key: cord-0015421-5ty6qzs1
authors: Pyles, Tiana Esther Helen; Umi, Shukura Ayoluwa; Madubuonwu, Sandra; Stiles, Allison; Devane-Johnson, Stephanie; Scott, Helen; Rhoads, Sarah; Russell, Jennifer H.
title: Breastfeeding Sisters That Are Receiving Support: Community-Based Peer Support Program Created for and by Women of Color
date: 2021-02-01
journal: Breastfeed Med
DOI: 10.1089/bfm.2020.0313
sha: 65e987bbce41803d5d5fe20acc658f9c13d5d585
doc_id: 15421
cord_uid: 5ty6qzs1

Substantial racial disparities accounted for 66% of non-Hispanic Black mothers initiating breastfeeding in 2015 compared with 83% of non-Hispanic white mothers and 87% of Hispanic mothers in Tennessee. Created in 2015, Breastfeeding Sisters That Are Receiving Support (BSTARS) uses key partnerships at monthly meetings that promote supportive environments with topics around breastfeeding education, support, and women's health issues. The BSTARS group helps rebuild the culture surrounding the health equity of Black women and women of color and their families by offering informational and emotional support, facilitate positive changes, and heal historical trauma. BSTARS addresses barriers to breastfeeding support for Black women and women of color, including lack of support from the mother's partner, family, or health care provider, generational myths, unawareness of public health programs to support breastfeeding, educational gaps, and embarrassment. This program incorporates critical partnerships, including health care providers, birth workers, and other supporters, into the organization to offer comprehensive support for the mother's continuity of care. The environment and educational support for breastfeeding and women's health issues are addressed under the lens of health equity and eliminating barriers experienced by the mother's color, or socioeconomic status. A mother's socioeconomic status often unjustly hinders her from receiving the lactation and social support needed for healthier outcomes. In 2019, the breastfeeding initiation rate in Tennessee increased to 71.3% among non-Hispanic Blacks. BSTARS has reached >500 families since its inception. BSTARS focuses their specific intervention on all facets of the family dyad, through teaching the importance of breastfeeding and breast milk now and sustainable for the future.

O ver the past decade, the benefits of breastfeeding and human milk have become well known. This complex substance provides the baby's microbiome, protection from infection, and training for the immune system. 1 As a result, the breastfed child has fewer infections, and lower rates of obesity, autoimmune disease, and immune system cancers. 1 Breastfeeding has also been found to decrease child abuse and neglect, 2 and decrease the risk of sudden infant death syndrome. 3 Human milk also reduces the incidence of central line sepsis and necrotizing enterocolitis in infants in the neonatal intensive care unit. 4 In addition to benefiting the baby, breastfeeding has been found to have maternal benefits, such as reducing postpartum blood loss and improving longterm cardiovascular health. 5 Breastfeeding rates in the world are stratified based on a woman's characteristics such as race and class. Of those breastfeeding rates, Black women's rates are often reported lower than other races' rates. 6, 7 Further examination of these statistics is needed on multiple levels. For this article, the term ''woman'' refers to anyone who can lactate and produce breast milk, and the terms ''African American,'' ''Black,'' or ''women of color'' will be used interchangeably. The potential impact of breastfeeding on infant and maternal health is significant, but racial disparities deprive women, infants, and families of these benefits.

Numerous studies have supported that many Black families experience poor treatment and lack of support from providers. 8 as well as lower quality 9 and access to care due to their class, gender, and race. 10 Systematic and structural racism has been blamed for this unfair disadvantage for Black women and why they are breastfeeding less. 11 Black women are more likely to be provided what is perceived to be simpler fixes of formula or water supplements for their infants compared with non-Black women in U.S. hospitals. 12 Racism is a barrier to fair treatment and access to breastfeeding information and education and underlies social determinants of health. 10 The region where a woman and her family live also impacts her overall health. Black women who live in the southern states of the United States have higher rates of chronic illnesses, increased mental health challenges, and premature death. 13 Although breastfeeding disparities continue to exist across the entire United States, breastfeeding rates in the southern region have consistently been lower than the U.S. national average, with breastfeeding rates of women of color in this region being even poorer. 14 The systematic barriers and disadvantages faced by Black women can be reduced through multilevel protective factor interventions and programs. Women report better communication with their provider when the provider is of the same race, 15 and when maternal care providers engage the woman in shared decision making. 16 Continuous lactation support for families has been identified as a strategy to increase breastfeeding initiation and duration. 17 Using these principles, peer-led and community-based support groups for Black women have been created and received well by women and their families. Examples of these peer support groups for women of color include Mocha Moms, 18 dedicated to motherhood, community service, and marriage enrichment; Mississippi Center for Birth and Breastfeeding Equity, educating families and training community health workers for healthier birth outcomes 19 ; and Reaching our Sisters Everywhere (ROSE), seeks to enhance the overall mental and physical health of African American women, babies, and their families through encouraging, promoting, and protecting breastfeeding in the United States. 20

