Perceptions of Racism and Discrimination in Birthing Centers: Implications for Exclusive Breastfeeding Practices Among Black Mothers

Background

Racial disparities in breastfeeding remain a significant public health concern in the United States (Green et al., 2021). Black mothers continue to experience lower rates of breastfeeding initiation and duration compared with White mothers, with disparities shaped by historical and contemporary structural racism, discriminatory clinical practices, and inequitable access to culturally responsive lactation support (Asiodu et al., 2021; Centers for Disease Control and Prevention [CDC], 2019; World Health Organization, 2019). Historical and structural inequities rooted in slavery, segregation, and systemic racism have shaped enduring stereotypes about Black motherhood and infant feeding. Although prior research has consistently documented racial disparities in breastfeeding initiation and duration among Black mothers, these disparities are increasingly understood as the product of structural racism, discriminatory clinical practices (Bartick et al., 2017; Davis et al., 2021), and inequitable access to culturally responsive lactation support (Asiodu et al., 2021; Davis et al., 2021; Green et al., 2021; Thomas, 2018). Less qualitative research has centered Black mothers’ perspectives on how institutional birth setting environments—often framed as holistic or affirming—shape exclusive breastfeeding decisions in the context of perceived racism and discrimination. This study addresses that gap by examining how mothers’ perceptions of racism and discrimination within institutional birth settings intersect with breastfeeding intentions and behaviors.

This study is guided by the social ecological model (SEM), which conceptualizes health behavior as the result of interacting influences across multiple levels—individual, interpersonal, community, and institutional/environmental. The SEM provides an organizing structure for understanding how mothers’ beliefs and capacities, their relationships with providers, peers, and family, the norms and resources in their communities, and the policies and practices embedded in institutional birth settings jointly shape exclusive breastfeeding (Attanasio & Kozhimannil, 2015). Consistent with this framework, findings are organized by SEM levels to illustrate multilevel mechanisms that enable or constrain breastfeeding (a conceptual diagram of the applied SEM appears as Figure 1).

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Figure 1.

Social Ecological Model (SEM) of Breastfeeding Influences.

Significance to human lactation: By centering the lived experiences of Black mothers within institutional birth settings, this study contributes practice-relevant evidence for improving clinical lactation care and organizational equity. Insights from participants identify specific policy, training, and workflow opportunities—such as privacy safeguards, respectful communication, timely and skilled lactation support, and workforce diversification—that can strengthen mothers’ autonomy and confidence in meeting exclusive breastfeeding goals. These findings inform clinicians, IBCLCs, and administrators seeking to operationalize anti-racist, culturally responsive lactation care.

Methods

This study employed a basic qualitative design guided by the social ecological model (SEM) to examine how multiple-level factors within birthing environments influence Black mothers’ exclusive breastfeeding experiences. The SEM was used a priori to inform the development of the research question, sub–research questions, and interview guide, enabling systematic exploration of individual, interpersonal, community, and institutional influences. The primary research question examined how Black mothers’ experiences in institutional birth settings and perceptions of racism and discrimination affected breastfeeding initiation and duration. Sub–research questions were aligned with SEM levels to explore individual beliefs and embodied experiences, interpersonal relationships with health-care providers, community and social influences, and institutional policies and practices perceived as discriminatory. When used in conjunction with multifaceted SEM, the basic qualitative design aims to understand the meanings participants assign to their lived experiences and how perceived racism and discrimination operate across multiple levels of the birthing environment to influence breastfeeding outcomes and engagement with lactation services. Findings are organized according to SEM-aligned analytic domains derived from the sub–research questions.

Data Collection

Data were collected between May and September 2021 via semistructured one-on-one virtual interviews, conducted by the principal investigator (an international board-certified lactation consultant and health equity researcher) via secure teleconference platforms, audio-recorded with participant consent, and averaged approximately 60 minutes in length. The semistructured interview guide was developed a priori and aligned with the study’s research question and sub–research questions informed by the SEM. An expert panel validated the interview guide for clarity, validity, and alignment with research objectives. Interview questions explored participants’ birthing experiences, interactions with health-care providers and lactation staff, perceptions of racism or discrimination, breastfeeding support, and institutional policies and practices within birthing environments. All participants provided informed e-consent before participation. Institutional approval was obtained from the Walden University Institutional Review Board (approval number: 12-09-20-0963796, approved in December 2020). All study procedures adhered to ethical principles for human subjects’ research, including voluntary participation, informed consent, and participant confidentiality.

Data Analysis

Demographic characteristics were summarized descriptively (see Table 1). Qualitative data were analyzed inductively using thematic analysis in ATLAS.ti 9, with subsequent organization of themes aligned to SEM levels. Analyst triangulation-enhanced analytic rigor and intercoder reliability was assessed using Krippendorff’s alpha (α range = 0.76–0.93). A data analysis structure table (see Table 2) outlines the coding framework, including code definition, categories, and themes. Trustworthiness was established through analyst triangulation, member checking, and maintenance of an audit trail. Following inductive coding, themes were organized according to SEM levels to illustrate how perceptions of racism and bias emerged across individual, interpersonal, community, and institutional contexts.

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Table 1.

Demographic Characteristics.

Variable	Category	n	%	Note
Age (years)	—	—	—	Mean ± SD = 29.4 ± 5.2
Age group	21–25	—	—
	26–30	—	—
	31–35	—	—
	36–40	—	—
Marital status	Married/partnered	6	60
	Single	4	40
Education	Some college or higher	8	80
	High school diploma	2	20
Household income	<$40,000	5	50
	$40,000–$70,000	3	30
	>$70,000	2	20
Insurance	Medicaid	4	40
	Private	6	60
Intended exclusive breastfeeding	Yes	10	100
Introduced formula within 3 months	Yes	7	70

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Table 2.

