Breastfeeding Medicine

Physicians blogging about breastfeeding

@nickkristof When Whites Just Don’t Get It: Breastfeeding is not a “personal behavior”

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In the past few weeks, I’ve found myself thinking a lot about privilege and parenthood. At the Breastfeeding and Feminism International Conference and the Kellogg #FirstFoods16 forum, I heard testimony from men and women of color who described structural barriers, indifference and outright hostility from health care providers and community members. These two meetings bracketed House Bill 2, in which the North Carolina state government legalized discrimination against trans, gay and lesbian individuals, and prohibited local municipalities from instituting a living wage.

These events and discussions drove home for me the multiple levels of sex, race, and class privilege that undermine the health and wellness of our nation’s families.

With these experiences fresh in my mind, this morning, I picked up the New York Times Sunday Review and saw Nicholas Kristof’s column, “When Whites Just Don’t Get It, Revisited.” Kristof reviews the burgeoning evidence of discrimination against people of color, from disparities in the quality of public schools serving children of color to experiments demonstrating that a job applicant named “Brendan” is 50% more likely to get a callback that an applicant with the identical resume named “Jamal.”

I was nodding in vigorous agreement, as Kristof affirmed the testimony I’d heard at Breastfeeding and Feminism and at the First Food Forum – until I hit this paragraph:

Reasons for inequality involve not just institutions but also personal behaviors. These don’t all directly involve discrimination. For instance, black babies are less likely to be breast-fed than white babies, are more likely to grow up with a single parent and may be spoken to or read to less by their parents.

In this aside about infant feeding, Kristof misses the crucial role of structural barriers that prevent women from breastfeeding – barriers that affect all families, but are especially severe for women of color. Contrary to popular belief, breastfeeding is not simply a “personal behavior” – it is constrained by the life circumstances and support (or lack thereof) that a woman receives from her family, her community, her employer, and her health care providers.

For example, maternity care is a major predictor of whether women achieve their infant feeding goals. Yet while suburban hospitals that serve insured women are adopting the Ten Steps, a set of evidence-based guidelines that enable women to achieve their infant feeding goals, safety net hospitals that serve Women of color are less likely to implement the Ten Steps. Indeed, as the Center for Social Inclusion reports, as of May 2015:

  • Forty-five percent of hospitals designated as Baby-Friendly are located in communities where the Black population is three percent or less.
  • Almost one-fifth of Black people live in states without a single Baby-Friendly hospital.

Structural barriers are not limited maternity hospitals; while the ACA requires private insurers to cover the cost of lactation care, Medicaid policy does not require such coverage, limiting access to breastfeeding support for low-income women.

Women of color seeking lactation support are unlikely to find an IBCLC who looks like them. Women of color are vastly underrepresented in the lactation profession, creating additional barriers for breastfeeding.

And many of the “unconscious biases” that Kristof describes in his column impact interactions between health care providers and breastfeeding women of color. As a straight, white, professional woman, I am unable to speak to these issues from my lived experience, but I’ve been listening, and learning, from the testimony of those who can.1

In a recent article in Maternal and Child Health Journal, one mother described her experience in the early postpartum period:

They had someone on call to issue me birth control because of my statistic, because I’m Black, 22… [and] unmarried, they had someone right as soon as I had my son…but no help to breastfeed…the lactate nurse, she was rude and …wasn’t even consistent.’’

At the 2016 First Food Forum, women of color shared their stories of struggling to breastfeed in the face of apathy — and sometimes animosity — from health care providers. Laura María Gruber described how, when her first child was born, the only place she had seen a woman breastfeed was in National Geographic. She received little help in the hospital; when she sought treatment for a breast infection, the doctor walked in the room with a formula sample and informed her, “Sometimes, breastfeeding just isn’t worth it.” When her second child was born, there were not enough lactation consultants in her hospital to help her latch her baby. When she left the hospital, phone calls to community support groups went unanswered for weeks. She described praying to God to help her daughter latch – and promising that, if her prayers were answered, she would become an IBCLC and help other women like her. The day she was scheduled to return to work, her daughter latched; “That first latch was the beginning of a lifetime of healing.” Gruber is now an IBCLC in San Antonio and runs Breastfeeding Housecalls, offering home visits, Skype consults, and community groups to support breastfeeding mothers. (Watch her presentation via YouTube.)