Memphis, Tennessee, is often recognized for its eclectic soulful music, resilient spirit, and indisputably as one of the best places to get good barbeque in the south. Residents of Memphis have a strong sense of community and friendliness. In contrast, Memphis is also known for the historical sanitation workers' deplorable labor conditions and the assassination of Dr. Martin Luther King, Jr. With this history in context and its location in an area with health inequities, breastfeeding rates reflect these inequities. In 2014, 62.8% of Black mothers initiated breastfeeding in Tennessee, compared with 78.3% of non-Hispanic white mothers and 84.6% of Hispanic or Latino mothers (Fig. 1) , 21 wherein Shelby County initiation rates were 58.5% of Black mothers and 87.1% of non-Hispanic white mothers and 78% of Hispanic or Latino mothers. 22 In the same timeframe, some zip codes in Shelby County, primarily composed of Black populations, had even lower initiation rates ranging from 52.1% to 55.3%. . 22 To aid Black families in reaching their breastfeeding goals, Breastfeeding Sisters That Are Receiving Support 24 and was trained and recognized as a ROSE Community Transformer. 20 Because of these strong community connections, BSTARS was developed through a partnership between the SCBC and the SCHD and was supported by ROSE. As BSTARS grew in independence, it maintained partnerships with the SCBC and ROSE. From its conception, BSTARS was set up as a community-based organization and structured to become self-sustainable. This structure helped to empower the voice of the members and build momentum. In 2017, BSTARS was incorporated and appointed a board of directors, and in 2018, BSTARS received its status as an IRS 501(c)(3) organization.

BSTARS uses a multifaceted approach to create ownership and support women with in-person meetings, special activities, social media support, and peer-led support. Women learn of BSTARS through social media posts, word of mouth, and provider referral. At its inception, the Tennessee Breastfeeding Hotline (TBH) was instrumental in promoting the organization and directing breastfeeding mothers to the new group. Activities and support provided by BSTARS are provided at no cost to the woman or her family. The allvolunteer BSTARS leadership team, board, and members are from various backgrounds, including mothers who have breastfed, community partners, and breastfeeding supporters. The BSTARS board comprised professionals and laypeople, including two physicians, breastfeeding peer counselors, birth workers, public health workers, researchers, International Board Certified Lactation Consultants (IBCLC), and other lactation support providers. This rich mix of supporters refers women into BSTARS and leads BSTARS activities, including monthly meetings, just-in-time lactation support, social media support, special activities, and community and provider breastfeeding education.

BSTARS provides a safe space of support each month for Black women and women of color and their families, along with a shared meal for dinner. Providing a meal allows families to enjoy dinner while attending the breastfeeding support meeting. The shared meal creates a family-like environment and helps everyone feel more at ease to discuss difficult topics together. The meetings are usually held at a local library. All members of the family are welcome and encouraged to attend. BSTARS meets families where they are in their perinatal and breastfeeding journey, regardless of their socioeconomic status. Everyone is treated equally, and the members of the group often express that they are relieved to find common ground among other attendees. The meetings begin with introductions as icebreakers, and participants are encouraged to share their stories, including successes and stressors. Each meeting has a centralized topic of discussion and typically focuses on self-care, such as baby blues and pelvic floor therapy, or an issue that addresses common reasons that Black women choose not to breastfeed: embarrassment, lack of breastfeeding education, lack of resources, lack of support from family, and lack of support from their health care providers. 14 The meeting space has been cultivated to promote safety, comfort, and breastfeeding welcome attitudes. Because of this atmosphere, mothers feel supported, ask questions, and then receive free just-in-time breastfeeding advice. Women and families attend meetings freely as their schedules allow and receive follow-up as needed. Women attending the meetings can be pregnant, currently breastfeeding, or breastfeeding supporters. BSTARS also cultivates a community to provide support outside the monthly meetings. Social media presence is a vital component of reaching some women as many have never attended a meeting in person yet receive their support through BSTARS' social media outlets.

