Abstract
Purpose:
To describe the breastfeeding attitudes and subjective norms of breastfeeding among African American Christians from the New England region.
Study Design and Methods:
A study was conducted using an online survey. Participants were recruited from four Christian churches in the New England region during the summer of 2021. Responses from direct questions about exclusive breastfeeding histories were tabulated. Open-ended question responses were analyzed using thematic analysis. Two results were merged to make the conclusions.
Results:
Participants (n = 101) aged 18–44 years (62.3%), college graduates (72.3%), and Catholics (71.4%) responded. Participants were willing to recommend six months of exclusive breastfeeding practice to relatives (89.9%) and friends/peers (87.9%) and support relatives (94.0%) and friends/peers (94.8%) to practice exclusive breastfeeding for 6 months. Breastfeeding attitude themes included beneficial and natural and receiving breastfeeding support. Subjective norms of breastfeeding themes included receiving support for breastfeeding; Christian leadership, teachings, and communal engagements; and gaps in Christian influence.
Conclusion:
The African American Christian community may be an emergent agent of breastfeeding social support for African American Christian women who chose to breastfeed. Health professionals should collaborate with African American Christian leadership to initiate programs to promote breastfeeding among African American Christian women in the United States.
Introduction
Infants globally (44%) and in the United States (25.8%) experience exclusive breastfeeding (EBF) for the first 6 months of life.1,2 In 2018, EBF at 6 months was least (20.4%) among African American (AA) infants in the United States. 2 This low EBF rate may be influenced by available support and the attitude of AAs.3,4
Diverse national, statewide, and culturally sensitive initiatives have been implemented in the United States with limited success to promote EBF rates. Examples include the Healthy People 2030 Goal to increase the proportion of infants breastfed exclusively through 6 months, Baby-Friendly Hospital Initiative, Socioecological Model of Breastfeeding, and Communities and Hospitals Advancing Maternity Practices.5–9 The initiatives focused primarily on breastfeeding women. In addition to these generalized findings, AA women have reported unmet needs for breastfeeding social support from relatives, health professionals, peers, friends, religious leaders, and members of the community to promote their breastfeeding efforts.3,10–12
AA religious communities have played key roles in the implementation of various health intervention programs, such as mental health.13,14 However, examining the role of religion in breastfeeding support, promotion, and/or protection for AA women has received limited attention. 15
The value of human milk for infants, both nutritional and health benefits, has been examined for Buddhists, Catholics, Hindus, Muslims, and Jewish cohorts.16–20 In addition, religious affiliation, attendance, and leadership were observed to favorably impact breastfeeding intentions and practice.15,16,21,22 For instance, infants from the Buddhist and Muslim faith experienced 2 years of EBF when religious leaders encouraged the women to do so based on religious teachings;20,23 consultation with a Jewish rabbi helped facilitate breastfeeding in a hospitalized infant; 16 and mothers who frequently patronized religious services were most likely to initiate breastfeeding than mothers who did not attend religious services. 22 The aim of this study was to use the theory of planned behavior (TPB) to explore the breastfeeding attitudes and subjective norms of breastfeeding among AA Christians in New England. The findings reported herein further the understanding of the possible role of faith communities in facilitating EBF.
Theoretical Framework
TPB includes three key components: attitude toward behavior (extent of favorable appraisal of behavior), subjective norms (perceived social pressure to exhibit or not to exhibit expected behavior owing to affiliation with referent individuals or groups), and perceived behavioral control (individuals’ self-efficacy, perceived ease, or difficulty about performance of expected behavior based on past experiences and assumptions of future obstacles).24,25 Based on the TPB, a favorable attitude and subjective norm to a particular behavior influences an individual’s perception of behavior under consideration. 25 In this study, breastfeeding attitude implies consistently favorable or unfavorable evaluations, feelings, opinions, expressions/interventions, and actions related to breastfeeding. In addition, this study defines subjective norms of breastfeeding as perceived social pressures associated with Christian beliefs and practices that positively or negatively affect breastfeeding. The TPB has guided several studies26–28 for which said TPB methodologies were incorporated and outcomes affirmed the relevance of TPB in favorable breastfeeding behavior modification.
