Here in the United States, parents and families are constantly told “breast is best.”

Yet our society is fundamentally unsupportive in helping families who truly wish to breastfeed to reach their goals, whatever they may be. There are few structures or programs in place that reinforce breastfeeding families in real, concrete ways.

The lack of social and cultural support for breastfeeding in America is much more insidious and more widespread than most new parents realize. It includes the absence of mandated paid family leave, which would make it easier to begin and maintain lactation; businesses that are unaware of laws related to breastfeeding and pumping; medical professionals who know little about breastfeeding; and so on. The barriers that breastfeeding mothers encounter make it difficult for many of them, but those barriers make breastfeeding even more challenging for poor women and women of color who have even fewer resources available to them.

Not every new mother wants to or is able to breastfeed. But if you want to successfully breastfeed your child in the United States, the onus is on you, the individual mother, to do it yourself if you have the means to do so: Pay for the breastfeeding class, ask the nurse to call the lactation consultant yet again, get your achy postpartum body to the support group. It’s no surprise, then, that most mothers seeking to breastfeed don’t, in a culture that “booby traps” them both during pregnancy and after birth. We need to hold this broken system accountable, instead of mothers themselves.

Making sure that hospitals—the very first system that mothers and babies usually encounter during and after birth—are encouraging breastfeeding in evidence-based ways is vital to bringing about change.

Breastfeeding is the biological norm for both mother and baby. Breastmilk is uniquely suited to human babies and provides them with optimal nutrition and immune protection, as well as a host of other positive health effects. Breastfeeding also has positive effects on a mother’s health. Although the American Academy of Pediatrics recommends exclusive breastfeeding until the age of 6 months, feeding with breastmilk substitutes is common in the United States for a multitude of medical and/or sociocultural reasons.

Although breastfeeding rates are slowly increasing overall, privileged women often have many more resources to be able to breastfeed. Women with lower education levels and lower incomes are shown to be more likely not to breastfeed their babies. Latina women generally initiate and maintain breastfeeding more than other ethnic groups, including white women; however, the disparities are clear: African-American women consistently have the lowest rates of both breastfeeding initiation and duration, as well as higher maternal mortality rates; the rate of infant mortality for African-American infants is nearly three times that of white infants. Hospital practices, which can also affect pregnancy outcomes, are often directly correlated with systemic racism, specifically racial disparity in care, as well as accessibility to care and insurance.

Making all hospitals “Baby-Friendly,” including and especially hospitals in low-income and racially segregated communities, is one systemic change that can actually support breastfeeding on a societal level and help to achieve equity across all populations of parents. Hospitals that support breastfeeding—rather than hampering it from the very start, as so many do with practices and policies that impact breastfeeding negatively—are one way to put our money where our mouth is, as it were: one concrete way to get breastfeeding off to the best start. 

The Baby-Friendly Hospital Initiative was launched in 1991 by the World Health Organization and UNICEF. It is based around the “Ten Steps to Successful Breastfeeding.” Steps include initiating breastfeeding within one hour of birth for all full-term babies, “rooming-in” (when babies are kept with their mothers rather than sent to a nursery), supporting breastfeeding on demand (rather than on schedule), and feeding formula only when medically necessary. Baby-Friendly hospitals must go through a certification process to prove they are using the ten steps in practice. Studies show hospitals that are Baby-Friendly have elevated rates of breastfeeding initiation and exclusivity, and that parents who experience six of the ten steps at their birthing facility are 13 times more likely to continue breastfeeding at six weeks postpartum than parents who experienced none of the ten steps.

If a hospital is designated Baby-Friendly, every mother who gives birth there will be supported in breastfeeding in the same evidence-based way, no matter her race, income, education level, whether or not she received prenatal feeding education, or any of the other factors that are shown to influence breastfeeding rates. Kimarie Bugg, founder of ROSE, a nonprofit organization dedicated to supporting African-American families in breastfeeding, says, “Baby-Friendly hospital designation is definitely a major game changer for racial equity and breastfeeding disparities in the United States.”

“Addressing systemic racism in the United States has to happen in order to prevent the disproportionate effects of health disparities,” she added.

