Introduction

One of the founders of Black Breastfeeding Week, Kimberly Seals Allers, said it best: “Can white certified lactation consultants help bridge the racial gap in breastfeeding rates? Perhaps, with a lot of cultural training. Could more African American consultants get us there much faster? Absolutely”.¹ According to projections based on US Census Bureau data, the United States will become increasingly more diverse, reflecting diversity of the global population, and resulting in a minority White population by 2045.² As this shift occurs, health care systems in the United States must pivot in order to meet the needs of the changing population. Providers will need to become more culturally aware and health care organizations will need to ensure that their providers reflect their patient populations.

Gaps exist in maternal and child health for Black and Brown people across the board that often lead to adverse outcomes and health disparities.³ In an effort to combat these gaps, a number of programs and initiatives have been implemented, such as the Pathway 2 Human Lactation Program at North Carolina Agricultural and Technical State University (NC A&T), a historically Black university.

Despite the many benefits of breastfeeding, Black infants have the lowest rate of breastfeeding initiation and duration. The Centers for Disease Control and Prevention (CDC) noted that in 2019, the percentage of birthing parents who initiated breastfeeding was 73.6% for Black, 85.5%for White, and 87.4% for Hispanic families.⁴ According to National Immunization Survey (NIS) data collected by the CDC for 2019: 83.2% of US infants began breastfeeding, but only 24.9% breastfed exclusively for six months, and 35.9% met the recommended breastfeeding duration of 12 months.⁵ These statistics have remained constant for more than five decades. The Surgeon General’s Call to Action to Support Breastfeeding, 2011 noted that even while researchers control for family’s income or education level, breastfeeding rates for Black infants are lower than for all other races at birth, six months, and 12 months.⁶

The number of Black babies not being provided human milk is a public health issue and it is evident in the state of North Carolina; 2017 Surveillance Updates by the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) show that the rate of Black parents breastfeeding at four weeks postpartum (57.9%) and eight weeks postpartum (48.4%) was lower than that of White (73.8% at four weeks; 65.4% at eight weeks) and Latina (75.4% at four weeks; 66.3% at eight weeks) parents in 2014.⁷ There are several complex factors that influence the decision to initiate and sustain breastfeeding for Black and Brown families. Ultimately, the associated negative connotations of wet nursing, slavery, and medical exploitation are some of the many nuanced cultural barriers that deny Black women and infants the many health benefits of breastfeeding.⁸ In 2022, finding a Black International Board Certified Lactation Consultants (IBCLCs) is difficult in most communities in both hospital systems and outpatient settings. Although Black IBCLCs exist, no one seems to know how many there are in the United States. The membership association does not release this information for publication. Nevertheless, it is estimated by those in the field that less than 3% of IBCLCs in the United States identify as Black or African American.

The NCAT P2P

The Pathway 2 Human Lactation Program at NC A&T (NCAT P2P) was funded in 2018 by the University of North Carolina–Chapel Hill’s RISE (Lactation Training Model- Reclaiming, Improving, and Sustaining Equity) Project and is housed in the College of Agriculture and Environmental Sciences (CAES) under the Department of Family and Consumer Sciences’ (FCS) Child Development and Family Studies Program. It is an 18-credit-hour curriculum (six courses) and collaboration with four hospital-based clinical sites and one health department clinical site, allowing each student to earn 300+ clinical hours. In 2020, the NCAT P2P was approved by the Lactation Education Accreditation and Approval Review Committee (LEAARC) and accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). To date, the NCAT P2P is the first and only Human Lactation Pathway 2 Certificate program at the graduate level at an HBCU, and the first of its kind at a public HBCU. In the fall of 2020, the program launched and accepted its first cohort, ultimately becoming the university’s largest graduate certificate program.

Centered around community, diversity, and equity, the NCAT P2P sets itself apart from other Pathway 2 programs by exceeding the number of didactic hours in the subject matter of Communication Skills set forth by the International Board of Lactation Consultant Examiners (IBLCE). In order to sit for the exam, applicants must have five hours of didactic coursework in Communication Skills. The NCAT P2P exceeds this requirement by designating two courses with an emphasis on cultural diversity and communication in health care.

The purpose of these courses is to expose students to their own conscious and unconscious biases, help them explore their own culture and how they have formed ideas and beliefs about others, and ultimately provide them with a firm foundation in culturally sound care.

The NCAT P2P was established in an effort to 1) increase breastfeeding/chestfeeding rates for all marginalized populations, especially Black and Brown families; 2) diversify the lactation workforce by creating more IBCLCs of color; and 3) produce more culturally aware IBCLCs. Encouraging students to dig into and address their own biases creates health care professionals who will address health disparities and assist with closing the breastfeeding gap for Black families, improving both infant and maternal health outcomes throughout the lifespan.

