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Examination of Factors That Contribute to Breastfeeding Disparities and Inequities for Black Women in the US

      Abstract

      Breastmilk is considered the optimal nutrition for newborns. US Black women continue to have the lowest breastfeeding initiation and duration rates. This Perspective examines factors associated with breastfeeding disparities and inequities among Black women through the lens of critical race theory and the social-ecological model. Recommendations to increase breastfeeding rates in this population include increased communication and educational strategies by health care professionals, education to recognize implicit bias and systemic racism in our health care system, early prenatal and ongoing postpartum breastfeeding support, increased community support, and breastfeeding groups developed by and for Black women. In addition, equity policies such as paid maternity leave and work policies that support milk expression would provide needed institutional support for women in the workplace.

      Key Words

      INTRODUCTION

      In the US, there has been a heightened recognition of racial morbidity and mortality inequities brought about by the coronavirus disease 2019 pandemic and health and social disparities that continuously impact Black, Indigenous, and People of Color (BIPOC) communities.

      Dictionary by Merriam-Webster. BIPOC.https://www.merriam-webster.com/dictionary/BIPOC. Accessed July 16, 2021.

      ,
      • Asiodu IV
      • Bugg K
      • Palmquist AEL
      Achieving breastfeeding equity and justice in Black communities: past, present, and future.
      Black women face disparities because of the intersection of racism and sexism.
      • Rosenthal L
      • Lobel M
      Gendered racism and the sexual and reproductive health of Black and Latina women.
      Black women have a complex history because of slavery and forced wet nursing, hypersexualization of the breast, and increased risk for sexual violence.
      • Pyles TEH
      • Umi SA
      • Madubuonwu S
      • et al.
      Breastfeeding sisters that are receiving support: community-based peer support program created for and by women of color.
      ,
      • Tillman S
      • Bryant-Davis T
      • Smith K
      • Marks A
      Shattering silence: exploring barriers to disclosure for African American sexual assault survivors.
      Enslaved Black women were experimented on by physicians in the development of the cesarean section and gynecological procedures, and the children born to enslaved Black women were viewed as capital for slaveowners.
      • Owens DC
      • Fett SM
      Black maternal and infant health: historical legacies of slavery.
      As a result, years of abuse and mistreatment have instilled a lack of trust and suspicion between Black people and medical institutions.
      • Owens DC
      • Fett SM
      Black maternal and infant health: historical legacies of slavery.
      In addition, Black women continually experience institutionalized racism that has a direct impact on their breastfeeding rates and experiences.
      • Scott KA
      • Britton L
      • McLemore MR
      The ethics of perinatal care for Black women: dismantling the structural racism in “Mother Blame” narratives.
      Institutionalized racism is defined as a systematic set of social structures (such as criminal justice systems and public education systems) and environments (such as policies, rules, and practices) that are part of the way a society or organization functions but which result in and support a continued unfair advantage to 1 group of individuals and unfair or harmful treatment of others on the basis of race.

      Cambridge Dictionary. Institutionalized racism.https://dictionary.cambridge.org/us/dictionary/english/institutionalized-racism. Accessed July 12, 2021.

      Despite health-related benefits of breastfeeding and breastfeeding being associated with positive health outcomes for mothers and babies, Black women in the US continue to have the lowest rates of breastfeeding initiation and duration.
      • Louis-Jacques A
      • Deubel TF
      • Taylor M
      • Stuebe AM
      Racial & ethnic disparities in U.S. breastfeeding & implications for maternal & child health outcomes.
      • Beauregard JL
      • Hamner HC
      • Chen J
      • Avila-Rodriguez W
      • Elam-Evans LD
      • Perrine CG
      Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015.
      • Li R
      • Perrine CG
      • Anstey EH
      • Chen J
      • MacGowan CA
      • Elam-Evans LD
      Breastfeeding trends by race/ethnicity among US children born from 2009 to 2015.
      • Jones KM
      • Power ML
      • Queenan JT
      • Schulkin J
      Racial and ethnic disparities in breastfeeding.
      The benefits of breastfeeding for mothers and infants have been extensively demonstrated, and breastmilk is accepted as the gold standard of nutrition for babies. For babies, research establishes that breastfeeding decreases risks of morbidity from otitis media, gastroenteritis, lower respiratory tract infections, and lower risks for inflammatory bowel disease, leukemia, childhood obesity, and sudden infant death syndrome.
      • Pyles TEH
      • Umi SA
      • Madubuonwu S
      • et al.
      Breastfeeding sisters that are receiving support: community-based peer support program created for and by women of color.
      ,
      • Louis-Jacques A
      • Deubel TF
      • Taylor M
      • Stuebe AM
      Racial & ethnic disparities in U.S. breastfeeding & implications for maternal & child health outcomes.
      ,
      • Bartick MC
      • Jegier BJ
      • Green BD
      • Schwarz EB
      • Reinhold AG
      • Stuebe AM
      Disparities in breastfeeding: impact on maternal and child health outcomes and costs.
      ,
      • Carlin RF
      • Mathews A
      • Oden R
      • Moon RY
      The influence of social networks and norms on breastfeeding in African American and Caucasian mothers: a qualitative study.
      For mothers, research suggests that breastfeeding reduces the risk for ovarian cancer, breast cancer, hypertension, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease, providing protection from the development of cancer and chronic diseases.
      • Pyles TEH
      • Umi SA
      • Madubuonwu S
      • et al.
      Breastfeeding sisters that are receiving support: community-based peer support program created for and by women of color.
      ,
      • Louis-Jacques A
      • Deubel TF
      • Taylor M
      • Stuebe AM
      Racial & ethnic disparities in U.S. breastfeeding & implications for maternal & child health outcomes.
      ,
      • Bartick MC
      • Jegier BJ
      • Green BD
      • Schwarz EB
      • Reinhold AG
      • Stuebe AM
      Disparities in breastfeeding: impact on maternal and child health outcomes and costs.
      ,
      • Carlin RF
      • Mathews A
      • Oden R
      • Moon RY
      The influence of social networks and norms on breastfeeding in African American and Caucasian mothers: a qualitative study.
      Increasing breastfeeding initiation and duration rates have been a continual goal for the Healthy People objectives

      U.S. Department of Health and Human Services. Healthy People 2030. Increase the proportions of infants who are breastfed at 1 year-MICH-16.https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants/increase-proportion-infants-who-are-breastfed-1-year-mich-16. Accessed September 15, 2021.

      ; however, meeting the goals has been unattainable to date. The Healthy People 2020 target rates for exclusive breastfeeding (EBF) were 25.5%.

