Infant formula crisis highlights breastfeeding barriers in Southern states

CDC map of breastfeeding initiation rates by county

Breastfeeding initiation rates in the South are dramatically lower than in other regions of the United States. Expanding Medicaid to cover lactation consultants could reduce racial and geographic disparities, experts said. (Map via the Centers for Disease Control and Prevention.)

Despite efforts in recent weeks by the federal government to address the ongoing infant formula shortage, parents are still struggling to find formula.

The Food and Drug Administration announced this week that nearly two million cans of infant formula from a United Kingdom-based company would arrive in the United States in the coming days. Abbott Laboratories — the Illinois-based company whose alleged unsanitary conditions led to a voluntary recall of baby formula, the deaths of two infants, and the closure of a large formula manufacturing plant in Michigan, sparking the crisis — announced it will release about 300,000 cans of EleCare infant formula that will undergo extensive testing before being distributed nationwide, according to the FDA. 

The U.S. formula shortage has been blamed on pandemic-related supply chain disruptions and a market with limited competition, exclusive contracts, and few big suppliers. Earlier this month, producers of infant formula were allowed to speed up the manufacturing process, and the Biden administration called on state attorney generals to crack down on price gouging of formula, according to a White House statement. 

In response to the formula shortage, some pundits advised mothers to breastfeed instead. But that advice, however well-intentioned, ignores not only medical realities but structural barriers to breastfeeding. Those barriers are particularly high in the Black community and in Southern states, where breastfeeding rates are lower.

"Breastfeeding is a reproductive choice issue," said Kimarie Bugg, the founder and CEO of Reaching Our Sisters Everywhere (ROSE) a national organization based in Georgia that aims to decrease racial disparities in breastfeeding. "We know there are long-term health benefits to a mother, a child, a family, and society if a woman is successful breastfeeding."

Black people have the lowest rates of breastfeeding initiation among all racial groups in the U.S., according to a 2015 study. People who breastfeed less are usually young, low-income, Black, unmarried, and beneficiaries of the Supplemental Nutritional Program for Women, Infants, and Children (WIC). Andrea Freeman, author of the 2019 book "Skimmed: Breastfeeding, Race, and Injustice," says another factor behind the racial disparity is a cultural stigma attached to breastfeeding that's rooted in enslavement, coupled with a concerted push to market baby formula to Black people during the mid-20th century.

There's also a geographic disparity, as Southern states overall have a lower rate of breastfeeding than the nation as a whole. According to the CDC's latest breastfeeding report card from 2020, 84.1% of U.S. infants born in 2017 were ever breastfed, compared to just 76.2% of infants in Southern states. Nationwide the rate is lowest in Louisiana at just 66.2%. Among the Southern states, only Texas and Virginia had breastfeeding initiation rates above the national average.

A Centers for Disease Control and Prevention report published in 2019 found that better maternal health care, along with increased work and family support, could narrow the racial and geographic breastfeeding gaps. Sociocultural norms, concerns about milk supply, income, and lack of accurate information are among the factors that affect a person's decision to breastfeed, according to the CDC. 

The American Academy of Pediatrics recommends breastfeeding exclusively for the first six months of an infant's life, noting that it leads to better health outcomes for both the parent and the infant. Maternal benefits include decreased risk of diabetes and hypertension, while infant benefits include better dental health and neurodevelopmental outcomes, the AAP said. It advises against breastfeeding only for people with HIV infections and infants with classic galactosemia, a rare genetic disorder. 

Facing South spoke with Bugg and other experts about what could be done to increase breastfeeding rates in the South. 

Lactation care under Medicaid 

Expanding Medicaid coverage to include lactation services — think breastfeeding classes or lactation consultants — could be one solution to the racial and geographic disparities in breastfeeding rates.

Nationwide, only one-third of state Medicaid programs cover breastfeeding education or lactation consultation services, according to a Kaiser Family Foundation report released this month. Nine states nationwide don't cover any of those services under Medicaid, and seven are in the South: Arkansas, Florida, Kentucky, Louisiana, Mississippi, Tennessee, and Texas. 

In the South, the states with the highest breastfeeding initiation rates are Georgia, South Carolina, North Carolina, Texas, and Virginia, according to federal data. Four of those states – Georgia, North Carolina, South Carolina, and Virginia – cover certain forms of lactation care through Medicaid. Generally, parents can get free breast pumps in Southern states through WIC or Medicaid. 

Greater racial diversity in the lactation consultant field could be a solution to the racial disparities in breastfeeding, according to Bugg, an early pioneer in lactation advocacy among Black communities. "Here in the state of Georgia, we want to make sure mothers are comfortable and the care they're getting is culturally appropriate," she said. “We do a lot of referring, depending on what their specific needs are."

ROSE holds support groups addressing the complexities in breastfeeding in Black communities. The group also sued Georgia over a 2016 requirement that those who want to teach women how to breastfeed obtain the equivalent of an advanced degree; in March of this year the courts ruled the requirement to be unconstitutional. Bugg said the legal victory ensured that lactation consultants would be available to rural parents and not just those concentrated in the Atlanta metropolitan area.

While South Carolina Medicaid does not pay for breast pumps, the state Department of Health and Environmental Control notes that the WIC program has lactation counselors on staff, support groups, and food packages for people who breastfeed exclusively, according to the DHEC website. WIC offices in all states also have lactation consultants on staff. 

But more could be done in South Carolina as well as other states, according to Tisha Felder, a behavioral scientist at the University of South Carolina's College of Nursing. Felder co-founded Mocha Mama's Milk, a virtual breastfeeding support group for South Carolinians that launched this spring. 

"If we want to see some changes, we need to invest in these maternal child health policies," including paid family leave and WIC's breastfeeding program, Felder said.