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https://doi.org/10.1177/1049732318759491
Qualitative Health Research
2018, Vol. 28(7) 1050 –1064
© The Author(s) 2018
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DOI: 10.1177/1049732318759491
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Research Article
International Board Certified Lactation Consultants
(IBCLCs) are professionals who “provide expert breast-
feeding and lactation care” (International Board of
Lactation Consultant Examiners [IBLCE], 2016).
Because of mounting evidence that IBCLCs help to sig-
nificantly improve breastfeeding rates in the United
States, the surgeon general has identified increasing
access to IBCLCs as an action step to support breastfeed-
ing (U.S. Department of Health and Human Services
[HHS], 2011). However, 11 states have a limited avail-
ability of professional lactation support (Centers for
Disease Control and Prevention [CDC], 2014).
Reducing disparities in the provision of lactation care is
of critical concern given current breastfeeding disparities.
Between 2004 and 2008, Blacks had lower rates of breast-
feeding initiation and duration in all states except for
Rhode Island and Minnesota (CDC, 2010). Southern
states, in particular, show serious racial inequality in
breastfeeding with 13 states having a gap between Black
and White breastfeeding that was at least 20 percentage
points different (CDC, 2010). Studies show that Black/
White gaps in initiation and duration persist even when
maternal age, income, education, rates of marriage, and
other explanatory variables are held constant (CDC, 2004).
Through semi-structured interviews with 36 IBCLCs
who assist mothers with breastfeeding, this study takes a
systematic look at breastfeeding disparities. Specifically,
this study documents race-based discrimination against
patients in the course of lactation care and links the
implicit bias literature to breastfeeding disparities. An
examination of discrimination in lactation care can yield
important information about the ways that race, class, and
gender structure the breastfeeding experiences of and
opportunities for mothers and babies in the United States.
History and Benefits of Lactation
Support
The professionalization of lactation consultants began
after La Leche League, a mother-to-mother breastfeed-
ing support program, sought to improve breastfeeding
rates that were as low as 20% in the mid-1950s. La
Leche League International (LLLI) convened a panel of
60 experts in 1985 to develop standards that continue to
shape the scope of lactation practice today. The IBLCE
was formed as a result of the panel, and the IBCLC
credential remains the only internationally recognized
759491QHRXXX10.1177/1049732318759491Qualitative Health ResearchThomas
research-article2018
1Graduate of Georgia State University, Atlanta, Georgia, USA
ORISE Research Fellow, Oak Ridge Tennesee, USA
Corresponding Author:
Erin V. Thomas, Research Fellow, Oak Ridge Institute for Science and
Education P.O. Box 117 Oak Ridge, TN 37831-0117, USA.
Email: erinvthomas@gmail.com
“Why Even Bother; They Are
Not Going to Do It?” The Structural
Roots of Racism and Discrimination in
Lactation Care
Erin V. Thomas1
Abstract
Through semi-structured interviews with 36 International Board Certified Lactation Consultants (IBCLCs) who assist
mothers with breastfeeding, this study takes a systematic look at breastfeeding disparities. Specifically, this study
documents race-based discrimination against patients in the course of lactation care and links the implicit bias literature
to breastfeeding disparities. IBCLCs report instances of race-based discrimination against patients such as unequal care
provided to patients of color and overt racist remarks said in front of or behind patient’s backs. This study connects
patient discrimination in lactation to institutional inequality and offers suggestions to address these inequities.
Keywords
breastfeeding; lactation consultant; IBCLC; patient discrimination; racism; health equity; diversity; qualitative; USA;
critcial race theory; semi-structured interview; thematic analysis
Thomas 1051
credential for lactation professionals (Thurman &
Allen, 2008). IBCLCs receive certification after they
complete the requirements for eligibility and pass an
exam given by the IBLCE. In 2013, there were 3.5
IBCLCs for every 1,000 live births—an improvement
from 2.1 in 2006 (CDC, 2014).
Data from 11,525 births in Philadelphia reveal that
delivering in a hospital that employed IBCLCs improved
breastfeeding initiation by 2.28 times even when research-
ers adjusted for race/ethnicity, education, insurance sta-
tus, age, marital status, route of delivery, birth weight,
and gestational age. For women receiving Medicaid, the
increase was even higher, at a 4.13 times increase in
breastfeeding initiation (Castrucci, Hoover, Lim, &
Maus, 2006). Researchers have also found that increasing
the level of intervention provided by lactation profession-
als through follow-up calls, for example, can significantly
impact breastfeeding initiation and duration for Latina
and Black mothers in particular (Bonuck, Trombley,
Freeman, & McKee, 2005). For mothers of babies admit-
ted to the neonatal intensive care unit (NICU), breast-
feeding rates are higher when a hospital employs an
IBCLC (50% rate of breastfeeding) versus when hospi-
tals do not employ an IBCLC (36.9% rate of breastfeed-
ing; Castrucci, Hoover, Lim, & Maus, 2007). In the state
of New York, lactation consultants are mandated at hospi-
tals where births occur and were responsible for an
increase in breastfeeding rates in the 1980s and 1990s,
when breastfeeding rates elsewhere fell (Rosenberg,
McMurtrie, Kerker, Na, & Graham, 1998).
Women who receive encouragement to breastfeed
from a nurse or physician are 4 times more likely to
breastfeed (Lu, Lange, Slusser, Hamilton, & Halfon,
2001). This remains true for mothers who are statistically
less likely to breastfeed. There is a “threefold [increase]
among low-income, young, and less-educated women . . .
