Supporting breastfeeding is one of the most cost-effective interventions that countries, including the United States, can make to improve maternal and child health outcomes. This commentary addresses why it is crucial for the United States to invest more in breastfeeding support ensuring that the needs and wants of people of color and other socio-economically disadvantaged groups are met.
IMPORTANCE OF BREASTFEEDING
Breastfeeding should be prioritized as a key component of a healthy food and nutrition system that is essential for advancing food security and nutrition, public health, and economic development in all countries. This is because, regardless of the level of socioeconomic development of nations, breastfeeding offers numerous well-documented health benefits to infants and children, such as reduced neonatal mortality, incidence of infectious diseases and childhood obesity risk, and improved cognitive development. Furthermore, it reduces the risk of major noncommunicable diseases among women, including breast and ovarian cancer, hypertension, cardiovascular disease, and type 2 diabetes.
BREASTFEEDING INEQUITIES
A recent international comparison of large-scale breastfeeding programs shows that even though breastfeeding promotion and support programs have been implemented and breastfeeding outcomes continue to improve in the United States, there is still a lot of room for improvement.1 According to the Centers for Disease Control and Prevention (CDC), in the United States, between 2008 and 2018, the proportion of women who were choosing to initiate breastfeeding increased from 74.6% to 83.9%, exclusive breastfeeding through 6 months increased from 14.6% to 25.8%, and the prevalence of breastfeeding at 12 months increased from 23.4% to 35.4%. Furthermore, there are strong breastfeeding inequities experienced by women of color and women of lower socioeconomic status largely driven by socioeconomic and ethnic/racial inequities in breastfeeding in the country. In the United States, almost 60% of women do not breastfeed for as long as they would like, and women of color are much less likely to meet their breastfeeding goals. Indeed, among women enrolled in the Supplemental Nutrition Program for Women Infants and Children (WIC), Black and Hispanic women are much less likely than their White counterparts to meet their breastfeeding goals.2 As recently seen in the United States, women who rely on formula may be subject to the added stress from formula shortages, whether they are a result of formula recalls or supply chain issues in the context of an oligopoly-like structure of the infant formula industry, and this crisis has affected women of color much more than White women. Why these inequities exist and what can be done to address them are the focus of this editorial.
BARRIERS FOR IMPROVING BREASTFEEDING
Breastfeeding outcomes can be improved by addressing breastfeeding protection, promotion, and support through intersectoral multicomponent policies and programs that operate across layers of the social-ecological model.3 When it comes to breastfeeding protection, women and families need access to paid maternity and paternal leave for a reasonable amount of time and workplace breastfeeding accommodations. Furthermore, parents, other caregivers, and families need to be protected against exploitative marketing practices from the breast milk substitutes (BMS) industry.4,5 Unfortunately, the United States remains the only high-income country without a federal mandate for paid maternity leave; as a result, many women return to work very soon after giving birth, especially lower-income women and women of color. Furthermore, women of color and those of lower socioeconomic status are more likely to be employed in part-time positions in service sector jobs that do not make accommodations for pumping or breast milk storage, another structural barrier that undermines breastfeeding equity.
In addition, the United States is the only country that voted against the 1981 World Health Organization (WHO) Code for Marketing of Breastmilk Substitutes, and there is evidence that BMS companies specifically target commercial milk formula marketing to families of color with infants and young children. This ubiquitous marketing is delivered via traditional and social media, product placement in stores, and even through health care providers. It often targets women because they are pregnant and in the early postpartum period, when they can be quite psychoemotionally vulnerable, strongly undermining the confidence that women have in their ability to breastfeed.4,5 Marketing efforts also include touting health benefits of BMS that are not supported by scientific evidence. In addition, marketing of toddler milks that are totally unnecessary, expensive, and rich in added sugars is particularly concerning, because regular cow’s milk is recommended for the vast majority of 12–24-month-old children.6 There is also strong evidence that US corporations, including the BMS industry and manufacturers of other ultraprocessed foods, alcoholic beverages, biotechnology, pharmaceuticals, chemicals, plastics, and electronic gaming are engaged together in well-organized lobbying efforts to undermine the WHO regulation proposals, including those designed to restrict BMS marketing,4,7 thus negatively affecting breastfeeding and other public health outcomes globally.
Regarding promotion, the global experience indicates that behavior change social marketing campaigns are effective at improving breastfeeding behaviors.1 However, on the one hand, previous attempts by the United States government have not yielded expected results, because they have been marred by controversy regarding the decision of the government to avoid discussion of the risks of not breastfeeding in campaign messaging.8 On the other hand, the WIC Loving Support Campaign has lacked the resources and depth needed to have a stronger impact on breastfeeding outcomes.9 One of the biggest challenges has been that even though WIC personnel are strongly supportive of breastfeeding, funding for meeting the breastfeeding counseling demand is quite limited in the context that WIC is the largest distributor of free infant formula in the world. Hence, it is not surprising that WIC participants have the lowest breastfeeding rates in the United States, even when compared against their low-income counterparts not enrolled in the program. This represents a major concern of inequity because WIC serves low-income families and ethnic/racial groups that have historically been discriminated against and are overrepresented in the program that serves more than half of the births every year in the United States. In essence, WIC is a program that strongly endorses breastfeeding while providing easy access to free infant formula in an environment where families are being bombarded with quite aggressive and predatory marketing.4–6 Marketing strategies include targeting women and families during pregnancy and the very early postpartum period, which is quite concerning because it has been established that early introduction of infant formula is a strong risk factor for the premature termination of breastfeeding.10
ENABLING THE BREASTFEEDING ENVIRONMENT
All women should have access to qualified breastfeeding counseling and support beginning in pregnancy and continuing throughout the perinatal and postnatal periods. The Baby Friendly Hospital Initiative Ten Steps are effective at improving breastfeeding outcomes3; thus, it is encouraging that, according to the CDC, the proportion of babies born in Baby Friendly Hospitals in the United States has increased from 4.5% in 2011 to 28.9% in 2021, and this initiative has been shown to improve breastfeeding outcomes across groups while reducing inequities.3 To ensure the continuum of breastfeeding care quality, breastfeeding support should be delivered through maternity facilities in partnership with community-based organizations following community-engaged approaches that are culturally sensitive and respect the dignity of all clients. Women of color in the United States often feel that providers do not listen to them or feel disrespected when trying to talk about infant feeding choices.11,12 Similar sentiments have been expressed by low-income rural White women in the United States (Seiger et al., p. S797). There is evidence that, among women of color, stereotyping, discrimination, and structural racism may play a role in the lack of attention that providers pay to their breastfeeding intentions and needs.11,12 Furthermore, there is a lack of ethnic/racial diversity among providers they have contact with, and the great majority have not received antiracism and trauma-informed care preservice or in-service education and training.
