Investing in Breastfeeding Will Advance Health Equity
Breastfeeding, specifically as experienced by Black women and birthing people, has a violently oppressive and political history, one that, furthermore, is far too unknown. The remnants of the past persist to this day, affecting everything from the $55-billion-a-year global infant formula business to the ever-present biases in health care–traumatic wet-nursing practices during the period of chattel slavery are their common origin.
This commentary will illuminate the shared narrative of violence against and exclusion of generations of Black women and birthing people in the United States, then will discuss today’s manifestations of that history, why ending them is so crucial, and how policy can intervene. Without increased awareness and significant structural action, this history will continue to shape our futures, and will continue to fuel health inequities and breastfeeding-related disparities.
Laws and policies impeding Black mothers’ ability to breastfeed their children began in slavery, and persist as a reminder of that institution today. In the United States, wet nursing was a practice of forcibly stripping enslaved women away from their newborn and infant children to exploit their bodies and labor by requiring them to nurse slave owners’ children. In addition to stripping these women of bodily autonomy, safety, and human dignity during the centuries-long institution of slavery, this often resulted in disproportionately high Black infant mortality and susceptibility to diseases for Black babies.
Patterns Too Consistent to Be Accidental
Although breastfeeding rates in the United States have increased over the past decade, racial disparities persist in each stage of breastfeeding, including early breastfeeding initiation within one hour of birth, exclusive breastfeeding for approximately six months after birth, and breastfeeding for a duration of two years or beyond. Painfully egregious, the racialized trauma of wet nursing is the genesis of Black women’s breastfeeding journey in the United States; and what I experienced following the birth of my first son—the very antithesis of respectful maternity care—reveals patterns too consistent to be accidental. Consequently, unless a conversation about breastfeeding begins by acknowledging and addressing historical and present-day institutionalized racism, it’s a conversation that will remain silenced and robbed of context.
Today, Black families have 2.3 times the infant mortality rate as white families, and Black infants are four times as likely to die from complications related to low birth weight when compared to white infants. Poignantly, a recent study found that the mortality rate was cut in half when Black babies were cared for after birth by doctors of the same race. Breastfeeding significantly protects against sudden infant death syndrome (SIDS), which is one of the five leading causes of infant mortality, and preterm birth, and low birth-weight infants—most of whom are Black—who are exclusively breastfed gain weight and have increases in their head circumference and length to the levels almost comparable to the standard fetal-infant growth norms.
Poignantly, a recent study found that the mortality rate was cut in half when Black babies were cared for after birth by doctors of the same race.
For the past several generations, the infant formula market has also played a significant role in these disparities. The industry has expanded drastically in recent decades, especially with the advent of social media, and is projected to be worth around $125.2 billion by 2030. The industry’s well-documented targeted marketing campaigns, which have been described as “unacceptably pervasive, misleading, and aggressive,” prompted the World Health Organization to launch a counter campaign, #EndExploitativeMarketing and to develop an International Code of Marketing of Breast-Milk Substitutes.
The implicit biases primarily responsible for producing health disparities today have the power to destroy Black women and birthing people’s health and lives. Even when controlling for socioeconomic status, disparities in breastfeeding initiation, duration, and exclusivity between Black families and white families continue to exist. As pointed out in a landmark study published in Pediatrics, the official journal of the American Academy of Pediatrics, “African-American infants were more than nine times more likely than white babies to be given formula in the hospital.” The authors conclude, “Why… Black mothers [are] disproportionately being given infant formula [is a question that] cannot be answered without another uncomfortable conversation about whose babies are valued, which mothers can be trusted to feed their babies without measured and monitored amounts, and who is worthy of the time needed to help someone start breastfeeding successfully.” Correspondingly, the Journal of Racial and Ethnic Health Disparities published research concluding that “Experiences of institutionalized racism influence breastfeeding initiation and duration, [and] structural level interventions are critical to close the gap of racial inequity in breastfeeding rates in the U.S.”1
The Benefits of Breastfeeding
We know that breastfeeding provides substantial nutritional, cognitive, emotional, and immunological benefits for the mother and baby. Yet, to date, breastfeeding is not widely considered a key pillar in the larger discussion about health equity—which is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Moreover, breast milk is rarely mentioned as a solution to addressing the social determinants of health, specifically in relation to food insecurity or malnutrition among infants and toddlers in the United States. Even in the vast body of existing legislation addressing access to food, specifically nutritious food, breast milk is missing despite being a first food that provides abundant and easily absorbed nutritional components, antioxidants, enzymes, immune properties, and live antibodies.