      Centers for Disease Control and Prevention. Breastfeeding facts. https://www.cdc.gov/breastfeeding/data/facts.html. Accessed April 30, 2021.

      The current EBF rate at 6 months is 24.9%, and the 2030 goal for infants who are exclusively breastfed through 6 months is 42.4%.

      Centers for Disease Control and Prevention. Breastfeeding facts. https://www.cdc.gov/breastfeeding/data/facts.html. Accessed April 30, 2021.

      For non-Hispanic Black (NHB) women, the 2015 EBF rate at 6 months is 17.2%.
      • Beauregard JL
      • Hamner HC
      • Chen J
      • Avila-Rodriguez W
      • Elam-Evans LD
      • Perrine CG
      Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015.
      ,

      Centers for Disease Control and Prevention. Breastfeeding rates (National Immunization Survey).https://www.cdc.gov/breastfeeding/data/nis_data/results.html. Accessed August 25, 2021.

      To reach the Healthy People 2030 goals, critical examination of breastfeeding disparities must be examined with a need for effective interventions implemented that target a reduction in those disparities.
      Disparities and inequities in breastfeeding rates are most apparent when breastfeeding rates are examined by race. Non-Hispanic White (NHW) women have reached all the Healthy People 2020 goals except any breastfeeding at 6 months, whereas Asian Americans are the only group that has reached all the Healthy People 2020 goals.

      U.S. Department of Health and Human Services. Healthy People 2030. Increase the proportions of infants who are breastfed at 1 year-MICH-16.https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants/increase-proportion-infants-who-are-breastfed-1-year-mich-16. Accessed September 15, 2021.

      Non-Hispanic Black women have the lowest breastfeeding rates of all racial/ethnic groups in the US, and the breastfeeding gap between Black and White infants is widening.
      • Beauregard JL
      • Hamner HC
      • Chen J
      • Avila-Rodriguez W
      • Elam-Evans LD
      • Perrine CG
      Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015.
      ,
      • Li R
      • Perrine CG
      • Anstey EH
      • Chen J
      • MacGowan CA
      • Elam-Evans LD
      Breastfeeding trends by race/ethnicity among US children born from 2009 to 2015.
      Addressing disparities and inequities in breastfeeding rates among Black women in the US is necessary because the health benefits of breastfeeding are clearly demonstrated to have positive maternal and child health outcomes. Racial/ethnic disparities in breastfeeding rates have significant implications for health outcomes and social and economic outcomes.
      • Bartick MC
      • Jegier BJ
      • Green BD
      • Schwarz EB
      • Reinhold AG
      • Stuebe AM
      Disparities in breastfeeding: impact on maternal and child health outcomes and costs.
      From a population health perspective, achieving optimal breastfeeding rates decreases the burden of disease for Black women and their children and results in positive health outcomes and significant cost savings. Suboptimal breastfeeding in the US is associated with 3,340 premature infant and child deaths per year and $3 billion in medical costs in 2014 US dollars.
      • Bartick MC
      • Schwarz EB
      • Green BD
      • et al.
      Suboptimal breastfeeding in the United States: maternal and pediatric health outcomes and costs.
      Identifying and addressing groups with the lowest breastfeeding rates will impact improving maternal/child health outcomes and reducing medical costs. For example, compared with NHW populations, NHB populations had 3.3 times the number of excess cases of necrotizing enterocolitis, 1.7 times the number of excess cases of acute otitis media, and 2.2 times the number of excess child deaths.
      • Bartick MC
      • Jegier BJ
      • Green BD
      • Schwarz EB
      • Reinhold AG
      • Stuebe AM
      Disparities in breastfeeding: impact on maternal and child health outcomes and costs.
      Although persistent breastfeeding inequities for Black women continue to exist, inequities may reflect a pattern of poor health outcomes for Black women and children and that breastfeeding may be a key factor in reducing or preventing those poor health outcomes.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      Despite increasing knowledge about factors that influence breastfeeding initiation and duration for Black women, an explicit examination of how systemic and institutional racism play into the continued inequities is much needed and long overdue.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      Addressing barriers and supporting Black women to meet breastfeeding goals is a health equity issue that impacts the health and well-being of current and future generations. This Perspective aims to provide context and background information concerning factors contributing to breastfeeding disparities and inequities among Black women in the US and to provide evidence-based recommendations for eliminating these disparities.

      THEORETICAL FRAMEWORK

      The social-ecological model and critical race theory (CRT) guide the background of this Perspective. The social-ecological model examines the dynamic interplay of the individual, relationships, communities, and society.

      Centers for Disease Control and Prevention. Violence prevention: the Social-Ecological Model.https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html. Accessed August 25, 2021.

      Breastfeeding initiation and duration among Black women are influenced by historical and cultural interactions that are best examined from a multilevel approach. Current interventions to promote breastfeeding among Black women are singular and not examined from a multilevel lens that could potentially provide a cumulative effect to produce better access to hospital and professional lactation education and support without both implicit and explicit bias.
      • Johnson AM
      • Kirk R
      • Rooks AJ
      • Muzik M
      Enhancing breastfeeding through healthcare support: results from a focus group study of African American mothers.
      The social-ecological model acknowledges that multiple levels of influence exist and that the levels are interactive and reinforcing.
      • Golden SD
      • Earp JA
      Social ecological approaches to individuals & their contexts: twenty years of health education & behavior health promotion interventions.
      The individual sphere of the social-ecological model examines the knowledge, attitudes, and beliefs of the individual. The relationship sphere examines the influence of friends and family. The community sphere reflects the influences of cultural values and norms, and finally, the societal sphere is guided by public policy.
      • Snelling A
      Introduction to Health Promotion.
      The social-ecological model approaches health inequity from the perspective that no 1 single approach has a direct impact on multisystem problems. When historical inequities are created by social, legal, or politically motivated policies and programs, the social-ecological model is best served by examining the 5 main tenets of CRT.
      Critical race theory offers a race equity methodology as a framework to examine racial hierarchy concepts.
      • Ford CL
      • Airhihenbuwa CO
      Critical Race Theory, race equity, and public health: toward antiracism praxis.
      Critical race theory, while grounded in the fields of philosophy, history, sociology, and law, enables the field of public health to examine root causes of health disparities and to develop interventions that are based on social justice and equity by addressing gaps in health, housing, education, and employment. Because breastfeeding disparities are deeply evident when examining race, CRT provides a viewpoint for equity-based interventions. Critical race theory, as defined by Delgado and Stefancic,
      • Delgado R
      • Stefancic J
      Critical Race Theory: An Introduction.
      has 5 main tenets. The first tenet (White privilege) is that racism is ingrained in society and is socially constructed (see tenet 4). Racism is described as the norm and is the usual way society conducts business and is a common experience for BIPOC in this country. There exists differential access to power, social status, education, and more solely on the basis of racial membership.
      The second tenet (microaggressions) emphasizes that racism in the US is normal (often unconscious or implicit) and not aberrational as it reflects the experiences of most people of color. For example, to highlight tenets 1 and 2, after World War II, higher education for White males increased significantly for men who served in the military because of the GI Bill (Servicemen's Readjustment Act of 1944). However, Black veterans were less likely to take advantage of the GI Bill because of their predominantly southern-based residences and a host of barriers such as fewer southern colleges, admissions officers less likely to admit Black veterans in the south, and those very same Black veterans less likely to leave their families with less socioeconomic security while attending college. In addition, the GI Bill provided each state administrative control for benefit disbursement, and southern lawmakers used numerous tactics to ensure that benefits were dispersed inequitably.

