First Food Justice: Infant Feeding Disparities and the First Food System

Frequently, physicians, policymakers, and others concerned with public health in the United States focus primarily on breastfeeding as a woman and infant's issue, and for those not professionally involved in public health or actively feeding a baby at the time, breastfeeding rarely crosses their minds.

Yet we all once consumed first foods—perhaps human milk or infant formula—and, as adults, between 80% and 90% of us will become parents. Annually, around 4 million babies are born in the United States. Most Americans—whether ourselves, our friends, our colleagues, and/or our neighbors—will thus be directly involved in providing first foods at some point in addition to having consumed them. Breastfeeding and first foods thus affect us all both as individuals and as a society of eaters and feeders.

Moreover, breastfeeding confers a variety of shared benefits that extend well beyond those engaged in feeding and/or eating. This includes having significant positive effects on community health and well-being, workplace strength, and environmental integrity.

Finally, we all affect breastfeeding. Society, the economy, and the environment constrain and enable breastfeeding success. Breastfeeding is thus an issue that both shapes and is shaped by everyone. It is important we recognize this reality for our own individual interests as well as those we as a citizenry hold in common.

Public health professionals have established with significant certainty that human milk is the optimal first food and should be the sole source of nutrition, energy, and sustenance for all infants until the recommended age of 6 months. Breastfed babies appear to experience a decreased incidence of many infectious diseases, cancers, type 1 and 2 diabetes, obesity, and asthma later in life when compared to those who do not breastfeed. More immediately, breastfeeding confers a variety of critical health benefits that result in breastfed infants being 21% less likely to suffer postneonatal infant mortality—premature death occurring between 28 days and 1 year of age—than those who do not breastfeed. ¹

Despite breastfeeding's known benefits however, breastfeeding rates are suboptimal in the United States. While around 80% of women and infants initiate breastfeeding, only around 50% of babies are still nursing at 6 months of age; moreover, less than 20% of infants are exclusively breastfeeding as recommended at this time. ² In part, because of this, our national infant mortality rate is close to a staggering six deaths per one thousand live births. This means that there are 56 countries in the world where babies are more likely to survive infancy than in the United States. Our nation's children are more likely to live if they are born in almost any other “developed country,” in Bosnia and Herzegovina, in Hungary, in Monaco, or in Czechia, for example. ³

Most Americans wish to have developed the strongest personal health qualities from birth as possible, and they wish that for the next generation, as well. In addition, we as a society tend to promote health and vitality, often projecting onto the world stage claims about our advanced medical technologies and the ability for our country's citizens to live long, healthy, and productive lives. Breastfeeding plays a central role in whether these narratives are true not only in words but also in practice. Breastfeeding is thus important not only to individuals but also American communities and the values and conditions we as a citizenry aim to uphold.

Breastfeeding is also a collective issue given its implications for our workforce. By shaping health not only in infancy but also throughout the life course, whether our country's babies breastfeed today will impact the size and strength of our nation's workforce tomorrow. More immediately, the health of our babies now influences the days of work parents and caregivers miss because they must call in sick to take care of an unwell child. One study comparing the medical attention 1,000 never-breastfed infants required when compared with 1,000 infants who were breastfed for at least the first 3 months of life, found that babies who never breastfed together required over 2,000 more doctor's office visits and hospital stays for lower respiratory tract illnesses, otitis media, and gastrointestinal illness in their first year of life, alone. ⁴ In other words, nonbreastfed babies were sick a lot more often than breastfed babies, and consequently, they required a caregiver to make time to bring them to the doctor's office or accompany them in the hospital at much higher rates than breastfed infants. Since 80% to 90% of adults are or will become parents, the amount of healthcare a child requires is an important issue for almost every U.S. employer, workplace, and member of a professional team, as all these actors risk losing colleagues for chunks of time if they must tend to an unwell child.

