A little more than 83% of U.S. families breastfeed after giving birth. This is the result of a large public health campaign that’s taken place over the past four decades to address falling breastfeeding rates following the introduction and marketing of infant milk formula and hospitalized births. The medical establishment has since promoted breastfeeding widely for its lifelong health benefits for infants and mothers.
While breastfeeding is the biological norm, and universally acknowledged by experts as the healthiest option for feeding an infant, we believe there is too much lip service and too little substantial support for families who want to breastfeed. Instead, families that struggle or fail to breastfeed often experience feelings of shame or failure. As researchers, though, we know myriad societal, health and economic forces make exclusively breastfeeding for six months — as recommended by all major health organizations — challenging.
Only 25% of U.S. infants are exclusively breastfed at six months, and this statistic is even lower among Black infants. Racism has long been implicated in infant feeding, from enslaved people wet nursing White infants instead of their own, to exploitative formula marketing to disparities in health care access.
While racism in breastfeeding support has been largely overlooked for decades, these disparities are becoming increasingly well-documented. This prompted our research team at the Boston Medical Center’s Breastfeeding Equity Center to dive deeper into the breastfeeding experiences of birthing people in Massachusetts to understand the current breastfeeding support landscape and ways to improve it.
When patients’ feeding plans are ignored or dismissed
We have been conducting in-depth interviews with Black mothers, and the picture painted by lactating parents is bleak — though there are glimmers of hope. Many mothers describe supportive nurses and lactation consultants who took the time to help them with latching and assisted when their milk came in. However, many patients also felt belittled by staff who lectured them in a condescending manner about what makes a good mother or offered unsolicited formula, disrespecting their feeding choices. These experiences reflect what we see in our clinical practice, where staff may leave racial bias unexamined in their interactions with patients. As health care workers, we have a responsibility to confront and address bias, and as researchers, we are using our studies to unmask it by talking directly to Black mothers.
One mother we spoke to recalled being taken to the recovery room, elated after delivering her first child. But her joy quickly turned to an unpleasant surprise when she saw a pack of premixed formula waiting on her nightstand. She had told her doctors she intended to exclusively breastfeed, and formula was not in her plan.
Hospitals that follow best practices should offer formula for medical reasons or if a parent requests it. While staff may feel that providing unsolicited formula is helpful, it undermines a mother’s decision to feed her child. This reinforces a lack of autonomy and unexamined bias, which impacts Black and Brown families. Seeing a patient struggling to breastfeed, staff often offer formula to help “make life easier,” but our emerging research shows that implicit bias causes this to happen more often with Black patients, while White families receive more breastfeeding help when they struggle.
Another mother, whose community and family all chose breastfeeding, was told by a doctor in the hospital that her baby needed formula to raise its blood sugar. She felt confused about why she was being told breastmilk alone was not good enough and why formula was the answer to her infant’s low blood sugar. Staff could have offered skin-to-skin contact and counseling about expressing breastmilk, even if the offer was alongside formula. There is growing evidence that skin-to-skin contact and colostrum — the breast milk that comes in the first days after birth — effectively reduce low blood sugar in babies who are at risk. When the mother is Black or Brown, not offering an alternative to maintain their breastfeeding goal undermines their feeding plan and represents bias.
The experiences of these mothers are not unique, even within hospitals designated as “baby-friendly;” these hospitals’ practices center the desires of birthing parents and the needs of their infants, and they also often promote successful breastfeeding. It is clear there is still much to be done to make baby-friendly hospitals a reality.
Change must come from the top of the hospital system
In our quest for solutions, we have also interviewed hospital staff about what is and isn’t working to help families meet their breastfeeding plans. We have learned staff is aware of various flaws in their work due to a mix of policy shortcomings and problematic attitudes.
Some recall overhearing assumptions about how immigrants “all mix feed.” Others have reported that some nurses seem to have trouble connecting with patients of a different race or ethnicity. (Yet most Black patients reported interacting almost exclusively with White nurses and health care professionals.) Staff have also felt pressure from their administrations to see more patients, which dramatically limits their ability to appropriately counsel patients on breastfeeding. Pressed for time, lactation consultants and nurses find themselves called more frequently to the rooms of White families because those families request their services more often and more vocally than Black and Brown families. In some hospitals, lactation consultants are not even sent to help families that have been given formula, even if they are still trying to breastfeed. Diversity and inclusion training is sometimes provided to doctors, but the budget is not allotted to frontline nurses who actually provide most breastfeeding counseling.