Study Design and Methods
Procedures and data collection
A purposeful sample was anonymously selected to complete direct questions about EBF histories (Table 3) and open-ended qualitative questions (Table 1) as part of an online study in 2021. In the larger study, a convergent parallel design, as defined by (Creswell and Clark’s, unpublished data) typology of mixed methods research, was used to explore participants’ breastfeeding experiences. Thus, in the main study, participants’ breastfeeding attitudes and the rate of EBF practice at 6 months were assessed. In addition, the main study explored the influence of Christian beliefs and practices on EBF practice among AAs in the New England region based on integration of the qualitative and qualitative databases.
Adapted Questions for Participants
Source: Kamoun and Spatz. 23
The demographic information included questions pertaining to EBF histories. Participants were recruited from four participating Catholic and Protestant churches within the New England region of the United States. The first author, A.G., spent two years in nurturing relationships with the leadership and members of the Black churches. An advertisement of the study, which included a link to the study site and the QR code, was made on the churches’ websites. Inclusion criteria comprised self-identification as an AA Christian of any gender, affiliation to any of the four participating churches, ability to read and write English, aged 18 years and older, and access to a computer or phone with internet. The Institutional Review Board approval was obtained prior to data collection. Using a Qualtrics platform, participants gave written electronic answers to open-ended and close-ended questions. Participants were asked to answer questions adapted from Kamoun and Spatz’s questionnaire on breastfeeding attitudes and subjective norms (Table 1). 23 The questions were initially pretested among nine AAs (clergy, parents, and pregnant women) from the four denominations. The feedback from the pilot test was used to finalize the final questions from the study. The duration for answering the questions was approximately 30–45 minutes. The findings were sent to leaders from the study site to confirm before the final article was sent for consideration for publication.
Data analysis
The open-ended responses were independently analyzed manually by two researchers following Braun and Clarke’s thematic analysis, guided by the definitions for breastfeeding attitudes and subjective norms of breastfeeding (Table 2). 29 Derived themes were compared and discussed until consensus was reached between the two researchers and the research team. A detailed audit trail was maintained to assure the trustworthiness of results.
Qualitative Data Analysis Structure
Results
The demographic details and direct questions about EBF are available in Table 3.
Demographics and Exclusive Breastfeeding Histories
n = 101. Data are given as n (%). Percentages are for each item. Fourteen responses were missing for Question 1. Twelve responses were missing for Question 3. Two responses were missing for Questions 6 and 7. One response was missing for Question 8. Four responses were missing for Question 7. Forty-three responses were missing for Question 10. Three responses were missing for Questions 11 and 15. Five responses were missing for Question 16.
EBF, exclusive breastfeeding; GED, General Educational Development.
Themes for breastfeeding attitude
Beneficial and natural
Beneficial and natural reflect favorable opinions, feelings, expressions, and intentions related to breastfeeding. Breastfeeding was reported to be beneficial to the infant, mother, and the nation.
Benefits for the infants were mainly health related—namely, protection from diseases (e.g., malnutrition and sudden infant death); support for growth and development, including brain development; and prevention of illness and support for immunity. Emotional wellness was also seen to be achieved through mother–child bonding.
Maternal benefits such as bonding with the infant, financial saving, and return to pre-pregnancy body shape and health for the mother were identified:
Breastfeeding is more convenient to both mother and baby because it is priceless, healthy, and nutritious. The bond shared between mother and child starts from breastfeeding. Breastfeeding helped me to lose off postpartum weight. (Female participant [FP] 23)
The benefits were also seen to have a wider effect on the family and community:
Breastfeeding promotes love and bonding of the mother and the baby. The long-term effect will transfer from top—the baby to the family to the community and finally to the nation as a whole … breastfeeding which is very healthy for the baby and the long-term effects on the family and community which will finally go to build a strong nation. (FP 65)
Receiving breastfeeding support
Receiving breastfeeding support refers to favorable breastfeeding support and individual actions on the part of fellow congregants. Pregnant women, new mothers, and puerperal women welcomed the emotional support and breastfeeding education they received from others in the workplace, at baby showers and in phone conversations, as well as in conversations in the church setting:
Yes, at church. We were at church and she was crying, so I decided to give her bottle because I was shy of taking my breast out in public. Then one of the elderly women approached me and advised me to take her to my car and breastfeed her. I did that and my daughter was happier after. (FP 52)
Yes, with women society in Church especially pregnant women and upcoming mothers to breastfeed their babies to avoid diseases and illness in children. (FP 30)
Topics for breastfeeding education focused on breastfeeding importance to both the infant and the mother, management of breastfeeding challenges, and physiology of lactation.