The program also recognizes the structural barriers that make it difficult for individuals of color to enter the field of lactation and purposefully builds an infrastructure that promotes a sense of community and camaraderie amongst program graduates. This supports them in their journey to become contributing members of the field of lactation and appealing candidates for employment in associated fields. The broad employability of graduates of this program creates the potential to increase public health outcomes for all.

In the spring of 2020, a listening session with members of the Triad (Greensboro, High Point, and Burlington) community was held in conjunction with local hospital and health department leadership concerning the creation of a community-based lactation clinic. The participants were < 12 months postpartum Black, Latinx, and rural families. The following are direct quotes from this listening session:

“Absolutely! The cultural competence is enough for me! So much energy is exuded in the hospital on cultural competence. It’s like having a White therapist who you have to explain contextual things to as it relates to our culture. That’s tiring. POCs will just get it. They will understand disparities as it relates to breastfeeding in our community, and the stigmas around them. Also, hospitals can be intimidating. To have a safe place to go to get help from people who look like us and understand us is a no-brainer.”

“Absolutely, I would use it, support it, and recommend it. I used my sponsored clinic and [La Leche League]. Both were incredible resources and provided a community, but the lack of representation bothered me from the start. These events naturally lead to other discussions regarding parenting and as [Contributor #1] said, the need to explain cultural context is additional labor.”

“My baby was admitted to the pediatric unit at seven weeks old due to failure to thrive. I tried breastfeeding in the hospital, and everything went fine. When I was discharged it hurt too bad to latch the baby, so I started pumping and using formula. I think the formula made my baby sick because she kept spitting up every time we would feed her, but my baby’s doctor told me that I was drinking too much water and that was making my baby spit up and her stools too loose. I saw one of the NCA&T lactation students in the [pediatrics] unit and she educated me on how to latch my baby and told me my baby’s stools were supposed to be loose. She helped me latch my baby. I thought it was going to hurt but it didn’t. My baby nursed for the first time since we had left the hospital! I felt way more comfortable talking to someone who looks like me because I felt like she was listening to me. I did not go back to the hospital for help when my baby stopped breastfeeding because they made me feel like I couldn’t do it when I asked for help, so I decided not to deal with it. I would love to have this kind of help at a clinic if I have more babies.”

As an 1890 land-grant institution, NC A&T has a rich history in food and agricultural sciences as well as natural resources and human sciences. The research team at NC A&T recognized the impact that the first food—human milk—can have on an individual’s life. After seeing significant improvements in the community’s breastfeeding initiation rates due to incorporating students into the clinical settings at both hospitals and health departments, the NCAT P2P turned its efforts to establishing a community-based lactation clinic and assisting with compiling a Breastfeeding Atlas catering to Black, Indigenous, and People of Color (BIPOC) (The Melanated Mammary Atlas).⁹ In the spring of 2022, the NCAT P2P collaborated with the MedCenter for Women at Cone Health in Greensboro to pilot the lactation clinic for seven weeks, for 16 hours per week, serving 29 mother-infant dyads. Based on the satisfaction expressed by families and providers, the program will open its own clinic in the spring of 2023, becoming the first Pathway 2 program to operate a community-based outpatient facility.

The NC A&T community-based lactation clinic will serve all nursing families, but will directly impact families of color by ensuring access to accurate, supportive, and equitable care related to lactation. Providing person-centered care and valuing a person’s lived experience is key to improving trust for women of color.¹⁰ The clinic will also focus on meeting the breastfeeding needs of those in the community who are enrolled in specific programs at the health department geared toward reducing infant mortality, the uninsured, and individuals who are seeking culturally responsive care.

Everything in our society impacts breastfeeding, and infant death rates are a direct reflection of the health and wellness of women in a community. For decades the maternal and infant mortality rates in the United States have been an ongoing public health concern. As a direct impact of systemic racism, Black birthing people have a maternal mortality and morbidity rate that is 4.8 times higher than that of non-Hispanic White women, and Black infants have a mortality rate twice as high as that of non-Hispanic White infants.¹¹ The NCAT P2P is working tirelessly to combat the Black maternal and infant health crisis. In just under two years, the NCAT P2P has added almost a dozen new IBCLCs to the lactation workforce in a variety of disciplines. Graduates are working in local hospitals in the NICU, Well Mother & Baby, and Perinatal Education departments, while others have sought employment in outpatient and private practice settings. Additionally, a handful combined their IBCLC with other certifications and entered academia to pursue advanced degrees or instruct. Each new IBCLC is aiding to move the pendulum of breastfeeding from being an infant feeding choice to a public health choice for Black families.

Disclosure of interests

NCAT P2P receives funding from Blue Cross Blue Shield of North Carolina and Every Baby Guilford. The author has no further interests to disclose.