Date of Defense:
Breastfed infants are at lower risk for several health problems, such as lower respiratory tract infections, gastroenteritis, otitis media, obesity, diabetes, eczema, asthma, sudden infant death syndrome, childhood leukemia and necrotizing enterocolitis. (1-8) For mothers, breastfeeding is associated with a lower risk of type 2 diabetes, breast and ovarian cancer, cardiovascular disease, and postpartum depression. (1-3,6,7,9) In acknowledgement of these health benefits, the American Academy of Pediatrics, the World Health Organization, and health experts recommend women breastfeed exclusively through six months and continue breastfeeding with complementary foods for up to one or two years of age or beyond. (1,10)
According to the Centers for Disease Control and Prevention Breastfeeding Report Card in 2014, 89.2 percent of women who gave birth in Minnesota in 2011 initiated breastfeeding, 59.2 percent were breastfeeding at six months post-partum, and 34.6 percent were breastfeeding at 12 months post-partum. (11) Minnesota breastfeeding rates were higher than U.S. national rates in all indicators and Minnesota achieved the HealthyPeople 2020 targets for three indicators – ever breastfed, breastfeeding at twelve months and exclusive breastfeeding at three months. (11)
However, many women in Minnesota and Minneapolis who participated in the Supplemental Nutrition Program for Women, Infants and Children (WIC) did not meet the HealthyPeople 2020 indicators or match Minnesota’s overall rates in any indicator, with the exception of women in the Minneapolis WIC program breastfeeding at twelve months. Data reported by the Minnesota WIC Information System for Minneapolis WIC infants born during calendar year 2013, showed 79.3 percent were ever breastfed, 48.1 percent were breastfed at six months and 38.4 percent were breastfed at 12 months. (12) Data reported by the Minnesota WIC Information System for Minnesota and Minneapolis WIC infants born during calendar year 2012 indicated disproportionately low breastfeeding rates among American Indian, non-Hispanic and Asian, non-Hispanic infants, and higher rates among Hispanic and Black/African American, non-Hispanic infants. (13) The surprisingly high breastfeeding rates among the Black/African American infants and women were misleading as this category included both U.S.-born African American women, who had lower breastfeeding rates, and Somali and East African women who had higher breastfeeding rates.
In 2014 the City of Minneapolis Public Health Advisory Committee commissioned this project to support their work identifying policy and systems-level opportunities to support breastfeeding. Their goals were to understand, from the perspectives of local health professionals, the (1) perceived practices, protective factors and barriers for breastfeeding in the local African American, American Indian, Hispanic and Latino, Hmong and Somali communities; and to (2) generate ideas for how the city of Minneapolis can create a more supportive breastfeeding environment.
The conceptual framework for the project was derived from three sources – stakeholder interests, a literature review, and the PEN-3 cultural model. (14,15) From these sources, four key concepts were identified to design the interview questions and guide data analysis – (1) breastfeeding practices, (2) supports, (3) barriers, and (4) intervention ideas. Questions centered on the breastfeeding practices in each cultural community, existing supports and barriers, and potential ideas for creating a more supportive environment for breastfeeding families.
Methodology and characteristics of respondents
This qualitative study used semi-structured, in-depth interviews with key informants in specific professional roles in the healthcare and social services sectors who served the selected cultural communities. The participants recruited for interviews all worked with pregnant and post-partum mothers, children and families in Minneapolis; occupied a professional role as healthcare provider, doula or community leader; and served at least one of the cultural communities of interest. Types of roles in the healthcare provider category included midwives, Internationally Board Certified Lactation Consultants (IBCLCs), visiting nurses, hospital nurses and Medical Doctors. Doulas were included because of their work supporting women before, during and after birth, and their known influence on breastfeeding initiation Examples of roles in the community leader category included case managers, program managers, educators, and nutritionists.
A snowball sampling procedure – also known as chain referral recruitment – was used to identify and recruit participants. Eleven initial contacts obtained from the Minneapolis Public Health Advisory Committee started nine separate snowballs and led to the recruitment of 55 potential participants. Perspectives from 40 participants were included in the final analysis – in-person or phone interviews were conducted with 31 participants and 9 participants submitted written responses to the interview questions. All but two participants were female and 24 or more participants provided information about the African American, Hispanic/Latino, Hmong and Somali communities. Only eight participants provided information about the American Indian community and only one Obstetrician participated. In terms of the gender and ethnic diversity of participants, over half interviewed were women who self-identified as Caucasian. Some participants self-identified as being from the cultural community they served – this was most common in the community leader category – although ethnicity was not a selection criterion.
The data were systematically analyzed using interview notes and selected sections of the digital audio recordings. NVivo, a qualitative data analysis program, was used for data management, organization, and analysis. Data were coded during two cycles into themes and sub-themes. A final codebook was developed consisting of the four initial main categories from the conceptual framework (practices, supports, barriers, ideas), with each main category containing five to six sub-themes.
Data analysis revealed key themes around the four areas of analysis: practices, supports, barriers, and ideas.
- Somali women
Professionals from different roles reported similar observations that Somali women want to breastfeed and believe it is good for their baby, they want to supplement with formula and value larger sized babies, they have a lack of understanding about colostrum, and they experience different post-partum practices in the United States compared to Somalia.
- African American women
Professionals across different roles observed a recent resurgence in breastfeeding initiation among African American teens, a lack of support from mothers and grandmothers, a lack of support from partners related to the belief that breasts are sexual and not for feeding, and the perceived cultural practice that Black women don’t breastfeed in public.