Breastfeeding is protective of maternal and infant health across the life course, thus increasing breastfeeding rates in Black communities is an important public health strategy to improve health outcomes. Furthermore, per the CDC, low rates of breastfeeding add more than $3 billion a year to medical costs for the mother and child in the United States, and, conversely, medical costs are significantly lower for fully breastfed infants because they usually require fewer sick care visits, prescriptions, and hospitalizations. Indubitably, breastfeeding is an important modifiable risk factor for both mothers and infants. And still, Black women and birthing people’s experiences of medical racism and implicit bias in health care settings adversely impact breastfeeding initiation, and the resulting health benefits, protections, and advances toward health equity, despite racism, bias, and discrimination being modifiable barriers.
The Necessity of Nuance
Unfortunately, breastfeeding is often presented as an independent choice or selected preference by those in a position of privilege, so perhaps the next best step for increasing breastfeeding awareness, education, and support is to shift the narrative away from posits of individualism and instead focus on the multisectoral influences that shape a new mother’s opportunity to even begin breastfeeding. While there is a vast body of existing legislation that focuses on workplace protections to secure breastfeeding duration, it can be considered a moot point if not preceded by paid family and medical leave, which secures the critical time period when successful breastfeeding is initiated, and exclusivity is practiced. Though the workplace protections are essential, there is a significant gap in legislation to address breastfeeding initiation—which, for most moms, begins in the hospitals and birthing centers immediately following birth—and reactively focuses on duration. I contend that the preconception and perinatal periods are the most important and impactful points of entry for promoting breastfeeding awareness, education, and support.
I contend that the preconception and perinatal periods are the most important and impactful points of entry for promoting breastfeeding awareness, education, and support.
My two breastfed babies, Ceylon III and Daxton, were first introduced to the world in 2020 and in 2021, respectively, at the same time I was working to inform lawmakers and the public about how the Black Maternal Health Momnibus Act advances breastfeeding awareness, education, and support. However, my now 2.5-years-and-counting breastfeeding journey didn’t begin so idyllically. As noted in Imbued With Nutritional Riches: A Black Mother’s Breastfeeding Journey, I discuss how I was perfectly capable of and wanting to breastfeed following the birth of my first son in December 2019, but vulnerable and exhausted having just given birth, and was actively dissuaded by the medical team. What if my breastfeeding experience ended with the medical professionals in the hospital who dismissed me and delegitimized my efforts? What if my growing family didn’t have access to a wealth of resources, including sixteen weeks of job-protected parental leave and out-of-pocket costs for a lactation consultant to visit our home within hours of my discharge from the hospital?
Denys breastfeeding her son. Source: Author.
Tying the Ends of the Rainbow
As a health policy professional who is only three months past the postpartum period following the birth of my second son in May 2021, I understand how policy informs practice; and I am familiar with the language and lens of both the impacted community and the stakeholders. To this end, what if there existed a health care system that enhanced new parents and families’ ability to breastfeed during the preconception period by increasing awareness and providing education about its benefits? What if we considered pregnant women and birthing people as “prospective” breastfeeding parents and began offering support and assistance during prenatal care, including making breast pumps available during pregnancy, so that’s one less task to complete during the vulnerable postpartum period as opposed to current Medicaid2 policies that require moms to wait until the birth of the baby to obtain a pump? What if the 65 percent of Black women in the United States who are enrolled in Medicaid during pregnancy weren’t just automatically “eligible” for WIC, but auto-enrolled, so that, too, could be one less task to complete during the vulnerable, exhausting postpartum period? What if there were federal investments in multilevel systems of support? The results would be astounding!