BSTARS is a community-based organization that is led by the needs of its members. BSTARS welcomes ideas and input from members and implemented several recommended activities during scheduled strategic planning meetings. Some of the activities include the BSTARS: A Star is Born Community Baby Shower, held annually in February, which provides families with opportunities to receive pregnancy, postpartum, breastfeeding, and child-rearing education with self-care tips. Families may receive free items such as car seats, portable play yards, and strollers at this event. Each July, a pool party is held at a community center to celebrate the anniversary of BSTARS while honoring community development and fellowship. To celebrate World Breastfeeding Week and National Breastfeeding Month, both in August, BSTARS hosts several activities such as a 3K walk and health fair. In 2020, BSTARS hosted its first national walk by inviting Black and Indigenous breastfeeding organizations across the country to stand in solidarity with BSTARS for breastfeeding and maternal health awareness. The walk was entitled, ''The Million Milk March.'' This activity focused on encouraging women to practice wellness and the intersection of self-care for mother and baby. Each December, BSTARS and SCBC have an inclusive joint meeting, reviewing the year's journey, and developing collective goals for the next year.

These collective goals include providing education to the community and health care providers. These educational partnerships include an annual conference and encouraging Black women to have additional breastfeeding training. Members of BSTARS are on the Tennessee Breastfeeding Symposium planning committee and provide content expertise on breastfeeding racial disparities. They have served panelists at local and national conferences and legislative events, discussing how racism and social determinates of health are impacting breastfeeding rates in Black women and opening the discussion on ways to work with the community to increase initiation rates. BSTARS also empowers its members and supporters to pursue further education to become birth workers, breastfeeding peer counselors, and obtain breastfeeding certification. BSTARS assisted the Tennessee Breastfeeding Coalition in sponsoring a Symposium a Certified Lactation Counselor (CLC) course in Memphis, TN, at a subsidized rate to support women of color and allies who wished to further their education and formal careers in lactation management.

Except for one cancelation for snow, from 2015 to February 2020, BSTARS had 63 consecutive monthly meetings with an average attendance of 32-40 adults and 18-24 children at each in-person meeting. BSTARS adapted to virtual meeting space in March 2020 due to the COVID-19 pandemic. Since March 2020, these virtual meetings averaged an attendance of 42-50 adults and 25-33 children. BSTARS has been a part of 18 community events since 2015. The BSTARS Annual 3K and Health Fair has reached >350 families since its inception and is supported by *15 vendors annually. The Annual Community Baby Shower assists *50-60 families each year.

After completing the CLC course in March 2020, 13 women successfully passed the CLC exam. With this new skill set and connections available through BSTARS, these women now connect with mentors as they begin their journey into the lactation field and have expanded the capacity of lactation support at monthly BSTARS meetings.

BSTARS is growing in recognition due to its success in partnering and providing support to the community. There are numerous spontaneous and planned opportunities for the members to make suggestions for new events, programs, or themes the organization can observe. In addition, three times a year, BSTARS offers strategic planning meetings, allowing a public structured space for members to plan out the organization's future. This strong community connection is reflected in the attendance at monthly meetings and annual events. The themed meetings have been successful in incorporating the family, particularly the fathers. For example, for June, in recognition of Father's Day, BSTARS strategically focuses on the importance of the father's role and presence in ensuring the family meets their breastfeeding goals. The Mother's Day meeting in May helps to honor moms and their birth journey and incorporates the need for grandmother support for the continued reclamation of breastfeeding for healthy families.

BSTARS is continually evolving as the organization and membership advance in resources and skill. BSTARS implemented a culture of equitable and equal input among members and board members. This absence of hierarchy is well received by the members and remains a unique reason explaining why membership continues to grow. In recognition of its impact on the community and breastfeeding in Shelby County, in 2017, BSTARS was honored and officially recognized by the United States Breastfeeding Committee as their first cultural coalition member. 25 Key partnerships have been essential to the launch and sustainment of BSTARS. For example, the TBH 5-year contract initiated in Memphis 2013-2018 increased awareness of BSTARS and TN's breastfeeding disparities. This partnership resulted in referrals and supporting events locally. 26 Through transitions in leadership and other dissolu-tions, new partnerships must be formed. For example, since July 2018, management of the TBH is located out of state and BSTARS has felt the impact of this move through a decrease in referrals into the program.

The COVID-19 pandemic interrupted the in-person BSTARS meetings, resulting in an additional need for virtual support. This challenge led to the opportunity to begin Facebook live meetings on the second and fourth Wednesday of the month at 6:30 pm, allowing BSTARS to expand the reach from exclusively local attendance to state, national, and international attendance. The BSTARS program has been a newly discovered resource for breastfeeding support for many women and their families during the pandemic through synchronous and asynchronous virtual support. The number of families supported or linked with BSTARS now averages *500 families.

