Structural Racism and Barriers to Breastfeeding on Chicagoland’s South Side

For African American (AA) families on Chicagoland’s South Side who choose to breastfeed, ﬁnding and receiving services needed to reach their goals are difﬁcult. The disparities in breastfeeding support across Chicagoland are symptomatic of inequitable health care access shaped by persisting structural racism. A number of community hospitals that once served AA families by providing easy access to care no longer exist. Recently, South Side obstetric unit and hospital closures have increased. Simultaneously, funding is increasingly competitive for community health organizations and federally qualiﬁed health centers. Institutions and agencies that do receive funding or adequately allocate funding to include lactation services cannot address breastfeeding barriers within socioeconomically marginalized communities. The unmet funding needs not only affect breastfeeding families but also impede the growth of a multilevel lactation care workforce. Finally, inconsistencies persist between breastfeeding information provided by lactation providers and delivery team care received in the hospital. Despite these barriers, we believe pathways exist to improve breastfeeding rates among South Side AA communities, such as perinatal home visiting services. Stakeholders must recognize the longstanding effects of structural racism and address the inequitable distribution of perinatal care across Chicagoland. Stakeholders must also place value in and be supportive of lactation care providers and the families they serve through both funding and policies. These changes, in addition to community-level collaboration, can improve breastfeeding rates for AA families on Chicagoland’s South Side.


Introduction
H uman milk is the optimal infant feeding source due to its health benefits for both infants and the breastfeeding* parent. 1 Exclusive breastfeeding is recommended for the first 6 months after birth, followed by continued breastfeeding for 1 year or longer, as mutually desired by the infant-parent dyad. 2 Despite continued public health efforts to increase rates of breastfeeding, barriers persist that result in inequitable access to breastfeeding services, disproportionately affecting African American (AA) breastfeeding families and support systems. 3

Setting and Population
Health care access in the United States has been continuously shaped by structural racism, which encompasses the ways in which society upholds racial biases through ''mutually reinforcing inequitable systems.'' 4 Chicago, Illinois, is notorious for its residential segregation, which continues to entrench both geographic separation of and disinvestment in AA communities. These policies have shaped disparities in health outcomes across the life course for AA residents, 5 the majority of whom live on the South Side of Chicagoland. 6 Despite just 17% of live births in Illinois being non-Hispanic Black, AA women have the highest rates of severe maternal morbidity, 101.5 per 10,000 deliveries, and the highest pregnancyassociated mortality ratio, 109 deaths per 100,000 live births. 7 Both of these rates are three times higher than white women. In Chicago specifically, the AA infant mortality rate is 10.5 per 1,000 live births, more than three times higher than white infants. 8 As for breastfeeding rates, the state of Illinois reports 84.2% for ''ever breastfed'' and 42.1% for ''exclusive breastfeeding at 3 months,'' 9 far exceeding rates on the South Side of Chicago. For example, in the neighborhoods of Englewood and Roseland, with majority (95% or higher) AA populations, ''ever breastfed'' rates are 1.4% and 6.8%, and for ''exclusive breastfeeding at 3 months,'' rates are 0.6% and 4.1%, respectively. 10 While a stark comparison, these breastfeeding rates are reflective of trends found across the United States. 3

Hospital Closures and Funding Priorities
More than 98% of deliveries in the United States occur in hospitals, 11 and thus breastfeeding is most often initiated in this setting. Hospital closures have occurred steadily since the 1970s across Chicagoland, primarily driven by structural changes in the health care system, rising health care costs, low Medicaid reimbursement, and bed size. 12,13 However, socioeconomic factors of the surrounding neighborhoods, like rates of unemployment and racial composition, drive closure as well. One study found that in Chicago, neighborhoods with majority AA populations possessed smaller hospitals, which were more likely to close due to economic resources and bed size. 12 This example clearly demonstrates the insidiousness of structural racism, with selective health care investment setting up communities for increased vulnerability when closures inevitably occur.
Perinatal health care access on Chicagoland's South Side has historically been shaped by hospital closures, notable ones include Englewood, Osteopathic, and Hyde Park hospitals. At the beginning of 2019, Chicago had 19 hospitals with obstetric (OB) units, with 6 located on the South Side (Table 1). In 2019, two South Side hospitals closed their OB units, 14 and in 2020, two more South Side hospitals temporarily closed their OB units due to the COVID-19 pandemic, 15 one of which will now close permanently due to low delivery rates and budgetary concerns. Finally, a third South Side hospital announced it will close permanently in 2021. These closures leave just three OB units on the South Side, compared to the six each on the North and West sides of Chicago.
Simultaneously, funding has become increasingly competitive for community health organizations and federally qualified health centers, which provide health care for underserved communities on the South Side. 16 In addition, safety-net hospitals often do not offer all possible resources and services due to their budgets being much smaller compared to larger, private, nonprofit institutions, such as university-affiliated hospitals. 17 Institutions and agencies that do not receive funding or adequately allocate funding to include lactation services cannot properly address breastfeeding barriers within socioeconomically marginalized communities. Thus, childbearing families may not receive appropriate levels of care based on their clinical needs and perinatal care may be fragmented as birthing families seek to establish a medical home within a health care landscape rife with service challenges. Although a maternity care desert is defined as a county with limited access to maternity care (e.g., no hospital offering OB care, no birth center, and no OB provider), 18 we believe this concept applies to the South Side context, where maternity care options are rapidly decreasing and families are forced to travel farther from their communities to access perinatal care and deliver their babies.

