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STARKVILLE, Miss.—As she stared through the nursery window at her four-day-old twins, 22-year-old Francesca Maxwell ticked off her reasons for wanting to breast-feed: Her obstetrician advised it. Her mother thought it a good idea. Even the babies’ father was all for it. Plus, she had recently read a brochure about the benefits of breast-feeding and one fact had stuck with her. “I was like, wow, they do have smarter babies with breast milk,” says Maxwell, who goes by Frankie. “That caught my attention—about the smarter babies.”
When she sat down to try pumping the next day, though, Maxwell decided she wasn’t so sure about breast-feeding after all—or at least not sure enough to attach the machine with strange-looking tubes and plastic parts to her breasts. “I got scared,” she says. “I was terrified of the pump.”
Breast-feeding is recommended by the American Academy of Pediatrics, the World Health Organization and many other groups and is considered the healthiest choice for giving babies the best possible start in life. It isn’t always easy for mothers, though, particularly in Mississippi, which has one of the lowest rates of breast-feeding in the U.S. and where role models, instruction and encouragement are often lacking. Bottle-feeding may seem less intimidating, especially when formula is readily available, as it was in Maxwell’s case. There were a few bottles of it in a free gift bag that appeared in her room at the maternity ward of OCH Regional Medical Center in Starkville. While Maxwell considered her feeding options, nurses gave the twins formula, which can doom breast-feeding efforts by interfering with a mother’s milk supply. And, even before the babies arrived home, her mother had stowed a carton in her room, “just in case.”
Like many Mississippi moms who intend to breast-feed, Maxwell faced a host of hurdles, some cultural. None of her friends breast-fed; a few said they find the practice “gross” and one even told Maxwell that she would “feel like a cow.” In the poor and rural Delta, women who participated in a recent focus group saw breast-feeding as unnatural—something that could potentially harm a baby and stigmatize a mother. Such perceptions may be passed down from mothers and grandmothers who themselves grew up surrounded by formula-fed babies.
“We always thought grandmothers were important,” says Sannie Snell, a health care consultant who conducted the focus group. (Snell’s work is funded by the W.K. Kellogg Foundation, which is among the various funders of The Hechinger Report.) “But we found they were negatively influencing their daughters not to breast-feed.”
Breast-feeding advocates say it’s not uncommon for Mississippians to react to the idea with disgust. “I had a mom who frowned her face up because I had been telling her about how beneficial it is,” recounts Tupelo-based lactation specialist and post-partum doula, Toni Hill, who works for the Northeast Mississippi Birthing Project. “She’s like ‘You want me to put my baby on my breast?’ And I say ‘Yeah,’ and she said `Ew!’”
Mississippi women who choose bottle-feeding over breast miss out on benefits that could prove critical in a state where so many children start out — and stay — behind. Like Maxwell, those who hope to breast-feed may hit formidable roadblocks. Breast pumps can be expensive; the one that Maxwell tried to use at the hospital in Starkville costs more than $300. Maxwell receives assistance through the WIC—or Women, Infants, and Children, the federal program that serves low-income mothers and children—but it only provides electric pumps if babies are premature or have problems latching on to the breast.
Then there is the workplace. Maxwell went into labor while working the grill at fast-food chain Bumpers Drive-In and could not envision nursing when she went back to work at the physically challenging job a few weeks later. The restaurant has no designated space for lactating mothers to pump, although Dan Douglas, owner of the Bumpers franchise where Maxwell works in Ackerman, said he’d be happy to make room for one if employees want one. “We’ve never run into this problem before,” Douglas said.
The obstacles Maxwell and other mothers here face help explain why only about 61 percent of Mississippi babies are ever breast-fed, compared to 79 percent nationwide, according to the Centers for Disease Control and Prevention. By 12 months, the rate of breast-feeding falls to about 10 percent—the lowest in the country and less than half the national rate. Mississippi also comes in dead last in the CDC’s state rankings of maternity practices that increase the likelihood mothers will breast-feed, such as ensuring that babies have skin-to-skin contact with their mothers right after birth; training for staff to help get new mothers started and a policy based on recommendations from the American Academy of Breastfeeding Medicine.
