Presenting Breastfeeding As A Choice Is Contributing To Black Infant Deaths

The current and much-needed national conversation regarding America’s black maternal and infant mortality crises is missing a critical thread: the role that breastfeeding plays in saving the lives of black infants. It’s an important point to make, particularly as World Breastfeeding Week starts Wednesday.

Studies show that even college-educated black women disproportionately give birth to babies who die during infancy from complications related to birth size and weight. Nationally, black babies die at more than twice the rate of white babies. And some areas of the country have it worse than others; in prosperous San Francisco, black infants die at a rate of 9.6 per 1,000 compared to a rate of 2.1 per 1,000 for white infants.

Breast milk can be lifesaving for premature infants, who often have underdeveloped guts and compromised immune systems. But black women have the lowest breastfeeding rates in the country, which means the babies who need breast milk the most aren’t getting it.

And this isn’t a new issue. For more than 40 years, stark racial disparities have existed between white and black breastfeeding rates, particularly when you look at women who exclusively breastfeed for six months and who exclusively breastfeed for 12 months (the gold standard of infant nutrition as recommended by the American Academy of Pediatrics). According to recent CDC data, only 17 percent of black infants were still breastfeeding at 12 months, whereas nearly double the rate of white infants met that standard.

Given the high stakes, it’s imperative to better understand why more black women aren’t choosing to or able to continue breastfeeding after birth.

National discourse often frames breastfeeding as a lifestyle choice instead of a public health matter ― more akin to choosing a cloth diaper as opposed to the preventative medicine it provides. But scientists are learning more and more every day about how a baby’s first foods shape their health trajectory. No mother should be made to feel bad about their infant feeding decisions; however, all women deserve informed decision-making.

Many mothers do consciously choose to breastfeed, and breast milk substitutes are important when needed, but talking about choice without a broader conversation of how those choices are shaped by a woman’s circumstances is simplistic ― and dangerous. Is breastfeeding really a “choice” for an hourly factory worker who has to return to the job two weeks after giving birth because Americans live in the only industrialized nation that doesn’t offer a federal paid maternity leave (and the small employer has not made any accommodations for the biological needs of new mothers)?

No woman, regardless of a paycheck, should have to choose between keeping her job or giving her baby breast milk.

Researchers have historically blamed low black breastfeeding rates on a lack of education about breastfeeding and its benefits. But just as we’re learning the black maternal mortality crisis is not only about prenatal education or income but more about the impact of historical trauma, policy gaps, and bias and racism in maternity care, we can’t ignore the impact these forces have also had on breastfeeding information access and support networks. And this means having an uncomfortable conversation about race.

Black women have always breastfed. In fact, during slavery, black women were known as “feeders” and often forbidden from breastfeeding their own children in order to breastfeed the children of their white owners. As the years went on, white middle- and upper-class women who viewed breastfeeding as beneath them were able to turn their children over to a wet nurse ― often a black woman.

This negatively associated breastfeeding with slavery and mammy-ism, a connection that lingers in the minds of many grandmothers and family matriarchs who are highly influential in modern black family structures. And it’s left today’s black women with a disproportionate lack of multigenerational support; many receive negative cues about breastfeeding from their older relatives. The tragic irony, here? Women who were previously actively breastfeeding white people’s children are now the ones breastfeeding their own children the least.

Stereotypes about who breastfeeds and who doesn’t, supported by media images, suggest breastfeeding is for white women of privilege; black women, on the other hand, have been stereotyped as good caretakers for other people’s children but distrusted as capable parents of their own.

This pernicious lie affects the information and support black women receive. In my work all over the country, black women consistently report their physician didn’t properly educate them on breastfeeding, often limiting the conversation to just one question ― “Will you, or won’t you? ― and then moving on. And thus, the stereotype of black women not breastfeeding becomes a self-fulfilling prophecy.

Studies have also shown that black mothers experience higher rates of early formula supplementation, which means they’re never even getting the chance to properly “choose” to breastfeed. One study found African-American infants were more than nine times more likely than white babies to be given formula in the hospital. Early supplementation is a death knell for continued breastfeeding because a woman’s milk supply increases the more you breastfeed (and decreases if you stop).

Why are black mothers disproportionately being given infant formula? This 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.

In the many spaces people are talking about breastfeeding, very few mainstream organizations are highlighting the impact of structural racism and inequities of support and access. Many public health agencies are overly focused on “evidence-based research” (of which black people were likely not participants) without valuing the experiential knowledge and lived experience of the black community as a source for real solutions.

The innovation needed to reverse America’s black infant mortality crises won’t come from a “savior” mentality, or from avoiding uncomfortable conversations about structural racism and bias in care practices, or from hiding behind “choice” rhetoric. And breastfeeding rates within the black community won’t be revived with a single solution approach.

Consider the broader food movement, for example, which acknowledges a person’s ability to eat well is impacted by where they live. Similarly, environmental factors and local access to support are critical factors in helping more black infants receive optimal nutrition. And we can’t ignore the valuable role of midwives, doulas and childbirth centers, especially when it’s clear our current maternity care system is failing black mothers and babies.

We must end the dangerous conversation of breastfeeding as a “choice” without a deeper discussion as to how black women’s choices are shaped by their circumstances, and how the lack of federal paid maternity leave means properly establishing and maintaining breastfeeding has become a privilege instead of a right. We must put black mothers and infants at the forefront of the breastfeeding conversation. Black communities also have solutions, can also lead innovation and ultimately save themselves and their infants ― if only we would listen.