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Understanding Breastfeeding Barriers at an Urban Pediatric Practice


Breastfeeding is the optimal nutrition for infants given the numerous health benefits that are conferred on mothers, infants, and society in a dose-dependent manner. However, low breastfeeding rates and racial breastfeeding inequities persist for the African American (AA) community due to historic structural racism. The issue is especially salient at the Rainbow Center for Women and Children, an urban health center in Cleveland, Ohio where approximately 90% of their mothers are AA, WIC-eligible, and publicly insured. Our study aims to elucidate factors contributing to breastfeeding practices and identify supports that could be added for women served at RCWC. The study was conducted within 2 cohorts both of exclusively AA  women. Wave 1 of the study included AA mothers who exclusively breastfed, did mixed feeding, or exclusively formula fed. Wave 2 included expectant women at least considering breastfeeding. Breastfeeding attitudes of those who had exclusively breastfed or practiced mixed feeding were not significantly different than those of expectant participants planning to breastfeed; mean attitude scores, however, were in the “neutral” range. Participants endorsed many sources of support for their feeding choices, including the infant’s father, their own parents, and family. However, the data show that even when women feel personally supported in their feeding choices by their partner and family, if additional breastfeeding help is needed, they will benefit from help accessing available resources. Thus, lactation support that helps women achieve their own breastfeeding goals is optimal; customized care ultimately can move the needle on racial inequities in breastfeeding for our society.

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  1. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk [Policy Statement]. Pediatr. 2012;129:e827–41.

    Article  Google Scholar 

  2. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 756: optimizing support for breastfeeding as part of obstetric practice. Obstetr Gynecol. 2018;132:e187–96.

    Article  Google Scholar 

  3. World Health Organization. Nutrition, breastfeeding. Updated 2019. <> Accessed 8/21/2019.

  4. Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, Bahl R. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr Suppl. 2015;104:3–13.

    Article  Google Scholar 

  5. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, Bahl R, Martines J. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr Suppl. 2015;104:96–113.

    Article  Google Scholar 

  6. Breastfeeding, data and statistics, breastfeeding rates. Division of physical activity, nutrition and obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. <> Accessed February 12, 2020.

  7. Centers for Disease Control and Prevention. Racial disparities remain in breastfeeding rates. JAMA. 2017;318(8):691.

    Article  Google Scholar 

  8. Beauregard JL, Hamner HC, Chen J, Avila-Rodriguez W, Elam-Evans LD, Perrine CG. Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015. MMWR Morb Mortal Wkly Rep. 2019;3068(34):745–8.

    Article  Google Scholar 

  9. Robinson K, Fial A. Lisa Hanson Racism, bias, and discrimination as modifiable barriers to breastfeeding for African American women: a scoping review of the literature. J Midwifery Womens Health. 2019;64:734–42.

    Article  PubMed  Google Scholar 

  10. Morrow AL, McClain J, Conrey SC, Niu L, Kinzer A, Cline AR, Piasecki AM, DeFranco E, Ward L, Ware J, Payne DC, Staat MA, Nommsen-Rivers LA. Breastfeeding disparities and their mediators in an urban birth cohort of Black and White mothers. Breastfeed Med. 2021;16(6):452–62.;PMCID:PMC8418439.

    Article  PubMed  Google Scholar 

  11. Davis C, Villalobos AVK, Turner MM, Long S, Lapinski MK. Racism and resistance: a qualitative study of bias as a barrier to breastfeeding. Breastfeed Med. 2021;16(6):471–80.;PMCID:PMC8215417.

    Article  PubMed  Google Scholar 

  12. Kaufman L, Deenadayalan S, Karpati A. Breastfeeding ambivalence among low-income African American and Puerto Rican women in north and central Brooklyn. Matern Child Health J. 2010;14:696–704.

    Article  PubMed  Google Scholar 

  13. Cricco-Lizza R. The milk of human kindness: environmental and human interactions in a WIC clinic that influence infant-feeding decisions of Black women. Qual Health Res. 2005;15:525–38.

    Article  PubMed  Google Scholar 

  14. Nommsen-Rivers LA, Chantry CJ, Cohen RJ, Dewey KG. Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Breastfeed Med. 2010;5:25–33.

    Article  PubMed  Google Scholar 

  15. RAMA Consulting Group, Inc. WIC African American Breastfeeding Focus Groups Final Report. Ohio Department of Health African American Breastfeeding Focus Group Project. 2011. (Accessed 1/30/22).

  16. Chapman DJ, Pérez-Escamilla R. Breastfeeding among minority women: moving from risk factors to interventions. Adv Nutr. 2012;3(1):95–104.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Jones KM, Power ML, Queenan JT, Schulkin J. Racial and ethnic disparities in breastfeeding. Breastfeed Med. 2015;10(4):186–96.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Johnson A, Kirk R, Rosenblum KL, Muzik M. Enhancing breastfeeding rates among African American women: a systematic review of current psychosocial interventions. Breastfeed Med. 2015;10:45–62.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Quick Facts, Cleveland OH. United States Census Bureau. United States Department of Commerce. Accessed 11/24/2021.