Instead, hospitals and birthing centers here routinely supplement with formula, according to the CDC, though the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists advise against it. Only 9 percent of Mississippi’s hospitals and birthing centers have comprehensive breast-feeding policies. And some 86 percent distribute free formula, the CDC found, even though public health groups warn against the practice.
To public health advocates, Mississippi is missing a crucial opportunity to combat some of the vexing problems facing its most vulnerable children. Breast-feeding lowers infant mortality, which is higher here than anywhere else in the nation: 7 infant deaths for every 1,000 live births. Breast milk, which contains a mother’s antibodies, enzymes and immune factors, also helps prevent colds, ear infections, stomach ailments, and food allergies—all pressing problems in the state, which has the lowest overall health rating in the nation. Breast-feeding can also avert Sudden Infant Death Syndrome (SIDS), obesity, and diabetes – all ailments that are more common in Mississippi than any other state.
Lesser-known benefits of breast-feeding could also give kids a crucial leg up in a state that ranks last on several education measures. Decades of research have shown that breast-fed children have better education outcomes than those who were formula-fed as infants— a difference that’s been measured in terms of spelling ability, reading comprehension, vocabulary word recognition, mathematical skills, teacher ratings, IQ scores and levels of school attainment. These benefits are greater the longer a mother breast-feeds and some have been documented to persist all the way through early adulthood. While some research has shown that exclusively breastfed babies have higher IQs, a 2006 analysis of multiple studies showed no difference in IQ between breast-fed and bottle-fed infants.*
Nationally, both white and Hispanic women are more likely to breast-feed than black women, according to the CDC. And those with more education are more likely to breast-feed than those with less, so it’s not surprising that Mississippi—and much of the Southeast—lags behind. Still, Mississippi finds itself at the bottom of a national trend. While 100 years ago the most advantaged women were most likely to use formula, the class situation has reversed itself. Now, least advantaged women are most likely to use formula. And Mississippi—the poorest state in the U.S, with a population that’s 37.4 percent black with one of the lowest levels of educational attainment—is among states where formula-feeding is most common.
Hill, who assists new mothers in northeastern Mississippi, says she regularly encounters misconceptions and biases about breast-feeding, particularly among African-American women. “They’re always like, ‘black women don’t breast-feed. That’s something white women do,’” says Hill. “And they say, ‘the baby’s going to be spoiled.’ We hear that all the time.”
Lackluster health department efforts
Mississippi’s State Health Department employs 20 full-time peer counselors throughout the state as well as 36 part-time peer counselors, who teach WIC participants about breast-feeding before they give birth and help them manage any complications that arise with it afterward. The Health Department also does some educating of mothers-to-be through the prenatal care it provides in seven county offices. But the staffing level in WIC-related efforts appears woefully inadequate to reach mothers of more than 5,000 infants who participate in the state’s program each year.
Budgetary constraints and a lack of personnel limit the department’s efforts, according to the health department’s communications director, Liz Sharlot. “There’s plenty of work and skilled professionals are few,” says Sharlot, adding that “we’re a poor, rural state.”
The bulk of breast-feeding education in the state gets done via relentless efforts from advocates, foundations, community groups and doulas like Hill, who say low breast-feeding rates are a self-perpetuating problem: Few women see other mothers holding infants to their breast, so they lack role models.
“You come in your office and tell a pregnant woman, ‘You need to breast-feed,’” says Hill. “Well, she [is] looking at you like that don’t even sound like nothing I want to do. The formula is easy. WIC going to give it to me.”
When WIC falls short
WIC does provide some free infant formula. But many mothers do not realize it doesn’t supply enough to fully sustain babies after their first few weeks. In the first three months of life, WIC provides mothers who don’t breast-feed with a monthly supply of 823-fluid ounces of reconstituted liquid formula. In the two months after that, the allotment goes up to 896-fluid ounces per month. Chelesa Presley, an outreach coordinator for the Delta HealthPartners Healthy Start Initiative in Tougaloo, said parents usually have to supplement WIC provisions with additional cans of formula to keep up with babies’ growing appetites; Presley, whose organization’s mission is to reduce infant mortality, estimates that 80 percent of her clients who use WIC-provided formula struggle to afford out-of-pocket expenses for formula, which can range up to $90 each month.** “They cut back on the formula and put more water,” says Presley, who, in several cases, has seen this practice result in babies being hospitalized for a failure to thrive. “Or they put cereal in the formula to extend it as a filler as early as two months. That leads to childhood obesity.”