BSTARS has been privately funded for 5 years. This support provides avenues for mentorship for new breastfeeding advocates and practitioners. Mentorship and support provided to members of BSTARS have contributed to professional growth and development of skills of some members. One example is a member who successfully journeyed from a CLC to an IBCLC. The financial challenge is one of the most difficult to overcome as BSTARS has no corporate connection. It is funded primarily by its members and fundraising efforts. Additional funding sources are intermittent and typically from other breastfeeding organizations and partners.

Breastfeeding rates for non-Hispanic Black infants rose in Memphis and Shelby County from 47.6% in 2008 to 65.9% in 2018. 22 Breastfeeding initiation rates have also risen across Tennessee with the overall breastfeeding rate in 2019 as 80.6% and 71.3% for non-Hispanic Black infants (Fig. 1) . 21 Breastfeeding education and support offered at local and state health departments, including nutrition counselors and peer counselors in the special supplemental nutrition program for women, infants, and children (WIC) offices, would benefit from being members of groups such as BSTARS. Practical lessons and lived experiences from this group will inform the counselors' practice. They will be able to tailor and integrate lessons learned to help their Black breastfeeding mothers.

A study on breastfeeding advice given to African American and white women by their medical providers and WIC nutrition counselors examined whether racial differences in advice contributed to racial disparities in breastfeeding rates. The study concluded that by report, African American women were less likely than white women to receive breastfeeding advice and more likely to receive bottle feeding advice from a WIC counselor. Both groups reported receiving breastfeeding advice from medical providers. Nutritional counselors' participation in groups such as BSTARS could provide an opportunity to gather culturally appropriate advice to utilize with the African American breastfeeding mothers they see. 27 Some of the unique challenges faced by African American mothers such as the history of breastfeeding and slavery, the use of infant formula as a status symbol, how breasts are portrayed in the media, and the lack of positive images of Black breastfeeding women are a few of what has negatively influenced African American women in the past. Education of all practitioners caring for African American breastfeeding mothers on this disparity could inform their practice and help practitioners provide evidence-based advice. 28, 29 Maternal health providers have an opportunity to play a pivotal role in supporting breastfeeding for Black women by informing them of the program.

Dissemination of information through local events, poster presentations in conferences, and article submissions by BSTARS leaders and members help bring awareness and interest to the initiatives positioning it for replication. BSTARS has developed strategic partnerships with leaders in other counties and cities that address Black women's breastfeeding needs, share experiences, and help with replicating the initiative.

By providing local community-led peer support, BSTARS addresses the woman and family's social determinates of health, such as education, income, and health care and wellness. In addition, BSTARS empowers women and families by teaching and practicing shared decision making with members.

Grassroots efforts such as BSTARS play a pivotal role in improving breastfeeding rates and the community's health and welfare. The BSTARS program provides a resource for Black women in an urban community in the south to connect with critical resources, including peer and lactation support, and receive essential pregnancy, breastfeeding, and postpartum education. The culture and lifestyle around the family-oriented judgment-free community-based environment provided in the BSTARS program support selfcare and safety to Black families and assist to achieve a woman's breastfeeding goals.

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Available at www .mochamoms.org/i4a/pages/index.cfm?pageid=1

Reaching Our Sisters Everywhere. Available at www.breastfeedingrose.org

Office of Vital Records & Statics. Birth Statistical System. Statistics prepared by Division of Family Health and Wellness

Office of Vital Records & Statics. Birth Statistical System. Statistics prepared by Shelby County Health Department, Office of Epidemiology

Breastfeeding Sisters That Are Receiving Support. Facebook. Available at www.facebook.com/BSTARS901

Available at www.shelbycountybreastfeeding.org

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The authors acknowledge Laura Hutton, Sierra Mullen, and Jennifer Kmet's contributions for data gathering and reviewing the article.

No competing financial interests exist.

The majority of BSTARS' funding from its inception have been from a private source in order to maintain momentum around the needed support. The partners: Shelby county breastfeeding coalition and reaching our Sisters everywhere continue to give financially for certain events and projects. The BSTARS board to directors is a 100% giving board and collectively supports the organization. BSTARS members past and present participate in fundraising activities, and private donations through its membership. BSTARS is a 501c3 and has only received 2 grants: Reaching Our Sisters Everywhere VIP Cohort in 2020 and United Health Care in 2020.