Identifying and examining personal bias and racism may address some of the disparities in breastfeeding outcomes for Black and Brown families, but these disparities do not occur in a vacuum. Institutional and systemic racism are part of the system that allows these imbalances to persist. Change needs to come from the top. It is the responsibility of hospitals and national organizations to make it possible for staff to receive training, intentionally hire more Black and Brown providers and lactation consultants with fair compensation, and create a culture of safety and accountability where incidents of racism are acknowledged and addressed seriously. Hospitals may commit to baby-friendly best practices, but without acknowledging that current practices are not providing equitable care, Black and Brown families will continue to face disparities in their breastfeeding journeys.
Making ‘breast is best’ work for everyone
Despite the current inequalities in breastfeeding support, we see plenty of reasons to expect progress in this space. Both patients and health care workers have voiced a need for intentional hiring practices that bring in more Black and Brown providers, such as language-concordant providers and lactation consultants, in order to create more culturally sensitive breastfeeding spaces. The Black and Brown communities we’ve spoken to, such as our patients at BMC, need more prenatal breastfeeding education and help advocating for their feeding plans. Training for staff must include exposure to the direct experiences of Black and Brown birthing people who have long been sidelined from giving input to improve their own breastfeeding experiences.
The Breastfeeding Equity Center’s next step is to guide all hospitals in providing breastfeeding support by learning more about what matters most to parents and the current limitations health care providers experience. By putting teeth behind the phrase “Breast is best” by implementing universally available support and antiracist hospital policies, more families will be able to achieve their breastfeeding goals.
Many healthcare interventions can help families successfully breastfeed and address compelling evidence of racist structures that perpetuate the vicious cycle of health inequities.
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Why we despise the phrase ‘breast is best’
by Katherine Standish, Afi Semenya and Candace Smith, The Emancipator May 16, 2024
Dr. Katherine Standish is a family medicine doctor and researcher at Boston University School of Medicine who specializes in breastfeeding medicine.
More by Katherine Standish
Dr. Afi Mansa Semenya is an assistant professor of family medicine and healthy equity researcher at Boston University School of Medicine.
More by Afi Semenya
Originally from Connecticut, Candace attended Tufts University as an undergraduate, where she majored in biology and child studies and human development before working for a Massachusetts-based managed care organization conducting patient focus groups to improve program services. She then studied medicine at Boston University, where Candace was a Medical Students for Choice Leader, the medical campus sustainability representative, and a leader of the Family Medicine Interest Group. Graduating medical...
More by Candace Smith
Why we despise the phrase ‘breast is best’
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A little more than 83% of U.S. families breastfeed after giving birth. This is the result of a large public health campaign that’s taken place over the past four decades to address falling breastfeeding rates following the introduction and marketing of infant milk formula and hospitalized births. The medical establishment has since promoted breastfeeding widely for its lifelong health benefits for infants and mothers.
While breastfeeding is the biological norm, and universally acknowledged by experts as the healthiest option for feeding an infant, we believe there is too much lip service and too little substantial support for families who want to breastfeed. Instead, families that struggle or fail to breastfeed often experience feelings of shame or failure. As researchers, though, we know myriad societal, health and economic forces make exclusively breastfeeding for six months — as recommended by all major health organizations — challenging.
Only 25% of U.S. infants are exclusively breastfed at six months, and this statistic is even lower among Black infants. Racism has long been implicated in infant feeding, from enslaved people wet nursing White infants instead of their own, to exploitative formula marketing to disparities in health care access.
While racism in breastfeeding support has been largely overlooked for decades, these disparities are becoming increasingly well-documented. This prompted our research team at the Boston Medical Center’s Breastfeeding Equity Center to dive deeper into the breastfeeding experiences of birthing people in Massachusetts to understand the current breastfeeding support landscape and ways to improve it.
When patients’ feeding plans are ignored or dismissed
We have been conducting in-depth interviews with Black mothers, and the picture painted by lactating parents is bleak — though there are glimmers of hope. Many mothers describe supportive nurses and lactation consultants who took the time to help them with latching and assisted when their milk came in. However, many patients also felt belittled by staff who lectured them in a condescending manner about what makes a good mother or offered unsolicited formula, disrespecting their feeding choices. These experiences reflect what we see in our clinical practice, where staff may leave racial bias unexamined in their interactions with patients. As health care workers, we have a responsibility to confront and address bias, and as researchers, we are using our studies to unmask it by talking directly to Black mothers.
One mother we spoke to recalled being taken to the recovery room, elated after delivering her first child. But her joy quickly turned to an unpleasant surprise when she saw a pack of premixed formula waiting on her nightstand. She had told her doctors she intended to exclusively breastfeed, and formula was not in her plan.
Hospitals that follow best practices should offer formula for medical reasons or if a parent requests it. While staff may feel that providing unsolicited formula is helpful, it undermines a mother’s decision to feed her child. This reinforces a lack of autonomy and unexamined bias, which impacts Black and Brown families. Seeing a patient struggling to breastfeed, staff often offer formula to help “make life easier,” but our emerging research shows that implicit bias causes this to happen more often with Black patients, while White families receive more breastfeeding help when they struggle.
