Researcher Seeks to Bridge Breastfeeding Disparity

Breastfeeding rates in the United States are rising, and that’s good news for babies, because breastfeeding provides babies with protection from certain infections during infancy and, potentially, from some chronic conditions later in life. But African American babies are less likely to be breastfed than other babies in the U.S., a disparity that not only contributes to poorer health outcomes among African American infants and children, but also sets the stage for inequalities that can continue throughout life.

That’s why Ifeyinwa Asiodu, an assistant professor at UC San Francisco School of Nursing, is working to close the gap. Her research sheds light on the reasons for the breastfeeding disparity, which she hopes will usher in changes at the individual, community and policy level that will lead to more African American babies reaping the benefits of breastfeeding.

Public Health Nurse to PhD

Ifeyinwa Asiodu Asiodu’s interest in breastfeeding in the African American community began 13 years ago when she became a public health nurse with San Mateo County’s Black Infant Health Program and, later, a senior public health nurse and maternal, child and adolescent health coordinator for the county. While conducting home visits, she encountered many African American women who wanted to breastfeed but didn’t have the support or resources they needed to begin or sustain doing so.

At the time, Asiodu was also studying at the School for a master’s degree in Advanced Community Health and International Nursing (now the Advanced Public Health Nursing program), but her work with women and babies led her to switch to the Perinatal Clinical Nurse Specialist program. When her mentors encouraged her to continue her studies in the School’s doctoral degree program, she began to think about a research career and what direction it should take.

“I went back to my roots in public health and decided [breastfeeding in the African American community] was an area I wanted to explore more,” she says.

Under the mentorship of Audrey Lyndon and Kathryn Lee, Asiodu secured funding from the National Institute of Nursing Research for her dissertation, which focused on identifying barriers to and facilitators of breastfeeding initiation in the African American community. She interviewed first-time African American mothers and their support persons, and spent substantial time in their communities, going to parenting groups and baby showers and visiting their homes.

“I wanted to see how they were thinking about infant feeding, and look at the different family dynamics at play, because I think the infant feeding decision doesn’t just involve the lactating person. There are a lot of different influences that either support or hinder,” she says.

Examining Cultural Barriers to Breastfeeding

Just as she’d observed during her public health visits, the mothers in her study really wanted to breastfeed but were hampered by systemic, institutional and cultural barriers. Limited family leave and the demands of school made it difficult for many to meet their breastfeeding goals. Many didn’t have adequate resources or support, such as help with child care or secure living arrangements, within their communities. Some mothers lacked role models that might have helped them persevere. “They didn’t necessarily see successful breastfeeding experiences among either family or friends,” says Asiodu.

That lack of breastfeeding role models is, in part, a legacy of slavery, says Asiodu. “African American women weren’t in control of their reproduction. They were forced to breed on demand and to be wet nurses. That history has an impact on perceptions of lactation,” she says. African American women were especially eager to leave those negative associations behind at a time when attitudes surrounding breastfeeding in general began to shift after the introduction of infant formula, which began to be marketed in earnest in the late 19th century.

Improvements in bottle and nipple design and the advent of in-home refrigeration in the early 20th century made formula an attractive alternative to breastfeeding for the women who could afford it. Breastfeeding began to be perceived as a marker of lower socioeconomic class, a perception that was reinforced as American women joined the workforce in increasing numbers after World War II and began to gain a measure of economic freedom. This, combined with the marketing efforts of formula manufacturers, contributed to a global decline in breastfeeding rates that continued until the 1970s.

Fast-forward several decades, and you have multiple generations of African American women who haven’t seen anyone breastfeed, something that Asiodu encountered in her dissertation work. While the participants in her study knew about breastfeeding and its benefits, it wasn't something they saw happening among their peers. “It was something done in private, and even if it was done, [they] got the message that it wasn’t something we do,” says Asiodu.

In addition, programs and campaigns aimed at increasing breastfeeding have inadvertently reinforced that message with media that have largely left out women of color. “If you go to a breastfeeding or childbirth class, the images and videos are not typically women of color,” says Asiodu. As journalist Kimberly Seals Allers wrote in an essay for Bravado Breastfeeding Information Council, “Most of the images we see of black women breastfeeding are semi-naked women in Africa whose lives seem so far away from the modern African-American lifestyle and experience.”

Socioeconomic Factors in Infant Feeding

In addition to cultural attitudes and experiences, socioeconomic factors contribute to the persistent gap in infant feeding rates. In a perhaps ironic shift, it is now wealthier women who breastfeed at higher rates. The relatively stingy family leave laws in the U.S. mean that new mothers who can’t afford to take unpaid time off from work have a short window in which to establish secure breastfeeding relationships with their babies. For working mothers, breastfeeding requires discretionary time for feeding or pumping breast milk – time that is in shorter supply among those with service, retail or other blue-collar jobs than among women with executive or professional positions.