Federal legislation gives WIC responsibility for breast-feeding promotion. According to the U.S. Department of Agriculture, which oversees the program, agency policy is to encourage breast-feeding unless mothers have a medical reason that makes them unable to do it. Yet, WIC participants nationwide are less likely to breast-feed than non-participants. This is also the case in Mississippi, where only 20 percent of infants in the WIC program are breast-fed, according to health department documents.
Part of the problem may be that, while the state provides formula to all WIC participants who say they’d prefer to bottle feed, the WIC breast-feeding promotion program in Mississippi is overburdened. The state spends approximates $10 million per year on formula for WIC recipients, according to the Department of Health. Meanwhile, the budget for breast-feeding promotion is about one tenth of that and that $1 million is spent on everything from staff salaries to educational materials and trainings, according to the Department of Health.
“It’s a great program but it’s not well supported,” former WIC lactation specialist Christina Chunn says of the agency’s breast-feeding promotion effort. Although the state says lactation specialists should see 20 to 60 clients monthly, Chunn estimates she had “between 275 and 300 clients at any given time” while working for WIC in Columbus. Peer counselors earn between $7.25 and $11.25 an hour, depending on their experience, according to the health department, and that means that even the best-paid full-time employees make only about $23,000 per year.
Rochelle Fields, a WIC lactation specialist in Jackson, says she logged interactions with 500 patients in a year of working half-time at the Jackson-Hinds Comprehensive Health Center in Jackson and more than 600 when she added in the people she saw in other locations. Fields says she hasn’t had a raise in over 10 years. And Toni Hill, who works part-time as a WIC peer counselor in addition to her doula work for the Northeast Mississippi Birthing Project, says that, at one point while working part-time for WIC, she had a caseload of between 600 and 700 mothers and pregnant women in Lee County.
‘There’s Ms. Presley’
While Mississippi’s small budget for breast-feeding promotion and low rates of breast-feeding present a “cautionary tale,” the lack of funding for breast-feeding-related efforts through WIC here is part of a national problem, according to Marsha Walker of the National Association for Breastfeeding Advocacy. “The funding isn’t there,” says Walker. “If the government is serious about wanting all mothers to breast-feed, they need to make sure there’s support to make that happen.”
“The WIC program is committed to providing breast-feeding education,” Debra Whitford, director of the national WIC program, responded in a statement, which pointed out that Congress provides the funding for the mother-to-mother support. Whitford also noted that breast-feeding initiation rates have risen “due to the efforts of WIC program staff,” having climbed from 41.5 percent of WIC mothers nationwide in 1998 to 67.1 percent in 2012. (Currently, 49 percent of babies nationwide are still breast-feeding at six months.)
In a statement, Mead Johnson, maker of Enfamil, said, “A mother’s decision to breastfeed or formula feed is personal, and we believe each mother should be supported in that decision regardless of how she chooses to feed her baby.” The statement went on to explain that the company has partnered with WIC “to ensure that every child has access to a strong nutritional start in life.”
The relationship between the federal program and breast-feeding is “complicated,” says Walker, who notes that WIC is both the largest purchaser of infant formula in the world and a critical force in breast-feeding education throughout the country. “For many mothers, the word breast-feeding is first heard in a WIC office,” she says.
