Abstract
Background: Breastfeeding is protective of maternal and infant health across the life course. Increasing breastfeeding rates in Black communities is an important public health strategy to address maternal and infant mortality and morbidity.
Methods: Data trends for the past 10 years suggest that Black-led community efforts; local, state, and national initiatives; and maternity care practices that are supportive of breastfeeding have been effective in improving and increasing breastfeeding rates among Black women.
Results: Yet breastfeeding disparities and inequities in Black communities persist. Systemic and structural barriers, such as racism, bias, and inequitable access to lactation resources and support continue to be issues in the United States.
Conclusion: Going forward, significant investments are needed to decolonize breastfeeding research and clinical practice. Public health and policy priorities need to center on listening to Black women, and funding Black, Indigenous, and People of Color (BIPOC) organizations and researchers conducting innovative projects and research.
Keywords: breastfeeding, Black women, racism, equity, communities
Introduction
Breastfeeding provides physiological, psychological, and immunological benefits for people who breastfeed their infants and for infants who are breastfed.1 Breastfeeding is also associated with economic benefits for society and significant health benefits over the life course course.1,2 For example, in the immediate postpartum period, people who breastfeed experience more rapid uterine involution, decreased postpartum bleeding, and, therefore, reduced the risks associated with closely spaced pregnancies.1,2 In addition, people who breastfeed lower their risk of heart disease, reproductive cancers, such as uterine and breast cancers, and type 2 diabetes.1–5 Breastfed infants are less likely to experience ear infections, necrotizing enterocolitis, gastrointestinal infections, and sudden infant death syndrome; and children that were breastfed experience lower rates of diabetes and obesity.1,2 Furthermore, in 2016, researchers estimated that breastfeeding as recommended by the World Health Organization (WHO)1,6 would prevent >820,000 child deaths and 20,000 maternal deaths a year and save $300 billion annually in reduced health care costs and improved economic outcomes for those nurtured by an exclusive human milk diet, globally.1,6 However, due to systemic and structural barriers, such as racism, bias, and inequitable access to lactation support and resources, suboptimal breastfeeding is more pervasive in Black communities in the United States.7
Breastfeeding disparities and inequities have persisted in these Black communities for >400 years, since the chattel enslavement of African women and families.7–9 Systemic racism, inequitable access to resources and support, and inadequate diversity among the lactation workforce are root causes and drivers of these disparities and inequities.7–9 Black women and birthing people have experienced unfortunate challenges in regard to meeting their infant feeding goals, specifically related to breastfeeding and chestfeeding.10–12 In fact the literature is clear, Black women and infants experience more racism, and systemic and structural barriers during the perinatal period in comparison with other populations.13–16 In-hospital health care providers are less likely to discuss breastfeeding options or services with Black women and maternity care practices supportive of breastfeeding are limited in Black communities13; formula feeding of Black infants immediately after birth is nine times higher than among White infants,14 and Black infants experience disparate care in neonatal intensive care unit (NICU) settings.15,16 Thus, we cannot continue to discuss racial inequities and disparities in breastfeeding without acknowledging historical, sociocultural, political, and economic contexts that support them over time.17 As all of these factors, and others, continue to impact breastfeeding initiation, duration, and exclusivity in Black communities.
Breastfeeding Trends: What Does the Data Show?
For several decades, the rates of breastfeeding among all populations have risen.18,19 Significant gains in breastfeeding rates for Black women have been noted in the past 10 years.20 The most recent 2020 CDC Breastfeeding Report Card, which reports on infants born in 2017, shows that 84% of infants born in the United States were ever breastfed, but only 58% and 35% of those infants were still breastfeeding at 6 and 12 months, respectively.18 This trend is a celebrated increase as the 2010 CDC Breastfeeding Report Card noted only 75% of infants had ever been breastfed and at 6 and 12 months, respectively, only 43% and 22% of infants born in 2007 were being breastfed.19 In regard to exclusive breastfeeding at 3 and 6 months after birth, we also see increases in rates over time from 33% and 13% in 201019 to 47% and 26% in 2020, respectively.18
Among Black women in the United States, we observed similar trends, as shown in Figure 1. According to the CDC National Immunization Survey (NIS), in 2010, 63% of Black infants in the United States had ever been breastfed.20 At 6 and 12 months, the rate of breastfeeding decreased to 36% and 16%, respectively. However, the most recent NIS (2017) illustrates that 74% of U.S.-born Black infants were ever breastfed, and that 48% and 26% of those infants remained breastfeeding at 6 and 12 months, respectively.20 In addition, the number of Black women providing human milk exclusively to their infants at 3 and 6 months after birth has also increased. In 2010, we saw ∼27% and 13% of Black infants being exclusively breastfed at 3 and 6 months, respectively.20 Whereas, in 2017, we saw noteworthy increases to 39% and 21% in the number of Black infants being exclusively breastfed at 3 and 6 months, respectively.20 Overall, a greater number of infants are receiving human milk throughout the first 6 months of life and more women will experience the protective mechanisms associated with breastfeeding.
