The fact that Serena Williams and Beyoncé suffered from life-threatening complications while pregnant should tell you something about the racialized experience of motherhood in this country. Both iconic Black women have spoken about the medical complications they experienced creating thriving families. For Williams, it was a pulmonary embolism. Queen Bey suffered from preeclampsia. Being rich and famous meant very little.
It may seem surprising that Black women are three times more likely than White women to die from pregnancy-related complications and are more likely to suffer from other issues, such as hypertension and diabetes in pregnancy, regardless of money and means. This reality is even more compelling evidence of the racist structures that perpetuate the vicious cycle of health inequities.
But it is a reality that can be changed.
Unequal health outcomes are mirrored in the breastfeeding journey for many Black women, who are less likely than White women to meet their own breastfeeding goals. Yet, breastfeeding itself provides some hope at breaking this cycle of maternal health inequities. Nursing moms are less likely to have future health problems, such as hypertension, obesity, and diabetes.
And for babies, breastfeeding not only decreases their risk of neonatal infections and chronic health problems later in life, but it also can save lives. Breastfed infants are 26% less likely to die between the second week of life and first birthday, compared with non-breastfed infants. This is breathtaking when one considers that the Black infant mortality rate is double that of White infants. Like other maternal health inequities, antiracist medicine and policies can improve breastfeeding outcomes, something two Boston hospitals are working to achieve.
Merina Bosquet, 34, a Haitian-born Boston resident, breastfed her older two children and planned to solely breastfeed her next baby, Mikel. This pregnancy was different. Bosquet now had gestational diabetes, a type of temporary diabetes in pregnancy, which disproportionately affects Black and foreign-born women in the U.S., and can cause problems with pregnancies, births, and/or breastfeeding, specifically in decreased milk production.
Fortunately, Bosquet’s pregnancy went fine. Baby Mikel was born full-term at Brigham and Women’s Hospital, where he was put directly on his mother’s chest — skin-to-skin — after delivery, a practice that leads to improved breastfeeding outcomes. Despite the documented success of immediate skin-to-skin contact, this practice isn’t always a given at hospitals across the country. Brigham and Women’s is certified as “Baby Friendly” which means they have specific policies and procedures to support families who want to breastfeed.
Mikel appeared to his mom and nurses to be latching well in the hospital, but on their first day home, Bosquet noticed he was sleeping longer periods between breastfeeding and not peeing very often. These were signs that he might not have been getting enough breastmilk.
The next day, at Mikel’s first pediatrician’s visit at Boston Medical Center, the doctor discovered that his weight had fallen much more than expected from his birth weight, and that his skin had a yellow “jaundiced” appearance. These were two more signs he might not have been getting enough breastmilk.
Mikel’s pediatrician drew a blood test for jaundice, and referred him to the Breastfeeding Medicine Clinic in BMC’s new Breastfeeding Equity Center. There, Emily Swisher-Rosa, a midwife and board-certified lactation consultant, saw that Mikel was very sleepy when he tried to breastfeed and hardly swallowed any milk once she and his mother were able to help him latch.
Swisher-Rosa also saw that his blood test result showed hyperbilirubinemia (another sign he wasn’t getting enough breastmilk) and that he would need extra help to clear the jaundice. Mikel was admitted to the pediatric unit that day.
There, Mikel was not only treated but also had a visit with Wilberthe Pilate, R.N., a lactation consultant of Haitian background. It mattered that Bosquet could speak to an expert with a nuanced understanding of her cultural background.
Pilate explained to Bosquet that her milk production hadn’t picked up fast enough in the first days – a common situation for mothers with gestational diabetes. Getting such little milk, Mikel didn’t have the energy to feed well, resulting in a vicious cycle of poor milk removal, affecting both the baby’s weight and the mom’s milk production. Pilate helped Bosquet use her breast pump to increase her milk production back up.
Mikel recovered and started gaining weight quickly by taking breast milk, plus a little formula, until his mother’s milk production increased, and they could stop the formula. After leaving the hospital, mom and baby had two more visits at the breastfeeding medicine clinic with Swisher-Rosa, and with Bosquet’s determination, and support from a hospital lactation team, Mikel was back to exclusively breastfeeding.
He was growing fine by the time he was 2 weeks old.
The medical and breastfeeding challenges Bosquet and Mikel faced are far too common for women of color, and the specialized and well-integrated lactation care that can help them get back on track is far too uncommon. The racial disparities that impact Black women’s breastfeeding journeys reflect the systemic and structural inequities throughout healthcare and society.
Multiple historical, social, and cultural factors, affecting both families and health care providers, complicate this situation. Because enslaved Black women were forced to wet nurse White children at the expense of their own children, breastfeeding itself has carried complex connotations for many Black women. Thus, the lower rates of breastfeeding success among Black families have perpetuated the false idea among health providers that women of color do not want to breastfeed, which in turn may lead health providers to minimize breastfeeding support and introduce formula even when the mother has enough milk.
In one study of low-income women, hospital introduction of formula was the largest contributor to shorter breastfeeding duration among Black infants compared with White infants. Early weaning from the breast has significant health consequences for both mother and baby.
Many healthcare interventions can help families successfully breastfeed.
The Baby-Friendly Hospital Initiative, a standardized program to increase breastfeeding rates worldwide through a 10-step approach to hospital-based breastfeeding support, reduces the racial disparities in breastfeeding initiation between Black and White women in the United States. But it’s not clear if it reduces breastfeeding disparities after they leave the hospital, or if the program is implemented equitably in all settings.
Small preliminary studies have found White women to be more likely to get breastfeeding support at certified Baby-Friendly hospitals than Black women, who often report discrimination in breastfeeding support. Unlike Bosquet, most Black parents never see a Black lactation consultant. As one study found, fewer than 2% of certified lactation consultants identify as Black.
Looking at the two Baby-Friendly Boston hospitals where Bosquet and her son, Mikel, received their care in that crucial first week of life, we are optimistic that reversing the racist structures in healthcare that maintain racial disparities in breastfeeding is possible.
The reality of Boston Medical Center’s outpatient breastfeeding medicine clinic being available to Medicaid patients is incredibly important and uncommon. The outpatient breastfeeding medicine clinic where Bosquet and Mikel receive medical care from a midwife and board-certified lactation consultant is a big start. Most lactation consultants in the U.S. are not integrated into health systems and must charge out of pocket as their services are not covered by insurance, further hampering the ability of low-income families and women of color from getting skilled clinical breastfeeding care.
We are also studying the extent to which breastfeeding support practices may vary by a mother’s race when it comes to care at the time of delivery in our two hospitals.
Serena Williams was at first ignored by her health care team when she developed symptoms of a blood clot. Are other Black mothers also being treated differently when they try to get help breastfeeding their babies?
The results of our study will help inform changes in hospital policies, staff training, and breastfeeding support, to ensure best practices are available to all patients regardless of color or immigration status.
Dr. Katherine Standish is a family medicine doctor and researcher at Boston University School of Medicine who specializes in breastfeeding medicine.
Dr. Afi Mansa Semenya is an assistant professor of family medicine and healthy equity researcher at Boston University School of Medicine.
This commentary was produced with support from a Solutions Journalism Network Health Equity Grant.