New mothers may not see WIC-provided formula as a factor in their feeding decisions, but it’s available at little cost —at first, anyway—and that makes it easier for mothers to choose not to breast-feed. Antwanette Chapman, a 16-year-old WIC recipient who lives in Ackerman, had intended to breast-feed her daughter, Autumn. She even met with a lactation counselor, who explained that Chapman’s milk supply wouldn’t increase unless she put Autumn to her breast or used a pump. The specialist told her to hold Autumn like she was “running with a football,” and showed her how to place her hand behind her daughter’s small neck to help her latch. But even with this help, Chapman, who was homeschooled during the first part of what would have been her junior year at high school, gave up breast-feeding Autumn just two weeks after she started. Despite her doctor’s assurances, Chapman says she was worried about breast-feeding when she was taking medications for a respiratory infection. Plus, she says with a sigh, “It was kind of hard…irritating and tiring.” And when she returns to high school in the next few months, she wants “to be focused on school.”
Autumn, now two months old, is getting Enfamil through WIC. Sometime in the next month or so, Chapman will likely need to purchase formula on her own to supplement her WIC supplies. Unmarried teens like Chapman are particularly likely to become mothers in Mississippi and especially unlikely to breast-feed for any length of time. “They think they’re going to lose their freedom,” is how Presley, the lactation consultant in Tougaloo, explains their resistance. Presley’s solution is to encourage the teen moms she works with to pump, which allows them more flexibility because other people can feed their babies bottled breast milk. She also repeatedly reminds them about the health benefits.
“They see me coming and they say, ‘There’s Ms. Presley – you know she’s gonna want you to breast-feed,’” Presley, says of the pregnant teen moms she meets with regularly. She doesn’t mind whatever eye-rolling she inspires, because she believes her persistent presence in the lives of these young mothers-to-be has helped at least some of them choose breast-feeding.
“It’s all about the relationships,” says Presley, who works closely with school principals, often meeting with them to go through girls’ schedules to find gaps between classes when they can pump. Educators are increasingly open to facilitating pumping during the school day, she says, noting that the librarian at Clarksdale High recently used her own money to buy a small refrigerator where students can store their pumped milk.
‘Nothing but time’
Desta Reff, a fellow in a joint project run by Harvard Law School and Mississippi State University, believes encouraging breast-feeding is one of the best ways to address a wide variety of challenges facing Mississippi’s poor. Reff, a lawyer, came to the Delta thinking she might work with single mothers in their early twenties or create an early education program, but soon realized that both efforts would reach children too late in life. “You’ve got to get to them earlier,” says Reff. “The earliest point you can intervene is optimal.”
So Reff, a nursing mother of two, has been speaking about breast-feeding to moms in a local parent group that’s part of Clarksdale Baby University, a program designed to improve family health by educating parents. Reff says no single effort could meet the many needs of the 12 mothers in her group, three of whom had their first children at age 13. “These are single mothers living in poverty who struggle with the fact that they can’t do everything for their children,” she says. “You can’t give them everything, but you can give them something that costs literally nothing but a little time.”
While breast milk is free, infant formula is not—and the multi-billion dollar industry has complicated the calculus of breast versus bottle. Getty Israel, a public health advocate based in Jackson, says that part of the reason Mississippi hasn’t done more to promote and protect breast-feeding is that “formula has the pocket of many politicians.”
Israel helped get a law passed in 2006 that allows women to breast-feed in any location. Four years later, she tried to get the legislature to consider another bill, not unlike the one California recently passed, which requires all hospitals in the state to adopt 10 steps that support breast-feeding, including giving formula only when medically necessary. But, Israel says, Rep. D. Stephen Holland, then chair of the health committee, wouldn’t bring the proposal to the full Public Health and Human Services Committee for a vote, though it had passed his sub-committee. Getty says that when she went by his office for an explanation, Holland sent a staff member to meet with her who told her that Holland “wasn’t going to tell hospitals how to handle formula.”***
Holland, a Democrat who has served in the Mississippi House since 1985, remembers the incident somewhat differently; he says the bill didn’t come to a floor vote because the members of his subcommittee didn’t agree on it. He also said that he “was very kind to that group and very receptive and gave them their day in court.” But Holland didn’t dispute the idea that he wouldn’t have wanted to impose restrictions on hospitals dealings with formula companies.
“It’s not the purview of the legislature to tell the hospitals anything,” Holland told me. “I wouldn’t force my opinion on anyone. Hell, that’d be like peeing in the damn Pearl River to get the Gulf of Mexico to rise.”