FIG. 1.
Black breastfeeding rates over time. Color images are available online.
The qualitative research conducted for the past decade has also elucidated important aspects related to barriers and facilitators of breastfeeding in Black communities. Researchers have noted the historical and sociocultural contexts perpetuating and dismantling inequities.10,17 Recent studies have also highlighted the significance of social media platforms as a mechanism to obtain necessary breastfeeding information and support during the perinatal period.21,22 Peer-to-peer support, whether in-person or virtual through social media platforms, is critical in Black communities.17,23 In addition, to the importance of intergenerational support of grandmothers and other social support persons.10,24,25 Researchers have also identified that Black women are meeting and exceeding public health recommendations in some communities; however, culturally appropriate information related to weaning after long-term breastfeeding was needed.26
It is important that we know and share these data; however, the story of breastfeeding in Black communities does not end with these numbers. The contextualization of these data is critical to obtaining a deeper understanding of the role of systemic and structural barriers in preventing Black women and families from meeting their infant feeding goals.10,17 We also acknowledge that every birthing and lactating person does not utilize the terms: women, mother, and breastfeeding, to describe themselves or their infant feeding practices. For the purpose of this article, this language is being used to be consistent with the data presented. However, we call on all of our colleagues, especially researchers to take steps to ensure that data collection on infant feeding is not exclusionary, or does not exclude people based on their gender, language, race, ethnicity, or cultural backgrounds.
Breastfeeding Trends: Making Sense of the Data
Breastfeeding rates in the United States are on the rise and Black women are breastfeeding. Each year, more and more women, infants, and families have greater access to maternity care practices, such as the Baby-Friendly Hospital Initiative (BFHI),27,28 which are supportive of breastfeeding and community resources that are culturally appropriate.27,28 This early and continuous support is critical to protecting, promoting, and supporting breastfeeding, especially as it pertains to maintaining these gains and increasing breastfeeding initiation, duration, and exclusivity rates in black communities. However, there is a critical need for the equitable implementation of The Ten Steps and the BFHI in hospitals serving communities with a high proportion of Black families.27,28 These data further highlight the significant efforts and contributions of Black-led community-based organizations and local, state, and national initiatives to address and improve breastfeeding inequities and disparities. Organizations such as Reaching Our Sisters Everyone (ROSE), Black Mothers' Breastfeeding Association (BMBFA), Center for Social Inclusion, and HealthConnect One as well as numerous community-led efforts such as the creation of Black Breastfeeding Week, online support groups, and community-centered peer-to-peer breastfeeding trainings have been instrumental in driving the breastfeeding trends observed in the United States today. Although there are still great opportunities for continued growth, support, and investment.
Discussion
For the past decade, there has been increased attention to the importance and normalization of breastfeeding in the lives of women, infants, and families. In 2011, the Surgeon General of the United States issued a Call to Action to Support Breastfeeding.29 This critical public health document outlined essential issues concerning infant feeding, specifically addressing breastfeeding initiation, duration, and exclusivity. The Surgeon General's Call to Action identified communities and community-based organizations as opportunities to strengthen and better support breastfeeding in the United States. Specifically, the Surgeon General highlighted community-based strategies such as (1) increasing peer-to-peer support; (2) ensuring continuity of care; (3) increasing maternity care practices that are supportive of breastfeeding; (4) funding nonprofit organizations that support breastfeeding, especially in communities of color; (5) ensuring that all MCAH public health programs include breastfeeding education and support; (6) developing a community and national campaigns to promote breastfeeding; and (7) ensuring the application of the International Code of Marketing of Breast-milk Substitutes (the WHO Code).29 Consequently, the Surgeon General has called for additional resources and investments into other public health strategies and community-based efforts that are supportive of breastfeeding mothers and infants.29 We must stand strong and continue to support the work of our community partners.