- Hispanic/Latino women
Professionals reported similar observations that local Hispanic and Latina women perceive cultural support for breastfeeding, breastfeed for longer durations, know breastfeeding is good and want to breastfeed, experience different practices for breastfeeding in public here compared to their home country, and supplement with formula.
- Hmong women
Professionals reported similar observations that local Hmong women have low breastfeeding initiation and duration, some families have a cultural belief that other people should not handle a woman’s breast milk, they supplement with formula, perceive formula as healthy, and perceive that Americans don’t breastfeed.
- American Indian women
Three community leaders and one midwife reported similar observations that American Indian women have low initiation and duration of breastfeeding, lack support from family and their culture to breastfeed, and lack knowledge about whether substances are passed to the baby through breast milk. These findings reflect limited perspectives and should be interpreted with caution.
- Women across cultural communities
Community leaders, hospital nurses and doctors reported that women know breastfeeding is healthy for babies but don’t always cite specific health benefits, that they perceive formula and breast milk as equivalent, and that the maternal benefits of breastfeeding are less known. Participants also observed a recent resurgence in breastfeeding initiation among younger women.
Six main themes emerged for supports for breastfeeding in Minneapolis cultural communities.
- Post-partum support when women return home is critical.
- Support from extended family, partner and friends.
- Support from other mothers. Examples reported included the WIC Peer Counseling program, doulas from Everyday Miracles or the Somali Doula Program at the University of Minnesota Medical Center – Fairview Riverside, and Baby Cafes through the Allina health system.
- Support within the healthcare system. Examples reported included hospital lactation consultants, the Baby-Friendly Hospital Initiative, programs to train healthcare staff, and the North Memorial Breast Milk Depot.
- Education. Examples reported included the ECHO Breastfeeding your Baby videos in multiple languages and the culture- and language-specific education programs through Everyday Miracles and The People’s Center Health Services.
- Policies. Examples reported included breast pumps provided through the federal Affordable Care Act, the Minnesota Healthy Baby Act (16,17) to license clinical lactation services statewide, and laws to protect mothers nursing in public.
Six main themes emerged in the category of barriers to breastfeeding.
- Lack of family, partner, peer and community support.
- Negative public perception, especially about breastfeeding in public.
- Barriers within the health system, health policies and with health providers. Examples reported included racism, discrimination and assumptions of staff; lack of staff knowledge; doctors are short on time to talk about breastfeeding; the Baby-Friendly Hospital Initiative is expensive.
- Lack of workplace and school support. Examples reported included short maternity leaves, lack of time and space to pump at work, and specific industries that may disproportionately impact low-income women such as retail, food service, manufacturing, janitorial services where time and space to pump is not as common.
- Inconsistent messages and disconnected resources. Examples reported included inconsistent access to lactation consultants, variability in lactation training credentials, the lack of connectedness between providers (e.g. Obstetricians and Pediatricians), and prenatal education classes were moved from hospitals to Amma Parenting Center in Edina.
- Gaps in language- and culture-specific support. Examples reported included a lack of information and visuals, lack of ethnic diversity of healthcare providers, especially Internationally Board Certified Lactation Consultants.
Five main themes emerged in the category of ideas to better support breastfeeding. Participants responded to the question, “What are your ideas for ways the city of Minneapolis could better support breastfeeding?”
- Launch a public awareness campaign to normalize breastfeeding. Nearly all participants mentioned some form of public awareness campaign and the need for more visuals in the community. Examples reported included keeping the messaging positive; creating visuals in maternity facilities, telling stories, making cultural birth art, designing nursing cover-ups from beautiful fabric; incorporating cultural champions such as Imams; and using statements such as “People like me breastfeed”, “I breastfeed because…”, “Let’s normalize breastfeeding”, “We are a breastfeeding friendly city”.
- Identify and recognize breastfeeding friendly organizations and create obvious places to breastfeed.
- Improve coordination of breastfeeding resources.
- Enhance support for peer-to-peer programs through community health workers. Examples reported included using community health workers more as breastfeeding peer counselors and doulas.
- Make lactation services more available, accessible and culturally specific. Examples reported included more on-site lactation consultants in pediatric and family practice clinics, home visiting lactation consultants, and diversifying the ethnicity of IBCLCs.
These recommendations reflect the opinions and perspectives reported by the 40 participants in this study and may inform future local policy or program efforts to promote a more supportive environment for breastfeeding in Minneapolis.
- Engage mothers/families in cultural communities for assistance in developing a public awareness campaign, with special effort to engage the American Indian community.
- Identify best practices from cities with successful programming and reach out to program staff for lessons learned and advice. Suggested cities and initiatives to contact include Latch On NYC in New York City, HealthConnect One in Chicago, MOMobile of Maternity Care Coalition in Philadelphia, and the Baby-Friendly Brookings project in Brookings, South Dakota.
- Ask the mayor or health department to publicly recognize organizations (health care organizations, employers, childcare facilities) that are Breastfeeding Friendly. Potential partners for implementing this recognition program might be the Minnesota Department of Health and the area chamber of commerce.
- Have the city health department reach out to existing breastfeeding coalitions and potential community partners to begin a dialog on how the city can partner with them to better support breastfeeding. First contacts might include the Minnesota Breastfeeding Coalition, the Hennepin County Breastfeeding Coalition, the Minnesota Hospital Association, and the Minnesota Community Health Worker Alliance.
- Expand home visiting/lactation services as part of the Mayor’s Cradle to K initiative.
Increase public lactation spaces. The city could consider renting or purchasing portable lactation pods such as the Mamava Lactation Suite.