Breastfeeding is for white women. This sentiment was expressed by several Black women featured in Chocolate Milk, an eye-opening documentary series that was shown during a 2-week virtual breastfeeding elective created for medical students and implemented amid the coronavirus disease 2019 pandemic.1 In addition to learning about proper latch techniques, effective positions, and the breastfeeding challenges that women face, our learning also revealed racial disparities in breastfeeding. As 2 medical students who identify as Black and Native American, we desired to dig deeper to better understand the roots of these disparities and the systemic changes we can advocate for within medicine.
Racial disparities in breastfeeding are similar to those that persist in other facets of health, including infant mortality. According to the Centers for Disease Control and Prevention (CDC), only 25.6% of all US infants born in 2017 were exclusively breastfed through 6 months of age. Whereas the 6-month exclusive breastfeeding rate among white infants born in 2017 was above the national average at 28.7%, only 21.2% of Black infants born in the same year and 19.6% of Native American infants born in 2015 (there is a lack of reporting after 2015) were exclusively breastfed for the first 6 months of life.2 Given the known benefits of breastfeeding for both mother and infant and the increased risks of comorbid health conditions for these communities, there is much to learn about how these disparities began and the policies that have fueled them.3 The explanation for the disparities among Black and Native American infants is likely multifactorial, but each group possesses a unique historical legacy.
The consequential effects of slavery may partly explain the disparity in breastfeeding rates among the Black community. For many enslaved women, breast milk supplementation arguably began at ∼3 months because the demands of slave labor prevented nursing women from optimally breastfeeding their infants.4 Additionally, supplementation was often with “potlicker,” the nonnutritious broth left over from cooking greens.4 The psychological impact of being a wet nurse, forced to provide nourishment to the slave master’s children instead of one’s own, likely has lasting effects because breastfeeding practices are often influenced by the practices of previous generations and may be shaped by historical trauma.4 In the 1950s, racially targeted formula advertisements promoted the false notion that formula provided superior infant nutrition.4 Today, Black mothers are twice as likely to receive in-hospital formula introduction than white mothers, possibly reflecting the long-standing impacts of many of the aforementioned historical elements, including these marketing schemes.5
Similarly, many factors contribute to the breastfeeding disparity within Native American communities. Although little is published about its history, the issue is rooted in loss of culture and the subsequent lack of trust in the Western health care system. Traditionally, breast milk was known as the first food and was a large part of the mother-child bond.6 However, many Native customs, including breastfeeding, suffered after the implementation of assimilatory policies and media campaigns.7,8 Countless lives were lost when Native American nations were forced to relocate hundreds of miles and children were separated from their families through government-funded boarding schools.7 These atrocities destroyed the relationship between tribal nations and the United States and interrupted the passage of traditional practices, such as breastfeeding, down from the elders.8 The influence of modern federal government campaigns over Native mothers is less conspicuous. Today, the distribution of commodity food boxes to new mothers (often containing powdered milk and formula) encourages formula, rather than breast milk, as the default form of nutrition for Native newborns.9
Many public health organizations have supported breastfeeding through various initiatives. One example is the Baby-Friendly Hospital Initiative (BFHI), which was established by the World Health Organization and United Nations International Children’s Fund in 1991 and recommends steps to promote and support successful breastfeeding. Although the number of Baby-Friendly–designated facilities has increased in the United States since its adoption, these facilities are disproportionately less accessible in neighborhoods of color. The CDC’s 2011 Maternity Practices in Infant Nutrition and Care Survey revealed that facilities in communities with >12% of Black residents were significantly less likely to implement even half of the supportive breastfeeding recommendations.10 A recent study, however, revealed significant increases in initiation and exclusive breastfeeding among African American infants with improved hospital compliance of BFHI steps.11 Additionally, the Indian Health Service (IHS) system has revealed successful adoption of BFHI practices. After release of the CDC’s report of low breastfeeding rates among Native women, breastfeeding promotion became a point of focus for the IHS, and since 2014, every IHS birthing hospital has become Baby-Friendly certified, a crucial step in creating equitable change for this community.12
Robust education on the benefits and promotion of breastfeeding in the medical curriculum across various trainee levels and multidisciplinary specialties is also a necessary step in reducing disparities. In 2011, the Surgeon General called on all health professional organizations to integrate breastfeeding education into medical training.13 However, standardized requirements have yet to be established within undergraduate and graduate medical education.13 Although research is limited, in a 2017 study of one medical school, 64% of students reported not receiving any formal breastfeeding education during their training.14 In pediatric residencies, breastfeeding education occurs in continuity clinics, faculty lectures, and rounds with faculty.3 Interestingly, surveys of pediatric, family medicine, and obstetrics and gynecology residency program directors revealed that pediatric and family medicine residents only receive ∼3 hours of breastfeeding education each year, whereas obstetrics and gynecology residents receive double that.3
Including innovative methods for delivering this education is an effective way to educate trainees with minimal resources. During our 2-week breastfeeding elective, we independently completed online modules (which contained a list of reading and video material curated by faculty educators), researched and presented on breastfeeding topics, and met virtually as a group to discuss various issues in breastfeeding. Additionally, we observed virtual lactation consultant visits with new mothers, in which we saw real-life challenges and tangible solutions. Equally important is increasing the recruitment of and supporting providers of color as potential advocates in this field. Because bias among trainees and providers can perpetuate the issue of racial inequities in breastfeeding, implicit bias training and antiracist training are important catalysts for change.15
Health equity cannot be achieved without institutional changes. The BFHI is a remarkable intervention; however, to be equitable, it needs to be accessible to all. Policies and budgets that mandate and support all facilities to adopt these practices as the standard of care would mark a step in the direction of equity. Although the issue of health inequities is not new, it is one that is finally garnering necessary attention. The myriad challenges facing Black and Native American communities have been underscored by the events of 2020, including racial disparities in the coronavirus disease 2019 pandemic and the high-profile deaths of Black Americans. Schools and training programs should offer formal breastfeeding curricula that address challenges in these vulnerable populations. As medical trainees, it is imperative that we learn and understand the historical context from which racial and ethnic inequities stem and the systemic factors that perpetuate them. Through this historically informed lens, we can approach patients with empathy and be equipped to appropriately address their beliefs and concerns regarding breastfeeding, an important international public health domain for ensuring healthy future generations.
We thank our virtual breastfeeding elective faculty cosponsor, Dr Lydia Furman.
Dr Lam, Ms Mieso, and Ms Burrow conceived, drafted, reviewed, and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Dr Lam was a contributing editor for Human Diagnosis; and Ms Mieso and Ms Burrow have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr Lam was a contributing editor for Human Diagnosis; and Ms Mieso and Ms Burrow have indicated they have no financial relationships relevant to this article to disclose.