When women of color give birth, healthcare providers treat them differently from white women, says one breastfeeding equity advocate. According to these women, healthcare professionals have an attitude that amounts to: “I need to watch you to make sure that you’re acceptable to take care of your baby,” the advocate adds.
In some instances, new mothers don’t receive the attention they feel they need. “I had my child, was put in the postpartum unit, asked for my lactation consultant, and didn’t receive one,” says one mom. “Then I was ready to be discharged, and 30 minutes before I was supposed to leave, the lactation specialist popped in and left. It’s not that I wasn’t educated or didn’t know how to advocate for myself. I simply didn’t have access.”
These types of experiences can be painful, humiliating, and all too common for a new mother, especially given that breastfeeding can present many challenges. “Every day there are white women who post on social media that they had the most amazing birth and that they were so cared for,” says a Seattle-based doula who helps mothers giving birth. “How does this happen when every single one of our clients, if they deliver in a hospital, leaves traumatized?”
The data suggest the anecdotal experiences aren’t aberrations. Black infants are 15% less likely to have ever been breastfed than white infants. And trends in breastfeeding rates show breastfeeding disparities between black and white infants widening.
The Centers for Disease Control and Prevention (CDC) has made reducing breastfeeding inequality a priority. CDC has engaged an Abt Associates-led team to implement the EMPower Best Practices project to train and provide technical assistance to staff at 125 hospitals nationwide. The goals are to increase coverage and adherence to evidence-based infant nutrition practices and reduce socioeconomic and racial breastfeeding disparities. The Abt team, which includes the UNC Chapel Hill’s Carolina Global Breastfeeding Institute and Population Health Improvement Partners, will train maternity nursing staff members from each participating hospital over the course of four years.
“Maternity nursing teams are asking for support in putting health equity principles into practice at their facilities,” says EMPower Best Practices Project Director Ann Cloud, an Abt health research monitoring and evaluation associate. “They want to better understand how to reflect upon the race or sociodemographic data at their hospital, and how to have difficult conversations among their team members about addressing disparities.”
Endemic Racism in Healthcare
Ample evidence suggests that racism, whether unconscious or intentional, is endemic in the practice of medicine. And it’s particularly damaging for breastfeeding, the clinical gold standard for infant feeding and nutrition. Breastfeeding reduces infant mortality and long-term risks of diseases such as diabetes and obesity for children and cancer for mothers. CDC estimates that the immunity to common illnesses that breastmilk provides infants and toddlers would save $3 billion a year in medical costs in the U.S. .
A number of factors may explain racial discrepancies in breastfeeding, such as a lack of education about nursing. And lactation consultants may prefer to spend more time with families they think will be successful with breastfeeding instead of prioritizing those most at risk for not meeting breastfeeding goals.
While 71% of moms come into the hospital intending to exclusively breastfeed, 56% leave the hospital breastfeeding. Only 41% of Black mothers leave the hospital breastfeeding. EMPower Best Practices will work to ensure providers offer all patients the same quality support for starting and continuing breastfeeding.
We teach evidence-based care to improve breastfeeding practices, and healthcare systems and their staff seek training in the cultural aspects of their relationships with patients—recognizing and addressing their biases. In some cases, that can spark resistance based on an initial inability to see one’s own inherent biases. “I often get pushback from leadership on how to engage with the community,” says a nurse manager and lactation consultant. “Nursing staff need to be task-oriented to be effective in day-to-day care, which can make the connection between cultural practices and results more difficult to recognize.”
Hospital teams participating in the EMPower program are asking myriad questions around health equity:
- How can we identify someone to serve as an Equity Champion?
- What is the role of the Equity Champion in day-to-day care of patients?
- How can we review our data to better understand disparities in our care?
- What are some approaches to hiring and retaining a more diverse nursing team that better represents our population?
- What are some tools for approaching difficult conversations with our nursing team?
- As we make progress reducing our disparities, what are some ways to keep our team engaged and motivated on that journey?
With different institutions at different stages in addressing equity, solutions require a tailored approach to help meet teams where they are in their equity journey. Often largely white hospital staffs today serve increasingly diverse populations. The majority of the 125 participating EMPower hospitals the Abt team supports report that they are just starting a discussion of equity. A smaller number have not yet started, and roughly the same number are fully implemented or starting to implement equity approaches.
In response to the equity questions the Abt team is receiving, the team has launched a Health Equity Community of Practice to provide information about how hospital staff can incorporate health equity into their operations. Activities will include educational webinars on cultural humility and bias with expert speakers and the chance to share challenges and solutions with peers.
One main goal is to enable those who are further along in discussing and incorporating health equity practices to share their insights, tools, and processes with those who are in earlier stages. Some teams within the program have reviewed their breastfeeding initiation rates by race and ethnicity, engaged leadership, and shared the relevant data with their maternity staff so they can use the data to begin those difficult discussions. The teams allowed time for self-reflection and open conversations and over time are beginning to see the impact, with breastfeeding disparities decreasing within their hospitals. Understanding the steps of these vital processes and being able to share with their peers is beneficial to all.
Where would training start? Birth equity experts advocate building from a foundational level of shared language and understanding of where disparities and equities come from. “We want to move past implicit bias and look at real cases to apply what providers have learned,” says one birth equity advocate. “Like how the outcome could have changed if you use the skills and tools you’ve acquired to make a patient feel as though they’ve been treated with respect.”
Introspection also is important. Providers must scrutinize practices ingrained over decades. “The nurses we work with are dedicated and diligent in their care; they genuinely want to help patients,” says Abt’s Cloud. “They are often working in under-resourced environments where they are overworked. It is very likely that people often don’t realize the full extent of their actions.”
When hospital teams are given the time to take a step back and offered guidance and space for self-reflection, they can begin to see how they may have inherent biases that come into play during their work. “That time of self-reflection follows them into daily care where they begin to have some ‘a ha’ moments,” Cloud adds.
Holding hospitals and staff accountable is another key element. “For our system, the culture changes overnight when physicians and residents started having to explain why they stopped breastfeeding when they previously didn’t have to do that,” one health care staff member says.
As EMPower Best Practices leads the charge for improving breastfeeding practices, much more is at stake. “It shouldn’t just be about the numbers of people who are breastfeeding at discharge,” says a New Orleans OB/GYN and birth equity advocate. “It should fundamentally be about ensuring the dignity of patients.”