      Blakemore E. How the GI Bill's promise was denied to a million Black WWII veterans.https://www.history.com/news/gi-bill-black-wwii-veterans-benefits. Accessed July 13, 2021.

      This bill was considered race-neutral but did not take into account these and other potential pre-existing societal norms and barriers for Black veterans.
      The third tenet (institutionalized racism) acknowledges that racism advances the interests of White individuals both materially and psychically, which provides little incentive for White individuals to dismantle racism. How race and racism are portrayed must be re-examined using contemporary and historical contexts through interdisciplinary methods. Minority groups periodically undergo differential racialization or the attribution to them of varying sets of negative stereotypes that may meet the needs and interests of White individuals in society. Stereotyping people on the basis of race undermines individual experiences and results in suboptimal health care.
      • Delgado R
      • Stefancic J
      Critical Race Theory: An Introduction.
      The fourth tenet is based on the social construction of race, which implies that different races experience the social environment differently. Race is not a factor of biology or genetics but a social invention.
      • Ford CL
      • Airhihenbuwa CO
      Critical Race Theory, race equity, and public health: toward antiracism praxis.
      ,
      • Delgado R
      • Stefancic J
      Critical Race Theory: An Introduction.
      A fifth tenet (intersectionality and antiessentialism) postulates that CRT is a framework that serves all of society when we use the lens of social justice to remove all forms of subordination of people. Within this tenet is the concept of intersectionality, such that no individual can fully or adequately claim membership in only 1 single group. Individuals generally represent membership in multiple groups and thus are representative of varying identities. For example, women may represent their Black culture, feminism, lesbianism, and even be identified by their faith. This implies that people of color play a crucial part in analyzing and understanding racial inequalities.
      • Delgado R
      • Stefancic J
      Critical Race Theory: An Introduction.
      It is our perspective that examining factors that contribute to breastfeeding disparities and inequities for Black women from the social-ecological model of no singular cause with a CRT lens enables health professionals to identify and dismantle structural racism within each sphere.
      To provide an evidence base for our perspectives, the literature was searched as follows. Both CINAHL Complete and PubMed were used to identify applicable studies and relevant articles found in peer-reviewed journals and historical-based articles to provide exemplars of institutional racism from 2011 to 2021. The resulting keywords were consistently used for each database: Black/African American, breastfeeding, disparities, inequities, racism, bias, self-efficacy, maternal/infant mortality, policy, and interventions. A hand searching (a methodological process that includes, but is not limited to, searching journal content and references lists for relevant articles that may have been missed during the initial database searches) of reference lists of published studies yielded relevant works that were included in the review. The results were limited to the English language and in the geographical location of the US.
      Database and manual searching identified 56 potentially eligible studies or contextually relevant articles: PubMed (n = 13), CINAHL Complete (n = 33), and other sources (n = 10). After duplicate studies were excluded, 50 screened studies were available for analysis; 9 articles were excluded, on the basis of the English language criteria, full article availability, and research conducted within the US. In total, 31 qualitative, quantitative, and mixed methods studies, and 10 additional articles published between 2011 and 2021, met the eligibility criteria for inclusion in this Perspective.
      Thirty-four of the studies focused on breastfeeding disparities, policy impacts on breastfeeding, and social or community factors that affect breastfeeding outcomes. Four articles are systematic reviews: 3 discuss the impact of the Baby-Friendly Hospital Initiative (BFHI) and interventions to improve breastfeeding rates, and 1 systematic review addresses implicit bias in health care professionals and gendered racism for women of color. Two scoping reviews focused on racism, bias, and discrimination and their impact on breastfeeding barriers to women of color. Two literature reviews focused on maternity leave and breastfeeding in the US and racial/ethnic disparities in breastfeeding. Two opinion/perspectives articles were included as they were deemed relevant to breastfeeding policies and equity issues in the US. The articles were then organized in the literature review by the applicability of the major spheres of the socio-ecological framework and CRT tenets.

       Literature Review

      The benefits of breastfeeding for mothers and infants have been extensively demonstrated, and breastmilk is accepted as the gold standard of nutrition for babies.

      U.S. Department of Health and Human Services. Healthy People 2030. Increase the proportions of infants who are breastfed at 1 year-MICH-16.https://health.gov/healthypeople/objectives-and-data/browse-objectives/infants/increase-proportion-infants-who-are-breastfed-1-year-mich-16. Accessed September 15, 2021.

      Disparities and inequities in breastfeeding rates among Black women in the US pinpoints several factors that appear to be effective in increasing breastfeeding initiation and duration rates.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      Increasing mothers’ self-efficacy and including support for mothers in breastfeeding education have been identified as important components within the individual and relationship spheres.
      • Pérez-Escamilla R
      • Martinez JL
      • Segura-Pérez S
      Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review.
      Within the community sphere, implementing the BFHI, providing prenatal breastfeeding education by health care providers, and providing postnatal support with breastfeeding peer counselors and lactation support are positive factors. From a societal perspective, addressing explicit (conscious) and implicit (subconscious) bias by health care providers and experiences of racism for Black mothers and creating policies that are aimed at addressing existing inequities in areas of education, housing, and employment are all positive factors associated with improved breastfeeding rates for this population.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      ,
      • Johnson AM
      • Kirk R
      • Rooks AJ
      • Muzik M
      Enhancing breastfeeding through healthcare support: results from a focus group study of African American mothers.
      ,
      • Pérez-Escamilla R
      • Martinez JL
      • Segura-Pérez S
      Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review.