Emergent Themes and Categories.

Subcode	Code	Category	Theme	Definition
Pain dismissal	Medical neglect	Pregnancy/birth outcomes and maternal experience	Individual level: Loss of autonomy	Instances where mothers felt ignored during labor or postpartum.
Lack of empathy	Communication barrier	Provider–patient interaction	Interpersonal level: Erosion of trust	Perceived emotional distance or bias from staff
Formula-first messages	Institutional messaging	Lactation support practices	Community level: Structural discouragement	Implicit or explicit encouragement to use formula over breastfeeding.
Policy inflexibility	Institutional control	Organizational (in)Formal policies and protocol	Institutional-level systemic invisibility	Policies limiting privacy, informed consent, cultural expression, or patient-centered decision-making.

Results

Ten Black mothers participated in the study. Table 1 presents the demographic characteristics of the sample, including age, marital status, education, income, and type of insurance. Participants ranged in age from 21 to 40 years (M = 29.4). Most held at least some college education and identified as working class or middle income. Six mothers were married or partnered, and four were single. Four participants reported Medicaid coverage, and six had private insurance. All reported a prenatal intention to breastfeed exclusively and met eligibility criteria, excluding medical contraindications to breastfeeding. Despite this intention, seven introduced formula supplementations within the first 3 months postpartum.

Discussion

This study contributes to qualitative literature examining how interpersonal and structural dynamics within institutional birth settings shape Black mothers’ breastfeeding experiences. Findings suggest that underutilization of lactation support reflects not diminished motivation or knowledge but a patterned response to experiences of dismissal, mistrust, and perceived invisibility within perinatal care systems (see Figure 2). Framed through the SEM, these findings underscore how racism operates across individual, interpersonal, organizational, and environmental levels to influence breastfeeding initiation and duration.

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Figure 2.

Pathway From Invisibility to Underutilization.

Consistent with prior research, participants described encounters characterized by invalidation of pain, limited access to lactation expertise, and differential treatment that eroded trust in health-care providers. Importantly, these narratives were reported across participants with varied educational attainment, insurance status, and income, reinforcing that breastfeeding disparities cannot be attributed solely to socioeconomic factors. Maternal intentions to breastfeed were strong across the sample, yet experiences within institutional birth settings frequently disrupted these intentions during the immediate postpartum period.

Alternative explanations warrant consideration. Participants’ interpretations of discriminatory treatment may reflect cumulative experiences with bias across health-care settings, potentially shaping perceptions of subsequent encounters. Likewise, mothers with negative experiences may have been more inclined to participate in this study, introducing possible selection bias. Despite these considerations, the convergence of narratives across participants and alignment with existing literature support the credibility and transferability of the findings.

These findings have implications for clinical practice and health systems. Interventions that rebuild trust—such as racially concordant lactation care, continuity of support, and accountability for respectful communication—may mitigate disengagement from postpartum services (Attanasio & Kozhimannil, 2015; Bleich et al., 2019). Future research should examine institutional practices, provider training models, and policy-level interventions that address structural contributors to inequitable lactation care. Mixed-methods studies may further clarify how perceptions of discrimination correlate with measurable service underutilization and breastfeeding outcomes.

Strengths of this study include its SEM theory-driven design, rigorous analytic procedures, which allowed for a multilevel interpretation of breastfeeding outcomes centered on Black mothers’ lived experiences. By situating Black mothers’ experiences and breastfeeding behavior within systems of care, this study advances understanding of how structural conditions—not individual deficits—shape inequities in lactation support and outcomes.

Limitations

Several limitations warrant consideration. As a qualitative study, this work prioritizes depth of understanding rather than generalizability. The small, purposive sample—while appropriate for the study aims, may not represent the full diversity of Black mothers’ experiences across rural, international, or non-U.S. health-care contexts. Participants’ accounts were self-reported and may be subject to recall bias, particularly given the 24-month postpartum inclusion window. However, this timeframe allowed for reflection on both immediate and sustained breastfeeding experiences. Virtual interviews increased accessibility but limited observation of nonverbal communication.

The researcher’s positionality—specifically, the shared racial and professional identity with participants—may have enhanced trust and disclosure while also requiring reflexivity during analysis; this was addressed through analyst triangulation and audit trail maintenance.

Finally, findings are situated within the sociopolitical climate of the early 2020s, a period marked by heightened awareness of racial inequities in health care, which may influence transferability.

Conclusion and Implications for Practice

Perceived racism and discrimination within institutional birth settings contribute to mistrust, emotional withdrawal, and underutilization of lactation and postpartum care services among Black mothers. These experiences reflect structural conditions—not individual deficits—that shape breastfeeding initiation and duration. For lactation professionals and birthing systems, these findings underscore the need to move beyond awareness-based approaches toward structural accountability. Equity-centered lactation practice requires consistent access to culturally responsive IBCLCs, transparent communication, respect for maternal autonomy, and organizational policies that actively counter bias. Clinical implications include integrating bias-responsive training into lactation education, increasing racial and cultural representation among lactation staff, and conducting routine organizational climate assessments to identify practices that undermine trust. Addressing disparities in breastfeeding outcomes requires not only supporting individual mothers but also transforming the systems in which lactation care is delivered.

Supplemental Material

Supplemental Material