[and a] nearly fivefold [increase] among Black women”
(Lu et al., 2001; 290). Lactation consultants are shown to
give more positive encouragement for breastfeeding than
nurses or physicians (Humenick, Hill, & Spiegelberg,
1998). Nurses cite a lack of lactation training in their edu-
cation (Hellings & Howe, 2000; Register, Eren,
Lowdermilk, Hammond, & Tully, 2000), and Bunik, Gao,
and Moore (2006) note that physicians are not adequately
instructed in lactation.
Breastfeeding matters because it is linked to an array
of health benefits, and breastfeeding for at least the first
year of a child’s life is recommended by the CDC, the
Surgeon General, and the American Academy of
Pediatrics (Gartner et al., 2005; Singh, Kogan, & Dee,
2007). Research shows that professional lactation support
can improve rates of breastfeeding initiation and duration
(Bonuck et al., 2005; Britton, McCormick, Renfrew,
Wade, & King, 2007; Castrucci et al., 2006; Caulfield
et al., 1998; Chung, Raman, Trikalinos, Lau, & Ip, 2008;
DiGirolamo, Grummer-Strawn, & Fein, 2003; Hopkinson
& Konefal Gallagher, 2009; Ma & Magnus, 2012; Taveras
et al., 2004), but these effects are likely lower when pro-
viders exhibit implicit bias and provide unequal care.
Racial Discrimination in Medical
Provision
Little research to date has explored implicit bias in breast-
feeding care. However, numerous studies have docu-
mented evidence of racist beliefs, biases, and practices
among medical providers that can be linked to racial
health disparities (Burgess et al., 2008; Cabral, Caldas
Ade, & Cabral, 2005; Drwechi, 2011; Hirsh, Jensen, &
Robinson, 2010; Middleton et al., 2005; Sabin, Rivara, &
Greenwald, 2008; Schulman et al., 1999; Smedley, Stith,
& Nelson, 2003; Stepanikova, 2006; Weisse, Sorum,
Sanders, & Syat, 2001). Medical providers are influenced
by implicit racial bias—unconscious racial bias—that
affects how they care for patients (Green et al. 2007;
Penner et al., 2010; Sabin et al., 2008; Sabin, Nosek,
Greenwald, & Rivara, 2009). For example, physicians are
less likely to refer Black women for cardiac catheteriza-
tion even when they show symptoms similar to their
White or male counterparts (Schulman et al., 1999).
Physicians also display more overt racism (Joseph,
1997; Mitchell & Sedlacek, 1996; Moskowitz et al.,
2011), have more negative views of Black patients, per-
ceive them to be less likely to follow medical advice, and
identify them as less intelligent (Moskowitz et al., 2011).
Physicians also exhibit differences in perceptions of dis-
ease prevalence among racial groups that affect how
patients are diagnosed (Balsa, McGuire, & Meredith,
2005). William Hall et al. (2015) and Dayna Matthew
(2015) provide extensive reviews of the literature on
implicit bias in health care. Some studies suggest that
Black medical providers reveal less implicit bias (Green
et al., 2007; Sabin et al., 2009; White et al., 2009). This is
problematic for breastfeeding, because lactation consul-
tants of color, in particular, face unique barriers to certifi-
cation and employment (Carothers, 2014; Lactation
Summit Design Team, 2014; Mojab, 2015; Payne, 2014).
Because a provider’s implicit bias is demonstrated to
negatively affect the care that patients receive, under-
standing the structural forces that contribute to implicit
bias and differential care is an imperative step in reducing
breastfeeding disparities in the United States. However,
many researchers have focused on the individual aspects
of implicit bias and have failed to link the implicit atti-
tudes of individual providers to their structural roots in
the organizations and societies in which providers are
embedded (Matthew, 2015). The literature on breastfeed-
ing disparities has often similarly ignored the impact of
1052 Qualitative Health Research 28(7)
racial discrimination on breastfeeding. Through semi-
structured interviews with 36 IBCLCs across the United
States, I link providers’ implicit bias to structural inequal-
ity to show the ways that organizations maintain and per-
petuate disadvantage and advantage.
Theory
Critical Race Theory
This study draws on Critical Race Theory. Critical Race
Theory argues that White supremacy—a historically
based and institutionally upheld ideology that privileges
White people, White experiences, and the status of
Whiteness—is maintained because racism is engrained in
our society and is constructed and reconstructed to disad-
vantage people of color (Burton, Bonilla-Silva, Ray,
Buckelew, & Freeman, 2010; Crenshaw, Gotanda, Peller,
& Thomas, 1995; Delgado & Stefancic, 2012). Critical
Race Theorists aim to trace the systemic nature of race in
our society, create meaningful social change, challenge
appeals to objectivity in the academy, and to centralize the
voices of People of Color (Crenshaw et al., 1995; Delgado,
1984; Delgado & Stefancic, 2012). Critical Race Theorists
also suggest that both history and power should be central
in discussions of race (P. J. Williams, 1991).