Black women in the United States have a much higher risk than White women of delivering premature newborns. They need to benefit much more from the knowhow on how to effectively feed these newborns with their own breast milk or with donor milk obtained through certified human milk banks. Breastfeeding reduces the risk of necrotizing enterocolitis, which is a major cause of mortality among premature babies and fosters, and this is key for the cognitive development of infants born prematurely.
MOVING FORWARD
Given the need to further improve breastfeeding outcomes in the United States while reducing ethnic/racial inequities and protecting women from predatory marketing practices of formula producers, ensuring infants’ food security and good nutrition, it is crucial for the US government to lead and invest much more in enabling large-scale sustainable multicomponent and multilevel programs through specific actions of a comprehensive and inclusive agenda (Box 1).
BOX 1—
Governmental Actions Recommended for Improving Breastfeeding Outcomes and Reducing Racial/Ethnic Inequities in the United States
| Breastfeeding protection |
| • Pass legislation to mandate paid maternity leave for at least 14 weeks (ideally 18 weeks) as recommended by the International Labor Organization. Also consider providing paternal leave for the first weeks after birth. |
| • Establish a task force to determine how the FDA and other agencies can regulate the unchecked marketing of infant formula and other commercial milk formula products. |
| • Conduct a consensus study through a neutral authoritative body to understand how to improve breastfeeding outcomes among WIC participants, given that while supporting breastfeeding it distributes massive amounts of free infant formula. |
| Breastfeeding promotion and support |
| • Launch a behavior change communications campaign co-designed with communities of color to call for all of society to support breastfeeding women and to make breastfeeding across settings (including in public) the social norm. |
| • Incentivize permanent reimbursements from government and private insurance for breastfeeding counseling services provided by community health workers or peer counselors to maternity facilities and community organizations. |
| • Form a task force to make recommendations on how schools of medicine, nursing, and allied health professions can substantially strengthen their breastfeeding education and training curricula, including antiracism and trauma-informed care content. |
| • Improve funds for research and expansion of certified human milk bank services in the United States. |
| • Design a public health emergency preparedness plan to support breastfeeding during public health emergencies such as the COVID-19 pandemic. The risks of not breastfeeding for the baby under emergency conditions should be clearly communicated to the public. |
| Monitoring and evaluation |
| • Enhance breastfeeding data collection through national food and nutrition monitoring systems, including BRFSS and NHANES, paying special attention to having representative samples from women of color. The capacity to collect data on infant feeding outcomes among premature infants should also be enhanced. |
| • Increase funding for large-scale multicomponent and multilevel breastfeeding programs implementation research through PCORI and federal agencies such as NIH, CDC, and USDA. |
Note. BRFSS = Behavioral Risk Factors Surveillance System; CDC = Centers for Disease Control and Prevention; FDA = United States Food and Drug Administration; NHANES = National Health and Nutrition Examination Survey; NIH = National Institutes of Health; PCORI = Patient-Centered Outcomes Research Institute; USDA = United States Department of Agriculture; WIC = Supplemental Nutrition Program for Women Infants and Children.
Although it is encouraging that, under the leadership of the CDC and other federal agencies, the United States continues to make strides in improving breastfeeding outcomes, further improvements and reduction in inequities will require strong, proactive leadership from the US government. This will require addressing persistently powerful structural barriers embedded in our market-driven political and economic systems that prioritize profits over public health. The recent second White House Conference on Hunger, Nutrition, and Health is providing the United States with a once-in-a-lifetime opportunity to ensure that, as a society, we make the case that breastfeeding should be a national priority as one of the key elements for improving food systems, public health, and early childhood development. We need to support the right that women have to breastfeed their children for as long as they want to or as long as it is recommended. Let’s take this opportunity to contribute to improve health, as well as food and nutrition security, for all. Personalized nutrition for optimal health begins with breastfeeding!
ACKNOWLEDGMENTS
The author deeply thanks Donna J. Chapman and Sofia Segura-Pérez for their insightful feedback on previous versions of this editorial. The author was partially supported to write this editorial by the Cooperative Agreement Number 5 U48DP006380-02-00 funded by the Centers for Disease Control and Prevention, Prevention Research Center Program, through a grant to the Yale School of Public Health (principal investigator, Rafael Pérez-Escamilla).
Note. The opinions expressed in this editorial are those of the author only and do not necessarily represent the official views of the Centers for Disease Control and Prevention.
CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.
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