Centuries-Old Caricature Drives Divide in Breastfeeding Rates

Despite decades of “breast is best” efforts, there remains a disconcerting divide in breastfeeding rates in America. National data show that only about 60% of African-American women breastfeed, compared with 80% of white and Hispanic women. In some states, namely in the South and Midwest, the gap is even wider.

A researcher in North Carolina may have recently uncovered a centuries-old source to the entrenched disparity—one with ugly origins.

African-American woman breastfeeding
Breastfeeding rates among African-American women are significantly lower than among white and Hispanic women.

For over 20 years, as a nurse and certified midwife, Stephanie Devane-Johnson delivered babies for women of all racial and ethnic backgrounds in the South. During this time, she found that when the topic turned to how her patients planned to feed their babies after birth, her African-American patients were more likely to default to formula feeding. In fact, most weren’t open to even talking about breastfeeding.

“That’s when I knew then there was something deeper going on,” Devane-Johnson said.

A Cultural Barrier

Devane-Johnson joined the world of academia to get to the root of her patients’ reluctance. For her doctoral dissertation at the University of North Carolina at Chapel Hill, in 2016 she conducted focus groups with dozens of African-American women, ranging in age and socioeconomic background, looking for insights on how they chose to feed their babies.

“We just sat around and had nice, sister-girl talk, like, ‘How did you decide how to feed your baby? What influenced you on how you were going to feed your baby? Were there any cultural reasons?’ ” Devane-Johnson said.

The informal conversations, often held at local hair salons and libraries, lasted hours and mapped the very different context in which African-American women decided to feed their babies compared to other women. Sociohistorical factors, Devane-Johnson found, such as stereotypes dating back to slavery, had negatively shaped some women’s attitudes towards breastfeeding.

Many of the women’s mothers or grandmothers had not breastfeed, said Devane-Johnson, so they saw it as a “white thing.” With no familial history, the only cultural memory some women had of breastfeeding came from the echoes of slavery, such as wet nurse or mammy caricatures. First fictionalized in Harriet Beecher Stowe’s Uncle Tom’s Cabin, a mammy was a slave who was forced to nurse the slave owner’s children, oftentimes at the expense of her own children.

“And they just did not want to be associated with that,” Devane-Johnson said.

Complex Reasons

The study fills key gaps in the breastfeeding literature, which has largely attributed the long-standing racial disparities to socioeconomic factors, such as being able to afford breast pumps, jobs with maternity leave, or time off work to breastfeed.

But to Devane-Johnson, the findings were not all together surprising. She says that the mammy stereotype as a barrier to breastfeeding had been discussed for years among the small community of black breastfeeding advocates. However, it was largely discounted by the broader community.

“People have been like ‘We are too far removed for [slavery] to be an issue,’ ” she said. “But just because it evokes emotion doesn’t mean it shouldn’t be reported on or researched.”

A mammy was a slave who was forced to nurse the slave owner’s children, oftentimes at the expense of her own children.

In 2017, Devane-Johnson published her research, the first of its kind, in the Journal of Human Lactation. The qualitative study was published in April 2018 in The Journal of Perinatal Education.

“I couldn’t believe that this perspective hadn’t been brought to the forefront sooner than this,” said Kirsten Davison, an associate professor at Harvard T.H. Chan School of Public Health. “It feels obvious to me that there are very complex reasons why rates of breastfeeding are very low in African-American women.”

Davidson said that while socioeconomic factors are still major contributors in the disparity in breastfeeding rates, the study highlights that other important factors are at play.

“To consider only one of those reasons means the programs that are being developed are really very limited because there are many influences that are unaddressed,” she said.

And in fact, public health researchers have recently reassessed the effectiveness of some of their efforts in the wake of data showing that the breastfeeding gap in America is widening instead of shrinking. In recent years, while rates across all racial groups have increased, African-American women have not seen as great of an increase as white or Hispanic women.

“It does give us pause to stop and say, okay, why are the rates increasing quicker among certain groups, and where do we need to focus our efforts now,” Erica Anstey, a CDC researcher who recently published a study on racial and geographic differences in breastfeeding.

In Washington, D.C., for example, there was still a 31% difference between black and white babies who were breastfed at 12 months. “That to me is huge,” Anstey said.

Shining a Light

Devane-Johnson, now an associate professor at Duke University School of Nursing, said she hopes her research adds to broader body of knowledge about barriers to breastfeeding within different races.

“It’s about shining a light on the unique aspects for African-American women, not trying to marginalize anybody else’s experience,” she said.

Janiya Williams, a black lactation consultant in North Carolina, believes research like Devane-Johnson’s is an important piece of the puzzle to bridging the breastfeeding gap.

“Slavery wasn’t that long ago for black people,” Williams said. “And I say that because my great-great grandparents were slaves.”

The other pieces of the puzzle are fighting stereotypes within the hospital setting. A recent study showed that the newborns of African-American women are nine times more likely to be given formula in hospitals than the babies of white mothers.

“It’s not like African-American women don’t want to breastfeed, but sometimes within the health care system, they have been stereotyped to formula feed,” Devane-Johnson said.

Work To Do

Williams and Devane-Johnson believe that a greater ratio of black lactation consultants could help fight the proliferation of those stereotypes. There are currently only around 100 black lactation consultants in the country, they said. Together they have started a started a certificate program at North Carolina A&T State University, which they hope to expand to other historically black colleges in the South.

Dr. Michal Young, a neonatologist at Howard University Hospital who has implemented several successful programs to increase breastfeeding rates among African-American women, says within in the broader American health care context, “we have a lot of work to do.”

Dr. Young attributes the issue to the lack of education, both within medical professionals and patients, on the many benefits of breastfeeding.

These benefits are well-documented. Studies show that, for moms, nursing can protect against obesity and lower the risk of breast and ovarian cancer. In babies, studies show that breastfeeding boasts both neuro- and immune system development. These benefits are especially important in the African-American community, which is also disproportionately impacted by high infant mortality rates.

Illuminating these benefits—as well as the barriers in accessing them—doesn’t mean shaming formula-feeding moms, said Dr. Young, just the opposite. Rather, medical professionals need to be aware of these barriers to breastfeeding to better support moms who try, she said. The culture and commitment to breastfeeding in the U.S. as a whole could also be improved, she adds, such as with milk banks (which are common in other countries), so that women who don’t make enough milk or are unable to breastfeed are not made to feel guilty.

“For moms who don’t make enough [milk] or cannot continue, I tell them the first amounts that they give, whatever they give, is a blessing and a gift and they shouldn’t feel bad about it,” Dr. Young said. “Because the most important thing is a mother’s love. It eclipses mother’s milk.”