       Individual Factors

      Black women acknowledge that breastfeeding is the optimal feeding choice for their infants and that exposure from family, friends, coworkers, health care providers, and the internet influenced them to initiate breastfeeding.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      The internet was cited as a useful tool for Black mothers to connect on social media sites with other breastfeeding Black mothers and allowed Black women to conduct their research about breastfeeding to help overcome challenges.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      However, a study of infant care practices of US-born NHB and foreign-born NHB women revealed that the use of books for infant care information was positively associated with stronger perceptions of control and favorable attitudes about breastfeeding, whereas the internet was not. It is postulated that the infant care books gave consistent positive information about breastfeeding while the information found on the internet conveyed both positive and negative information about breastfeeding.
      • Safon CB
      • Heeren TC
      • Kerr SM
      • et al.
      Disparities in breastfeeding among U.S. Black mothers: identification of mechanisms.
      In addition, addressing subjective norms about breastfeeding such as overdependence on the mother at the individual level may help improve breastfeeding duration for Black women in the US.
      • Deubel TF
      • Miller EM
      • Hernandez I
      • Boyer M
      • Louis-Jacques A
      Perceptions and practices of infant feeding among African American women.
      Breastfeeding self-efficacy, a modifiable factor, is an indicator of self-confidence and a strong predictor of breastfeeding success.
      • Reno R
      A pilot study of a culturally grounded breastfeeding intervention for pregnant, low-income African American women.
      ,
      • Brockway M
      • Benzies K
      • Hayden KA
      Interventions to improve breastfeeding self-efficacy and resultant breastfeeding rates: a systematic review and meta-analysis.
      A community grounded and equity-focused pilot intervention of 25 pregnant Black women with low income revealed that 80% of the women experienced increased self-efficacy with regard to breastfeeding.
      • Reno R
      A pilot study of a culturally grounded breastfeeding intervention for pregnant, low-income African American women.
      The dynamic breastfeeding assessment process was created with input from Black mothers with low income to identify breastfeeding goals and barriers. The dynamic breastfeeding assessment process was completed one-on-one with a participant and facilitator. The participant first identified her breastfeeding duration goal and motivation and was then provided with 2 sets of cards. One set of cards identified factors that support breastfeeding, and the other set identified barriers for breastfeeding. The facilitator used motivational interviewing to create a written plan with the participant to use supportive factors and address barriers. The researchers used the Breastfeeding Efficacy Scale-Short Form. An increase in self-efficacy was noted when comparing pretest and posttest assessments, and the researchers concluded that the written plan helped empower women to reach their breastfeeding goals.
      • Reno R
      A pilot study of a culturally grounded breastfeeding intervention for pregnant, low-income African American women.
      Interventions focusing on increasing self-efficacy may help empower Black women to overcome the barriers they face in meeting breastfeeding goals.

       Relationships and Social Support

      Support from the mother's social network is vital to infant feeding choices.
      • Carlin RF
      • Mathews A
      • Oden R
      • Moon RY
      The influence of social networks and norms on breastfeeding in African American and Caucasian mothers: a qualitative study.
      ,

      Centers for Disease Control and Prevention. Breastfeeding rates (National Immunization Survey).https://www.cdc.gov/breastfeeding/data/nis_data/results.html. Accessed August 25, 2021.

      ,
      • Golden SD
      • Earp JA
      Social ecological approaches to individuals & their contexts: twenty years of health education & behavior health promotion interventions.
      ,
      • Pérez-Escamilla R
      • Martinez JL
      • Segura-Pérez S
      Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      ,
      • Asiodu IV
      • Waters CM
      • Dailey DE
      • Lyndon A
      Infant feeding decision-making and the influences of social support persons among first-time African American mothers.
      • Schindler-Ruwisch J
      • Roess A
      • Robert RC
      • et al.
      Determinants of breastfeeding initiation and duration among African American DC WIC recipients: perspectives of recent mothers.
      • Segura-Pérez S
      • Hromi-Fiedler A
      • Adnew M
      • Nyhan K
      • Pérez-Escamilla R
      Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review.
      • Muse MM
      • Morris JE
      • Dodgson JE
      An intergenerational exploration of breastfeeding journeys through the lens of African American mothers and grandmothers.
      Women are influenced by their social networks regardless of race or social network type. In addition, women not only rely on their friends with previous childrearing experience but also on the infant's father and maternal grandmother. Although the social norms of a network influence feeding decisions, a mother who has at least 1 network member that supports breastfeeding was sufficient to help them resist opposing norms and continue to breastfeed.
      • Carlin RF
      • Mathews A
      • Oden R
      • Moon RY
      The influence of social networks and norms on breastfeeding in African American and Caucasian mothers: a qualitative study.

       Community

       Breastfeeding Friendly Hospital Initiative

      The BFHI initiative was created in 1991 and is a critical component of the World Health Organization/United Nations International Children's Emergency Fund strategy for child feeding.
      • Pérez-Escamilla R
      • Martinez JL
      • Segura-Pérez S
      Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review.
      The BFHI is based on the implementation of the Ten Steps to Successful Breastfeeding. The Ten Steps are a framework of evidence-based recommendations to guide improvements in breastfeeding initiation and duration.
      The BFHI and adoption of the Ten Steps have been effective in increasing breastfeeding initiation and duration disparities. Communities and Hospitals Advancing Maternity Practices was launched in 2014, and the project aimed to decrease racial breastfeeding disparities in 4 southern states by implementing the Ten Steps and assisting with BFHI designation.
      • Merewood A
      • Bugg K
      • Burnham DL
      • et al.
      Addressing racial inequities in breastfeeding in the Southern United States.
      The findings indicated that increased compliance with the Ten Steps was associated with a decrease in racial disparities in breastfeeding for Black women. For Black women, breastfeeding initiation increased from 46% to 63%, and EBF duration increased from 19% to 30% over the 31 months the project lasted.
      • Merewood A
      • Bugg K
      • Burnham DL
      • et al.
      Addressing racial inequities in breastfeeding in the Southern United States.
      There appears to be a dose-response relationship among the number of the Ten Steps women are exposed to and increases in positive breastfeeding outcomes and duration.
      • Pérez-Escamilla R
      • Martinez JL
      • Segura-Pérez S
      Impact of the baby-friendly hospital initiative on breastfeeding and child health outcomes: a systematic review.
      The BFHI provides evidence-based standards to ensure that Black women receive equitable postpartum lactation care.

