The Historical,Psychosocial,and Cultural Context of Breastfeeding in the African American Community

Breastfeeding is widely acknowledged to be the most complete form of infant nutrition and is touted by the American Academy of Pediatrics (AAP) as the “ideal method of feeding and nurturing infants.” ¹ Breastfeeding provides a range of benefits for the infant's growth, immunity and development. It also has health benefits for the mother, including a reduced risk of premenopausal breast cancer, earlier return to prepregnancy weight, reduction of postpartum bleeding, and reduced risk of osteoporosis. Data suggest that mothers' desires alone are not enough, but multiple and complex barriers exist, thus moderating support that women need from health care providers, public health professionals, family members, society, their community, and employers is paramount to meet their breastfeeding goals.

There are a number of complex factors that influence the decision to initiate and continue breastfeeding, including those “external” to women, such as cultural beliefs. The cultural context and environment of decision making are illuminated through the prism of traditions and historical and cultural events. ² The ideology and sentiment of breastfeeding have changed during the course of history and have evolved within the African American community. Breastfeeding was necessary for infant survival as the only source of nutrition in early days of civilization. In the 1500s with the introduction of chattel slavery through the brutal abduction of nearly 12 million enslaved across the Atlantic from the African continent, ³ “wet nursing” became a practice brought by the English colonists to North America.

Both Frederick Douglass and Booker T. Washington described the relationships between enslaved mothers and children to be distant. Frederick Douglass, who had no memory of seeing his mother before the age of 7, spoke about how the rigors of enslaved life prevented mothers from spending much time with small children, except for brief moments at the start and end of their days, if they lived on the same property. ⁴ According to Tannenbaum, ⁵ when an enslaved woman gave birth to a baby, if it was viable, it likely suckled at its mother's breast. However, the conditions and length of time she nursed her baby would have greatly varied, depending upon factors, including whether she was nursing other children, if she lived in the quarters with her children, and if her children remained on the same plantation or were sold away. ⁵

Many enslavers separated their enslaved into groups known as gangs. Women with nurslings were often put into a “sucklers gang” and worked under special conditions to accommodate breastfeeding. This might involve slightly more rations, and two to three 15- to 30-minute breaks in a day to nurse, likely ensuring malnutrition began in infancy. Many lactating enslaved Black women were forced to nurse their owners' children, often increasing the mortality rate for the wet nurses' own child. Moreover, the emotional upheaval of birth, possibly infant death, caring for someone else's child, while depriving their own, and a lack of dignity and respect were aspects of the despicable and unspeakable practice of forced wet nursing. Black wet nurses often saw their own children only once every two weeks as they lived with the owner's family, providing not only breast milk but also domestic services to the child and family. ⁶

In the article, “Negro Nurse,” an enslaved domestic, describes, “I frequently work from fourteen to sixteen hours a day. I am compelled by my contract, which is oral only, to sleep in the house. I am allowed to go home to my own children, the oldest of whom is a girl of 18 years, only once in two weeks, every other Sunday afternoon—even then I'm not permitted to stay all night. I not only have to nurse a little white child, now eleven months old, but I have to act as playmate, or “handy-Andy,” not to say governess, to three other children in the house, the oldest of whom is only nine years of age.” ⁷ Juxtapose this with the confused and dichotomous emotion of a woman rearing someone else's child. In an excerpt describing a white child's relationship to his wet nurse, the author notes… “[it]always held a peculiar place in my regards. A [B]lack nurse taught me, it is probable, my first steps and first words, and was as proud of both performances as the happy mother herself.” Having lost a relationship with her own child, or even witnessing the death of her own child due to neglect from her duties to the white family, this “proud” stance may not have held the same connotation as envisioned. Research has shown enslaved wet nurses coped with the loss of their child by either detaching themselves or forming a bond toward the white children they cared for.