In addition, breastfeeding can directly impact a mother's health. This includes helping her recover more quickly from delivery and experience a decreased likelihood of obesity and cancers later in life when compared with those who do not breastfeed. Breastfeeding thus has the potential to influence the workplace also through increasing the speed at which new mothers return to their jobs and their health as employees for several years to come.

Finally, the potential for babies to live and thrive in our country influences the international talent we as a nation attract to our labor force as well as our ability to retain the workers we currently have. Supporting breastfeeding and its contributions to (reducing) infant mortality and (increasing) population health and wellness therefore also impacts the size and quality of workforce in this indirect way.

In addition to strengthening our workforce, breastfeeding substantially reduces U.S. healthcare expenses. As breastfeeding rates have improved in our country, costs associated with caring for sick infants have hand-in-hand decreased. In fact, given the connections between breastfeeding and healthcare costs, a 2010 study in the journal Pediatrics finds that increasing exclusive breastfeeding for 6 months among 90% of U.S. families would, in 2007 dollars, contribute to ∼13 billion dollars a year in direct and indirect healthcare savings. This would also prevent close to 1,000 infant deaths. If 80% of U.S. families breastfed this long, that number would be closer to 10.5 billion dollars in savings with around 741 infant deaths spared. ⁵ Prior studies also find that increasing breastfeeding in this country would save society billions of dollars through reduced healthcare costs. And importantly, it is likely that these savings are in fact well underestimated, since the health benefits to nursing mothers and throughout the life-course for the breastfed baby are not included in current calculations.

Breastfeeding also has shared economic impacts through its relationship with the food system. Consider the Women, Infants, and Children program (WIC)—a fully federally funded program. WIC buys over 50% of formula in the United States and provides it to participating families at no charge. As such a large purchaser, WIC is able to negotiate down the cost of the formula. Nonetheless, it still costs WIC close to 1 billion dollars a year to purchase and then provide infant formula to clients. This is an expense all U.S. taxpayers would save on if breastfeeding rates increased. ⁶ It is important to note that WIC does offer an enhanced food package to nursing moms, which also costs taxpayers money. However, this is typically a healthier food package than WIC offers otherwise; nursing mothers on WIC are thus likely to eat and be healthier than if they were feeding their infants formula, resulting in an expected net savings to society through the positive impact on the mother's workplace performance and healthcare costs.

Finally, breastfeeding also impacts the environment. It is estimated that for every one million babies fed, one and a half million cans of formula are consumed. ⁷ Formula requires processing, packaging, shipment, and storage before it reaches consumers, and then postconsumption, it results in waste from disposed formula containers, scoops, and additional packaging. This creates significant environmental burdens not associated with breastfeeding. Formula consumption is also environmentally intensive because it necessitates bottles being produced and distributed, and because there are additional resources required when bottles of formula are warmed (before feeding) and sterilized (between feedings).

Consider also states of emergency, such as natural disasters. Nonbreastfed infants are up to 20 times more likely to die in these situations than any other group. ⁸ When hurricane Katrina hit, for example, most formula-fed babies lost access to their food supply among the severe food shortages there. Not only did this cause hunger and malnutrition issues in the immediate term but also, once formula supplies increased infants experienced health risks associated with mixing formula with a potentially contaminated water supply. Similar problems arose during the recent Flint Water Crisis, as well. Here, however, formula had been prepared with potentially toxic water for months and, in some cases, years before the lead contamination was even discovered.

Just as it is important to take seriously breastfeeding's social, economic, and environmental impact, so too must we critically regard how society, the economy, and the environment impact breastfeeding. Indeed, if we want to reap breastfeeding's shared benefits, we must recognize and address our common role in fostering them.

As a public, our attitudes shape breastfeeding. A study in 2001 demonstrated that around 60% of Americans do not believe a woman should have the right to breastfeed in public. ⁹ Even if this statistic has improved in the last decade and a half, we still know that women are regularly shamed in this country if they try to nurse in community spaces, despite that many states now have laws in place to protect a woman's right to publicly feed. There are consistent reports of women being removed from buses, asked to leave restaurants, and shamed in malls and airports for nursing their children. Even some places of worship ask breastfeeding moms to leave if they attempt to feed their babies during religious services. Whether or not a given mother experiences this derision firsthand, such an atmosphere of unacceptance and scorn shapes mothers as a population. Indeed, if women and their communities of support feel they cannot and/or should not publicly nurse, they begin to question breastfeeding overall; mothers are then much less likely to nurse, whether in public or in private.

