Black/African American Breastfeeding Experience: Cultural, Sociological, and Health Dimensions Through an Equity Lens

Background: Disparities in breastfeeding (BF) continue to be a public health challenge, as currently only 42% of infants in the world and 25.6% of infants in the United States are exclusively breastfed for the first 6 months of life. In 2019, the infants least likely to be exclusively breastfed at 6 months are African Americans (AA) (17.2%). Materials and Methods: A scoping review of the literature was undertaken by using Arksey and O'Malley's six-stage framework to determine key themes of AA women's experience BF through an equity lens. Electronic databases of CINAHL and PubMed were searched for peer-reviewed, full-text articles written in the English language within the past 5 years by using the terms BF, AA, Black, sociological, cultural, equity, health, attitude, exposure, initiation, continuation, barriers, and facilitators. Results: Initially, 497 articles were identified, and 26 peer-reviewed articles met the eligibility criteria. Through an equity lens, three main themes emerged, which summarized AA women's BF experience: cultural (family, peers and community support; misconceptions; personal factors), sociological (prejudices, racism, home environment; financial status; sexuality issues; BF role models; employment policies), and health dimensions (family involvement; timely and honest information from staff; baby-friendly hospital initiatives; postnatal follow-up; special supplemental nutrition program for women, infants, and children). Conclusion: For AA women, exclusively BF is beset with diverse cultural, health, and sociological challenges. Multifaceted approaches are needed for successful resolution of BF challenges to bridge the racial gap in BF in the United States. Future studies may explore interventions targeted to modifiable barriers to improve BF outcomes.


Introduction
B reastfeeding (BF) offers key preventative health benefits for women and their infants. To receive these optimal health benefits, exclusive breastfeeding must be maintained by women and their infants for the first 6 months of life.
The Healthy People 2030 (MICH-2030-15) initiative recognizes the health benefits of BF and has set a public health goal that 42.4% of infants in the United States be breastfed exclusively through 6 months. 1,2 Although 42% of infants in the world meet the public health goal, only 25.6% of infants in the United States meet this target of being exclusively breast fed for the first 6 months of life. 1,2 Even more concerning is that African American (AA) women in the United States, 3 in particular, have the lowest BF initiation and continuation rates, with only 17.2% of infants exclusively breastfed at 6 months. 4 The preventative health benefit of BF increases with longer BF duration. Women who report a cumulative BF history of 12 months or more decrease their risk for breast and ovarian cancers, diabetes, hypertension, and return to prepregnancy body shape. 3,5,6 BF supports maternal well-being during the fourth trimester of pregnancy after birth by decreasing the risk of depression, anxiety, and stress symptoms, and it increases maternal self-efficacy. 7 BF also provides lifelong infant health benefits; the longer infants exclusively breastfeed, the greater benefit in reducing infantile and respiratory diseases (COVID- 19), sudden infant School of Nursing, University of Connecticut, Storrs, Connecticut, USA. death syndrome, and chronic diseases related to obesity. [8][9][10][11][12] Ultimately, the public health burden of not BF results in a global gross expenditure of U.S. $341.3 billion, with $114.97 billion incurred by the North America Region. 13 The early cessation of BF (before 3 weeks) costs the United States an estimated $3.0 billion annually (2010 dollars) due to purchase of formula, increased infantile diseases and health visits, and lost wages ($2.3 billion being maternal costs). 13 Many AA women encounter unique challenges in initiating and sustaining BF. Notably, inadequate social support, 4,12,14,15 various forms of prejudices, 16 racism, 17 misconceptions about BF versus formula feeding, 18 insufficient financial resources, 16,19,20 as well as personal factors such as low selfefficacy, negative attitudes, unwillingness to breastfeed, misconceptions about the benefits, 21,22 and inadequate resources. 23 Support is a critical factor in addressing these challenges to meet and sustain BF practice. 4,15,24 AA women who obtain some forms of support from relatives, health staff, and employers are more motivated to breastfeed. 15,25 In addition, participating in programs such as Centering during Pregnancy, Baby-friendly Hospital Initiative (BFHI), and the ''Supplemental Nutrition Program for Women, Infants and Children Services,'' also known as the WIC Program, encourages BF initiation and duration. The aforementioned types of support contribute to women's BF self-esteem and it has been found that women with high self-esteem breastfed more frequently and for longer duration. [26][27][28] The purpose of the scoping review was to explore the BF experiences of AA women, with critical attention to the cultural, sociological, and health dimensions through an equity lens to positively impact BF initiation and continuation in the United States.