Although the United States has undergone significant
changes in its social, political, and economic climate
since the 1940s that have altered the way in which Whites
maintain racial privilege, Bonilla-Silva and Lewis (1999)
argue that this means that the racial structure is main-
tained in more covert ways that avoid racial language
while maintaining White supremacy (Bobo, Kluegel, &
Smith, 1997; Bonilla-Silva & Forman, 2000). This lais-
sez-faire racism approach holds that Whites continue to
blame Black victims for their failures but attribute minor-
ity success to unfair advantages that are perceived to be
gained through affirmative action practices (Bobo et al.,
1997). Similarly, researchers have documented Whites
engaging in discursive maneuvers such as “I am not rac-
ist, but . . .” in an attempt to minimize racist statements
(Bonilla-Silva & Forman, 2000; van Dijk, 1993). The
postracial ideology argues that racism is no longer a sig-
nificant contributor to racial inequality in the United
States (Bonilla-Silva, 2010). Individuals who hold to pos-
tracial ideologies contend that racism has diminished
overtime and often point to the civil rights movement as
a consistent marker of progress. Sociologists have consis-
tently challenged this view by pointing to continued
inequalities in all major social institutions.
Because most contemporary organizations—including
hospitals, clinics, and pediatric offices—are dominated
by White (and often male) leadership who hold to postra-
cial ideologies and lack basic awareness of structural
racism (and sexism), the organizations are typically
unable to address the unique concerns of patients of color
and the discrimination that they experience (Bonilla-
Silva, 2010). Relying on assumptions of a postracial soci-
ety, racialized aspects of health care delivery bubble
under the surface of these organizations and place undue
burden on patients of color who routinely experience
invisibility, exclusion, and hostility. This study uncovers
these racialized assumptions and traces the systemic
nature of racism in breastfeeding care.
Method
Through semi-structured, intensive interviews with 36
IBCLCs across the United States from November 2015
to March 2016, I examined how race shapes patient dis-
crimination in lactation services. I utilized qualitative
methods to capture stories and thoughts that are diffi-
cult to measure through other methods (Berg, 2009;
Gubrium & Holstein, 2003; Lofland, Snow, Anderson,
& Lofland, 2006; Weiss, 1994). An intensive interview
involves a preconstructed research guide as well as
“ordinary conversation and listening as it occurs natu-
rally during the course of social interaction and semi-
structured interviewing” (Berg, 2009; Lofland et al.
2006, p. 17; Weiss, 1994).
I identified potential interviewees through the distri-
bution of recruitment ads on various professional lacta-
tion networks, breastfeeding advocacy groups, and a
listserv for professional lactation providers. Interviewees
included IBCLCs from private practice, hospitals, physi-
cian offices, WIC (Women, Infants and Children Food
and Nutrition Service), nonprofits, and public health
agencies. All participants were IBCLC-certified at the
time of the interview. After a review of the scholarly lit-
erature on breastfeeding professionals to understand
existing knowledge and gaps, I developed a semi-struc-
tured interview guide and conducted interviews via tele-
phone. The interview guide—which was constructed as
part of a larger study on lactation services and the IBCLC
profession—asked participants to identify instances of
patient discrimination in the course of lactation care.
Interviews generally lasted approximately 1 hour and
were audio recorded and transcribed with the partici-
pant’s permission.
Study materials were labeled with unique, random
identification numbers. Participants were also assigned
random aliases, and the study was approved and overseen
by a university institutional review board that insured that
the study adhered to ethical standards. Given the geo-
graphic spread of the sample, it is unlikely that partici-
pants knew each other well, but it is possible that they
knew each other professionally, through online lactation
communities or were acquainted at lactation conferences.
Thomas 1053
This is one of the reasons that aliases were used and no
information that could identify their current or former
workplaces, bosses, and so on were reported.
Data were analyzed using in-depth thematic analysis
(Braun & Clarke, 2006). All interviews were coded by
the author using NVivo software. Each transcript was
read in its entirety. Drawing on the existing literature, I
then went through each transcript and identified codes.
Codes were revised and expanded as needed through an
iterative engagement with the data before being grouped
and sorted into themes and subthemes. This involved
identifying preliminary codes and then going back to pre-
viously read transcripts to uncover any additional exam-
ples of those codes.
Consistent with Guest, Bunce, and Johnson (2006)
methods for reaching theoretical saturation, coding was
initiated with an initial sample of six interviews. Six more
interviews were then added and analyzed. When new
themes emerged, the previously analyzed interviews were
reanalyzed for instances of those themes as well. This
process continued until all 36 interviews had been coded.
As themes developed from the initial interview samples,
a codebook was developed by the author and provided a
definition of the code, notes on when to use the code, and
examples of the code in the data. Thirty-six interviews
proved adequate to reach saturation.
Ultimately, nine coding groups were identified, spe-
cifically “patient discrimination,” “overt discrimination,”
“implicit bias,” stereotypes and slurs,” “control,” “less
quality or quantity care,” “invisibility and ignoring,”
“White semantic moves,” and “institutional inequality.”
Figure 1 illustrates how these codes relate to one another.
The types of discrimination that patients are subjected to
are categorized broadly as “overt” or “implicit bias.”
Subthemes are further identified under each. The codes
“White semantic moves” and “institutional inequality”
provide the primary theoretical thrust from Critical Race
Theory. These codes helped to feed both the implicit bias
and overt racism that contribute to patient discrimination
in lactation. An example of some of the themes and quotes
that fit within them is identified in Table 1.
Findings
Table 2 provides descriptive statistics for the sample
population. Respondents self-identified their race in an
open-ended question as either White (n = 20), Black
(n = 13), multiracial-Black (n = 2), and one participant
identified as non-White Hispanic. Participants in the
sample are highly educated with 44.44% (n = 16) hold-
ing a bachelor’s degree and 44.44% (n = 16) holding a
master’s degree or higher. Participants lived in 15 dif-
ferent states. Respondents are most likely to be employed
in hospitals (n = 12; 33.33%) or private practice (n = 11;
30.56%). Others are employed in federal, state, or local
breastfeeding programs; pediatric offices; WIC; or mul-
tiple setting.