In addition to creating ideological barriers, lacking public support for breastfeeding contributes to the still too numerous concrete obstacles that negatively influence breastfeeding success in the United States. For example, many places in the United States have inadequate—in both quantity and quality—public spaces for pumping and nursing. A significant portion of childcare facilities are not trained in handling expressed milk; so infants in these facilities must consume formula even if their primary caregivers originally did not intend for them to do so. Meanwhile, around 440 hospitals have achieved Baby-Friendly status across the country, which indicates they have policies and practices in place to strongly facilitate breastfeeding. This results in only around 21% ¹⁰ of our babies being born in settings that are known to positively shape whether they receive human milk as their first food or not. ¹¹

Workplaces also influence breastfeeding. Approximately 25% of U.S. moms return to work within just 2 weeks of giving birth. ¹² Because it often takes a few days after delivery for human milk to come in, these mothers have only a few more days to develop adequate feeding patterns with their child before returning to work. Meeting the recommended breastfeeding durations is often biologically and emotionally impossible for mothers and infants in this situation. It takes time both physically and mentally to establish a healthy and effective milk supply and breastfeeding relationship between a mom and baby; returning to work in under 2 weeks in many cases prohibits this from happening.

Moreover, many U.S. employers do not support breastfeeding when mothers do return to work, whether in their workplace policies, practices, and/or attitudes. In many American communities, over 50% of employers still have no breastfeeding policy or places for moms to express milk, for example. ¹³ Even among employers who do have policies to facilitate breastfeeding, mothers frequently report confronting employer and/or coworker attitudes that dissuade her from expressing milk and/or create hostile work environments if she tries to do so. ¹⁴

Finally, our environment shapes human milk quality and access. Toxic contaminants build up in women's bodies over their prepregnancy lifetime and then accumulate in human milk postpartum. This includes toxins such as bisphenol A (commonly referred to as BPA, a plastic component), perchlorates (used in rocket fuel), perfluorinated chemicals (often termed PFCs, used in floor cleaners and nonstick pans), phthalates (used in plastics), chloroform (a refrigerant), benzene (found in both gasoline and cigarette smoke), and the heavy metals cadmium, lead, and mercury. Currently, studies suggest that in most humans, the benefits of breastfeeding outweigh the negatives of the contaminants accumulating within human milk, but there is concern about this balance shifting in future generations. ¹⁵

Before concluding, I must emphasize one more critical aspect of breastfeeding's shared nature: much of breastfeeding's social, economic, and environmental affects and the impacts of society, the economy, and the environment on breastfeeding differ by race and class in this country, among other social categories. In many ways, then, breastfeeding is not only a social, economic, and environmental issue but also a social, economic, and environmental justice issue, in particular.

By justice, I refer to the notion that the benefits, opportunities, risks, and obstacles to something (in this case, breastfeeding) are shared equally across all social groups. Injustice, then, connotes a state in which these elements are not shared equally, but rather some groups experience a disproportionate amount of benefits and opportunities, while others unequally bare much of the risks and obstacles. Currently in the United States, our breastfeeding landscape is largely unjust.