       Prenatal and postpartum support

      Prenatal breastfeeding education by health care providers and postpartum support in the hospital and the community is greatly needed. For Black women who were considered long-term breastfeeders (breastfeeding > 6 months), the importance of breastfeeding education and social support were identified as contributing factors to success.
      • Gross TT
      • Davis M
      • Anderson AK
      • Hall J
      • Hilyard K
      Long-term breastfeeding in African American mothers.
      Health care providers, lactation consultants, and peer counselors with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition and educational support program have all been identified as instrumental in supporting Black women to successfully breastfeed.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      Support and encouragement from postpartum nurses are crucial in the early establishment of breastfeeding.
      • Reno R
      Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA.
      Nurses’ supportive behavior is predicted by their knowledge and attitudes toward breastfeeding.
      • Reno R
      A pilot study of a culturally grounded breastfeeding intervention for pregnant, low-income African American women.
      Support from doulas during labor and in the postpartum period have also been found to be helpful with breastfeeding success, and doula support contributed to overcoming early breastfeeding obstacles leading to continued breastfeeding.
      • Bernaix LW
      Nurses’ attitudes, subjective norms, and behavioral intentions toward support of breastfeeding mothers.
      Black women seeking prenatal care self-reported that all health care providers who interacted with them, whereas pregnant did not provide adequate support.
      • Johnson AM
      • Kirk R
      • Rooks AJ
      • Muzik M
      Enhancing breastfeeding through healthcare support: results from a focus group study of African American mothers.
      ,
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      Determining factors that support better rapport between patient and provider is critical to improving care. Some research suggests that patient-provider race concordance creates a positive rapport and establishes trust.
      • Street Jr, RL
      • O'Malley KJ
      • Cooper LA
      • Haidet P
      Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity.
      However, in another study, self-disclosure by the provider about similar health experiences established trust between patient and provider. Race concordance between patient and provider was not identified as the most beneficial factor; self-disclosure with empathy was consistently identified as a significant covariate. This is significant because matching patients by race would be difficult, and the research indicates that training health care providers about self-disclosure to help establish rapport and trust is effective.
      • Nazione S
      • Perrault EK
      • Keating DM
      Finding common ground: can provider-patient race concordance and self-disclosure bolster patient trust, perceptions, and intentions?.
      Some women indicated that they had detailed conversations about breastfeeding with their health care providers, whereas many indicated that their doctor asked about feeding preferences and did not educate the women about the benefits of breastfeeding.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      Qualitative interviews with 33 Black breastfeeding women demonstrated a need for specific prenatal breastfeeding education regarding what to expect and how to breastfeed.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      An additional study noted that African American pregnant women (n = 20) who received various levels of breastfeeding information ranging from a pamphlet on breastfeeding to discussions at each prenatal visit were overall satisfied with their prenatal care and education provided. Of significance, there were gaps in postnatal support and lactation care. Women expressed beliefs that culturally sensitive continuous care (prenatal through postpartum) and a need for long-term relationships with prenatal professionals were equally valued and needed when implementing the Ten Steps to Successful Breastfeeding model as an intervention.
      • Miller EM
      • Louis-Jacques AF
      • Deubel TF
      • Hernandez I
      One step for a hospital, ten steps for women: African American women's experiences in a newly accredited baby-friendly hospital.
      The role of peer counselors and Black women's involvement with WIC are positive sources of prenatal and postpartum support. Community support is a key factor in continued breastfeeding success after discharge from the hospital, and relationships with health and lactation professionals are considered vital during the prenatal period to proactively plan for the postpartum period.
      • Johnson AM
      • Kirk R
      • Rooks AJ
      • Muzik M
      Enhancing breastfeeding through healthcare support: results from a focus group study of African American mothers.
      ,
      • Segura-Pérez S
      • Hromi-Fiedler A
      • Adnew M
      • Nyhan K
      • Pérez-Escamilla R
      Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review.
      All of the participants in a qualitative study of successful breastfeeding Black women cited the support from the peer counselors as helpful. For Black women living in rural areas, it was noted as particularly helpful.
      • Gross TT
      • Davis M
      • Anderson AK
      • Hall J
      • Hilyard K
      Long-term breastfeeding in African American mothers.
      Those WIC peer counselors tended to be more aware of contributing factors influencing Black women's success in breastfeeding.
      • Gross TT
      • Powell R
      • Anderson AK
      • Hall J
      • Davis M
      • Hilyard K
      WIC peer counselors’ perceptions of breastfeeding in African American women with lower incomes.
      In contrast, Black WIC recipients living in Washington DC and Mississippi were less likely to use free telelactation applications and other breastfeeding support resources (A. T. Hunt, PhD dissertation, 2018).
      • Schindler-Ruwisch J
      • Roess A
      • Robert RC
      • et al.
      Determinants of breastfeeding initiation and duration among African American DC WIC recipients: perspectives of recent mothers.
      Black women with higher incomes may have additional resources, including private International Board-Certified Lactation Consultants (IBCLCs). During the coronavirus disease 2019 pandemic, with many services shuttered, telelactation (virtual consultations) was deemed an alternative to direct face-to-face services.
      • Louis-Jacques A
      • Schafer EJ
      • Livingston TA
      • Logan RG
      • Marhefka SL
      Modesty and security: attributes associated with comfort and willingness to engage in telelactation.
      Louis-Jacques et al
      • Louis-Jacques A
      • Schafer EJ
      • Livingston TA
      • Logan RG
      • Marhefka SL
      Modesty and security: attributes associated with comfort and willingness to engage in telelactation.
      noted that while their participants were nearly equally representative of White (51%), Black (25%), and Hispanic (25%) new mothers, Black women were less likely to use telelactation, even if the service was free because of privacy concerns of breast exposure and security surrounding access to video chatting platforms. Mothers with low income were also less likely to use or previously use lactation support but were open to support groups, websites, or text messaging for baby-related information. Nearly all mothers (94.3%) in this study had a smart mobile phone, but willingness to use available technologies on their phones was limited for those who were lower-income and unemployed.
      Positive community support for breastfeeding is evident in the success of a community-based support group; Breastfeeding Sisters That Are Receiving Support (BSTARS) was formed in 2015 in Memphis, Tennessee, by women of color for women of color.
      • Pyles TEH
      • Umi SA
      • Madubuonwu S
      • et al.
      Breastfeeding sisters that are receiving support: community-based peer support program created for and by women of color.
      The BSTARS uses partnerships at monthly meetings to support an equity-focused health lens for women of color and their families. In addition, BSTARS addresses barriers to breastfeeding and provides emotional and educational support for Black women, and the strong community connection is reflected in the high attendance rate of monthly meetings and annual events.
      • Pyles TEH
      • Umi SA
      • Madubuonwu S
      • et al.
      Breastfeeding sisters that are receiving support: community-based peer support program created for and by women of color.