When the sample is separated out by race, Whites
were concentrated in hospitals and private practice, while
respondents of color are more evenly spread across job
sites. Respondents of color were concentrated in lower
age groups with 68% (n = 11) reporting between the ages
of 30 and 39. By contrast, Whites concentrated in their
50s (n = 9; 45%).
Figure 1. This figure illustrates how thematic codes relate to one another. The types of discrimination that patients are
subjected to are categorized broadly as “overt” or “implicit bias.” Subthemes are further identified under each. The codes
“White semantic moves” and “institutional inequality” provide the primary theoretical thrust from Critical Race Theory. These
undergird implicit bias and overt racism.
1054 Qualitative Health Research 28(7)
Patient Discrimination
Both Black and White IBCLCs reported numerous
instances of racial discrimination toward patients.
However, consistent with previous research, IBCLCs
of color reported more instances of race-based patient
discrimination. Reports of patient discrimination most
often involve assumptions that patients of color will
not breastfeed, which results in less attention being
given to providing lactation services to them. Others
reported explicit racial remarks and negative views
made by colleagues about patients of color. White-
dominated imagery in breastfeeding resources and
instances of Black mothers being more likely to receive
prescriptions for long-acting birth control and referral
to social work were also reported. These disparities
can be linked to racist and controlling images of
women of color.
Implicit bias: Less quality and quantity care. The majority
of participants reported instances of implicit bias—or
unconscious racial bias—on the part of physicians,
nurses, and lactation consultant colleagues. Kyra, a
30-year-old Black IBCLC, described it this way as
follows:
I see Black moms come in there outside of means and no one
really helps them with breastfeeding because the statistics
say that they don’t really breastfeed. So why waste the
money if they are not going to do it?
Table 1. Study Themes and Examples.
Example Theme Subtheme Theme Description Illustrative Quote
Implicit bias Less quantity
and/or quality
care
Unconscious racial bias in which
a patient receives less care
and attention than their White
counterparts
“Honestly, this is going to sound really bad,
but I see it every day . . . I see Black moms
come in there outside of means and no one
really helps them with breastfeeding, because
the statistics say that they don’t really
breastfeed. So why waste the money if they
are not going to do it?”
Implicit bias Invisibility and
ignoring
Unconscious racial bias in which
experiences, images, and stories of
people of color are ignored or made
invisible
“She picked only White women for the
educational literature that we were going
to disperse. And I thought that was a great
oversight. Because then it looks like only
White women breastmilk for their babies.
And I just, I told her ‘for women of other
ethnicities to be successful, they need to see
other women who look like them.’”
Implicit bias Race-based
referrals
When patients of color are more likely
to be referred to social services,
offered birth control measures, and
so on.
“The doctor comes in and goes, ‘Hey, do you
want us to tie your tubes?’ . . . Yes! But she
had been told by other friends to expect
that, because apparently it’s kind of common
that if you’re a Black woman and you’re on
Medicaid, you will be asked if you want to tie
your tubes. Which is—that’s fucked up!”
Overt racism Stereotypes and
slurs
Overt racial remarks or actions made
to or about patients of color on the
basis of race
“She has these big huge Asian nipples. You
know what I mean? Asian nipples?!”
“We don’t want these people having any more
babies than they already do.”
White semantic
moves
When Whites use language to minimize
the experiences of people of color
and/or appear uncomfortable
discussing race. This use of language
and the silence surrounding race
helps to uphold racism and inequality
in care.
“(Long pause) Um . . . uh . . . One of my
African American clients said that she felt not
listened to, but, since I wasn’t there, I can’t
comment on what I would have observed.”
Institutional
inequality
When workplaces are unequally
structured by race. This inequality
upholds the normative White culture
of an organization and conceals
racism and discrimination.
“There has never been a minority in the role
of a manager, supervisor, or dietitian—and
this is [a diverse area of the country] so
diversity is not lacking . . .”
Thomas 1055
Anna echoed Kyra’s and others observations when she
notes that
there is already a preconceived idea that all Hispanic mothers
will want to give formula or that all African American mothers
are not going to initiate breastfeeding. So I would see almost
like less effort given to them. You know like: “Why even
bother; they are not going to do it.” You know? . . . I definitely
saw that.
These observations are consistent with existing research
on racial discrimination and inequality in health care.
Implicit bias is one of the most commonly discussed
forms of patient discrimination in the literature. Patricia,
an older, White IBCLC sums up the essence of this kind
of discrimination when she said, “I have certainly seen—
I would call it ‘unwishing prejudice’—people who don’t
realize what they are doing.” Implicit bias is uncon-
sciously used in these situations to categorize and make
decisions about how to prioritize work within existing
time constraints. Because IBCLCs and other lactation
providers hold assumptions about patients of color, they
are likely to focus their efforts on clients they perceive to
be more interested in breastfeeding.
The assumptions that providers make about patients
are not only race-based but also often intersect with other
social identities. As Nancy showed, providers often per-
ceive African American clients who are also on Medicaid
as not wanting breastfeeding services: “The OB/GYN
office used to think that their clientele didn’t lend itself to
wanting to breastfeed. And by clientele, I mean African
Americans who are on Medicaid.” Lactation consultants
reported that this discrimination was most often directed
at Black mothers but it was also noted to occur with vari-
ous Asian groups—particularly with Asian immigrant
groups, Latinas, and individuals who speak English as a
second language.
