Date of Award

2016

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

College of Nursing

First Advisor

Susan D. Newman

Second Advisor

Shannon Phillips

Third Advisor

Martina Mueller

Fourth Advisor

Sarah N. Taylor

Abstract

Purpose: The purpose of this dissertation was to explore southeastern United States (U.S.) rural-dwelling African American Mothers’ barriers and facilitators to adoption of Baby-Friendly practices and associated breastfeeding decisions. First, an integrative review was conducted to determine the impact in the U.S. of the Baby-Friendly Hospital Initiative (BFHI) on early infant health and breastfeeding outcomes. Next, a mixed-methods study was conducted to explore barriers and facilitators to Baby-Friendly practice adoption for southeastern U.S. rural-dwelling African American mothers. Finally, a directed content analysis approach was used to explore themes of maternal perceptions of Baby-Friendly practices and breastfeeding experiences based upon concepts from the BFHI using the Social Ecologic Model (SEM). Problem: In the U.S., low rates of breastfeeding persist despite evidence that breast milk serves as optimal infant nutrition and provides protection from illnesses and diseases (APHA, 2007; Brenner & Buescher, 2011; CDC, 2014; DHHS, 2011; WHO, 2009). African American mothers and low-income mothers have historically had low rates of breastfeeding initiation, duration, and exclusivity, yet little is known about factors contributing to this trend (CDC, 2014; Labbok, Taylor, & Nickel, 2013; DHHS, 2011; VanDevanter, Gennaro, Budin, Calalang-Javiera, & Nguyen, 2014). The BFHI is a World Health Organization (WHO) and United Children’s Fund (UNICEF) sponsored curriculum to establish supportive environments and educational services that enhance mothers’ initial breastfeeding experiences and to influence maternal decisions to initiate and maintain breastfeeding (APHA, 2007; CDC, 2013; Philipp & Radford, 2006; Saadeh, 1996, 2012; WHO, 2009). A review of the research literature revealed no published studies that explored southeastern U.S. rural-dwelling African American mothers’ perceptions of barriers and facilitators to adoption of Baby-Friendly practices, including associated breastfeeding decisions (Munn, Newman, Mueller, Phillips, & Taylor, 2016). The specific aims of this dissertation were: Aim 1: To determine the impact in the U.S. of the BFHI on early infant health and breastfeeding outcomes using an integrative review of the literature. Aim 2: To determine factors influencing southeastern U.S. rural-dwelling African American mothers' adoption of Baby-Friendly practices and associated breastfeeding decisions using a convergent parallel mixed-methods design. Aim 3: To explore the influence of barriers and facilitators to maternal adoption of Baby- Friendly practices, maternal perceptions, and experiences on breastfeeding decisions using a descriptive qualitative approach and directed content analysis with a group of both urban- and rural-dwelling southeastern U.S. African American mothers in a regional hospital serving a rural population. Design and Theoretical Basis: A convergent parallel mixed-methods study design, informed by the SEM (McLeroy, Bibeau, Steckler, & Glanz, 1988) guided the collection of quantitative and qualitative data during a designated two-month time-period. Qualitative and quantitative data were collected and analyzed separately, then converged to gain a more comprehensive understanding of the barriers and facilitators to maternal adoption of Baby-Friendly practices for the study population. Findings: Mothers who were African American and rural-dwelling had greater odds for non-adoption of Baby-Friendly practices relative to other groups (ORs = 5, 10 respectively, p-values ≤ 0.01). Mothers who received a lactation consult and had moderate or completed skin-to-skin contact had greater odds for adoption of Baby-Friendly practices relative to other groups (both OR ≥ 17.5, p-values <0.05). Directed content analysis revealed six themes: maternal desire to breastfeed, infant state, maternal state, milk supply concerns, provider support, and access to breastfeeding equipment and support services. Convergence of quantitative and qualitative data provided descriptive explanation of predictors of maternal adoption of Baby-Friendly practices and offered a comprehensive depiction of barriers and facilitators to participation in Baby- Friendly practices and successful breastfeeding for the population. Conclusions: While lack of breastfeeding information, support, and equipment access hindered breastfeeding success, the presence of breastfeeding information, support, participation in maternal/infant bonding practices, and early breastfeeding increased maternal desire to breastfeed and resulted in greater breastfeeding success. These findings provide information for health care providers to effectively tailor Baby-Friendly practice implementation among rural dwelling and African American mothers and to increase their infant bonding and breastfeeding success.

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