  20. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, JG. Conde, Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.

    Article  Google Scholar 

  21. Kim JH, Fiese BH, Donovan SM. Breastfeeding is natural but not the cultural norm: a mixed-methods study of first-time breastfeeding, African American mothers participating in WIC. J Nutr Educ Behav. 2017;49(7 Suppl 2):S151–1611.

    Article  PubMed  Google Scholar 

  22. de la Mora A, Russell DW, Dungy CI, Losch M, Dusdieker L. The Iowa infant feeding attitude scale: analysis of reliability and validity. J App Soc Psychol. 1999;29(11):2362–80.

    Article  Google Scholar 

  23. Mitchell-Box K, Braun KL, Hurwitz EL, Hayes DK. Breastfeeding attitudes: association between maternal and male partner attitudes and breastfeeding intent. Breastfeed Med. 2013;8(4):368–73.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hein DV. An integrated approach for understanding health behavior; the I-change model as an example. Psychol Behav Sci Int J. 2017;2(2):555585.

    Article  Google Scholar 

  25. Gijsbers B, Mesters I, Knottnerus JA, Van Schayck CP. Factors associated with the initiation of breastfeeding in asthmatic families: the attitude-social influence-self-efficacy model. Breastfeed Med. 2006;1(4):236–46. (PMID: 17661604).

    Article  PubMed  Google Scholar 

  26. Nommsen-Rivers LA, Dewey KG. Development and validation of the infant feeding intentions scale. Matern Child Health J. 2009;13(3):334–42.

    Article  PubMed  Google Scholar 

  27. Louis-Jacques AF, Marhefka SL, Brumley J, Schafer EJ, Taylor TI, Brown AJ, Livingston TA, Spatz DL, Miller EM. Historical antecedents of breastfeeding for African American women: from the pre-colonial period to the mid-twentieth century. J Racial Ethn Health Disparities. 2020;7(5):1003–12. (Epub 2020 Mar 2 PMID: 32124420).

    Article  PubMed  Google Scholar 

  28. Gyamfi A, O’Neill B, Henderson WA, Lucas R. Black/African American breastfeeding experience: cultural, sociological, and health dimensions through an equity lens. Breastfeed Med. 2021;16(2):103–11.;PMCID:PMC7891224.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Robinson K, Fial A, Hanson L. Racism, bias, and discrimination as modifiable barriers to breastfeeding for African American women: a scoping review of the literature. J Midwifery Womens Health. 2019;64(6):734–42. (Epub 2019 Nov 11 PMID: 31710173).

    Article  PubMed  Google Scholar 

  30. Woods Barr AL, Miller E, Smith JL, Cummings SM, Schafer EJ. #EveryGenerationMatters: intergenerational perceptions of infant feeding information and communication among African American women. Breastfeed Med. 2021;16(2):131–9. (PMID: 33591228).

    Article  PubMed  Google Scholar 

  31. Trivedi D. Cochrane Review Summary: support for healthy breastfeeding mothers with healthy term babies. Prim Health Care Res Dev. 2018;19(6):529–30.

    Article  PubMed  Google Scholar 

  32. Coughlin SS. The need for research-tested smartphone applications for promoting breastfeeding. Mhealth. 2016 May;2(5):18.

  33. Mieso B, Neudecker M, Furman L. Mobile phone applications to support breastfeeding among African-American women: a scoping review. J Racial Ethn Health Disparities. 2020 Nov 20.

  34. Dauphin C, Clark N, Cadzow R, Saad-Harfouche F, Rodriguez E, Glaser K, Kiviniemi M, Keller M, Erwin D. #BlackBreastsMatter: process evaluation of recruitment and engagement of pregnant African American women for a social media intervention study to increase breastfeeding. J Med Internet Res. 2020;22(8): e16239.;PMCID:PMC7445612.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Breastfeeding in the community: program implementation guide. NACCHO 2018. National Association of County and City Health Officials.

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We thank the women who participated, the obstetrical providers and CenteringPregnancy™ nurses for their support, and Monica Chavan MS2 for work on the Pediatric Practice Breastfeeding Database.


The work was supported by a Rainbow Babies and Children’s Hospital Faculty Fund Pilot award to Dr. Furman.

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Authors and Affiliations



Dr. Furman designed the study, was responsible for study oversight and data integrity, and drafted and revised the manuscript. Ms. Feinstein interviewed all participants, aided in data interpretation, and revised and reviewed the manuscript. Dr. DeLozier conducted the statistical analysis and revised and reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Lydia Furman.

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Ethics Approval

The University Hospitals Cleveland Medical Center Institutional Review Board approved this research. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and the Belmont Report.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

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Protected health information and identifiable data were not collected.

Competing Interests

The authors declare no competing interests.

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Furman, L., Feinstein, J. & Delozier, S. Understanding Breastfeeding Barriers at an Urban Pediatric Practice. J. Racial and Ethnic Health Disparities (2022).

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  • Breast feeding
  • Lactation
  • African Americans
  • Health resources