For example, Pam, a middle-aged, White IBCLC, who
classifies her town as “pale, pasty White” reports
instances of colleagues providing differential care to vari-
ous immigrant groups:
I also have noticed that, if someone comes from, let’s say,
China, the nurses might not work as hard on breastfeeding
because they assume that they’re going to be formula feeding
because that’s what all Chinese women do, right? All
immigrants do that. All, you know, Muslims do that. So there’s
a lot of that sort of like—group everyone together and take one
characteristic, label it to everyone, and then you know, you’re
kind of excused from maybe working a little harder or actually
getting to know that person. I do see a lot of that.
These reports suggested that groups for whom breastfeed-
ing rates are already low are also those who are least likely
to be offered professional lactation services. When lacta-
tion services are provided to them, participants note that
those services are sometimes provided with less care and
attention. Irene describes one such situation as follows:
Table 2. Selected Characteristics of Sample.
Frequency Percentage
Gender (Female) 35 97.22
Race (self-identified; open-ended question)
White 20 55.56
Black 13 36.11
Multiracial 2 5.55
Hispanic 1 2.78
Age group
20–29 1 2.78
30–39 13 36.11
40–49 6 16.67
50–59 11 30.56
60–69 4 11.11
70+ 1 2.78
Education
High school 1 2.78
Some college 1 2.78
Associates degree 2 5.56
Bachelor’s degree 16 44.44
Master’s degree 13 36.11
Doctorate 3 8.33
State
CA 4 11.11
CT 1 2.78
FL 2 5.56
GA 4 11.11
MA 1 2.78
MI 1 2.78
MO 1 2.78
NC 3 8.33
NJ 1 2.78
NY 4 11.11
OH 1 2.78
PA 6 16.67
TX 2 5.56
VI 1 2.78
WI 2 5.56
Undisclosed 2 5.56
Job site
Hospital 12 33.33
Private practice 11 30.56
Federal/state/local program 3 8.33
Pediatric office 3 8.33
WIC (Women, Infants
and Children Food and
Nutrition Service)
3 8.33
Multiple settings 2 5.66
Other 2 5.66
1056 Qualitative Health Research 28(7)
I worked in the outpatient breastfeeding clinic . . . with the
White mothers, [the consultants] seemed to take their time
with them. Like they would let the appointments go longer
than the normal expected time, and things like that. African-
American mothers, they were kind of like, “Okay, let’s get
this solved.” It felt more rushed.
These microaggressions—subtle and often brief indigni-
ties that communicate a negative message to people of
color (Constantine & Sue, 2007)—can be hard to recog-
nize and address. Researchers suggest that Whites often
attribute microaggressions to mere misunderstandings
(Sue, Capodilupo, & Holder, 2008). This means that
IBCLCs of color, who are more likely to lack the struc-
tural power to challenge the discrimination they witness,
are forced to unpack patient discrimination and decide
how to respond quickly among supervisors and cowork-
ers who may dismiss their observations as aberrant misin-
terpretations. For example, as Kecia reports,
Sometimes I find that I have to suppress my anger to keep
my job. When every bone in my body wants to tell this
particular person, “What you just said to me was a very
microagressive statement. What you just said to me was
obviously because you have problems with me being
Black.” . . . And I have to walk away and do my job. And I
have done that over and over and over again. And it is
difficult.
Implicit bias: Invisibility. IBCLCs reported that White imag-
ery and culture dominates much of the breastfeeding lit-
erature and resources. For example, as Tina—a
35-year-old Black IBCLC—detailed, her supervisor
chose only White women for the educational literature
that her hospital designed:
In my opinion, for people to be successful at something, at
anything, it is good for them to see images of people who
look like them that are successful . . . I thought [choosing
only White images for a pamphlet] was a great oversight.
Her supervisor responded by noting that the material was
already sent to the printer, so they will have to consider
that next time the materials were printed. Blaming the
budget or the printer absolved this supervisor from taking
personal responsibility and answering for a discrimina-
tory and inept decision. When Whites hold positions of
authority, they are able to conceal their—intentionally or
unintentionally—discriminatory behavior from a wider
audience. This protects their own interests and the norma-
tive White culture of the organization.
Similarly, participants confirmed decades of research
regarding the organizational culture of some prominent
breastfeeding organizations. This is clear in Tanya’s
description of her own experience at La Leche League:
When I went I saw lots of women who were homemakers.
They were what we like to call granola—cloth diapering,
organic eating, attachment parenting, and those types of
things. But they were awesome with the breastfeeding. I felt
like women who were more like me—meaning they wanted
to breastfeed but not necessarily to adopt everything else—
especially women who have to go back to work, maybe there
is no spouse or someone at home to help you. It just didn’t
seem like it was a place where they could have shared and
similar experiences with women who looked like them and
had you know similar experiences . . . so they might toss out
the breastfeeding with the rest of it.
This form of motherhood that Tanya describes is consistent
with the ideology of “intensive mothering.” The ideology
of intensive mothering is “a gendered model that advises
mothers to expend a tremendous amount of time, energy,
and money in raising their children” (Hays, 1996: x).
A “good” mother is most often presented as White and
middle class. In contrast, the “bad” mother selfishly
works in the paid labor market to afford luxuries, ignores
the cries and bonding needs of her child(ren), and allows
other women to care for her children (Hays, 1996). This
model of “good” and “bad” mothering, historically con-
nected to the LLLI movement, is both racist and classist
because it ignores the historical and economic realities
that make intensive mothering more readily available to
White and middle class women rather than Black or lower
class women (Blum, 1999; Collins, 2002; Hays, 1996).