Materials and Methods
The scoping review was done based on the seminal scoping review method as outlined by Arksey and O'Malley. 29 In the first stage, the research question to be addressed was identified as, ''What is the experience of AA women in the United States?'' In the second stage, articles were selected based on relevance to the topic from the databases of PubMed and CINHAL. The search terms adopted for the review were: BF, AA, Black, sociological, cultural, equity, health, attitude, exposure, initiation, continuation, barriers, and facilitators.
The third stage involved the selection of data. This was limited to full-text articles written in the English language from peerreviewed journals, all research types (qualitative, quantitative, and mixed methods), and published within the past 5 years. Stage four concentrated on charting the data based on iterative process whereas stage five focused on collating, summarizing, and reporting the results. Lastly, for validation, a lactation consultant was asked to validate the scoping review analysis.
The initial search of the electronic database resulted in the identification of 497 articles-with 96 duplicates, and 338 not addressing the research question. Subsequently, 63 full text-articles remained eligible for screening, 36 were excluded for unrelated outcomes, and 1 article was excluded that was a secondary analysis of historical data. Thus, 26 fulltext articles remained for the scoping review analysis (Fig. 1). ''Arksey and O'Malley framework'' was used to conduct a quality assessment of the studies (Table 1).

Results
Initially, 497 articles were identified, and 26 peerreviewed articles met the eligibility criteria (Fig. 1). Table 1 provides the complete overview of findings from each of the reviewed articles. Through an equity lens, three general themes emerged to describe the BF experiences of AA women in the United States, namely, cultural, sociological, and health dimensions. The definitions of the themes cover three dimensions and include: (1) Cultural, which includes the personal and familial network values influencing or inhibiting women to breastfed; (2) Sociological, which includes the larger community perception of BF, sexualization of the breast, and the societal issues of prejudice and racism toward AA women BF; and (3) Health, the interface between women and their health care providers, and health care system to support BF.

Theme one: Cultural dimension
Culture defined the BF decisions of AA women in the United States. 16,22,30 The family, peers, and community were important agents for social support. Families, peers, and community persistent support and encouragement for women boosted BF. 19,[31][32][33] The communal networks were instrumental for education, counseling, appraisal, interaction, engagement, successful transitions, positive deviance, reinforcement, and emotional well-being. 26,34,35 The AA women who breastfeed exhibit positive deviance. Positive deviance refers to the fact that such women chose to breastfeed their infants contrary to the cultural norms of not breastfeeding post-slavery. Such influences became possible through in-person interactions, virtual platforms, and religious affiliations. 30,33,36 Various forms of misconceptions on BF were observed within the AA community. For instance, some relatives, peers, and close neighbors claimed that breastfed infants become overly dependent on their mother; such myths pressurized women to initiate formula supplementation. 23 Formula supplementation was seen as inexpensive, required less time, and allowed women to manage and maintain their social life. 20,37 Conversely, social media engagement brought shifts in maternal BF beliefs and perceptions, 38 which resulted in increased willingness to breastfeed beyond the infant's first year. 36 Personal factors influenced the BF experiences of women. Maternal self-determination, positive attitude, positive deviance, high self-efficacy, spirituality, and empowerment 20,32 motivated women to breastfeed. On the contrary, women who experienced stress, shame, guilt, 34 embarrassment of public exposure, 16 prejudiced public perceptions, challenges with milk expression, 21,22 BF pain, and previous limited BF success 39 were more likely to not breastfeed compared with the other women. 26 Theme two: Sociological dimension Issues of prejudice and racism may have an influence on AA women's BF practices. 32,39 Health professionals, for example, pediatricians and obstetricians, negatively posited that AA women are less likely to breastfeed their infants and had less BF knowledge. 17,32,39 Prejudice in BF is grounded in historical antecedents, where AA women were mandatory ''wet nurses'' 16 to the slave masters' children instead of BF their own infants and current racial challenges. 18 For instance, racism in the workplace was associated with lower odds of BF duration at 3-5 months; whereas higher odds of BF duration at 3-6 months were observed in study participants who had experienced racism with the police. In addition, lower odds of BF initiation were reported in U.S.born AA women or a woman with a U.S.-born parent and residents of mainly Black communities as compared with women who lived in predominantly White communities in childhood. 18 Household composition and living arrangement are critical components of the social life of AAs. 16 AA women mostly lived in multigenerational households or as single parents. 16,40 The home environment affected maternal BF decisions and support postpartum. 25 For instance, women who lived in resource-limited communities experienced major financial challenges. 16,20,40 Therefore, the limited income constrained maternal access to the procurement of electric BF pumps and additional BF resources. 16 Such experiences influenced the perceptions of some of the women to view BF as expensive. 16 Working AA women, in particular, indicated a persistent need for organizational support toward BF. 19,39 Support recommendations included paid maternity leave, absence of dissuasive remarks, encouragement toward maternal BF efforts, access to electric pumps, and insurance coverage for BF pumps. 19,23 Women were optimistic that addressing these factors will overcome stigma around public BF. 26 Moreover, the need to promote national policies favorable to BF at the workplace was recommended. 16 The over-sexualization of AA women's breast was an issue, specifically emphasis of the breast for sexual acts rather than nutrition. 16 Thus, suggestions were made to engage all spheres of influence to address images of the sexual breast versus the nurturing breast. 32 In addition, BF role models were noted to be important in the BF experience of AAs. 20,23,41 Such role models focused on emotional, tangible, informational, and encouragement interventions for women. Older sisters and grandmothers were recognized as the best suited for such roles. 20,23,41 Theme three: Health dimension The health dimension theme encompassed the importance and value of a supportive health care system and supportive health care professionals toward the success of women's BF experiences. For instance, timely and honest information from staff, WIC, BFHI, postnatal support, and follow-up was identified. 16,19,21,22,32,39,40,42 Such information was meant to promote persistent support and encouragement, which included training on milk expression. 21,26 The quality of BF information provided by health care providers was important. 40 Thus, culturally sensitive educational interventions and initiatives responsive to women's time and activities were stressed. 32 When health care workers failed to include such interventions, staff were deemed not supportive and lacked adequate information and skill to educate AA women on BF. As a result, women lost confidence and relied more on relatives and peers. 42 In addition, women preferred a system and professional approach to be inclusive of the partners in BF decisions. 25  Another health care system mentioned by women was the role of peer counselors and there was an indication of a positive impact on lactation. 38 Women viewed peer counselors' educational efforts as truthful, confidential, supportive, and helped dispel misconceptions about BF. Although effective, there remains a need to establish standard guidelines for peer counselors' BF interventions. 38 An exemplar of the integration of the community, health care system, and BF is the Communities and Hospitals Advancing Maternity Practices Program. 28 AA women received community-based perinatal BF support, which contributed to increased BF initiation (46-63% [p < 0.05]) and exclusivity (19-31% [p < 0.05]) 28 rates.

