Racial inequality in the U.S. is so entrenched, so debilitating, that even Black babies—even, sometimes, within their first hours of life—are impacted by it.

Consider, for a moment, these chilling facts:

The infant mortality rate for Black babies is 2.4 times higher than it is for white babies in the U.S.

Black infants are two times more likely to die from SIDS and SUID than white infants.

Black infants experience nearly four times as many deaths related to short gestation and low birth weight.

Black preterm infants, compared with white infants, are three times more likely to suffer from necrotizing enterocolitis (NEC), and twice as likely to die from the condition.

Not surprisingly, bigotry plays a critical role in this disparity; research shows that racism-induced stress can have adverse effects on the health of Black women and, subsequently, on their babies. Lack of access to quality care also contributes to the mortality gap.

But there’s still another factor at play here, and it’s one that often goes overlooked, perhaps because it taps into a controversial debate: breastfeeding.

For too long, the dialogue around breastfeeding has been a deeply privileged one that erases and ignores Black women. And until we confront this fact, we can never fully address what amounts to an alarming health crisis for Black mothers in America.

It’s not a coincidence that Black mothers, while facing high rates of infant mortality, also have the lowest breastfeeding rates in the nation. There is a direct link between breastfeeding and infant health — studies show that breastfeeding helps lower incidences of SIDS, a leading cause of infant death, and reduces the occurrence of NEC, a condition that causes bowel tissues to die and is the leading cause of death in low-birthweight infants. So why do so few Black mothers breastfeed their children?

Part of it may have to do with the legacy of slavery: Some Black women have been reluctant to breastfeed, experts note, because slaves were often forced to nurse their slave masters’ children. Further, the advent of formula in the 1920s through ’40s brought with it “aggressive marketing” to Black communities; formula companies pushed the notion of their products being “the substance for sophisticates” and the choice of the elite.

Moreover, the health-care system has turned its back on women of color. Put simply, Black mothers often lack the community resources they need to successfully learn about and initiate breastfeeding. (Many of these forces, it’s worth noting, have also impacted American Indian/Alaska Native women, who breastfeed at higher rates than Black women, but lower rates than white women.

As a Center for Social Inclusion report put it:

“Many mothers want to choose to breastfeed because of the significant, inarguable benefits it offers both the mother and child, but without the right support, the choice is made for them.”

One of the most significant barriers to support exists in the very first place many infants see: the hospital.

Because hospital practices in the first hours and days after birth are essential to the success of breastfeeding, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have requirements in place for what they call “Baby-Friendly” hospitals. Facilities with this designation must, for example, initiate breastfeeding within the first hour of birth and train all staff to implement breastfeeding protocols. Some of the policies of the Baby-Friendly initiative — like a requirement that there be skin-to-skin contact between a mother and her baby immediately after birth — have been criticized by doctors and mothers for being ineffective and unsafe. Still, research shows that breastfeeding rates are higher in these hospitals. Moreover, Black breastfeeding rates in particular are significantly better in these hospitals. In a 10-year study of an inner-city neonatal intensive care unit, breastfeeding initiation rates for Black infants increased by 28% (compared to 10% overall) since the hospital’s designation as Baby-Friendly.

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The health-care system has turned its back on women of color.
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The problem? In areas where more than 12% of the population is Black, most hospitals do not follow recommended breastfeeding practices, and Baby-Friendly hospitals are nowhere to be found. This lack of initial support, combined with the implicit bias in health care that women of color already face, set Black women up for failure from the literal beginning.

As a result of these institutional barriers “in that first 28 days of life, a good chunk of our Black babies are not making it to that first year,” Andrea Serano, certified lactation counselor and program manager at ROSE (Reaching Our Sisters Everywhere), a breastfeeding support organization, tells me. “What we’re finding in our community is that there is this limited access to breastfeeding resources across the spectrum.”

ROSE is one of many organizations fighting to fix this resource gap; in addition to supporting Black breastfeeding through interventions, its members sit at the table with policymakers who can influence breastfeeding support efforts nationally — crucial in a landscape where racial disparities in breastfeeding are proven to decrease when the law supports breastfeeding. Black Mothers’ Breastfeeding Association is another organization working diligently on this front. Through advocating for legally mandated pumping breaks and private spaces for working mothers, championing to require insurance companies to provide no-cost lactation services, prohibiting child care facilities from discriminating against breastfed infants, and pushing for national legislation protecting a wider group of working moms, these organizations use policy and the law to help close the breastfeeding class and race gap.

But the solution to this troubling gap in infant mortality will take more than organizations like ROSE and USBC pushing for change. It will also take re-framing the debate around breastfeeding altogether.

While there is ample research supporting the benefits of breastfeeding, there has been a movement in recent years to challenge its hegemony. Movements like “Fed Is Best” are predicated on the idea that, quite simply, mothers should be supported in choosing whatever clinically safe feeding option is best for them, be it breastfeeding, formula, or a combination of both.

In many ways, pushback against the “breastfeeding only” approach is understandable: In a society that sadly insists on cultivating “mommy wars,” it’s important to respect the autonomy of all mothers.

But at the same time, this debate is a problematically privileged one. Black women not only face immense barriers to breastfeeding, but according to the CDC, are sold formula in hospitals at higher rates. As previously mentioned, there’s historical precedence to this resource disparity as well: The emergence of formula in the 1920s and ’30s led to lower breastfeeding rates across the U.S. — but when evidence began showing the health benefits of breast milk, white mothers gained greater access to that information, and began nursing again at higher rates.

When there’s such historic, disproportionate access to education and resources, what’s presented as a choice is really no choice at all.

“The reality is that we have to talk about race, and that is a very uncomfortable topic, and many have issues with coming to terms with it,” said Serano. So instead, we dismiss the benefits of breastfeeding as overstated, citing the weak correlations between breastfeeding and lower food allergies. We talk about the struggles of women who initiated breastfeeding with support and could not continue. These discussions are important — but while Black infants are dying and evidence tells us that initiating breastfeeding could turn that around, they should not be centered as the most important discussions.

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The reality is that we have to talk about race
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Instead, we must focus on the disparities that need to be addressed in order to ensure women of color have access to breastfeeding resources and are empowered enough to make the choice to initiate breastfeeding. We must stop dismissing the maternal health inequities that Black women face as purely socioeconomic, when evidence shows that this is not the case — cultural factors, including attitudes toward breastfeeding influenced by slavery, and stress and depression caused by racial disempowerment and systemic discrimination, have played a key role in the infant mortality gap.

What’s happening in this country with Black infants is nothing short of a public-health crisis. If there’s a national discussion to be had about breastfeeding, let it be that one.