The profession of lactation consulting was born from
LLLI, and LLLI remains one of the most prominent
breastfeeding organizations. LLLI’s prominence allows
the league to contribute considerably to the cultural lens
through which IBCLCs view their patients.
Implicit bias: Race-based referrals. Assumptions made
about patients of color are also displayed in the services
and referrals that are provided to patients who use drugs,
are drug dependent, or show signs of mental illness. As
Kecia reports,
What I have experienced in our hospital is drug addicted
mothers who could be in treatment—so a mother who is trying
to kick heroine might be taking methadone; a mother who
smokes marijuana might be trying to kick the habit. Many of
the methadone mothers are White. Many of the pot smokers
are Black. And I have seen that more of the methadone mothers
are receiving support than the marijuana users.
Mothers were not only provided varying levels of support
on the basis of race but were also funneled into social
work and other referral systems differentially. Irene
echoed these observations when she discussed mothers
on the postpartum floor with a history of drug use, depres-
sion, or anxiety:
Thomas 1057
Social work was always quick to be ordered to go see [Black]
mothers, [compared to] a White mother. They would say,
“Oh, that mother, she’s really going through a lot. Oh, my
God, I feel so sorry for her.” But the Black mother, they were
like, “Is there a social work consult? If there’s not a social
work consult, then we need to order one.”
The consequences of this differential treatment can of
course be quite significant for patients of color who could
fail to get adequate treatment for their drug dependence
or mental health concern, be referred to law enforcement,
or have their children removed from their custody.
These reports are substantiated by existing literature in
which researchers have documented that physicians are
more likely to require postpartum drug tests for African
American mothers (Chibnall et al., 2003), that people of
color are more likely to be reported for child maltreat-
ment (Derezotes & Poertner, 2005), that people of color
who are accused of abuse are more likely to be “screened
in” for an investigation (Gryzlak, Wells, & Johnson,
2005; Sedlak & Schultz, 2005), and that disparities and
bias in mental health care referrals continues (U.S. HHS,
2001). These findings are also consistent with a breadth
of research that document the ways that minorities dis-
proportionately experience punitive treatment across
social institutions—such as in education, law, health care,
and employment (some examples, Artiles & Trent, 1994;
Bowles & Gelfand, 2009; Eberhardt, Davies, Purdie-
Vaughns, & Johnson, 2006; Glaze, 2011; Hamner, Kim,
Baird, & Bigoness, 1974; Jacobs & Carmichael, 2002;
Morris & Perry, 2016; O’Connor & Fernandez, 2006;
Rocque & Paternoster, 2011; Skiba et al., 2011; Skiba,
Michael, Nardo, & Peterson, 2002; U.S. Department of
Justice, 2014).
Respondents also reported that birth control methods
like Depo-Provera are often pushed on women of color
directly after birth. Depo-Provera, a contraception injec-
tion, was the most commonly mentioned form of birth
control pushed on women of color by providers. This is
particularly problematic for breastfeeding disparities
because Depo-Provera is a long-acting birth control
method that has been linked to sterilization racism—the
“organization of racist controlling images, policies and
practices of delivering reproductive health care that oper-
ate to constrain, minimize, or completely eliminate the
reproductive activities of women of color while sustain-
ing and ensuring the reproductive rights of European
American women” (Volscho, 2011: 676). As Volscho
(2011) details, health care providers likely filter their per-
ception of patients based on racist and controlling images.
These perceptions—consciously or unconsciously—
impact which patient providers suggest or prescribe long-
acting birth control to. Indeed, Volscho (2011) finds that
African American women and Indian American women
are more likely than White women to use Depo-Provera
after controlling for age, estimated parity, region, marital
status, household income, educational attainment, and
insurance status. Other forms of birth control are also
pushed on women of color as Emily, a White IBCLC,
discusses:
I’ve seen clients and patients and friends, actually, they go to
the hospital, they have their baby . . . The doctor comes in
and goes, “Hey, do you want us to tie your tubes?” . . . Yes!
But she had been told by other friends to expect that because
apparently it’s kind of common that if you’re a Black
woman, and you’re on Medicaid, you will be asked if you
want to tie your tubes. Which is—that’s fucked up!
These practices are not noted to occur among White
women and are undoubtedly influenced by controlling
and racist images that paint Black mothers—and low-
income Black mothers in particular—as welfare queens
that are draining society (Collins, 2002).
Overt Racial Discrimination Against Patients
Stereotypes and slurs. Stereotypes about racial minori-
ties were employed in more overt ways as well—most
often behind patients’ backs. Isabel, a 38-year-old,
self-identified Hispanic American IBCLC, worked
alongside a White mentor during her certification pro-
cess and recalls her mentor leaving a room with “a His-
panic WIC client” and saying, “I don’t understand
them. Why are these people always lying? . . . Why are
they liars?” Isabel suggested to her mentor that “[The
mother] is not lying to you. It is that she is telling you
what she thinks you want to hear because she doesn’t
trust you yet.”
Anna, a 30-year-old White participant, similarly noted
that she had witnessed Asian families “want certain
drinks or privacy and things. And you know it really
turned the nurses off and makes them not go back and
help them. They wanted them to just comply.” Even more
overt examples of discrimination include remarks like
those made by Tina’s supervisor when she said, “She has
these big huge Asian nipples. You know what I mean?
