The Racial Disparity in Breastfeeding

Breast milk provides optimal nutrition for infants, giving them the vitamins, protein and fat they need to grow. Some studies suggest that breastfeeding may even reduce the risk of certain allergic diseases, asthma and obesity in babies, as well as type 2 diabetes in moms.

But for minority moms and babies, breastfeeding can pose unique challenges including systemic lack of paid leave, provider bias and cultural barriers.

The American Academy of Pediatrics recommends breastfeeding as the sole source of nutrition for the first six months of a baby’s life and continued breastfeeding with complementary foods through at least the first year. The percentage of babies who start out breastfeeding has increased in recent years, with 81.1 percent of women breastfeeding their babies at birth; however, breastfeeding rates for African-American mothers are significantly lower than rates for other racial groups. In addition, Hispanic women initiate breastfeeding at slightly lower rates than white women.

UNC maternal-fetal experts Alison Stuebe, MD, and Venus Standard, MSN, have studied racial disparities in breastfeeding. We asked them why these gaps exist and what can be done to improve breastfeeding rates in minority populations.

Unpaid Leave Hurts Minority Moms

Lack of paid maternity leave disproportionately affects families of color.

“Department of Labor studies show that African-American and Hispanic mothers are more likely than white women to be sole earners and to have low-wage jobs that lack paid sick leave,” Dr. Stuebe says.

This means they must get back to work soon after the baby is born.

“The Department of Labor found that 23 percent of employed women were back at work within 10 days of having a baby,” Dr. Stuebe says. “This is not enough time to establish breastfeeding.”

A woman with no savings or paid leave is at an enormous disadvantage because she cannot afford to take unpaid leave.

“We can reduce health disparities by protecting each woman’s right to breastfeed her children,” Dr. Stuebe says.

Providers May Carry Bias

Dr. Stuebe says another barrier to breastfeeding in minority populations relates to provider support. Tamar Ringel-Kulka, MD, MPH, assistant professor of maternal and child health at the Gillings School of Global Public Health, led a community-based research study in Durham, North Carolina, that examined breastfeeding in African-American communities. Participants shared that they felt their doctors simply assumed they would formula feed because of their race.

“I think providers make assumptions about what a woman’s feeding intentions might be, based on her race, ethnicity, income, age, marital status and occupation,” Dr. Stuebe says. “Providers may ask the questions about breastfeeding differently, or not ask at all, based on those assumptions.”

For example, Dr. Stuebe says she has found that providers tend to make assumptions about Latina women and breastfeeding around a concept called los dos.” This phrase, which means “both,” is used to describe the common practice of using formula supplementation with breastfeeding.

Dr. Stuebe says this means that if a Latina woman asks for formula, her provider might assume she is doing “los dos” and not feel the need to explain why exclusive breastfeeding is recommended for the first six months or that colostrum is nutrient-dense.

Colostrum, also known as first milk, is the milk produced by the mammary glands in late pregnancy and the first few days after giving birth.

In addition, Dr. Stuebe says language can be a barrier to optimal provider support.

“If a Spanish-speaking woman says, ‘I need formula. I’m worried my baby isn’t gaining enough weight’ through the interpreter or through the provider’s mediocre Spanish, the provider might just give her a sample without trying to educate her on the importance of breastfeeding,” Dr. Stuebe says. “It would be different than a woman who spoke the same language as the provider, and they could communicate and the provider might say, ‘Well, here’s why we encourage you just to give breast milk.’”

Cultural Barriers and Norms Play a Role

Standard says cultural barriers also are a factor in minority populations’ decisions to breastfeed.

For example, some mothers in the Hispanic community consider it taboo to breastfeed for the first three days of their baby’s life, she says.

“They think it is harmful to the child to breastfeed those first couple of days, so the colostrum is off-limits,” Standard says.

But colostrum is rich in nutrients that assist with immunity, growth and tissue repair.

Cultural barriers also exist in the African-American community. Standard says she experienced them herself.

“When I gave birth 40 years ago, formula was just becoming popular and the thinking was that if you could afford formula, why wouldn’t you use it versus breastfeeding, which was for those who could not afford formula. Also, my mom told me not to breastfeed, so I didn’t,” Standard says. “Thirty years later, breastfeeding was taboo for different reasons (among African-Americans). It was not that formula was too costly, because you could get it on WIC (the Special Supplemental Nutrition Program for Women, Infants and Children) if you wanted it, but instead you didn’t breastfeed because none of your friends were breastfeeding. You wear the same shoes and clothes as your friends, so if your friends aren’t breastfeeding, you aren’t either.”

Standard says she has started to see a shift in attitudes toward breastfeeding among African-American patients in the past five years because of the work of breastfeeding advocates.

Campaigns that promote breastfeeding for women of color, such as the Normalize Breastfeeding campaign on Facebook created by African-American photographer Vanessa Simmons, are “helping to let them know there is no stigma around breastfeeding and that breastfeeding is most beneficial for your baby,” Standard says.

Dr. Stuebe notes fewer women of color are trained as lactation consultants compared with white women. To address this systemic barrier, UNC’s Carolina Global Breastfeeding Institute was recently awarded $1.3 million to train lactation consultants at colleges serving communities of color.

There is also strong evidence that peer counseling is effective, particularly for getting breastfeeding started.

“If mom has mastitis (infection), the baby has a cleft lip or the baby’s in the NICU (neonatal intensive care unit), then you need someone with more training, but sometimes you just need a girlfriend,” Dr. Stuebe says. “Having a person who you can identify with who can say, ‘Oh, I breastfed, and yeah, my mom thought it was crazy, but we made it work and now she gets it’ — that can make a big difference.”

Training the Next Generation of Providers

Standard says she also emphasizes the importance of breastfeeding when she provides obstetrical care to her patients and in the childbirth classes she teaches. In addition, she makes it a point to teach medical residents cultural differences and how to help navigate those.

“Because our residents are from all over the country, they may not have experience with other cultures,” Standard says. “They may not have experienced the stigma African-American women fear about breastfeeding. So if we have an African-American patient who tells us she is not planning to breastfeed, they can see how I work with that patient to explain the benefits of breastfeeding. When you’re training your students, you can tell them all you want, but what they see you do is more important.”

If you have questions about breastfeeding, talk to your doctor or pediatrician. If you don’t have one, find one near you.