       Neighborhoods

      Neighborhood resources such as access to primary care, social cohesion, and safety can impact breastfeeding support.
      • Kummer L
      • Duke N
      • Davis L
      • Borowsky I
      Association of social and community factors with U.S. breastfeeding outcomes.
      The National Survey of Children's Health analyzed breastfeeding demographics and neighborhood data and noted that neighborhood amenities such as parks/playgrounds, libraries/bookmobiles, recreation centers, and sidewalks/walking paths, social support defined as having ≥ 1 person that provides emotional support, neighborhood safety (feeling safe in the neighborhood), and the child having a medical home in which they receive regular medical care were independently associated with initiating breastfeeding and EBF at 6 months.
      • Kummer L
      • Duke N
      • Davis L
      • Borowsky I
      Association of social and community factors with U.S. breastfeeding outcomes.
      These data support evidence that the social and structural health of a neighborhood affects the health of its community members and perinatal health outcomes. However, these findings are nuanced and differ by race-ethnicity, suggesting that differing neighborhood contexts, social norms, and infant feeding practices vary and require different approaches for breastfeeding support in different communities.
      • Kummer L
      • Duke N
      • Davis L
      • Borowsky I
      Association of social and community factors with U.S. breastfeeding outcomes.
      Black millennial mothers (n = 15) reported that the care they were able to receive was influenced by their socioeconomic status, which is influenced the participants’ financial stability, type of insurance, and geographical location, and further highlights the impact of institutionalized racism and access to resources. Participants noted the intersectionality of race and assumptions by health care providers that mothers were of lower socioeconomic status. These mothers reported increased experiences of mistreatment and discrimination.
      • Lee YI
      • Baker S
      Understanding the racialized breastfeeding experiences among Black millennials.

       Societal Racism and Implicit Bias

      Experiences of racism and implicit bias by health care providers among Black women have a direct impact on the initiation and duration of breastfeeding rates.
      • Robinson K
      • Fial A
      • Hanson L
      Racism, bias, and discrimination as modifiable barriers to breastfeeding for African American women: a scoping review of the literature.
      Current literature supports an association between experiences of racism and poor health outcomes; however, the literature examining the relationship between breastfeeding and racism is limited.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      ,
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      Health care providers working with Black pregnant and breastfeeding mothers are often challenged to meet the needs of this population. Health care providers need to recognize the specific historical and cultural contexts that Black women face and have the skills to provide expert care in a conscious and contextualized manner.
      • Johnson AM
      • Kirk R
      • Rooks AJ
      • Muzik M
      Enhancing breastfeeding through healthcare support: results from a focus group study of African American mothers.
      The Black Women's Health Study revealed that health care providers who are not members of the marginalized group often contribute to and perpetuate racially biased assumptions about Black women and breastfeeding.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      Implicit bias is the unconscious association and stereotypes a person has about another individual in regard to race, gender, sexuality, or religion.
      • FitzGerald C
      • Hurst S
      Implicit bias in healthcare professionals: a systematic review.
      Health care providers’ unchecked implicit bias often led to stereotypical assumptions that Black women may not initiate breastfeeding. Thus, structural barriers often prohibit Black women from meeting breastfeeding goals.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      Providers’ implicit bias negatively affects the care a patient receives. Understanding and addressing the structural components of implicit bias is imperative to improving breastfeeding disparities and inequities.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      The structural components of implicit bias are based on institutional racism, which is associated with social structures and environments that are consistently underfunded and do not provide optimal health and well-being for marginalized populations.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      When IBCLCs were interviewed (n = 38) on racial discrimination in lactation care, the participants reported race-based discrimination and unequal care for women of color. Although both White and Black women reported cases of racial discrimination from nurses, doctors, and fellow IBCLCs, IBCLC's of color reported even more cases of race-based discrimination consistent with previous research.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      In our opinion, breastfeeding literature lacking images of people of color is a not-so-subtle inference of White dominance or perception that only White women choose to breastfeed. Breastfeeding images in educational materials or other media sources are also an extension of role modeling, which may be lacking for BIPOC communities.
      • Rhodes EC
      • Damio G
      • LaPlant HW
      • et al.
      Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program.
      We may add that implicit bias for health care providers is not exclusive to the medical setting; it is endemic to the larger society of social inequities including housing, education, and employment and must be addressed at the root of the problem to enable structural changes.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      Another important aspect to examine is the effect of systemic racism on Black mother's health and the impact on breastfeeding. Black mothers are 2–3 times more likely to die from pregnancy-related complications when compared with White women, and that the disparity exists despite socioeconomic status, which provides strong evidence that societal structural components can impact the health of Black women.

      Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System.https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm. Accessed August 15, 2021.

      Morrow et al
      • Morrow AL
      • McClain J
      • Conrey SC
      • et al.
      Breastfeeding disparities and their mediators in an urban birth cohort of Black and White mothers.
      noted maternal health was a key component of racial disparities in breastfeeding. The researchers found that the higher frequency of Black mothers with hypertension and obesity negatively impacted breastfeeding rates. Focus on prenatal maternal health by health care providers is needed to improve breastfeeding success in the postpartum period.
      There is a deficit in federal policies that aim to promote breastfeeding, which also impacts equity among breastfeeding mothers.
      • Gonzalez-Nahm S
      • Grossman ER
      • Benjamin-Neelon SE
      The role of equity in US states’ breastfeeding policies.
      A review of equity-based policies, state policies (including statutes), and regulations were examined with search terms that included race/ethnicity and socioeconomic status. The policies were categorized into 6 different themes: (1) breastfeeding in public, (2) breastfeeding in the workplace, (3) maternity leave, (4) discrimination with respect to breastfeeding status, (5) breastfeeding practices in hospitals, and (6) breastfeeding practices in licensed child care facilities. All states had policies that protected public breastfeeding, but those policies lacked structural breastfeeding support.
      • Gonzalez-Nahm S
      • Grossman ER
      • Benjamin-Neelon SE
      The role of equity in US states’ breastfeeding policies.
      The continued segregation of Black Americans into underfunded and low-performing schools perpetuates education and economic disparities.
      • Orfield G
      • Frankenberg E
      Increasingly segregated and unequal schools as courts reverse policy.
      As a result, many undereducated Black women with low income work low-paying jobs that do not provide adequate family leave or even break periods to express milk.
      • Reno R
      Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA.
      As part of the Affordable Care Act coverage, women now have access to breast pumps with some exceptions. Medicaid data indicates that breastfeeding education, lactation consultation, and breast pumps are still unavailable to women in at least 14 states that do not offer expanded Medicaid options.

      US Department of Health & Human Services. Are breast pumps covered by the Affordable Care Act?https://www.hhs.gov/answers/affordable-care-act/are-breast-pumps-covered-by-the-affordable-care-act/index.html. Accessed August 15, 2021.