Holland and other Mississippi legislators have in fact received donations from Abbott Laboratories, which produces Similac (until recently, the brand distributed through Mississippi’s WIC program), and Wyeth, maker of Promil and other infant formulas. While it’s not clear that these small donations were a factor in the handling of the 2008 proposal, companies that stand to gain from formula feeding still put money into marketing and lobbying in Mississippi—and there is no countervailing force with a financial stake in breast-feeding to push back against them.
‘Baby Friendly,’ hospitals
Some public health workers hope scientific research and advocates will fill the void, as Anne Merewood made clear at a meeting of the Mississippi Perinatal Quality Consortium in Ridgeland in November. An associate professor of pediatrics at the Boston University School of Medicine, Merewood helps hospitals and birthing facilities around the country voluntarily become “baby friendly,’’ by taking the 10 steps recommended by an international organization that promotes breast-feeding. Two hundred and twenty four institutions across the country already have. But, Merewood acknowledged the particular difficulties in Mississippi, which doesn’t have a single baby-friendly hospital. “When you try to change perceptions, you get a lot of pushback,” she said to the nodding audience.
Lactation specialists and doctors told of hospital staff who felt they didn’t have time to teach about breast-feeding and administrators who didn’t know about its health benefits. Merewood suggested hospitals might do better by trying to achieve just one or two of the 10 criteria on the list, such as eliminating pacifiers or having newborns room with their mothers whenever possible.
[pullquote author=”” description=”” style=”new-pullquote”]Mississippi women who choose bottle-feeding over breast miss out on benefits that could prove critical in a state where so many children start out—and stay—behind.[/pullquote]Cultural change is slow work, Merewood seemed to be saying. And others slogging away at the roots of Mississippi’s low breast-feeding rates share her view. Sannie Snell, the health care consultant who conducted the focus groups in the Delta, has been working with 25 churches near the town of Indianola on the gradual process of combatting resistance to breast-feeding. Snell is helping institute “healthy baby Sundays,” when pastors talk about breast-feeding, and a “mother of the church” campaign, which she hopes will ultimately increase appreciation and acceptance of women who breast-feed. She’s also developing criteria for “infant-friendly churches.”
Snell will soon launch another project that focuses on a group of Mississippi mothers for whom breast-feeding is especially hard: those whose premature infants are in neonatal intensive care units. The lack of transportation to get them—and their milk—to and from the hospital is yet another hurdle that’s higher in this state where prematurity is especially common and NICUs few and far between. It’s yet another piece of the puzzle, one of many obstacles that, in Mississippi, still tip the balance away from breast-feeding during a baby’s first days and weeks.
For Frankie Maxwell in Starkville, that critical time when her babies could still easily start breast-feeding is past. Maxwell’s twins are now two months old and she never did manage to start them on the breast. In the end, a pile-up of obstacles outweighed all the advice she received. While the babies remained in the hospital because of their size after Maxwell was discharged, she would have had to drive 20 minutes each way to bring them her milk. On top of all the other adjustments to becoming a mother of two and her fear of pumping, Maxwell was afraid she wouldn’t be able to produce enough milk. As she anticipated going back to a workplace where she assumed pumping would be impossible, she went with formula.
In the throes of sleepless nights caring for Madison and Mason, who are now home, Maxwell finds it hard to believe that she’ll ever have another child. But if she does, she hopes she won’t use formula next time. “I’ll definitely try breast-feeding,” says Maxwell. “I wanted to have that experience.”
*Clarification: This story has been updated to include a link to research showing no difference between the IQs of breast-fed and bottle-fed babies.
** Clarification: This story has been updated to identify Chelesa Presley, an outreach coordinator for the Delta HealthPartners Healthy Start Initiative in Tougaloo.
***Correction: This story has been changed to include the correct timeline for Getty Israel’s efforts to pass a bill requiring hospitals to support breastfeeding — four years after successfully getting another law passed — and to correct how far the bill got in the state legislature: It passed a sub-committee but was not introduced in the full Public Health and Human Services Committee.
This story was produced by The Hechinger Report, a nonprofit, independent news website focused on inequality and innovation in education.