by Allison Micarelli-Sokoloff
May 19, 2010

Breastfeeding should be an equal opportunity experience for all women, but for many, breastfeeding is a missed opportunity. While many factors contribute to a woman’s decision to breastfeed—support at home and from health care providers, a woman’s work environment, the media and its perception of normal infant feeding, and misinformation about the effects of formula feeding—the decision to breastfeed isn’t always black and white. Or is it?

Research
A recent report by the Centers for Disease Control and Prevention (CDC), found that non-Hispanic black women in the U.S. were least likely to breastfeed compared to other racial groups.

Results
Using data from the National Immunization Survey—an on-going telephone survey conducted nationwide—among those surveyed, 75 percent initiated breastfeeding, 42 percent breastfed for six months, and 21 percent breastfed for one year. Hispanic women were most likely to initiate breastfeeding (80 percent); followed by non-Hispanic whites (73 percent); and non-Hispanic blacks (54 percent).

“What we saw across the U.S. were lower breastfeeding rates among non-Hispanic black women in all but two states [Minnesota and Rhode Island],” says Kelley Scanlon, epidemiologist at the CDC, who supervised the study. “In the last 20 years, differences in breastfeeding initiation rates between non-Hispanic black and white women have narrowed, however differences in breastfeeding duration have not. When you think of improving the duration women breastfeed, you think of support received in the hospital, when returning home, and to work—hospital practices, social support, and worksite support. We’re trying to understand more, so we can better address disparities in breastfeeding with our strategic plan.”

Data suggest that there may be experiences unique to non-Hispanic black women that contribute to their decision to bottle-feed:

• Lack of culturally relevant information and images of non-Hispanic black women breastfeeding.

• Perceptions that breastfeeding is inferior to formula feeding or conflicting messages about breastfeeding.

• Need for non-Hispanic black women to return to work sooner, where, until recently, support for breastfeeding was often insufficient.

• Lack of social or partner support.

In 2003-2004, in an effort to glean what women knew about breastfeeding and what their early experiences with breastfeeding were like, Erika Reed-Gross and her colleagues at Westat conducted focus groups with low- and middle-income African-American women in three southeast cities. Their findings support the theory that African-American women, though well informed about the benefits of breastfeeding, receive little information about how to breastfeed. The women surveyed reported a lack of support in the hospital, citing limited access to lactation counselors and ready access to free formula. Despite an expressed desire to breastfeed, they indicated that they were rarely counseled about breastfeeding after birth and that their babies were often supplemented with formula.

According to Reed-Gross, the issue of low breastfeeding rates among African-American women extends beyond racial lines. It’s a socioeconomic issue, a cultural issue, a childrearing issue. Reed-Gross’ findings identify two factors that may explain the low breastfeeding rates among African-American women: lack of comfort with the idea of feeding their child in public (some women stated that their communities, families, and churches were not supportive of breastfeeding in public); and lack of support for breastfeeding beyond 8-10 weeks citing concerns that their babies would be spoiled or too attached. Some women were taught that a child should learn self-reliance, especially when a mom returns to work or school. Says Reed-Gross, “For African-American groups, privacy concerns and values around childrearing merit more research and discussion.”

Recommendations
In December 2009, the CDC hosted a meeting where experts, including Reed-Gross, explored possible reasons for the racial disparities.

“We don’t have the answer,” says Scanlon. “We brought together these experts to try to understand why disparities in breastfeeding persist. What we do know is that we have strategies for promoting breastfeeding in all populations; we just don’t know if the practices are equally reaching all populations. We promote strategies for improved hospital practices, worksite support, peer support, education for new mothers, and media and social marketing. The question is, are there certain strategies we are missing?”

Whether or not a strategy is missing, one thing is for certain: non-Hispanic black women in the U.S. need more support for breastfeeding, starting in the hospital. Although lack of hospital support affects all women, Reed-Gross points out that there is research beyond this study and these focus groups to suggest that African-American women in particular receive little hospital support and may be the most harmed by this lack of support because for many African-American women, there is less support when they leave the hospital and return home to offset the negative experiences in the hospital.

“As a group, these women had negative experiences in the hospital and that had a deleterious effect on their experience breastfeeding at home,” says Reed-Gross of her focus group. “A lot of women had issues with breastfeeding and felt they had nowhere to turn. ‘Am I doing this right?’ ‘How frequently should I feed?’ ‘Who do I call for help?’”

Programs like The Baby-Friendly Hospital Initiative (BFHI)—a global program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF)—foster environments where breastfeeding is the norm, in all communities and all states, among all ethnic groups, across the nation. BFHI assists hospitals in giving mothers the information, confidence, and skills needed to successfully initiate and continue breastfeeding their babies. Though data collection regarding the impact of the BFHI on breastfeeding rates in the U.S. has just begun, some studies show positive results.

Researchers at Boston Medical Center have reported that during the implementation of the BFHI, breastfeeding rates among U.S.-born African-American mothers rose from 34 percent to 74 percent in 1999.

The BFHI is a start, but with the majority of hospitals not BFHI-compliant (there are currently 91 Baby-Friendly hospitals across the U.S. and only one in the southeast), there is a lot more work to do. As a nation, we need a heightened awareness not only of the benefits of breastfeeding but of the information and support all mothers need to initiate and continue breastfeeding for at least the first year of a baby’s life. Without adequate support, even the best of intentions are unlikely to be realized.