Themes for subjective norms of breastfeeding
Bible support for breastfeeding
Bible support for breastfeeding describes the respondents’ perception of the positive influence of the Bible has. It also describes the impact the Bible has on congregants following the Bible’s teachings:
Yes, congregations are always eager to do things enshrined in the Bible. (Male participant [MP 11])
Some participants provided biblical evidence (Bible quotations) in support of Christian beliefs and practices related to breastfeeding. Participants reported that the Bible mentions breastfeeding, and Christianity supports breastfeeding.
Two messages were evident. First, the Bible identified breastfeeding as a source of nourishment for infants. Second, breastfeeding was supported and encouraged until weaning. An exemplar of an infant breastfed until weaning was cited by one participant to be Baby Samuel:
1 Sam.1:22–24 Weaning of Samuel by Hannah. (MP 2)
Some respondents (25) provided biblical references and quotes in support of breastfeeding (Table 4).
Bible Quotations in Support of Breastfeeding
1 = Old Testament and 2 = New Testament.
Christian leadership, teachings, and communal engagements
Christian leadership, teachings, and communal engagements in the church community include participants’ reported desire to establish Christian leadership around breastfeeding support, breastfeeding role modeling, and educational initiatives to promote breastfeeding in their congregations. The aforementioned initiatives were currently formally unavailable.
Christian leaders, such as pastors, were observed to be influential and trusted sources of advice for women in the church. Participants reported the significant role of Christian leaders in maternal decisions, inclusive of breastfeeding. Christian leaders were held in reverence. The congregants were observed to adhere to advice from the pulpit:
Most women believe in Christianity, and if their pastor says breastfeeding is good, I think they would heed to that advice. (MP 6)
Yes, because our people normally believe and trust in our Christian pastors and leaders. (MP 10)
The critical role of breastfeeding role modeling was revealed. The role models were aligned with “Hannah,” a biblical breastfeeding role model. Hannah gave birth to a son (Samuel) at an advanced age. Hannah, with the support of her husband, breastfed Samuel until weaning (when Samuel was more than 1 year old). The breastfeeding role models were self-identified women who willingly shared their breastfeeding successes with other women to encourage their breastfeeding efforts. Some of the breastfeeding role models had two or more children and breastfed between 6 months and 2 years. The benefits for both mother and infant health and well-being were reported:
I breast fed all my three children at least 6–8 months, and it was the best experience any mother should try. They slept more, were happy babies, and I loved every bit of the experience. (FP 12)
According to some participants, Christian community gatherings served as their main social meeting avenues. For such participants, the idea of breastfeeding activities organized by the church would be beneficial. Suggested and ongoing activities in support of breastfeeding included Christian teachings on breastfeeding during women’s fellowship programs, baby showers, and youth gatherings for pregnant women, new mothers, and puerperal women. During such meetings, suggested discussion topics might include the benefits of breastfeeding compared with formula feeding, duration of breastfeeding, and management of breastfeeding challenges inclusive of maternal resumption of work and breastfeeding.
Finally, the diverse forms of emotional support from partners and others in the Christian community helped motivate some women to continue with their breastfeeding efforts. For instance, words of encouragement were seen to boost the confidence of women to breastfeed. Furthermore, women felt empowered to breastfeed when supported by their partners as well as when adequate breastfeeding information was shared with them through continuous education and publicity.
Gaps in Christian influence
Gaps in Christian influence refer to the evidence that some respondents were unaware of any Christian or biblical support for breastfeeding. These respondents did not regard or consider Christian beliefs in their breastfeeding practices or consider infants’ and/or personal unique circumstances. Such mothers made their breastfeeding decisions at their own discretion.
Some participants were unaware of references to breastfeeding in the Bible or considered breastfeeding option as a woman’s choice only:
I have no idea what the Bible says about breastfeeding. (FP 41)
I don’t think the Bible does. I don’t think it would help much or be useful. I think it’s the woman’s choice and no one else’s. (FP 15)
Thus, their focus was on the infant’s individual needs or the woman’s convenience. Women who experienced low human milk production readily adopted formula and mixed feeding. Women who worked outside their homes mostly opted to formula feed because of convenience.