Asian nipples?!” and “Everything smells like curry in
there.” These provider’s biases reflect larger societal
trends in the ways that the bodies of people of color are
sexualized, fetishized, and racialized (Collins, 2004) and
are consistent with a long and ongoing history of Whites
casting minorities as having unique and offending smells
(Smith, 2006). These participants’ comments are also
consistent with studies that find that medical providers
more often interpret people of color as noncompliant and
are likely to give less care and attention to them (Hall
et al., 2015).
1058 Qualitative Health Research 28(7)
Institutional Inequality: The Limits of
Confronting Racial Prejudice Against Patients
When IBCLCs of color witness discrimination against
patients, they may experience feelings of frustration,
sadness, or anger. Yet, IBCLCs of color often lack the
institutional authority to challenge such comments. For
example, in Isabel’s workplace, “[i]nstitutional racism is
almost tangible . . . There has never been a minority in
the role of a manager, supervisor, or dietitian—and this
is [a diverse area of the country] so diversity is not lack-
ing.” She similarly experienced exclusion in her work-
place. Isabel reports that the WIC clinic she worked in
had created an official list of IBCLCs in the county that
WIC staff could refer mothers to. As she stated, “The list
not only excluded me but also excluded the 3 other
minority IBCLC’s in the county.” When she confronted
management about the exclusion, they told her that it had
been an oversight. This explanation provides little con-
solation to Isabel: “[T]he point is that we are so invisible
that we are not even considered as part of the group; we
are an oversight.”
Overt bullying from supervisors also occurs. As Irene,
who was called “stupid” and “other derogatory names,”
reported,
The work environment was really hostile. It was not friendly
at all. It didn’t start off that way, but as time went on, as it got
closer to the end of the program, it started getting more and
more hostile and unfriendly and stressful . . . so much so that
I had threatened to quit at least two or three times because it
was just so overwhelming. It was stressful.
When Irene reported workplace issues to her superiors,
there was no follow-up to address the underlying issues.
Instead, Irene reports being cast as the “angry Black
woman” with a “bad attitude.” After she threatened to
quit the program, Irene’s supervisor responded by saying,
“Well, you know if you quit, that’s failure, right?”
Confronted with the pressure of feeling like a failure,
Irene decided to continue with the program:
I would try to coach myself to get through the remaining
time of the program . . . I did make it to the end, and I was
glad I kind of did it. But, then again, if I had to choose to do
it again, I don’t think I would do it again. As a matter of fact,
I know I wouldn’t do it again.
Irene’s experience shows the complex ways that racism
operates in the workplace. Irene dealt intimately with
workplace hostility from coworkers and supervisors in an
environment she describes as “a program that was set out
to help Black women become IBCLCs, but was also done
in a way which created more barriers and more hurdles to
overcome.” When she challenged workplace hostility, she
was denied meaningful support, instructed that quitting
would make her a failure, and blamed for the hostility.
When another Black intern entered the program behind
her, the intern experienced similar hostility and left the
program after a few months. Irene reflects that “there was
no longer, you know, a door where you could say, ‘It was
all her. She made that up. She was the problem.’”
Given this existing institutional inequality, consultants
must find small ways to push back on racist assumptions,
remain silent, or potentially risk confronting the situation.
Confronting the situation could result in being cast as the
“angry Black woman” and/or job loss. Lactation consul-
tants of color report being acutely aware of the risks asso-
ciated with addressing racism. They regularly discuss the
consequences of speaking out and how they weigh when,
how, and/or if they should address discrimination against
patients or themselves. They also discuss the pain and
frustration that comes from feeling unable to address
racial issues. Isabel reflected,
I’m going to get emotional talking about it. It feels wrong to
me that people can get personal if someone like me—or
anyone who has felt a victim of [racism]—bring it up. They
are like, “How dare you accuse me of such a thing.” . . . I was
thinking about it the other day. I just need to voice it. It is not
like I am pointing the finger at you. It is just like “Hear me
out!” All I need to do is say it. Just listen . . . [Talking about
racism] is one of those things that is like “Don’t talk about
it” And it is shameful and that is like shutting my voice
down. And that hurts even more.
In this excerpt, Isabel identifies the postracial ideology
that dominates society and structures workplaces across
the United States. It silences the concerns of minorities
and covers up discriminatory practices in medical care.
White Semantic Moves That Conceal Racism:
“Did I Choose the Wrong Word?”
White IBCLCs in this study consistently acknowledged
that patients experience some form of race-based dis-
crimination. Most often, they report discrimination that
involves coworkers giving less care or attention to moth-
ers and babies of color. However, when White IBCLCs
were asked about discrimination against patients, they
often seemed uncertain or hedged their statements.
Bonilla-Silva (2010) argues that Whites use semantic
moves in their speech to express and conceal racial views
that post-Civil Rights norms no longer permit. For exam-
ple, when asked whether patients are discriminated
against in the hospital, Toni, a 40-year-old White IBCLC
noted, “One of my African American clients said that she
felt not listened to, but since I wasn’t there I can’t com-
ment on what I would have observed.” These kinds of
statements suggest that the lived experiences of clients of
Thomas 1059
color cannot be trusted at face value, but require a third
party, “unbiased” observer to determine whether discrim-
ination did in fact occur.
