How do we close the stubborn racial gap in breastfeeding? New book offers ideas

The United States has one of the lowest rates of breastfeeding in the world, and it's been known for decades that the rates are particularly low among black women. Research offers various explanations for this disparity. Among them: Health care providers are less likely to talk to black women about breastfeeding during pregnancy or after birth. Black moms tend to lack adequate family leave and return to work earlier after childbirth, often to jobs that do not accommodate breastfeeding.

And black newborns are far more likely to be given formula in the hospital—nine times more likely than white newborns, according to a study that found this to be the most important factor in a mother’s decision to forego nursing.

In her new book, “Skimmed: Breastfeeding, Race, and Injustice,” legal scholar Andrea Freeman untangles the fraught history of breastfeeding disparities and the implications for the health of black children and mothers through the astonishing story of America’s first surviving identical quadruplets.

The Fultz sisters were born to a black-Cherokee family of tenant farmers in North Carolina in 1946. They were instant celebrities and exploited by their white doctor. He named them Mary Louise, Mary Ann, Mary Alice and Mary Catherine, after his own relatives and without their parents’ permission. He displayed them behind glass and organized public viewings from 2 p.m. to 4 p.m. daily. When they were 6 years old, he had a judge remove them from their home and placed in the care of a nurse. He sold the rights to use them for marketing to the highest bidder, baby formula company Pet Milk. 

While it profited through racially targeted marketing and built a large customer base of black families, the girls lived in poverty.

It may be easy to read the Fultz story as an outrageous tale from a bygone era, before the civil rights movement and informed consent. But Freeman argues that the saga encapsulates the legal, social, cultural and economic barriers that to this day hinder black women from freely choosing how to feed their babies.

“This is a structural problem, not an individual problem or an education problem or an issue of personal preference,” Freeman said in an interview. “People are not presented with true choice. The goal of my work isn’t to change people’s minds or send a message that everybody should breastfeed. It is to advocate for structural reform, to make it possible for everybody to have a choice.”

Freeman traces the roots of the racial gap to slavery. Black women were forced to cut short breastfeeding their babies to return to work quickly or serve as wet nurses for the children of slave owners. 

“Because slavery was so brutal, oppressive and disrespectful to black families and to the role of mothers in the families, it was necessary for white society to develop stereotypes — lies — about black women to justify the practices,” Freeman said. “Maybe most significant is the stereotype of a black woman who loves to serve white people and loves white children even more than her own … This stereotype has continued way past slavery. It’s been a constant in films and other popular culture. And it connects to this myth that black women won’t breastfeed, shouldn't breastfeed, won’t be interested in breastfeeding. That myth infiltrates health care practitioners, unconsciously. So there’s a difference in the way that black women are treated by doctors and nurses.” 

"This is a structural problem, not an individual problem or an education problem or an issue of personal preference. People are not presented with true choice. The goal of my work isn’t to change people’s minds or send a message that everybody should breastfeed. It is to advocate for structural reform, to make it possible for everybody to have a choice," Freeman told me.

Rich in nutrients and antibodies, breast milk confers many well-documented health benefits. These include protection against ear infections, respiratory infections, asthma, sudden infant death syndrome and gastric distress. Breastfeeding helps teeth align properly, and it’s associated with a lower risk of obesity and Type 2 diabetes later in life. For women who breastfeed, it lowers the risk of breast cancer and there’s some evidence it offers protection against ovarian cancer, heart disease and diabetes.

The American Academy of Pediatrics (AAP) recommends that mothers feed their infants breastmilk exclusively for the first six months and combine it with the introduction of foods at least until 12 months, ideally longer. 

According to the most recent federal data, 74% of black newborns and 85% of white newborns initiate breastfeeding.  Those numbers drop within a week, and the racial gap widens as babies get older. Only 17% of black babies and 30% of white babies meet the AAP recommendations of six months of exclusive breastfeeding.

A study in the journal Pediatrics estimated that if 90% of families followed the AAP recommendations, the United States would annually save $13 billion in costs for  health care and lost work due to illness, and prevent roughly 900 infant deaths annually. It’s an urgent equity issue, given that black infants die at much higher rates than white babies, and black children are at much higher risk of developing many of the ailments that breastfeeding helps prevent.

So what will it take to boost breastfeeding rates across the board and close the racial gap? Freeman, an associate professor of law at the University of Hawaii at Manoa, points to key policies she says would help:

Adopt the World Health Organization ban on formula advertising. The U.S. is the only developed country that has not signed on to WHO’s International Code of Marketing of Breast Milk Substitutes, originally drafted in 1981. It prohibits formula companies from making contact with pregnant women or mothers of young children. It also sets standards for labeling, prohibits the promotion of formula and distribution of free samples at health facilities, and forbids company representatives from offering health care workers “financial or material inducements” — things like payments, conference sponsorships, branded office supplies, invitations to pay golf — to push formula. “If the United States signed on to the WHO Code, parents could make their infant feeding decisions free of undue and well-financed corporate influence,” Freeman writes.

Probably nothing more clearly illustrates the lobbying muscle of the formula industry than the government’s refusal to endorse the code. Consumers might never notice all the ripple effects of that refusal. In a newspaper op-ed earlier this year, Dr. W. Robert Revelette, a past president of the Kentucky Chapter of the American Academy of Pediatrics, lambasted the national AAP for continuing to accept support from formula makers and, perhaps not coincidentally, remaining silent on their aggressive marketing practices, despite the association’s public stance that breast milk is best.

Adopt “baby-friendly” hospital policies. These international standards require hospitals to implement 10 steps to help mothers initiate and sustain breastfeeding, including skin-to-skin contact and keeping mother and baby in the same room. The standards also bar maternity facilities from accepting free or discounted formula or feeding formula to newborns unless there's a medical need. A study published in January examined the impact of the 10-steps approach in four Southern states, where the black-white breastfeeding gap runs as high as 32%. The approach increased breastfeeding across all races and hospitals, with black women showing the largest gains.

Bar hospitals from distributing packs of free formula. Freeman writes that free formula giveaways disproportionately lower breastfeeding rates for mothers of color, first-time mothers, ill mothers and those with lower education levels. Only four states —  Rhode Island, Delaware, Massachusetts and New York — ban the practice, although many hospitals have voluntarily stopped doing it.

Improve workplace accommodations. Federal law requires employers to provide break times for new mothers to pump milk, and a private place other than a bathroom in which to do it. But the law does not require employers to provide storage for the pump or the milk and it doesn't protect against discrimination. For example, female pilots and attendants are suing Frontier Airlines, claiming the company fails to accommodate breastfeeding. Freeman reports that two-thirds of cases alleging breastfeeding discrimination from 2008 to 1018 led to the employee losing her job.

Mandate adequate parental leave. The U.S. is the only industrialized country without a federal law requiring paid parental leave. Freeman writes that only four states — New York, New Jersey, Rhode Island and California — offer paid leave and none of them cover a parent's full salary. Researchers at UC San Francisco studied the impact of the legislation in California and New Jersey and found it increased breastfeeding rates, but mainly among higher-income women who could afford to take time off.