As declared by the CDC, “Breastfeeding is an investment in health, not just a lifestyle decision!” Building upon what already exists—including the Momnibus, the DEMAND Act, the PUMP for Nursing Mothers Act, the Pregnant Workers Fairness Act, and the FAMILY Act—what is needed is federal legislation that comprehensively addresses low breastfeeding initiation, duration, and exclusivity among historically and systematically marginalized communities through federal policies, programs, and partnerships. Key policies that would make this happen include the following:
Establish an Office of Breastfeeding and Human Lactation within the Department of Health and Human Services to generate a whole-of-government approach to protecting, advancing, and affirming breastfeeding advocacy, awareness, education, and support. The Office would work in coordination with other HHS offices, initiatives, and divisions—including the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development and the CDC’s Division of Nutrition, Physical Activity, and Obesity—and across all federal agencies to instill a strategic, whole-of-government approach to breastfeeding equity.
Enact federal legislation that bolsters the Baby-Friendly Hospital Initiative and increases federal investments in Birthing-Friendly Hospitals. Baby-Friendly Hospitals have been shown to increase rates of breastfeeding initiation and duration; and Birthing-Friendly Hospitals are the Centers for Medicare and Medicaid Services’ first-ever hospital quality designation that specifically focuses on maternal health through a publicly reported hospital designation. Surely, pairing the aforementioned with the Centers for Disease Control and Prevention’s national survey of Maternity Practices in Infant Nutrition and Care would be cutting-edge! This particular program assesses maternity care practices and provides feedback to encourage hospitals to make improvements that better support breastfeeding by promoting greater levels of representative community engagement and requiring data disaggregation.
Investing in breastfeeding to advance health equity requires increased federal funding in education access and quality—a social determinant of health. We need federal legislation that establishes investments in lactation education at minority-serving institutions, like Historically Black Colleges and Universities (HBCUs), to increase the number of diverse clinically trained, community-based healthcare professionals with breastfeeding expertise. By funding HBCU schools of nursing and allied health sciences to offer certifications for graduating students entering the maternal-child health field, the result would be an increased number of trained clinicians who can provide culturally congruent, targeted, evidence-based resources and training around breastfeeding initiation, duration, and exclusivity. Authorizing robust funding for existing federal grants that support maternal-child health epidemiology programs at academic institutions, community-based organizations promoting breastfeeding, and disaggregated data collection at research institutions are educational and societal investments that would be transformational. Undoubtedly, breastfeeding requires equitable access to support and training for multisectoral increases in lactation knowledge.
In this demand for policy and system changes, it is imperative that policymakers, public health officials, practitioners, and the public understand that—like paid family and medical leave—breastfeeding is a public health imperative, and with substantial, systems level investments, breastfeeding will advance health equity!
Notes
Emphases in this paragraph added by the author.
Medicaid covers 42% of births in the United States.
As the director of policy and partnerships at the National Women’s Health Network, Denys shifts paradigms and shapes policies that represent women in all their diversities. An expert strategist and extended breastfeeding mom, she champions health equity by advancing breastfeeding awareness and support through high-impact advocacy campaigns and consensus building that engages government, nonprofit, and community entities.
Investing in Breastfeeding Will Advance Health Equity
Breastfeeding, specifically as experienced by Black women and birthing people, has a violently oppressive and political history, one that, furthermore, is far too unknown. The remnants of the past persist to this day, affecting everything from the $55-billion-a-year global infant formula business to the ever-present biases in health care–traumatic wet-nursing practices during the period of chattel slavery are their common origin.
This commentary will illuminate the shared narrative of violence against and exclusion of generations of Black women and birthing people in the United States, then will discuss today’s manifestations of that history, why ending them is so crucial, and how policy can intervene. Without increased awareness and significant structural action, this history will continue to shape our futures, and will continue to fuel health inequities and breastfeeding-related disparities.
