Abstract
I
A mother's role in the life of her child before, during, and after pregnancy is both vital and critical. A mother's preconception and interconception care is key to healthy birth outcomes. According to the U.S. Centers for Disease Control and Prevention (CDC), once a woman has given birth, one of the most highly effective and preventive measures she can take to protect the health of her infant is to breastfeed. 2
However, in the United States, breastfeeding rates among U.S. women fall short of the Healthy People 2010 national goals, which are (1) to increase to 75% the proportion of women who initiate breastfeeding, (2) to increase to 50% the proportion of women who continue breastfeeding their babies until 6 months of age, and (3) to increase to 25% the proportion of women who breastfeed their babies until 1 year of age. 1 Additionally, breastfeeding rates show that only 45% of African American women reported ever breastfeeding compared with 66 and 68% of Hispanic and white women, respectively. 3
It wasn't always that way, according to Monique Sims-Harper, director of A More Excellent Way Health Improvement Organization and a spokeswoman for the California Breastfeeding Coalition. “When blacks came to this country they breastfed their babies and often their masters' babies.” After slavery ended, she says, “Black women often continued to work as wet nurses for white families. They were really the experts in the field.”
Wet nursing claimed the benefits of breastfeeding for the offspring of white masters while denying or limiting those health advantages to enslaved infants. On the other hand, wet nursing required slave mothers to transfer to white offspring the nurturing and affection they should have been able to allocate to their own children. 4 Slave owners would stop black women from breastfeeding early because it reduced fertility and allowed early breeding among the enslaved Africans. Slave owners did this to grow the population on the plantation. This decision was a detriment to the infant. Wet nursing undoubtedly had emotional and mental effects that have been ignored and disregarded until this day.
The tide slowly turned in the 1920s, during the Great Depression. Breastfeeding became the way of life because mothers could not afford formula. However, aggressive marketing by the formula companies in the 1930s and 1940s made formula feeding the choice of the elite or “the substance for sophisticates,” whether white or black.
What was once the only choice for women had now become the secondary choice as formula companies invaded communities with advertised promises that formula-fed children were healthier and stronger. Formula was especially appealing to working moms and became the obvious choice for those with little or no time to breastfeed.
This change would unknowingly transform the nation's perspective on breastfeeding and thus create an issue that would impact African American communities for generations to come.
Community Impact
The impact of fewer breastfed babies in the black community cannot be ignored. The rates of asthma, respiratory infection, and childhood obesity are increasing among infants and black children. Even worse, black babies are dying at 2.4 times the rate of white infants—a sobering disparity that the CDC says could be reduced by at least 50% simply by increasing breastfeeding among black women. Studies prove that exclusive breastfeeding reduces the risk of these diseases.
Barriers to Breastfeeding
In order to combat the low breastfeeding rates in the black community, key stakeholders must discuss the barriers black women are facing.
During the winter of 2007/2008, Soul Food for Your Baby (SFYB) conducted 10 focus groups with expectant or new mothers, grandmothers, and fathers. Overall, the focus groups aimed to assess among African Americans the perceived benefits and risks of breastfeeding, as well as cultural perceptions and barriers to breastfeeding.
The barriers noted in the SFYB report 5 included cultural attitudes, pain, lack of education, lack of support, and socioecologic issues. Focus group participants reported breastfeeding in the black community is somewhat compromised. Although breastfeeding is embraced in other cultures, there seems to still be a stigma in certain communities of color.
Other studies show women with friends who have breastfed successfully are more likely to choose to breastfeed. On the other hand, negative attitudes of family and friends can pose a barrier to breastfeeding. Some mothers say that they do not ask for help with breastfeeding from their family or friends because of the mixed messages they receive. 5
Barriers to breastfeeding also include little to no support from healthcare professionals and hospitals at the time of delivery. Nearly all births in the United States occur in hospital settings, but hospital practices and policies in maternity settings can undermine maternal and infant health by creating barriers to supporting a mother's decision to breastfeed. National data from the ongoing CDC survey of Maternity Practices in Infant Nutrition and Care (mPINC) indicate that barriers to breastfeeding are widespread during labor, delivery, and postpartum care, as well as in hospital discharge planning. Results of the 2009 mPINC survey showed that, on average, U.S. hospitals scored only 65 out of a possible 100 points on an overall measure of breastfeeding-related maternity care. 6
Other common barriers include little to no access to jobs that promote maternity leave, a private space to pump, or the ability to pump at work.
“African-American women are also less likely to receive traditional healthcare services, so they don't always get a formal breastfeeding education. These institutional barriers then create a knowledge gap, as black women who want to try breastfeeding are less likely than non-black women to have sisters, mothers or friends who can offer their own experience and advice. In the African-American community, because our rates are so low, we don't see breastfeeding as the norm,” says Dalvery Blackwell, the co-founder of the African American Breastfeeding Network of Milwaukee, WI.
Community Support
The success rate among mothers who want to breastfeed can be greatly improved through active support from their families, friends, communities, clinicians, healthcare leaders, employers, and policymakers. Given the importance of breastfeeding for the health and well-being of mothers and children, it is critical that we take action across the country to support breastfeeding.
