Success Stories

• New qualitative research has cast light on the low breastfeeding rates of African Americans in the United States.
• This research employed Black Feminist Theory to analyze the contents of many long interviews, in which participants were given space to explain and expand on their views.
• Unlike the vast majority of studies on the topic, the research looked at the experiences of African American women who continued breastfeeding for an average of 10 months.
• The study suggests that engaging faith communities and social media, and addressing conflicting understandings of the breast as both nurturing and sexual, may help to increase breastfeeding rates in the African American community.

Anyone involved in healthcare in the United States has probably heard that breastfeeding rates among African American mothers are much lower than those of any other racial grouping. As it happens, breastfeeding initiation rose by 8% in the African American community between 2000 and 2008, but the aforementioned gap still didn’t narrow. Research into the topic tends to focus on why these women aren’t breastfeeding, with studies often emphasizing statistical results, sometimes based on narrowly worded questionnaires. Recently, however, a nurse named Becky Spencer turned this perspective on its head: she has sought to understand African American breastfeeding successes.

Spencer’s paper [1], which she co-authored with two other researchers at Texas Woman’s University’s College of Nursing—Karen Wambach and Elaine Williams Domain—also doesn’t read like a typical ‘medical’ study. She chose methods more common to anthropology. The idea was to approach the topic free of assumptions, to ask open-ended questions, and to let interviews and focus groups run on for an hour or two.

“I was not interested in just continuing the narrative of asking what’s wrong with this population, and what I can do to fix it,” she says. “I really like the positive deviance approach. In this case, finding the outliers that match the rest of the population—the African American mothers who do have successful breastfeeding experiences.” The mean length of breastfeeding for the women who provided individual accounts for the study was 10 months.

Spencer was inspired to work on the topic by a shocking fact: In the United States, an African American infant is twice as likely to die before the age of one compared to a white infant—even when the mothers’ education level is held constant using statistics. Breastfeeding rates certainly aren’t the only contributor to this, but they are likely part of the answer. Receiving breast milk, as opposed to formula, reduces the odds of developing and dying from at least two prominent killers of young infants, necrotizing enterocolitis (a condition in which parts of the intestines start to die, mostly found in preemies), and SIDS (Sudden Infant Death Syndrome)—which is the second biggest killer of under one year olds in the country.

“One of the interesting things about our results,” says Spencer, “is that the women’s experiences had very little to do with health considerations; they only mentioned health in the sense that they would talk about growth, or report developments like ‘my baby rolls over’.” Instead, breastfeeding was mainly about bonding with the baby, about the empowerment of accomplishing what sometimes wasn’t well supported in the community, and about experiencing femininity in a way that wasn’t sexual. In the words of one interviewee, “Breastfeeding solidified and helped me to appreciate my womanhood and the way my body is different that allows me to do these awesome things. And not having to reject it or saying that my body’s only… this sexual object.”

This dual cultural identity of the breast—as a nurturing organ and as a sexual one—was front and center of many of the study participants’ experiences of breastfeeding. It presented itself as a tricky tension to navigate socially, tempting many to give up. “Just google the word ‘mother’ and then the word ‘woman’,” says Spencer. “African American women are very sexualized in U.S. culture—and they have been since slavery. Showing one’s self in public is so taboo. The resistance to breastfeed in public is bound up with resistance to being sexualized.” And the absence of visual examples of mothers breastfeeding in the community has a kind of feedback effect, discouraging other women from breastfeeding in public, or at all.

Spencer is also conducting focus groups of African American men who have fathered successfully breastfed infants, in order to understand their experiences of the period while their partners were breastfeeding. “Every single one brought up having to share their partner’s body with the baby. You’d even hear the women say ‘They belong to the baby now but they will belong to him later’—referring to their own breasts,” notes Spencer.

The health benefits of breastfeeding were brought up spontaneously much more often in the male focus groups; these dads also often reported feeling a sense of pride in the fact that their child was breastfed. Perhaps one under-appreciated point, Spencer suggests, is the sense of struggle that fathers themselves experience while they watch their partner having difficulty or feeling pain breastfeeding. “It just kills them to watch women struggle,” she says. Why this might be especially prominent among African American men was suggested to her by a male teacher who runs a daddy boot camp in the same community. “So many of these men grew up in single-parent households, and often grew up watching their mothers struggle without being able to do anything about it. He thinks that some of that sense of powerlessness might be transferring to watching their partner breastfeeding,” Spencer explains.

Whether or not that’s the case, solid support—from the infant’s dad, from the grandma, and from friends and medical professionals—was extremely important to the women who started and managed to stick to breastfeeding. This conclusion rings true to researchers working in states other than Texas, where Spencer works.

Janelle Richardson has, for the past five years, been studying a sample of African American WIC mothers in Ohio. Unlike Spencer, Richardson is African American herself—a distinction that some of the academic literature suggests helps to acquire more in-depth answers in this kind of discursive research setting. She thinks Spencer’s paper hit the nail on the head, though. “Her research is pretty well aligned with my findings… It captures the embarrassment that many African Americans feel over breast feeding.” In an attempt to reduce so-called ‘interviewer effects’, Spencer explicitly set out to approach the work using the framework of Black Feminist Theory, which, like mainstream feminist theory, questions the traditional insertion of women in society, but explicitly expands those discussions to consider intersections of race and gender (for a more complete treatment of Black Feminist Theory, see Collins (2002) [2]).

On the matter of social support, Richardson emphasizes that the whole of the health system has to be on board, and employers still need to make it easier for women to pump, despite legal changes in many states requiring them to provide appropriate time and space within the working day. “What happens after a mom goes home [from the hospital] matters,” says Richardson. “Studies show that nurse visits and peer telephone calls help moms stay focused on breastfeeding.” In the paper, Spencer’s discussants put forward the idea of leveraging social media to offer information and road-tested tips to breastfeeding moms experiencing difficulties. Unlike friends and lactation support counselors, Facebook is there if you need it at 2am, after all.

Aloka Patel, who is also working to understand breastfeeding rates among African American mothers, concurs that support is really crucial. As an associate professor of pediatrics, her professional home is the NICU of Chicago’s Rush University Medical Center. When mothers have a premature offspring being treated there, 98% of them provide the infant with milk, regardless of race, she explains. “So how they start doesn’t vary. But we see that by the time of discharge, differences start to show up.” Patel has conducted various types of analysis with her breast milk provision data, one of which is a spatial analysis of where mothers live in relation to the hospital. Before she crunched the numbers, distance seemed like an obvious explainer for why some women kept making the trip to the NICU, while others’ visits trailed off. Yet distance didn’t prove statistically significant. For reasons not yet fully understood, having access to a car was what really mattered for African American women with an infant in the NICU; it didn’t matter for white or Hispanic women. Patel is hoping to understand this result through qualitative research. “The Spencer paper was really quite striking,” she says. “It highlights how much we don’t know. I think we need others like it, at other centers.”

Richardson has an even grander vision. She believes the U.S. should plough more resources into measuring and seeking to understand initiation and duration of breastfeeding in the African American community. When asked what the most surprising item in Spencer et al.’s paper, Patel says that she was did not expect to see that some churches fail to encourage breastfeeding. Some in the paper do, though: the supportive ones provide a room for privacy, and a few even have a TV in that room for mothers to keep up with the action in the main hall. The support of faith communities, the role of social media, and the need to tackle the often-reinforced idea that breastfeeding cannot be extricated from being sexually provocative, are all action points in the work. But the broader lesson from this paper is simpler. Spencer sums it up, “I don’t think this is something that science can fix.”