leaves with employers.21



SME data strongly suggest that the ability to positively increase breastfeeding initiation in African American mothers will require focused strategies at various levels.20 There are a number of complex issues that influence the state of breastfeeding initiation among African American mothers. These issues are vast, inclusive of beliefs on culture and sexuality, familial and network influencers, informational sources, intentions, and other barriers and facilitators, consistent with the Conceptual Model for Breastfeeding Behavior. The findings also suggest that increasing rates of breastfeeding initiation among African American mothers will require a comprehensive approach. This reinforces the premise of the social ecological model, supporting the realization that the decision to initiate breastfeeding by African American mothers is not solely determined by one level, the individual, but instead is contingent on multiple levels and factors external to the individual.22


The availability of IBCLCs of color must be increased to appropriately support the breastfeeding needs of mother-infant pairs. This can be accomplished by mobilizing several suggestions outlined in The Surgeon General's Call to Action to Support Breastfeeding.15 Community-based initiatives in racial and ethnic minority communities, such as the development of student human lactation education programs to increase careers in lactation consultation and community-based training sites in area health education centers, are strategies to increase the number of IBCLCs of color. It is also essential that the support provided by IBCLCs to breastfeeding mother-infant dyads of color be identified as a standard of care, inclusive of full health benefit coverage for lactation support by third-party payers and consistent reimbursement for services provided by the role of IBCLCs independent of having another professional certification or licensure.15


We also know that WIC spends 25 times as much money on the purchase of infant formula versus breastfeeding support.23 Creating universal breastfeeding peer counselor support is of paramount importance. In addition, we know that nurse/peer counselor interventions can statistically significantly increase breastfeeding duration,24 yet such interventions have yet to be adopted as wide-scale preventative interventions. These strategies need significant investment by a large number of key stakeholders, including mothers, fellow members of the African American community, government, public health, insurers, and healthcare officials to actualize change and achieve increased initiation rates.




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APPENDIX Interview Guide for Subject Matter Experts


1. Please tell me about your specific role within your organization.


2. Please tell me about any additional work with local, national, or international organizations to promote breastfeeding practices.


3. How has/have your role(s) influenced the state of breastfeeding practice in Pennsylvania, Philadelphia, or nationally?


Perceptions of Barriers and Facilitators


4. What do you see as the most influential barriers of breastfeeding initiation among African American women? Please describe.


5. What do you see as the most influential facilitators of breastfeeding initiation among African American women? Please describe.


6. What cultural factors have been most prominent in decision-making for African American mothers concerning breastfeeding initiation?


a. To clarify, cultural factors pertain to African American perceptions/beliefs about breastfeeding, African American cultural perceptions/issues of sexuality.


7. What social/environment factors have been most influential in decision-making for African American mothers concerning breastfeeding initiation?


a. To clarify, social environment factors pertain to network interactions, social support/influence, and informational sources within the African American or professional community.


Policies, Legislation, and Organizational Practices


8. What national policies have been most influential in supporting or hindering African American mothers in breastfeeding initiation?


9. What local laws have been most influential in supporting or hindering African American mothers in breastfeeding initiation?


10. What federal, state, county, or local community programs have been most influential in supporting or hindering African American mothers in breastfeeding initiation?


11. What professional or organizational healthcare practices have been most influential in supporting or hindering African American mothers in breastfeeding initiation?


Next Steps for Breastfeeding Initiation Improvements in the African American Community


12. Are there any laws that if implemented on a national or local (community) level could help to successfully achieve improvements in breastfeeding initiation among African American mothers? Any laws that should be amended that could help increase breastfeeding initiation?


13. Are there any federal, state, or county community programs that if implemented could help improve cultural and social environment perceptions of breastfeeding for African American mothers? Any federal, state, or county community programs that should cease or be amended that could help increase breastfeeding initiation?


14. Within your community, what positive facilitators or negative barriers of breastfeeding initiation can be related to the Women, Infants, and Children's Program (WIC)?


a. As a reminder, cultural factors pertain to African American perceptions/beliefs about breastfeeding, African American cultural perceptions/issues of sexuality. Social environment factors pertain to network interactions, social support/influence, and informational sources within the African American or professional community.Are there any organizational/hospital practices that if consistently implemented could improve breastfeeding initiation rates among African American mothers? Any organization/hospital practices that should be suspended or amended that could help increase breastfeeding initiation?


Barriers of Implementation


15. What role, if any, do you believe racism plays in the ability of African American mothers to initiate breastfeeding or receive the support they need to breastfeed?


16. What are the most significant obstacles in getting these laws, policies, programs/practices implemented? Nationally? Within the community?


17. What are the most significant obstacles in getting these laws, policies, programs/practices amended or suspended? Nationally? Within the community?


18. In your opinion, who or what will be most influential in overcoming these barriers to achieve increased rates in breastfeeding initiation among African American mothers?




19. Are there any additional thoughts you would like to share regarding increasing breastfeeding initiation among African American mothers?


[Context Link]


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African American mothers; barriers; breastfeeding initiation; facilitators; social environment