Discussion
This scoping review provides valuable insight into the BF experiences of AA women in the United States. Through an equity lens, three main themes were identified that influenced the BF experiences of AA women in the United States, namely, the cultural, sociological, and health dimensions.
Similar to earlier findings, the cultural experiences of racism, positive deviance, personal factors such as self-esteem, maternal attitude, and BF misconceptions [16][17][18] contribute to AA women's BF outcomes. These findings suggest that AA women need support with the mitigation of existing misconceptions and racial challenges to bridge the gap in BF. Such efforts may be achieved through the strengthening available via social support efforts by the familial associations, social networks. 19,[31][32][33]36 In addition, active inclusion of religious bodies as primary partners in BF promotion with the AA population should be included as part of cultural and sociological targeted interventions. 19,[31][32][33]36 Exemplars for these community-, state-, and tribal-level interventions targeting BF promotion for all women of diversity are supported by the national coalition of organizations, the United States Breastfeeding Committee (USBC). The USBC is committed to mitigating barriers by addressing the essential components of culturally competent BF care: consider Culture, show Respect, Assess/Affirm differences, show Sensitivity and Self-awareness, and do it all with Humility (CRASH). 43 AA women's need for socioeconomic support was confirmed in this review. 16,19,20 A significant social barrier in AA women's BF is the lack of BF role models across generations. 23,41 An additional barrier is the perceived social value of the female breast as a sexual organ and not a source of nutrition. 16 Targeted messaging is needed to promote the nutritional value and less emphasis on the over-sexualization of the AA female breast. Together, the change in messaging will support women to feel more comfortable to breastfeed with less stigma and better self and public acceptance.
Lastly, as observed in previous studies, women called for health care systems and health care providers to support their BF efforts. 15,25 In this scoping review, women emphasized the need for persistent, truthful, family-inclusive, culturally sensitive support from the first to the fourth trimester. 28,32,42 Thus, health professionals who actively engage with AA women throughout the four trimesters of pregnancy must proactively promote BF initiation and continuation. Further, BF support needs to integrate perinatal programs beginning in the community and continuing to the hospital setting and then back into the community so women and infants can receive the benefits of BF.

Conclusions
AA women's BF experiences are confronted with diverse and unique challenges. These challenges require the collaborative efforts on the part of the individual woman, her family and peers, her community (religious institutions and employers), the health care system and its providers, as well as national policies for successful mitigation. The results of such efforts will address the current gap in BF initiation and continuation of BF for AA women and infants in the United States. Future studies should explore social support, including the role of the religious community, and its influence on AA's BF outcomes.