Laws and policies impeding Black mothers’ ability to breastfeed their children began in slavery, and persist as a reminder of that institution today. In the United States, wet nursing was a practice of forcibly stripping enslaved women away from their newborn and infant children to exploit their bodies and labor by requiring them to nurse slave owners’ children. In addition to stripping these women of bodily autonomy, safety, and human dignity during the centuries-long institution of slavery, this often resulted in disproportionately high Black infant mortality and susceptibility to diseases for Black babies.
Patterns Too Consistent to Be Accidental
Although breastfeeding rates in the United States have increased over the past decade, racial disparities persist in each stage of breastfeeding, including early breastfeeding initiation within one hour of birth, exclusive breastfeeding for approximately six months after birth, and breastfeeding for a duration of two years or beyond. Painfully egregious, the racialized trauma of wet nursing is the genesis of Black women’s breastfeeding journey in the United States; and what I experienced following the birth of my first son—the very antithesis of respectful maternity care—reveals patterns too consistent to be accidental. Consequently, unless a conversation about breastfeeding begins by acknowledging and addressing historical and present-day institutionalized racism, it’s a conversation that will remain silenced and robbed of context.
Today, Black families have 2.3 times the infant mortality rate as white families, and Black infants are four times as likely to die from complications related to low birth weight when compared to white infants. Poignantly, a recent study found that the mortality rate was cut in half when Black babies were cared for after birth by doctors of the same race. Breastfeeding significantly protects against sudden infant death syndrome (SIDS), which is one of the five leading causes of infant mortality, and preterm birth, and low birth-weight infants—most of whom are Black—who are exclusively breastfed gain weight and have increases in their head circumference and length to the levels almost comparable to the standard fetal-infant growth norms.
For the past several generations, the infant formula market has also played a significant role in these disparities. The industry has expanded drastically in recent decades, especially with the advent of social media, and is projected to be worth around $125.2 billion by 2030. The industry’s well-documented targeted marketing campaigns, which have been described as “unacceptably pervasive, misleading, and aggressive,” prompted the World Health Organization to launch a counter campaign, #EndExploitativeMarketing and to develop an International Code of Marketing of Breast-Milk Substitutes.
The implicit biases primarily responsible for producing health disparities today have the power to destroy Black women and birthing people’s health and lives. Even when controlling for socioeconomic status, disparities in breastfeeding initiation, duration, and exclusivity between Black families and white families continue to exist. As pointed out in a landmark study published in Pediatrics, the official journal of the American Academy of Pediatrics, “African-American infants were more than nine times more likely than white babies to be given formula in the hospital.” The authors conclude, “Why… Black mothers [are] disproportionately being given infant formula [is a question that] cannot be answered without another uncomfortable conversation about whose babies are valued, which mothers can be trusted to feed their babies without measured and monitored amounts, and who is worthy of the time needed to help someone start breastfeeding successfully.” Correspondingly, the Journal of Racial and Ethnic Health Disparities published research concluding that “Experiences of institutionalized racism influence breastfeeding initiation and duration, [and] structural level interventions are critical to close the gap of racial inequity in breastfeeding rates in the U.S.”1
The Benefits of Breastfeeding
We know that breastfeeding provides substantial nutritional, cognitive, emotional, and immunological benefits for the mother and baby. Yet, to date, breastfeeding is not widely considered a key pillar in the larger discussion about health equity—which is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Moreover, breast milk is rarely mentioned as a solution to addressing the social determinants of health, specifically in relation to food insecurity or malnutrition among infants and toddlers in the United States. Even in the vast body of existing legislation addressing access to food, specifically nutritious food, breast milk is missing despite being a first food that provides abundant and easily absorbed nutritional components, antioxidants, enzymes, immune properties, and live antibodies.