The enslaved were keenly aware that childbearing had less to do with maternal desires and instincts and building healthy families and more with adding human capital to the plantation for domestic work. Ellen Betts was a wet nurse in St. Mary's Parish, Louisiana. She is quoted as saying, “And I tell you dat Marse William was de greates' man whatever walk dis earth….Mis' Sidney was my marster's fust wife and he had six boys by her. Den he marry de wider Cornelia and she give him four boys. With ten chillum pringin’ up quick lak dat and all de cullud chillum comin’ along fast as pig litters, I don't do nothin’ all my days but nuss, nuss, nuss….I nuss so many chillum [,] it done went and stunted my growth.” ⁷

The echoes of enslaved women being denied basic rights under deplorable conditions that these nurse maids in the American South were subjected to and forced to relinquish their milk still resound among Black women today. “On the one hand, 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 enslaved mothers to transfer to white offspring the nurturing and affection they should have been able to allocate to their own children.” ⁸ Perhaps, Black women did not talk to their sister, daughters, and granddaughters about how to feed their babies because the residue of terror, oppression, and gendered dehumanization of enslavement overshadowed the emotional bond of mother and child codified in the practice of wet nursing, galvanizing a stunted and complex mothering experience. ⁹

Conversely, other cultures did not have such negative connotations regarding wet nursing. In Israel, children were deemed a blessing and breastfeeding was considered a religious obligation. However, breastfeeding was not always possible due to lactation failure or the mother dying from childbirth. Thus, wet nursing initially began as an alternative of need (2000 BC) rather than an alternative of choice for women who were unable to feed their infants, including mothers who had died during childbearing. In Greece, in 950 BC, women of higher social status demanded wet nurses and others often abandoned specifically female infants requiring feeding support. ¹⁰ Biblical references note several examples of wet nurses, most notably being the women hired by Pharaoh's daughter to nurse Moses, whom she found in the bulrushes.

Wet nursing promoted written contracts at the height of the Roman Empire (300 BC–400 AD) with physician support and qualifications for wet nurses documented in the medical literature. In England in the 17th and 18th century, wet nursing was commonplace, respectable and a well-planned, popular source of income. A woman could earn more money as a wet nurse than her laborer husband in the Industrialized Era. ¹⁰ With the availability of animal's milk and advances in food preservation and formula development in the 19th and 20th century, formula feeding became a feasible substitute for breastfeeding. Societal class tended to dictate breastfeeding practices where wealthy women considered breastfeeding unfashionable and worried it would ruin their Figures. ¹⁰ In addition, breastfeeding prevented women from wearing socially acceptable clothing of the time, ¹⁰ while interfering with social activities, such as attending theater performances. ¹¹

Aggressive marketing of formulas, including direct to consumer practices in 1988 in developing countries, contributed to the ideology of formula as empowering and a “status symbol” to attain. Thus, this allowed women the freedom not to be “tied down” to her baby, since with increasing income comes the ability to decide rather than be forced to breastfeed. Although breastfeeding rates reached 90% in the 20th century, rates declined to 42% in the 21st century.^12,13 Formula companies in the 1930s and 1940s marketed formula as the choice of the elite, “the substance for sophisticates.” White women led the charge to infant formula. Black women followed suit. Nevertheless, when white women reversed course, led by celebrity cache and a new ideal of “good mothering,” Black women did not buy-in. Meanwhile, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the largest purchaser of infant formula in the United States. ¹⁴

Throughout the evolution of infant feeding practices, historical aftermaths have contributed to the legacy and emotional context of infant feeding trends. The tradition of wet nursing for African American women is inherently linked to white supremacy, slavery, medical racism, and the physical, emotional, and mental abuse that enslaved African American women endured. Thus, the decision to breastfeed and the act of breastfeeding may remain deeply affected by the generational trauma of wet nursing during slavery. To cope with this horrific torture of the mind, mothers may attempt to disassociate themselves from the past history of slavery and the practice of wet nursing. In addition, the yoked caricature of the “mammy,” which even in the 21st century is integral to the sale of certain syrup brands, often has negative connotations in the African American community.