Although the Affordable Care Act (ACA) now requires employers to provide “reasonable break time” and “a place other than a bathroom” for nursing mothers to express breast milk for one year after childbirth, the provision doesn’t apply to some workers who are exempt from overtime pay regulations or whose employers have gross revenues of less than $500,000 per year.

Moreover, while the ACA mandates that most insurers cover the cost of a breast pump for lactating mothers, certain plans are exempt. In the case of Medicaid, whether a pump must be covered depends on state law. And, Asiodu adds, the law doesn’t specify what kinds of pumps must be covered. Some plans cover only manual pumps or standard electric (rather than hospital-grade) pumps, which can make pumping enough milk to sustain an infant through a day away from its mother difficult and time-consuming.

Equally important, says Asiodu, there is a large variation between plans in terms of the timing in which mothers receive their pumps after submitting a claim. If a woman receives her pump weeks after returning to work, her production of breast milk may already have decreased to the point where she can no longer provide enough for her baby to eat throughout the day.

Building Communities of Support

Despite the inadequacies of current policy in supporting breastfeeding among African American women – which may only get worse if the ACA is repealed – there is progress on the cultural front, thanks to the efforts of groups that focus on supporting breastfeeding among women of color. In 2013, a trio of activists began promoting the final week of August’s National Breastfeeding Month as Black Breastfeeding Week. It’s grown to an annual celebration that includes community events, presentations and a social media campaign with the hashtag #lifteverybaby.

Groups like Black Women Do Breastfeed and the National Association of Professional and Peer Lactation Supporters of Color and their social media presence provide positive images and spaces for women of color to share their breastfeeding stories and receive culturally sensitive support. And, says Asiodu, general breastfeeding advocacy groups are beginning to pay more attention to – and include imaging that features – women of color.

The potential for social media to support breastfeeding surprised Asiodu when it came up in her research. She asked women participating in one of her studies how they received their information on caring for themselves and their babies, expecting them to cite pamphlets, books or classes. Instead, they all mentioned social media apps they used on their cell phones. “These were lower-income, lower-socioeconomic-status women, but they still had access to this technology,” she says. “It highlighted that the way in which people are getting information is changing.” Asiodu’s research in this area resulted in a 2015 paper published in the Journal of Obstetric, Gynecologic & Neonatal Nursing.

Social media were especially important for women who didn’t have other support for meeting their breastfeeding goals. “They went online and found groups with moms who were in similar situations and who looked like them, and they found support and motivation that way, which was nice to see,” she says.

One drawback of social media, however, is the potential for inaccurate information to spread. It’s a concern Asiodu has heard from lactation consultants and breastfeeding peer counselors. While most groups do a good job of monitoring their communities for inappropriate medical advice, she says, there’s a need for more information from qualified experts.

She’d also like to see more health care providers having open-ended conversations with families about feeding options early in pregnancy. Such in-person discussions give the provider a chance to meet a woman where she is and correct misinformation or point her to culturally informed resources and support options specific to her needs. “We need to ask who in her circle is supportive of her decision [to breastfeed] and include them in the conversation,” says Asiodu.

Examining Other Factors

Asiodu has been expanding her work to look at other factors associated with breastfeeding in the African American community. After getting her PhD degree in 2014, she did postdoctoral research at the University of Illinois at Chicago with a research team working with the Rush Mothers’ Milk Club. The team brought Asiodu in to work on two papers on barriers to breastfeeding among low-birth-weight babies discharged from Rush University Medical Center’s neonatal intensive care unit (NICU).

They found that factors as disparate as family support, establishment of feeding goals and lack of access to a car affected rates of breastfeeding. This is troubling because breastfeeding is particularly beneficial for these babies, as it can reduce the potential for poor outcomes associated with low birth weight and prematurity, including necrotizing enterocolitis, a potentially lethal disorder that afflicts 8 percent of NICU babies. African American babies have higher rates of prematurity, low birth weight and infant mortality than their peers, so increasing breastfeeding among that population could help reduce associated health disparities.

Asiodu continues to look for other research opportunities to improve the well-being of African American mothers and babies. She’s working on grant requests to fund research into additional breastfeeding-related factors that affect health, including breastfeeding’s effects on growth and development, and the role of stress in lactation.

While a tremendous amount of progress has been made in the last five to 10 years, there is still a great deal of work to do to achieve breastfeeding equity in this country. “It’s going to take a multifaceted approach to address [breastfeeding] disparities,” she says. “It’s important to move the science forward.”