Breastfeeding is protective of maternal and infant health across the life course, thus increasing breastfeeding rates in Black communities is an important public health strategy to improve health outcomes. Furthermore, per the CDC, low rates of breastfeeding add more than $3 billion a year to medical costs for the mother and child in the United States, and, conversely, medical costs are significantly lower for fully breastfed infants because they usually require fewer sick care visits, prescriptions, and hospitalizations. Indubitably, breastfeeding is an important modifiable risk factor for both mothers and infants. And still, Black women and birthing people’s experiences of medical racism and implicit bias in health care settings adversely impact breastfeeding initiation, and the resulting health benefits, protections, and advances toward health equity, despite racism, bias, and discrimination being modifiable barriers.
The Necessity of Nuance
Unfortunately, breastfeeding is often presented as an independent choice or selected preference by those in a position of privilege, so perhaps the next best step for increasing breastfeeding awareness, education, and support is to shift the narrative away from posits of individualism and instead focus on the multisectoral influences that shape a new mother’s opportunity to even begin breastfeeding. While there is a vast body of existing legislation that focuses on workplace protections to secure breastfeeding duration, it can be considered a moot point if not preceded by paid family and medical leave, which secures the critical time period when successful breastfeeding is initiated, and exclusivity is practiced. Though the workplace protections are essential, there is a significant gap in legislation to address breastfeeding initiation—which, for most moms, begins in the hospitals and birthing centers immediately following birth—and reactively focuses on duration. I contend that the preconception and perinatal periods are the most important and impactful points of entry for promoting breastfeeding awareness, education, and support.
My two breastfed babies, Ceylon III and Daxton, were first introduced to the world in 2020 and in 2021, respectively, at the same time I was working to inform lawmakers and the public about how the Black Maternal Health Momnibus Act advances breastfeeding awareness, education, and support. However, my now 2.5-years-and-counting breastfeeding journey didn’t begin so idyllically. As noted in Imbued With Nutritional Riches: A Black Mother’s Breastfeeding Journey, I discuss how I was perfectly capable of and wanting to breastfeed following the birth of my first son in December 2019, but vulnerable and exhausted having just given birth, and was actively dissuaded by the medical team. What if my breastfeeding experience ended with the medical professionals in the hospital who dismissed me and delegitimized my efforts? What if my growing family didn’t have access to a wealth of resources, including sixteen weeks of job-protected parental leave and out-of-pocket costs for a lactation consultant to visit our home within hours of my discharge from the hospital?
Tying the Ends of the Rainbow
As a health policy professional who is only three months past the postpartum period following the birth of my second son in May 2021, I understand how policy informs practice; and I am familiar with the language and lens of both the impacted community and the stakeholders. To this end, what if there existed a health care system that enhanced new parents and families’ ability to breastfeed during the preconception period by increasing awareness and providing education about its benefits? What if we considered pregnant women and birthing people as “prospective” breastfeeding parents and began offering support and assistance during prenatal care, including making breast pumps available during pregnancy, so that’s one less task to complete during the vulnerable postpartum period as opposed to current Medicaid2 policies that require moms to wait until the birth of the baby to obtain a pump? What if the 65 percent of Black women in the United States who are enrolled in Medicaid during pregnancy weren’t just automatically “eligible” for WIC, but auto-enrolled, so that, too, could be one less task to complete during the vulnerable, exhausting postpartum period? What if there were federal investments in multilevel systems of support? The results would be astounding!
As declared by the CDC, “Breastfeeding is an investment in health, not just a lifestyle decision!” Building upon what already exists—including the Momnibus, the DEMAND Act, the PUMP for Nursing Mothers Act, the Pregnant Workers Fairness Act, and the FAMILY Act—what is needed is federal legislation that comprehensively addresses low breastfeeding initiation, duration, and exclusivity among historically and systematically marginalized communities through federal policies, programs, and partnerships. Key policies that would make this happen include the following:
In this demand for policy and system changes, it is imperative that policymakers, public health officials, practitioners, and the public understand that—like paid family and medical leave—breastfeeding is a public health imperative, and with substantial, systems level investments, breastfeeding will advance health equity!
Notes
Tags: health care, black maternal health, health equity