Breastfed children have at least six times greater chance of survival in the early months than non-breastfed children. An exclusively breastfed child is 14 times less likely to die in the first 6 months than a non-breastfed child, and breastfeeding drastically reduces deaths from acute respiratory infection and diarrhea, two major child killers. 7
To increase breastfeeding rates in underserved communities, key stakeholders must work together to combat the issue. For example, in Madrid, Spain, The Global Breastfeeding Initiative was established to increase breastfeeding rates by the Excellence in Paediatrics community. Excellence in Paediatrics is passionate about breastfeeding and understands the importance that breastfeeding infants for the first 6 months exclusively, with continued feeding until 12 months, has on the long-term health and well-being of the child. Its members have identified emerging barriers that mothers and families face in their modern lives that often interfere with their ability to breastfeed successfully. 8
This global health initiative is just one example of how we can impact communities when a grassroots approach is adopted and implemented. The Global Breastfeeding Initiative is committed to convening stakeholders to form breastfeeding embassies in key countries, who will share best practices and ideas at their Annual Global Breastfeeding Summit. Stakeholders are committed and will act as conduits to increase breastfeeding rates on local and national levels. The initiative is all-inclusive in its structure and makeup and recognizes that breastfeeding rates can only be increased through collaboration among all key stakeholders.
In 1991, UNICEF and World Health Organization launched “The Baby-Friendly Hospital Initiative” to ensure all maternities, whether free standing or in a hospital, become the center of breastfeeding support. A maternity facility can be designated “Baby-Friendly” when it does not accept free or low-cost breastmilk substitutes, feeding bottles, or teats and has implemented10 specific steps to support successful breastfeeding. 9
Health reform is key to combating barriers that moms face on local and state levels. For example, the new Patient Protection and Affordable Care Act has implemented legislation to protect moms desiring to breastfeed, in following sections:
1. Section 4207: “Reasonable Break Time for Mothers” • Businesses of greater than 50 employees provide unpaid break time and a place other than the bathroom for nursing mothers to express their milk up until the child is a year of age. 2. Section 2713: “Coverage of Preventative Health Services” • The U.S. Preventative Services Task Force recommendation for breastfeeding includes pre- and postnatal breastfeeding education and formal breastfeeding evaluations undertaken by trained caregivers in the hospital and outpatient care settings, followed by interventions to correct problems as needed.
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A Call to Action
In 2011, “The Surgeon General's Call to Action to Support Breastfeeding” pressed for expansion of some methods that have been proven to improve breastfeeding rates for all women. Those include programs that provide mother-to-mother support and peer counseling as well as more “Baby-Friendly” hospitals. Such hospitals would have all nurses trained in breastfeeding support and follow World Health Organization recommendations such as helping mothers initiate breastfeeding within an hour of birth and avoiding formula unless medically necessary. The CDC recommends that babies be breastfed exclusively for at least the first 6 months of life. 2
Further training of and conversations by clinicians are key with new mothers about how important it is to breastfeed and teach them how to do it. Most medical, residency, and nursing programs do not teach students enough about breastfeeding. Training and continuing education programs are important for clinicians to be more confident about giving advice on breastfeeding.
Preconception education should be presented during annual obstetrical appointments and presented during sex education classes for middle and high school students.
Final Thoughts
The recommendations on breastfeeding from the World Health Organization and UNICEF are as follows:
• Initiation of breastfeeding within the first hour after the birth
• Exclusive breastfeeding for the first 6 months
• Continued breastfeeding for 2 years or more, together with safe, nutritionally adequate, age-appropriate, responsive complementary feeding starting in the sixth month
There are hundreds of documented cases that prove breastfeeding has a profound impact on a child's survival, health, and development. Communities of color with the highest infant mortality rates and the lowest birth outcomes can benefit from ongoing, hands-on case management from grassroots organizations like Great Beginnings for Black Babies, Inc. (GBBB). For more than 25 years, GBBB has served more than 500 families annually through case management, health education, and preconception/interconception education. GBBB's mission is to reduce infant mortality in targeted communities by encouraging women to seek early and continuous prenatal care and to adopt healthy lifestyles, to promote the healthy development and growth of babies and children, and to promote healthy and strengthened outcomes for families.
GBBB is collaborating with Centinela Hospital, located in Inglewood, CA (a designated Baby-Friendly Hospital) for the implementation of Welcome Baby, a universal home visitation program that emphasizes skin-to-skin support. GBBB is committed to improving breastfeeding rates in the black community and the communities in which it serves. Our Black Infant Health program is committed to increasing breastfeeding rates specifically in low-income communities in Los Angeles County. Through one-on-one support and group interventions, GBBB's staff work in conjunction with clients, their families, and other community-based organizations to create an environment where clients are encouraged, supported, and empowered to breastfeed. Clients are provided with hands-on education, materials, and supplies that encourage breastfeeding, and the staff is trained to provide an empathetic approach to moms unsure about breastfeeding or who have barriers that may prevent them from being able to breastfeed.
If we as a nation are committed to increasing a black woman's desire to breastfeed, it's imperative for local and national organizations, doctors, healthcare professionals, and community organizers to come together and create programs with a holistic approach that examines the historical impact that slavery, wet nursing, and formula marketing have had on a woman's desire and ability to breastfeed. As we address “negative” cultural norms in the black community around breastfeeding, we will see barriers decrease. I believe by acknowledging where we've been as a nation, then we can prepare for where we're going. All women are entitled and should be educated and supported regarding their decision to breastfeed. Continued support will enable moms to make an informed decision that's guaranteed to impact the life of her child.
Footnotes
Disclosure Statement
No competing financial interests exist.