For nonminoritized women, the “mammy” figure evokes a feeling of nostalgia for the nurturing maternal Black nursemaid, who may have cared for and coddled them in their early years. For Black women, that same mammy maid caricature (and the idea of breastfeeding) may evoke visceral reactions regarding Black women being subjected to castigation from the cruel and inhumane mistreatment of forced reproductive servitude. In a qualitative study of social and cultural influences on Black women's infant feeding decisions, study participants—unprompted—noted slave era wet nursing practices and the mammy stereotype as historical reasons that impact their infant feeding decisions today. ¹⁵ The authors note specifically that historical influences such as subjugation and marginalization of Black Americans can contribute to implicit biases when it comes to making health decisions, not necessarily limited to infant feeding. Echoes of past oppression create an environment that is ripe for aversion to medical establishment recommendations.

This historical context lends itself to a psychosocial response to infant feeding decision making that is simultaneously steeped in familial or community influence on formula feeding. The historical context of infant feeding embodies the brutality and callousness of wet nursing; however, the abuse and mistreatment of African Americans within the health care system are much more extensive and immensely consequential. This is shocking and sobering not only for the mother/infant dyad, but also for the African American population as a whole in explaining the historical aversion to medical care potentially engendering significant health disparities. Not only were enslaved women subjected to the cruel and inhumane practice of wet nursing but also enslavers would hire out or sell their captives to physicians for “clinical material” that fed medical research and bolstered nascent physician training.

Enslaved persons were used as experimental subjects, as physicians believed that Black people had low intellectual capacities and were sexually promiscuous, that diseases manifested differently in Black people, and that they could not be trusted to take medicine, follow treatment, or maintain basic standards of hygiene without white supervision. ⁸ “[Enslaved] hospitals” and clinic wards provided experimental subjects for uncoordinated “research” projects as physicians rationalized these common beliefs. African American experimentation was a prerequisite for medical journals. Notably, half of the original articles in the Southern Medical and Surgical Journal, published in 1836, included experiments performed upon Black patients. ¹⁶ Medical physicians tenaciously rationalized abusive experiments as Black people were thought not to feel pain or anxiety, and thus performed painful surgical explorations without anesthesia on them. Dr. Charles White declared that “[Black people] bear surgical operations much better than white people and what would be the cause of insupportable pain for white men, a Negro would almost disregard…[I have] amputated the legs of many Negroes, who have held the upper part of the limb themselves.” ¹⁶ Women were not exempt from such experimentation as many gynecologic advances were achieved by exquisitely painful surgeries by Kentucky surgeon, Efraim McDowell.

The cruelty did not end with continued “research,” as noted by the removal of Dr. J. Marion Sims statue in 2018 from Central Park New York across from the New York Academy of Medicine. Dr. J. Marion Sims was a 19th century physician, known as the “father of gynecology,” yet advanced his career by performing painful surgeries on enslaved Black women without anesthesia, while financially supporting this abuse through contributions from fellow surgeons.^16,17 Maltreatment and exploitation continued into the 19th century at which time Black cadavers were shipped to medical schools for dissection and to museums and traveling shows for casual public display and profit by whites. ¹⁸ Black families had no recourse when family members died and were not buried, but snatched and transported to dissection laboratories for medical students to learn anatomy. Even after the abolition of slavery, grave robbers continued the sinister method of obtaining material for medical student education.

The Tuskegee Syphilis Study is likely the most notorious case of African American exploitation in which 600 Black men with syphilis were denied accepted and available medical treatment by the U.S. Public Health Service to study the progression of the disease even to the stage of symptomatic neurosyphilis. Despite public uproar years later, Tuskegee was the forerunner for a host of similar medical abuses, including radical brain surgery performed at the University of Mississippi on African American boys as young as 6 years old to cure them of aggressive or hyperactive behavior. The same procedure was recommended for participants in the urban Watts' riots. As recently as 1992–1997, Black parents were intimidated by researchers from the New York State Psychiatric Institute and Columbia University's Loewenstein Center to allow the administration of the dangerous drug, fenfluramine, to the younger brothers of Black juvenile offenders. Newborn babies were not immune. A 1925 Journal of the American Medical Association (JAMA) article highlights the experiments of Dr. M. Hines Roberts, who bypassed informed consent, subjecting 423 “Negro newborns” in Atlanta to painful spinal taps to study how the trauma produced by the needle could cause injuries. ¹⁶