Another mother, whose community and family all chose breastfeeding, was told by a doctor in the hospital that her baby needed formula to raise its blood sugar. She felt confused about why she was being told breastmilk alone was not good enough and why formula was the answer to her infant’s low blood sugar. Staff could have offered skin-to-skin contact and counseling about expressing breastmilk, even if the offer was alongside formula. There is growing evidence that skin-to-skin contact and colostrum — the breast milk that comes in the first days after birth — effectively reduce low blood sugar in babies who are at risk. When the mother is Black or Brown, not offering an alternative to maintain their breastfeeding goal undermines their feeding plan and represents bias.
The experiences of these mothers are not unique, even within hospitals designated as “baby-friendly;” these hospitals’ practices center the desires of birthing parents and the needs of their infants, and they also often promote successful breastfeeding. It is clear there is still much to be done to make baby-friendly hospitals a reality.
Change must come from the top of the hospital system
In our quest for solutions, we have also interviewed hospital staff about what is and isn’t working to help families meet their breastfeeding plans. We have learned staff is aware of various flaws in their work due to a mix of policy shortcomings and problematic attitudes.
Some recall overhearing assumptions about how immigrants “all mix feed.” Others have reported that some nurses seem to have trouble connecting with patients of a different race or ethnicity. (Yet most Black patients reported interacting almost exclusively with White nurses and health care professionals.) Staff have also felt pressure from their administrations to see more patients, which dramatically limits their ability to appropriately counsel patients on breastfeeding. Pressed for time, lactation consultants and nurses find themselves called more frequently to the rooms of White families because those families request their services more often and more vocally than Black and Brown families. In some hospitals, lactation consultants are not even sent to help families that have been given formula, even if they are still trying to breastfeed. Diversity and inclusion training is sometimes provided to doctors, but the budget is not allotted to frontline nurses who actually provide most breastfeeding counseling.
Identifying and examining personal bias and racism may address some of the disparities in breastfeeding outcomes for Black and Brown families, but these disparities do not occur in a vacuum. Institutional and systemic racism are part of the system that allows these imbalances to persist. Change needs to come from the top. It is the responsibility of hospitals and national organizations to make it possible for staff to receive training, intentionally hire more Black and Brown providers and lactation consultants with fair compensation, and create a culture of safety and accountability where incidents of racism are acknowledged and addressed seriously. Hospitals may commit to baby-friendly best practices, but without acknowledging that current practices are not providing equitable care, Black and Brown families will continue to face disparities in their breastfeeding journeys.
Making ‘breast is best’ work for everyone
Despite the current inequalities in breastfeeding support, we see plenty of reasons to expect progress in this space. Both patients and health care workers have voiced a need for intentional hiring practices that bring in more Black and Brown providers, such as language-concordant providers and lactation consultants, in order to create more culturally sensitive breastfeeding spaces. The Black and Brown communities we’ve spoken to, such as our patients at BMC, need more prenatal breastfeeding education and help advocating for their feeding plans. Training for staff must include exposure to the direct experiences of Black and Brown birthing people who have long been sidelined from giving input to improve their own breastfeeding experiences.
The Breastfeeding Equity Center’s next step is to guide all hospitals in providing breastfeeding support by learning more about what matters most to parents and the current limitations health care providers experience. By putting teeth behind the phrase “Breast is best” by implementing universally available support and antiracist hospital policies, more families will be able to achieve their breastfeeding goals.
Related
Paying attention: Boston hospital helps breastfeeding Black moms, babies thrive
Many healthcare interventions can help families successfully breastfeed and address compelling evidence of racist structures that perpetuate the vicious cycle of health inequities.
It’s possible to change low rates of Black breastfeeding, but it starts with acknowledging the legacy of slavery
Increasing breastfeeding through a public health approach isn’t enough. First, we need to reshape Black breastfeeding narratives.
Katherine Standish
Dr. Katherine Standish is a family medicine doctor and researcher at Boston University School of Medicine who specializes in breastfeeding medicine. More by Katherine Standish
Afi Semenya
Dr. Afi Mansa Semenya is an assistant professor of family medicine and healthy equity researcher at Boston University School of Medicine. More by Afi Semenya
Candace Smith
Originally from Connecticut, Candace attended Tufts University as an undergraduate, where she majored in biology and child studies and human development before working for a Massachusetts-based managed care organization conducting patient focus groups to improve program services. She then studied medicine at Boston University, where Candace was a Medical Students for Choice Leader, the medical campus sustainability representative, and a leader of the Family Medicine Interest Group. Graduating medical... More by Candace Smith