Kimberly Seals Allers shared her story, describing how breastfeeding her daughter was an empowering act: “Breastfeeding allowed me to have a commitment that spoke louder than my personal circumstances.” (Watch her presentation via YouTube.) She went on to co-found Black Breastfeeding Week to rewrite the dominant narrative that “Black women don’t care about our children.” Indeed, Seals Allers noted, for too long, “Black women have been stereotyped as perfectly desirable to care for other people’s children, but not capable of taking care of our own.”

Seals Allers has coined the term “First Food Deserts” to describe the barren landscape faced by breastfeeding Women of color. She’s currently leading the First Food Friendly Breastfeeding Campaign, which is engaging communities to learn how to support real choices for infant feeding.

Seals Allers and Gruber were two of more than 200 stakeholders who gathered in Washington last week for the 2016 First Food Forum: Achieving Health Equity in Every Community. The Kellogg Foundation is funding multiple projects aimed at addressing the structural barriers that prevent too many women of color from achieving their breastfeeding intentions. We need to acknowledge the structural and institutional barriers that create First Food Deserts for too many families. As James Baldwin has written, “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

I am a long-time admirer of Kristof’s work, and I appreciate his efforts to address persistent racism in the US. However, I urge him to face the reality that, for many women of color in the US, breastfeeding is not an actionable choice – and a choice that is not protected is not a choice; it is a privilege.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

April 3, 2016 at 6:05 pm

6 Responses

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  1. First rate, Alison. And it applies to the underclasses in Australia as much as to those of colour (over-represented in the latter, of course.)

    Maureen Minchin

    April 3, 2016 at 7:48 pm

  2. Excellent essay. Many women of all colors are not able to reach their own breastfeeding goals due to all sorts of structural reasons. Of course, there are also many women of all colors who think breastfeeding doesn’t matter, or who think it is disgusting and animalistic. I was surprised and appalled when an African-American student attending a guest lecture I was giving last week expressed the opinion that breastfeeding was gross and unsanitary and proclaimed proudly “No one in my family breastfeeds.” We have a long way to go on all fronts.

    Kathy Dettwyler

    April 3, 2016 at 8:11 pm

  3. Very interesting and timely. Breastfeeding solely a ‘personal behaviour’???? Dear oh dear….

    Interesting to note that in the UK, black (African and Afro-Caribbean), Asian (in UK terms, this usually means of Indian, Pakistan and Bengali background) and Chinese mothers are more likely to initiate breastfeeding than white mothers, regardless of socio-economic characteristics. The same goes for more recently-arrived migrants from Eastern Europe.

    There are historical reasons for all of this, unsurprisingly.

    Heather Welford

    April 4, 2016 at 4:14 am

    • And by the next baby, here in Australia immigrant women who have successfully breastfed before are choosing to formula feed. What does that say about our culture?

      Maureen Minchin

      April 4, 2016 at 6:11 am

  4. I hope to help bring lactation support to women of color. I specifically want to help bring lactation support to Hispanic women. We desperately need professional support from people fluent in the language and culture. I was treated very poorly during my stay originally at the hospital my son was born until they realized I spoke English and was married to a white man. The truth hurts, but minorities are not given the same level of support even within the lactation community.

    Marianette Henriquez

    April 4, 2016 at 8:24 am

  5. […]  Stuebe AM. @nickkristof When Whites Just Don’t Get It: Breastfeeding is not a “personal behavior” Breastfeeding Medicine Blog. April 3, 2016. Accessed online:… […]

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