Between 1987 and 1991, U.S. researchers studied an experimental measles vaccine, administered (without appropriate informed consent) as much as 500 times the approved dosage to African American and Hispanic babies in Los Angeles. ¹⁹ African American reproductive rights were trodden as women underwent forced tubal ligation if they suffered from mental delay. Researchers, including the federal government, have coerced soldiers and prisoners to endure radiation and biological weapons. Such cruel exploitations of often unwilling and involuntary African American patients by the medical establishment has prompted skepticism in the African American community and a reluctance to participate in medical research (and by extension often reluctance in complying with medical recommendations, such as breastfeeding and chronic medical treatment). Most African Americans today are aware of at least the Tuskegee experiment through family knowledge transmitted from generation to generation rather than knowledge obtained in school.

Establishing and supporting breastfeeding are critical to success; however, many Black women decline to breastfeed their infants, possibly considering cultural and historical influences. “Perhaps, it's because some women's grandmothers still feel traumatized remembering the treatment of wet nurses. Perhaps, it's because the [B]lack women want to finally feel [she] owns [her] own body and isn't prostituting [herself] out to be food for someone else. Maybe it's because traditionally, over the past few centuries, [B]lack women haven't gotten to have the role for their own children and they don't consider it normal.” ²⁰

Thus, the history of breastfeeding and abuse by the medical establishment are critical to the conversation on reproductive justice and birth equity, highlighting the rights of mothers in both the private and public sphere. Even today, the vestiges of slavery, racism, implicit bias, and discrimination in birth equity and birth justice practices loom where women may not feel their voices are “heard,” resulting from neglectful and disrespectful care. Promoting respectful care is being increasingly recognized as a critical element of strategies to improve the quality of maternity care and add a humanistic approach to patient education and care.

Respectful care can be defined as “an approach to care that emphasized the fundamental rights of women, newborns, and families and that promotes equitable access to evidence-based care, while recognizing the unique needs and preference of both women and newborns.” ²¹ Respectful care is touted through education, quality of care, shared decision making, informed consent, dignity, and nondiscrimination and support women in being active decision makers in their birth experience and plans for feeding their infant. ²² Several themes emerge in providing a typology of respectful maternal care, including being free from harm and mistreatment, maintaining privacy and confidentiality, preserving women's dignity, prospective provision of information and seeking informed consent, ensuring continuous access to family and community support, enhancing the quality of the physical environment and resources, providing equitable maternity care, engaging with effective communication, respecting women's choices that strengthen their capabilities to give birth, availability of competent and motivated human resources, and provision of efficient and effective care and continuity of care. ²¹ Breastfeeding, in theory, should be grounded in this framework.

The associated negative connotation of wet nursing, slavery, and medical exploitation is one of the many nuanced cultural barriers that denies Black women and infants the many health benefits of breastfeeding, and may be a key factor promoting the alarmingly increased rates of Black infant mortality, particularly in the preterm, premature infant. This is an important conversation to address the collective health of the African American community, as mothers attempt to reclaim accountability and conscientiousness for the health of their infant. This is a choice that has previously been divorced from the Black mother/infant health care conversation due to prior cultural atrocities perpetuated by society and the health care profession. The traumatic perceptions, grief, and sorrow experienced by the African American culture toward the infants' first food must be addressed to amass the important long-term benefits of breast milk for infant brain development, immunity, chronic disease, and the population. “Our children need that nourishment to compete in today's world—a world in which a child isn't just competing with his neighbor or even people in America for the best jobs but a world in which a child halfway across the world is gunning for his or her job.” ²² Mothers need to be empowered by their partner, family, health care providers, and the community to be able to provide their infant the best preventative medicine for a healthy start to life, as well as promoting the critical bonding experiences of motherhood. Accretion of the long-term benefits of breastfeeding in decreasing chronic medical illness is a critical public health strategy to improve the health of the African American population.