      Segura-Pérez et al
      • Segura-Pérez S
      • Hromi-Fiedler A
      • Adnew M
      • Nyhan K
      • Pérez-Escamilla R
      Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review.
      noted that increased access to a breast pump did not increase breastfeeding rates but rather increased the rates of feeds involving expressed breastmilk. This finding demands further investigation regarding how access to a breast pump can better support an increase in breastfeeding rates and what factors influence increased breastfeeding vs increased feedings of expressed breastmilk when a mother has easy access to a breast pump.

      DISCUSSION

      The literature identifies the importance of support for Black women in each sphere of the social-ecological model. We surmise that factors that will contribute to breastfeeding disparities need to be identified with a multilevel approach to address issues from an upstream perspective with attention to needed structural changes. A women's self-efficacy about breastfeeding is crucial, and increasing self-efficacy is key to helping Black women meet breastfeeding goals. Black women have identified breastfeeding knowledge and self-perseverance as positive factors increasing personal self-efficacy.
      • Reno R
      A pilot study of a culturally grounded breastfeeding intervention for pregnant, low-income African American women.
      From a broader perspective, Black women have also identified a general lack of acceptance about breastfeeding within the Black American culture and American culture as personal barriers that influence breastfeeding self-efficacy.
      • Reno R
      Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA.
      The experience and cultural expectations of Black women in the US are reflected in the breastfeeding rates of US-born vs foreign-born Black women. The foreign-born status of a Black woman is a strong positive indicator of breastfeeding duration even when accounting for social, maternal, and infant factors.
      • Safon CB
      • Heeren TC
      • Kerr SM
      • et al.
      Disparities in breastfeeding among U.S. Black mothers: identification of mechanisms.
      Black women identify breastfeeding as the healthiest feeding option for infants but report a lack of role models and normalization of breastfeeding.
      • Asiodu IV
      • Waters CM
      • Dailey DE
      • Lyndon A
      Infant feeding decision-making and the influences of social support persons among first-time African American mothers.
      Identifying and connecting Black women with other Black women, who have successfully breastfed, in the prenatal period establishes connections for successful breastfeeding initiation and duration.
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      ,
      • Gross TT
      • Davis M
      • Anderson AK
      • Hall J
      • Hilyard K
      Long-term breastfeeding in African American mothers.
      Increasing social media visibility of Black women breastfeeding will also contribute to normalizing breastfeeding and providing role models.
      • Gross TT
      • Davis M
      • Anderson AK
      • Hall J
      • Hilyard K
      Long-term breastfeeding in African American mothers.
      It is our position that the dominance of White imagery in breastfeeding literature reflects racist cultural stereotypes about who breastfeeds and who does not and perpetuates a lack of role models for Black women. Black breastfeeding mothers have been able to find support through social media such as Facebook (Facebook, Inc). Black women found Facebook support to be empowering for themselves and others, and the online support helped change personal breastfeeding perceptions.
      • Robinson A
      • Davis M
      • Hall J
      • Lauckner C
      • Anderson AK
      It takes an e-village: supporting African American mothers in sustaining breastfeeding through Facebook communities.
      The relationship sphere includes the importance of support from the mother's partner, family, and peers. The influence of close contacts is essential for breastfeeding initiation and duration rates. Including the mother's partner in breastfeeding education is a necessary component in increasing breastfeeding initiation and duration. Including individual social network members who can provide strong support for breastfeeding will enhance a mother's determination to breastfeed.
      • Carlin RF
      • Mathews A
      • Oden R
      • Moon RY
      The influence of social networks and norms on breastfeeding in African American and Caucasian mothers: a qualitative study.
      We present the argument that incorporating close social network members in prenatal visits to discuss the benefits of breastfeeding will engage support people and foster an opportunity for further education.
      The community sphere highlights the importance of creating support outside women's social networks. The BFHI and Ten Steps compliance is a powerful component of increased breastfeeding rates for Black women. The evidence-based guidelines and policies support successful breastfeeding initiation and duration among Black women specifically.
      • Merewood A
      • Bugg K
      • Burnham DL
      • et al.
      Addressing racial inequities in breastfeeding in the Southern United States.
      However, access to hospitals in which maternity care practices are supportive of breastfeeding is dependent on zip codes. Analysis of maternity practices in infant nutrition and care found that in zip codes where the percentage of Black residents was higher, hospitals were less likely to recommend supportive breastfeeding practices compared with zip codes where the percentage of Black residents was lower, and hospitals were more likely to recommend supportive breastfeeding practices.
      • Lind JN
      • Perrine CG
      • Li R
      • Scanlon KS
      • Grummer-Strawn LM
      Centers for Disease Control & Prevention (CDC)
      Racial disparities in access to maternity care practices that support breastfeeding - United States, 2011.
      Therefore, national efforts are needed to ensure that hospitals are providing evidence-based practices that are supportive of breastfeeding regardless of birthing location.
      Community support from the prenatal period through the postnatal period is another identified factor that helps reduce breastfeeding disparities for Black women. Breastfeeding support from health care providers, nurses, lactation consultants, and WIC peer counselors have all been identified as integral components for success.
      • Gross TT
      • Davis M
      • Anderson AK
      • Hall J
      • Hilyard K
      Long-term breastfeeding in African American mothers.
      ,
      • Reno R
      Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA.
      Support from these community members is critical to help Black women meet breastfeeding goals, especially if the mother is experiencing a lack of support from family and friends.
      • Asiodu IV
      • Waters CM
      • Dailey DE
      • Lyndon A
      Infant feeding decision-making and the influences of social support persons among first-time African American mothers.
      Systematic social and professional support throughout the perinatal period needs to be the norm for increased breastfeeding success among Black women with the understanding that the availability of support is dictated by differing social, structural, and institutional contexts.
      • Asiodu IV
      • Waters CM
      • Dailey DE
      • Lyndon A
      Infant feeding decision-making and the influences of social support persons among first-time African American mothers.
      ,
      • Reno R
      Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA.
      Organizations seeking to implement community-level support systems for Black mothers must conduct a comprehensive analysis of the needs of the community to identify any barriers with the ultimate goal of making it easier for mothers to sustain breastfeeding.
      • Reis-Reilly H
      • Fuller-Sankofa N
      • Tibbs C
      Breastfeeding in the community: addressing disparities through policy, systems, and environmental changes interventions.
      Implicit bias from health care providers and structural racism affects Black women's self-perception, support from social networks, community networks of support, and policies that promote equity. Implicit bias from health care providers sabotages Black women's success with breastfeeding. Provider bias leads to a lack of education and support for Black women, and Black women experience exclusion, invisibility, and even hostility with breastfeeding experiences.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      Structural roots of racism are reflected in the racial segregation of patients and providers in housing, inequities in education and employment, and targeted criminalization of Black men.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      ,
      • Graff G
      Redesigning racial caste in America via mass incarceration.
      Organizations, hospitals, and agencies that provide services for breastfeeding mothers are encouraged to examine current hiring practices, employment data, educational materials, and policies that perpetuate inequities and provide evidence-based implicit bias training for employees.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      It is our viewpoint, on the basis of the findings in this Perspective, that breastfeeding promotion and support can be best advanced using a social justice approach with inclusivity and equity as its foundation. The overall goal is the removal of breastfeeding barriers, and to value and support breastfeeding for all women.
      • Smith P
      Social justice at the core of breastfeeding protection, promotion and support: a conceptualization.
      Current US federal policies such as the Family and Medical Leave Act (FMLA) and the Affordable Health Care Act have provided women with some support. The FMLA protects a woman's right to return to work into the same position after 12 weeks, but it is unpaid time, and women who work minimum wage jobs and/or are sole breadwinners do not always have adequate resources to stay home for the full 12 weeks to establish breastfeeding.
      • Morrow AL
      • McClain J
      • Conrey SC
      • et al.
      Breastfeeding disparities and their mediators in an urban birth cohort of Black and White mothers.
      The Affordable Health Care Act ensures women unpaid break time to express milk in a private setting, but federal legislation only protects the right for employers with 50 employees or more.
      • Hawkins SS
      • Dow-Fleisner S
      • Noble A
      Breastfeeding and the Affordable Care Act.
      State laws vary in breastfeeding support and can do more to protect women's ability to continue breastfeeding. Policies that provide structural support such as paid parental leave and workplace policies that offer protected break times for breastmilk expresssion
      • Morrow AL
      • McClain J
      • Conrey SC
      • et al.
      Breastfeeding disparities and their mediators in an urban birth cohort of Black and White mothers.
      are essential to the successful employment of Black women who desire to exclusively breastfeed.
      • Safon CB
      • Heeren TC
      • Kerr SM
      • et al.
      Disparities in breastfeeding among U.S. Black mothers: identification of mechanisms.
      The US is 1 of only 3 countries in the world that does not provide national or universal paid family leave.
      • Jou J
      • Kozhimannil KB
      • Abraham JM
      • Blewett LA
      • McGovern PM
      Paid maternity leave in the United States: associations with maternal and infant health.
      Although FMLA provides for either partner to take time off from work, it is generally unpaid leave unless vacation or sick leave are also taken (if provided by employer). Paid family leave is an equity-focused policy. Reported data on maternity leave stratified by job, education, and race, noted that short maternity leave is related to early breastfeeding cessation and reflects inequities in society.
      • Navarro-Rosenblatt D
      • Garmendia ML
      Maternity leave and its impact on breastfeeding: a review of the literature.
      Use and duration of paid maternity leave is associated with lower odds of rehospitalization for mothers and infants and improvements in stress management and healthy exercise habits.
      • Jou J
      • Kozhimannil KB
      • Abraham JM
      • Blewett LA
      • McGovern PM
      Paid maternity leave in the United States: associations with maternal and infant health.
      Equity-focused federal and state policies that target specific Black neighborhoods with low breastfeeding rates and increased funding for BFHI in hospitals that serve those neighborhoods are imperative.
      • Griswold MK
      • Crawford SL
      • Perry DJ
      • et al.
      Experiences of racism and breastfeeding initiation and duration among first-time mothers of the Black women's health study.
      Such policies would reflect the fifth tenet of CRT within the context of sex/gender and race.