Consider people of color and breastfeeding in the United States, for example. In black communities, breastfeeding rates are consistently around 16% to 17% points behind their white counterparts. ² This disparity contributes to black babies being more than twice as likely to die than white infants overall, and around three and a half times more likely to die when compared to white infants for reasons connected to low birth weight, in particular. ¹⁶

Society plays a role in this. Studies suggest that messaging—in the media and from various influential community leaders, for example—tend to unequally discuss the negatives of breastfeeding vis-à-vis black communities. This includes disproportionately emphasizing issues such as pain during breastfeeding, the inability for a mother to properly lactate, and the failure of infants to thrive. Even the common reporting of breastfeeding statistics by race tends to create a comparison between white and black racial groups (as I myself did in the beginning of the prior paragraph), which lacking context can (re)victimize black women and infants by positioning them as “behind,” “lagging,” and/or “insufficient” despite the great strides they have made in the face of obstacles white populations experience comparatively less, including historic trauma, the erasure of lived lactation knowledge in their communities, and high allostatic loads.

Consider also the role of public health professionals and the hospital setting on racial disparities in breastfeeding initiation and duration. Over 85% of IBCLCs, certified nurse-midwives, and nurse practitioners in this country are white.^17,18 This is problematic because many women report feeling most comfortable with and most likely to seek out breastfeeding guidance from health practitioners with similar experiences, understandings, and backgrounds as them, and because significant research shows that there are marked disparities in how public health, medical care, and human service providers treat patients of different socioeconomic and racial/ethnic backgrounds. This includes, whether intentionally or not, suboptimal medical treatment with regard to diagnoses and pain management when white providers are treating black (as opposed to white) patients. ¹⁹

The lack of culturally relevant breastfeeding support for people of color in this country is compounded by the fact that supportive breastfeeding practices in U.S. birthing facilities are substantially lower in zip codes where black residents are greater than ∼12% of the population (the average percentage of black residents in the United States) compared to areas where black residents comprise less of the total population. In areas with greater black populations, for example, early initiation of breastfeeding occurs in hospitals around 46% of the time, versus around 60% in whiter zip codes; meanwhile, in areas with a greater percentage of black residents, hospitals implement a limited use of breastfeeding supplements around half as frequently as in areas where white residents comprise more of the population. ²⁰ This constitutes such an injustice because studies suggest that in hospitals where breastfeeding support is optimal regardless of a patients' race, racial differences in breastfeeding initiation and duration appear to almost completely disappear. ²¹

In fact, broader forces present such consistently large obstacles to breastfeeding success in predominantly black and also low-income areas of the United States that these places are often classified as “first food deserts,” a term coined by Kimberly Seals Allers based on her community projects in Birmingham, Alabama, Jackson, Mississippi, and New Orleans, Louisiana. According to Seals Allers' research, funded by the W.K. Kellogg Foundation, a first food desert was defined as a geographic area where social and economic dynamics unequally constrain breastfeeding when compared with other locations. For example, in her work in these cities, she found common similarities in cities with high black populations and low breastfeeding rates: no Baby-Friendly hospitals within a 35-minute commute; 50% or more of employers have no breastfeeding policy or places to nurse/express milk; 30% or more of childcare facilities are untrained to handle expressed milk; 50% or more of the public reports feeling uncomfortable when seeing a woman breastfeed; and there is a persistent and widespread lack of culturally relevant healthcare support, peer support, and public spaces that facilitate breastfeeding. ¹³ Where you live and work, then, unequally impact what you feed and how you eat (Seals Allers).

In addition, environmental disasters tend to disproportionally harm communities of color. We saw this when both Hurricane Katrina hit and the Flint Water Crisis came to light, for instance. Research also shows that hazardous waste sites and heavily polluting industries are unequally located among communities of color in the United States. Black and indigenous peoples are thus more likely to have dangerous contaminants bioaccumulating in their human milk than white groups. ²² This environmental injustice extends to Inuit peoples, who have seven to 50 times higher polychlorinated biphenyl (PCB) and mercury levels in their human milk than most other mothers due to their nutritional dependence on seafood high up on the food chain. ²³

Minority children will become the majority in our country shortly, and thus the disparities in breastfeeding that I have concluded with discussing will become an increasingly central problem with implications for all Americans. This combined with the added dimensions of breastfeeding explained at the outset of this article lead me to stress that for the sake of our society, economy, and environment, our society, economy, and environment must better facilitate breastfeeding among all groups, whether social majorities or not.