The aesthetic value of the female breast was viewed as being of more value and importance than its nutritional benefit for the infant. Formula feeding was viewed as acceptable by young women who held misconceptions that breastfeeding will make their breasts sag and that the sagging breast would make the women less attractive to their male partners:
Lately I hear the young women who say if they breastfeed their babies, their breasts will sag and they may lose their men. (FP 65)
Discussion
Although gaps in Christian influence were identified, this study suggests the AA Christian community may be an emergent agent of breastfeeding social support for AA Christian women who chose to breastfeed. The current study reported of receiving breastfeeding support; biblical support of breastfeeding; and Christian leadership, teachings, and communal engagements, which align with previously observed results.15,21–23 This is supporting evidence that the AA church should be targeted by health care professionals as a place to build community support for breastfeeding. In addition, this study illustrated emotional support of breastfeeding among some women participants in the absence of formalized breastfeeding support initiatives in their Christian communities. This finding is contrary to breastfeeding support among Muslims. 23
Furthermore, EBF histories from women were within the standard recommendations of 6 months and continued breastfeeding up to or beyond 2 years, which align with the results within the Buddhist and Muslim communities.2,20,23 AA Christian women who opt to breastfeed will wish to adhere to the standard recommendations when supported. Furthermore, the numerous benefits of EBF (e.g., nutritional, health, and bonding) experienced by the participants buttress results from across all the previous studies.16–18,20,23,32 Therefore, breastfeeding promotion activities should continue to stress the benefits of EBF. Finally, the influential role of the Christian leadership in the support and promotion of EBF was noted, which aligns with previous study participants from Buddhist, Islam, and Jewish faiths.16,23 Future breastfeeding intervention programs in the Christian community should involve Christian leaders to assure favorable outcomes.
Other findings from the study that have not been documented by the previous studies focused on breastfeeding social support activities within the Christian community. First, there was a recognition that Church activities at the study sites had large attendance rates, and such meetings may be the only opportunity for some congregants to learn about breastfeeding. Therefore, there was the need to promote balanced social support for breastfeeding and correct misconceptions through regularized Church activities. Some of the suggested activities included health education at youth and women’s programs, baby showers, and the promotion of breastfeeding role models. Topics for discussion should include the benefits and management of breastfeeding challenges (including EBF practice and working outside the home). Churches should also be inclusive of women in their breastfeeding during services.
The provision of emotional support (through words of encouragement) for women who chose to breastfeed from the AA Christian community was reported. In addition, paternal support was identified to be important. Fathers and men in general, including the male clergy, should offer support that could be modeled after biblical role models such as Elkana. Elkana provided emotional support to the wife, Hannah, who breastfed the son, Samuel, until weaning. Finally, the Christian community was challenged to proactively publicize EBF. Nurses could play a critical role in working with AA churches to advocate for, promote, protect, and support breastfeeding behaviors.
Moreover, it seems like the aforementioned results could be used by a community health worker or health ministry to connect to the Centers for Disease Control and Prevention’s recommendations (Exodus 2:6–9 donor milk, wet nursing; Luke 11:27 breastfeeding health benefits for mothers).
Limitations
The small number of participants limits the generalizability of the findings; however, the results sufficiently describe the area of interest and potential for EBF support in the AA Christian communities. Voluntary response bias is also a possible limitation. Participants who answered the survey may have been more interested in the topic area. Church leaders from the study sites provided feedback on the findings. Lastly, the region and denominations of the participants may have influenced the study outcome.
Clinical Implications
Breastfeeding education should continue to stress the benefits of breastfeeding to the baby, mother, family, and community.
Breastfeeding mothers need continuous support from their religious communities.
AA Christian community may be an emergent agent to promote EBF.
Health care providers should collaborate with Christian leaders to initiate programs to promote EBF.
Self-identified voluntary EBF role models should be supported to empower women who opt to breastfeed.
Future studies may conduct phenomenological or intervention research on breastfeeding social support among AA Christians from New England and/or within the United States.
Footnotes
Acknowledgment
Authors’ Contributions
A.G.: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Visualization; Writing—original draft; Writing—reviewing and editing. U.T.J.: Methodology; Writing—reviewing and editing. B.O.’N.: Methodology; Validation, Writing—reviewing and editing. R.L.: Methodology; Writing—reviewing and editing. D.L.S.: Methodology; Writing—reviewing and editing. W.A.H.: Methodology; Validation; Writing—reviewing and editing.
Author Disclosure Statement
No conflict of interest exists.
Funding Information
A.G. obtained funding from the Margaret McNamara Education Grant and the PEO International Peace Scholarship US-Canada Programs, 2021/2022 and awards from the University of Connecticut—Graduate School Doctoral Dissertation Fellowship and School of Nursing Pre-doctoral Fellowship.