Working to Close the Breast-Feeding Gap

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When Dr. Chelsea McKinney became pregnant with her first child nine years ago, she and some of her friends, all African-American, felt that their families weren’t supporting their desire to nurse.

Dr. McKinney, of NorthShore University HealthSystem in Evanston, Ill., said that despite decades of the “breast is best” message, African-American women often are not encouraged to nurse as much as white women.

“When your mother hasn’t breast-fed, it’s hard to get that support to breast-feed your own child,” Dr. McKinney said. “This is where health care providers have the opportunity to step in.”

She examined the topic of race and breast-feeding for her doctoral dissertation at Northwestern University in 2012 and found significant evidence of early formula supplementation in hospitals serving lower-income populations.

She was the lead author of a National Institutes of Health community study published last summer in Pediatrics, which found that the newborns of African-American women were nine times more likely than the babies of white mothers to be given formula in hospitals – a factor the researchers considered a significant contributor to the entrenched disparity in breast-feeding rates between black, white and Hispanic mothers.

The study included 1,636 mothers who gave birth between 2008 and 2010 in Baltimore, Washington, D.C., and Lake County, Ill., and found that only 61 percent of black mothers initiated breast-feeding, compared to 78 percent of white mothers.

Spanish-speaking Hispanic mothers, many of whom came from socioeconomic backgrounds similar to those of the black women studied, were most likely to initiate breast-feeding at 91 percent. What separated them from their black female counterparts was a reported family history of breast-feeding, a factor considered critical to breast-feeding success.

She found that hospitals serving lower-income populations “often rely on formula companies for financial support and lactation consultants are seen as supplemental, not essential,” Dr. McKinney said. “If a mother doesn’t make it clear that she wants to exclusively breast-feed, the nurses, who are already overwhelmed, will just pop a bottle in a baby’s mouth in the hospital. You’re already at a disadvantage.”

The study results mirror national data. Although breast-feeding rates continue to climb across racial groups, a recent National Immunization Survey found just 66.4 percent of black women initiated breast-feeding in 2012 and only 35.3 percent were still breast-feeding at six months. More than 80 percent of white and Hispanic mothers initiated breast-feeding, with a little more than 50 percent still breast-feeding six months later.

Keturah Redmond hoped to breast-feed after giving birth to her first child in an Atlanta hospital in 2012. Despite the help of a hospital lactation consultant, she and her daughter struggled. A nurse suggested supplementing with formula and sent Ms. Redmond home with a week’s worth of formula samples. She stopped breast-feeding soon after that.

“A lot of black mothers don’t have much support from home from a grandmother or father who might say, ‘Just give that baby a bottle,’ if the baby is crying or fussy,” said Ruby Crawford-Hemphill, assistant chief nursing officer at the University of Cincinnati Medical Center, who has worked with black mothers and families on breast-feeding education community initiatives.

In Ms. Redmond’s case, she tried again with her second child, a boy born in 2015 at a different Atlanta hospital. That time she feared that the colostrum she expressed wasn’t enough to keep him satisfied. The hospital sent her home with a bag of formula samples and coupons, and she stopped breast-feeding after three weeks.

“They showed me how to put the baby to my breast but they didn’t teach me about breast-feeding,” said Ms. Redmond, of Snellville, Ga., who is now 24, “It was discouraging to struggle with what I thought was supposed to come natural, and I wish they had at least told me what to expect and what was normal.”

Ms. Redmond said she thought she had to pump in addition to nursing at the breast to increase supply and keep up with the amount of formula her son was taking by bottle. Family members told her to give up when she complained of exhaustion. When she sought help from a WIC nutritionist, Ms. Redmond said she got formula coupons instead.

“I’m a pediatrician and I’ve always advised mothers not to supplement, especially in the first few weeks of establishing breast-feeding, so hearing that there was still so much introduction of formula in the hospital was surprising to me,” said Dr. Madeleine Shalowitz, a co-author of the N.I.H. study who is an associate professor of pediatrics at the University of Chicago Pritzker School of Medicine.

It didn’t surprise Dr. Ifeyinwa Asiodu, an assistant professor at the University of California, San Francisco. She began studying the impact of cultural and familial support on black women’s feeding decisions after working with pregnant mothers and new parents as a researcher, registered nurse and international board certified lactation consultant.

She said necessary steps include providing greater access to lactation assistance in lower-income communities, addressing beliefs that formula is a superior nutritional option and examining the resistance to a historical narrative of black women serving as wet nurses for white families during slavery.

“Breast-feeding is an especially important public health issue in the African-American community which is disproportionately impacted by prematurity, low birth weight, and infant mortality,” said Dr. Asiodu, who is completing research on social media impact on breast-feeding success.

“While breast-feeding cannot prevent prematurity or low birth weight, it has strong potential to mitigate poor birth outcomes and prevent infant mortality by supporting infant health, neurodevelopment and immune system development in vulnerable infants.”

“There’s a sense of stigma,” said Ms. Crawford-Hemphill, the Cincinnati nursing administrator and lactation consultant. “I’ve encountered black women who will say they aren’t a slave, or they don’t want the baby to be too attached to them or that no one else can help care for them if they’re being breast-fed.”

Like Ms. Crawford-Hemphill, black women are working on the ground in many major cities throughout the United States to change that narrative through peer-to-peer support before and after birth, whether through hospitals, the Women, Infants and Children program or in community-based breast-feeding groups led by black breast-feeding mothers, supporters and lactation consultants.

Groups like the Atlanta-based R.O.S.E. (Reaching Our Sisters Everywhere) and the Detroit-based Black Mothers’ Breastfeeding Association have helped pioneer an in-person support group model and stage local conferences that include black mothers and health care professionals to provide culturally sensitive assistance. Social media has provided a new opening for support, with groups like Black Women Do Breastfeed on Instagram and lactation consultants providing advice in Facebook groups geared toward black women.

“I was breast-feeding my first child and saw a lack of black representation in breast-feeding images and stories shared online,” said Nicole Sandiford, the founder of Black Women Do Breastfeed. Ms. Sandiford, now a mother of two in Charlotte, N.C., had her first child in 2009.

“I felt the narrative around black breast-feeding needed more balance,” she said, “because lots of black people were breast-feeding and should be able to see themselves reflected in breast-feeding advocacy.” She added: “Visible black breast-feeding helps to dispel the stigma against breast-feeding in some black communities.”

Ms. Redmond said that when she and her husband had their third child, a boy, in May, social media was a factor in her decision to give breast-feeding another try.

“My husband and I decided that this was going to be our last baby, making this my last chance to get it right,” she said. “We still had some bumps but I was more informed thanks to other breast-feeding moms. I didn’t even bring formula into my house this time. I threw away every coupon they sent me.”

“A lactation consultant did come to see me in the hospital and she was the most attentive of all of them, but I didn’t ask for much help from her,” Ms. Redmond said. “I feel like I got too much bad advice in the past. I knew that I had to teach myself.”