Breastfeeding is an especially important public health issue in Black communities, particularly given that Black families and communities continue to experience the highest burden related to poor maternal and infant health outcomes, including higher incidence of preterm birth, low birth weight, maternal mortality and morbidity, infant mortality, and lower breastfeeding rates.3,30 Owing to lifetime exposure of racism, bias, and stress, Black women experience higher rates of cardiovascular disease, type 2 diabetes, and aggressive breast cancer.3–5 Given that cardiovascular disease and postpartum hemorrhage are leading causes of maternal mortality and morbidity, increasing breastfeeding rates among Black women can potentially save lives.3–5 Yet breastfeeding is rarely seen as a women's health, reproductive health, or a public health strategy to address or reduce maternal mortality and morbidity in the U.S. Inequities in lactation support and breastfeeding education exacerbate health inequities experienced by Black women, specifically maternal mortality and morbidity, and thus a greater investment in perinatal lactation and breastfeeding education and resources is warranted. Breastfeeding is an essential part of women's reproductive health. This point has been further made during the coronavirus disease 2019 (COVID-19) pandemic.
The current COVID-19 pandemic has significantly impacted the way individuals, families, and communities access and receive maternity care services, support, and resources, globally.31 Owing to COVID-19 restrictions, lactation support and maternity care practices supportive of breastfeeding have been significantly impacted.32–34 To mitigate the spread and exposure to COVID-19, many hospitals, clinics, public health programs, and community-based organizations implemented very restrictive visiting policies. These restrictions eliminated critical birth and breastfeeding education, support, and community resources. Furthermore, staff were substantially reduced (e.g., essential vs. nonessential), services transitioned to online, virtual or telehealth consultations, or programs completely closed their doors.31,34 At the height of the pandemic, patients that were identified as being severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive or under investigation were often separated from their infants immediately after birth.33,34 The separation of maternal–infant dyads potentially impacted bonding, skin-to-skin opportunities, and breastfeeding and chestfeeding initiation and may have long-term health consequences for the dyad.33,34 Given that Black, Indigenous, and People of Color (BIPOC) communities have experienced higher rates of COVID-19 infections and deaths and inequitable access to testing and vaccines, the pandemic has only exacerbated pre-existing health disparities and inequities impacting Black communities.35–37 Going forward, we need multiple public health and clinical strategies that center community experiences and expertise and are informed by Community-Based Participatory Research (CBPR) principles.36,37
Finally, we need to shift the narrative as it pertains to Black breastfeeding in the United States. We know disparities exist. However, what are we doing to reduce and eliminate disparities and inequities? Context and actions matters. We need to decolonize breastfeeding research by decentering the white supremacy, Eurocentrism, and racism embedded within scientific, biomedical, and public health projects, and creating new research paradigms and practices that have been developed by and for Black communities, such as those outlined by the Black Mamas Matter Alliance, Center for Social Inclusion, and Reaching Our Sisters Everywhere.38–41 We need to decolonize clinical practice by increasing the number of BIPOC lactation support persons (International Board-Certified Lactation Consultants, Certified Lactation Consultants, Certified Lactation Educators, Breastfeeding Peer Counselors, etc.) in all settings where lactation support is needed. We need more research that highlights positive breastfeeding experiences of Black women, families, and communities. We need to shift from a deficit-based model to a more resilience-focused perspective. We also need to address the lack of diversity among breastfeeding researchers and research teams.42 It is unethical and potentially harmful to conduct research on disparities and inequities with all White research teams.42 This practice has gone on long enough and it is time we call out this perpetuation of racist ideology and research oppression. We need more BIPOC breastfeeding and lactation researchers asking questions, developing and testing interventions, analyzing data, and disseminating recommendations. We also need more investment in community-led and initiated research. Finally, we need to trust, support, and listen to Black women to effectively increase equitable and just breastfeeding outcomes.
Conclusion
Breastfeeding protects the health of women, infants, and children across their life course. Significant gains have been achieved in the past 10 years; however, there is still a great deal of work to do as it pertains to protecting, promoting, and supporting breastfeeding in Black communities. We need to properly fund black-led community-based organizations and researchers and continue to support efforts that call for diversification of the breastfeeding and lactation workforce. To achieve breastfeeding equity and ultimately justice, we need to trust, support, and listen to Black women.
Authors' Contributions
Conceptualization, project administration, writing original draft, review, and editing by I.V.A. Conceptualization, review, and editing by K.B. Conceptualization, project administration, review, and editing by A.E.L.P.
Acknowledgments
The authors are very thankful to Drs. Caryl Gay and Audrey Lyndon for their critical and meaningful reviews and comments of this article.
Disclosure Statement
No competing financial interests exist.
Funding Information
Ifeyinwa Asiodu was supported by a NICHD/ORWH-funded K12 (K12 HD052163), Hellman Family Fellows Fund, and Society of Family Planning Changemakers Award.
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