Baby-Friendly is shown to be effective not only in private hospitals, but in public hospitals that serve a wider and more racially diverse patient base, as well—San Francisco General Hospital saw its breastfeeding initiation rates rise from 81 percent in 2002 to 98 percent in 2010. Two years later, in 2012, Los Angeles County + USC Medical Center, one of the largest public hospitals in the country, became certified, while all Indian Health Services facilities went Baby-Friendly in 2014.

Getting off to an effective start directly after birth is shown to increase positive breastfeeding outcomes in the long run. After all, breastfeeding, for all it’s touted as being “natural,” doesn’t actually come naturally to many mothers and babies. But for those who can, mother-baby dyads need information, education, and support, especially during the vulnerable first few days. At a Baby-Friendly hospital, every nurse in both the labor and delivery and postpartum units has taken 20 hours of lactation training, including teaching mothers how to latch their babies, hand express their milk, and more. Providers (doctors and midwives) are also required to take breastfeeding instruction. Having dedicated, knowledgeable, hands-on support in the first few days of baby’s life can make a huge difference in terms of the self-confidence and comfort of breastfeeding mothers.

For hospitals, becoming Baby-Friendly means a serious overhaul of the ways that babies and mothers have been cared for for generations, including completely rewriting and restructuring many policies and procedures, like phasing out newborn nurseries and making sure infants are given time to be skin-to-skin with their mothers directly after birth. Another huge obstacle? Baby-Friendly hospitals must purchase their own formula, rather than having it donated by formula companies. They also agree not to give out free formula samples to mothers when they are discharged from the hospital. The certification process is administrated through Baby-Friendly USA. Becoming Baby-Friendly certified usually takes multiple years, with backing from “local champions” as well as significant administrative resources, and hospitals are required to re-certify every five years.

Dr. Rose St. Fleur, a pediatrician at K. Hovnanian Children’s Hospital in New Jersey, explains that step ten “also requires hospitals to connect with their communities in order to provide breastfeeding support services that are easily accessible after going home. So, in essence, a Baby-Friendly hospital is able to step up as an much-needed advocate and voice for a breastfeeding woman, not just in the hospital setting, but also within her community.”

Culturally competent care is another hugely important piece of the breastfeeding equity puzzle, as is increasing the ranks of support professionals (International Board Certified Lactation Consultants, peer breastfeeding counselors, and support group leaders) who are people of color. Data clearly shows that Baby-Friendly hospitals can have a real impact on these racial and socioeconomic disparities.

Right now, the decision to breastfeed is not a realistic one for every woman, because women are still not supported by policies and programs that provide all women, regardless of socioeconomic status, with education, support, and control over their bodies and reproductive health. Baby-Friendly hospitals can begin to change that.

Of course, Baby-Friendly hospitals are not a panacea for America’s myriad breastfeeding ills; it’s far from a perfect system. One of the ten steps includes eschewing pacifiers, but the true effects of them on the breastfeeding relationship are being called into question with recent research. And what about, as was covered in a 2014 Slate piece, women who don’t want to breastfeed or who feel pressured or guilted into it by medical staff? If you give birth at a Baby-Friendly hospital, are you required to breastfeed? Absolutely not. After all, forcing women into doing something, no matter the circumstances, is not responsible health care. But advocates for Baby-Friendly say that the majority of women really do want to breastfeed.

Kimarie Bugg explains: “What we know is that 79 percent of women of childbearing age in the United States intend to breastfeed. I have been a professional nurse for 37 years working in underserved communities with vulnerable children. What I hear from women of color is ‘Why didn’t someone tell me about all these benefits?’”

The Baby-Friendly Hospital Initiative isn’t about forcing women to breastfeed. It’s about making a better system so all families have an equal playing field in breastfeeding support. To be sure, it will be difficult to get more hospitals, and more hospitals that serve at-risk populations, to actually become Baby-Friendly. There’s no way to guarantee that underserved communities will have access to Baby-Friendly certified hospitals (or indeed, hospitals that practice any of the ten steps), especially as hospitals in communities of color continue to close. But working toward Baby-Friendly care as the standard rather than the exception to the rule is a strong step to achieving equity.

Currently, there are 286 hospitals and birthing centers in the United States that are designated Baby-Friendly, representing around 13 percent of births in our country. That’s a start—but it’s not enough. More Baby-Friendly hospitals means better care from the ground up, an important building block in the overall strategy to increase systemic support for breastfeeding. When the system is more supportive, women have the information—and the right—to make the best feeding decisions for themselves, their babies, and their families.