      IMPLICATIONS FOR RESEARCH AND PRACTICE

      It is our assessment, on the basis of the findings in this Perspective, that health care providers and nurses need to address breastfeeding disparities among Black women in the US from the individual level to the societal level. All health care providers, but particularly White health care providers, who work directly with racially diverse patients need training on implicit bias to better understand how their experience of spatial separation and isolation from people of color fosters a racialized socialization that shapes White individuals’ views and attitudes.
      • Thomas EV
      “Why even bother; They are not going to do it?” The structural roots of racism and discrimination in lactation care.
      In our viewpoint, it is imperative that health care providers learn how to examine racial stereotypes, biases, and strive to actively disengage from them. Health care providers may best serve all members of their community if they consider incorporating support from the mother's social network during breastfeeding education because this has been shown to increase breastfeeding success within the relationship sphere.
      • Carlin RF
      • Mathews A
      • Oden R
      • Moon RY
      The influence of social networks and norms on breastfeeding in African American and Caucasian mothers: a qualitative study.
      ,
      • Jefferson UT
      • Bloom TL
      • Lewis KR
      Infant feeding exposure and personal experiences of African American mothers.
      ,
      • Asiodu IV
      • Waters CM
      • Dailey DE
      • Lyndon A
      Infant feeding decision-making and the influences of social support persons among first-time African American mothers.
      More studies are needed to examine the implications of structural racism and implicit bias on breastfeeding education and support for Black women. Many of the studies reviewed were qualitative studies with small representative sample sizes. Larger studies are needed to examine best practices for effective implicit bias training of all health care practitioners who intersect with pregnant, postpartum, and lactating Black mothers. Carefully designed studies that acknowledge the tenets of CRT and the social-ecological model are needed to ensure the engagement of Black women, health professionals, and community leaders. Further longitudinal studies are needed for evidence-based community-led programs that target improving breastfeeding rates for Black women.
      Breastfeeding provides many health benefits for mothers and babies. It is the first food for a newborn and provides optimal nutrition for optimal health. The breastfeeding rates for Black mothers in the US are a critical component of population health. Dismal maternal and infant mortality rates for Black women and Black newborns reflect the endemic racial bias and lack of equity in health care.

      Taylor J, Novoa C, Hamm K, Phadke S. Eliminating racial disparities in maternal and infant mortality: a comprehensive policy blueprint.https://www.americanprogress.org/issues/women/reports/2019/05/02/469186/eliminating-racial-disparities-maternal-infant-mortality/. Accessed August 25, 2021.

      Reducing disparities and inequities in breastfeeding rates among Black women in the US will not only affect maternal, and infant mortality rates but will also begin to address the larger systematic inequities and disparities evident in our society. Critical race theory provides a paradigm for investigating the root causes of health disparities with the basic features of race consciousness (race is socially constructed, and not necessarily a risk factor but a marker for racism-related exposures), changing the perspective to that of marginalized groups rather than from the perspective of the White majority, and acknowledging that the tenets of CRT can be applied as a conceptual framework for health and intervention research.

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