Lactation Services Undervalued
These unmet funding needs not only affect breastfeeding families but also are likely to impede the growth of a multilevel lactation care workforce. The distribution of existing lactation providers is an important barrier in Chicagoland. As lactation providers in this context, we are concerned by the South Side's lack of International Board Certified Lactation Consultants (IBCLCs) and other lactation service providers, as well as breastfeeding support groups for AA families. Instead, we find that AA families on the South Side rely predominantly on infant feeding services from The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. Although still best known within AA communities as a formula supplementation service, Illinois WIC programs are actively working to improve their reputation as a breastfeeding support resource. 19 Despite improvement and best efforts, those of us who are or have been WIC providers supporting breastfeeding have found a lack of continuity and inconsistencies regarding the information and support shared with birthing parents by health care providers in hospitals and clinics, as well as the broader community. Oftentimes at the time of delivery, health care providers in hospitals interrupt or delay early breastfeeding efforts. This is due to various reasons, which include, but are not limited to, a lack of knowledge about breastfeeding best practices and the undervaluing of breastfeeding. 20,21 In our opinion, this mismatch in the valuation of breastfeeding between lactation providers and the hospital delivery team is a key space where interventions are needed to improve lactation education for health care workers, as well as lactation support for families.

Improving Breastfeeding Rates
Despite the hospital closures and funding challenges outlined above, we believe there are pathways through which breastfeeding rates can be improved for AA families on Chicagoland's South Side. Home visiting services for childbearing families are an intervention we want to highlight due to the gaps in perinatal care and breastfeeding support these services can fill, while simultaneously easing the burdens birthing families face when seeking out and accessing care. 22 Six programs offer home visiting services in Chicago and most of these programs are funded by state and federal government: Chicago Family Case Management, Early Intervention, Family Focus, Healthy Start, Healthy Families Illinois, and Family Connects Chicago. Most of these programs focus on high-risk populations; therefore, we highlight the efforts of Family Connects Chicago, a universal postpartum nurse home visiting service for families of newborns, with visits occurring 2-3 weeks postpartum and is currently being piloted in the city. 23 Benefits of a universal service include the reduction of stigma, assessing risk across the population, and ensuring those who need specialized care get connected to resources. 24 Home visit services can aid in the creation of a broader network of care for Chicagoland families that encompasses breastfeeding support. The nurses conducting home visits for Family Connects have lactation training and can refer participants to lactation care providers and/or WIC services. It is important to note that home visit services must engage end users and key stakeholders to develop service components that actualize their needs, while also evaluating the service to maintain quality of care, and advocating for policies and funding that sustains long-term support.

Conclusion
We believe more investment from government at federal, state, and local levels, as well as health care institutions and other key stakeholders on Chicagoland's South Side is necessary to achieve increased rates of breastfeeding among AA communities. These entities must recognize the longstanding effects of structural racism on the health of the communities they serve, advocate for more equitable distribution of hospitals with OB units and perinatal care services, as well as value and support the work of lactation services and support systems through both funding and policies. This will entail meeting the needs defined by both providers and the members of communities being served. 21 It is our opinion that collaborative efforts between lactation care providers and social services like home visiting can transform how breastfeeding is conceived of, as well as improve breastfeeding rates for AA families on Chicagoland's South Side.