Similarly, Sara, a 40-year-old White IBCLC, said, “I
don’t know if this would count but . . . there are a lot of
judgements made about patients you know . . . Is that
what you mean?” Like Sara, other White IBCLCs appear
uncertain and/or uncomfortable discussing racial dis-
crimination. Renee, a 40-year-old White IBCLC, makes
this explicit when she discussed her fears addressing
racial inequality:
I’m almost scared to say this—I do think there are some
fears of properly welcoming other races. So sometimes I am
worried about getting it wrong. If I was to post “Black moms
welcome” would that be seen as positive? Did I choose the
wrong word? Should it be African American? I have to say
that I have some of those fears. And especially with so much
social media, it is very easy to get blasted for doing—even if
you do something with a good heart . . . The term
microaggression and privilege, they both scare me and leave
me somewhat frightened of reaching out at times, because if
I chose the wrong word, it may be seen as a microaggression
and really I was just trying to do the right thing.
In Renee’s exposition, we see how post-Civil Rights
era norms about race-related speech make her fear being
labeled a racist. This fear overwhelms her ability to see
that any White person in a racialized society is likely to
engage in behavior or language that is racist. The goal,
then, is not to stop speaking about racism, but to be open
to feedback. White reluctance to address racial issues per-
petuates inequality by maintaining “post-racial” norms
that silence discussions of race and leave coworkers and
patients of color subject to discrimination.
Discussion
This study has documented that patients of color rou-
tinely experience invisibility, exclusion, and hostility in
the course of lactation care. This leads to inequality in
lactation services that likely contribute to disparities in
lactation practices. In addition, this study has documented
semantic moves used by White providers and the persis-
tence of racial inequality in medical settings that both
help to conceal and perpetuate race-based patient dis-
crimination in lactation. Bonilla-Silva (2010) argues that
the silence that surrounds racial matters is a result of post-
Civil Rights era changes in social norms that have sug-
gested that any discussion that could sound or be
perceived as racist is immoral. As he notes, “because the
dominant racial ideology purports to be color blind, there
is little space for socially sanctioned speech about race-
related matters” (Bonilla-Silva, 2010, p. 55). It is unsur-
prising that White IBCLCs are more likely to engage in
semantic moves that minimize the experiences of people
of color and appear uncomfortable discussing race. But it
is important to note that the origins of these beliefs and
feelings are structural—not individual.
Bonilla-Silva (2010) argues that most Whites share a
“White habitus”; that is, they experience spatial segrega-
tion and isolation from minorities that foster a racialized
socialization process that shapes White’s tastes attitudes,
emotions, and views. This “universe of Whiteness” that
Whites experience on a daily basis
fosters a high degree of homogeneity of racial views and even
of the manners in which Whites express these views. Despite
the civil rights revolution, Whites, young and old, live a
fundamentally segregated life that has attitudinal, emotional,
and political implications. (Bonilla-Silva, 2010, p. 125)
Bonilla-Silva (2010) and other Critical Race theorists
draw attention to the structural roots of White beliefs and
attitudes and the ways that Whites learn to uphold “post-
racial” silence regarding racial matters through semantic
moves. Drawing from this same tradition of thought,
Matthew (2015) argues that implicit bias in health care
delivery is structural in its roots and emanates from larger
inequalities in society. Providers and patients are sepa-
rated by racial segregation in housing, inequalities in edu-
cation, employment inequality and more that all impact
the stereotypes and unconscious bias that providers have
against patients.
In other words, implicit bias on the part of medical pro-
viders is not unique to the medical setting. It exists and origi-
nates from elsewhere in society. As Critical Race Theory
argues, the implicit biases that providers exhibit are endemic
of larger social inequities and must be addressed at their
source. As D. R. Williams and Rucker (2000) suggest,
Effectively addressing healthcare disparities will require
comprehensive efforts by multiple sectors of society in order
to address larger inequities in major societal institutions.
There is clearly a need for concerted society-wide efforts to
confront and eliminate discrimination in education,
employment, housing, criminal justice, and other areas of
society which will improve the socioeconomic status (SES)
of disadvantaged minority populations and indirectly
provide them with greater access to medical care (79-80).
This strategy is consistent with Critical Race Theory’s
aim to trace the systemic nature of race in society, to cre-
ate meaningful social change, and to centralize the voices
of People of Color.
Although research suggests that implicit biases can be
altered (Blair, 2002; Dasgupta & Asgari, 2004), this strat-
egy fails to hold organizations and institutions account-
able for their role in perpetuating implicit bias. Matthew
(2015) argues that
1060 Qualitative Health Research 28(7)
a broader view of racial biases that impact health outcomes
must include discrimination in all social determinants of
health including residential segregation, employment inequity,
inequitable education funding, and enormous income
disparities that reinforce the implicit bias that physicians have
been shown to hold against their patients (76).
This strategy may seem daunting and unrealistic for hos-
pitals, agencies, and organizations that provide day-to-
day services for women who are breastfeeding. Indeed,
many of the solutions that Matthew (2015) suggests
involve policy and legal work that falls outside of a given
provider’s capacity. However, these organizations can—
at the very least—take a concerted look at their work-
place structure and culture to uncover the ways that their
particular hospital, clinic, agency, and so on is organized
to reinforce racial inequality. When workplaces structure
employment in discriminatory ways and conceal or
ignore racism, implicit biases—which employees bring
into the workplace already—are maintained and perpetu-
ated in interactions with patients.
Put another way, workers come to jobs with existing
implicit biases that are influenced by structural inequality
outside of the workplace. White workers, for example,
may be racially isolated from people of color due to race-
based inequality in housing, wealth, education and more
that shape life outside the workplace. They are influenced
by stereotypes about people of color from an array of
sources. This is largely outside the organization’s imme-
diate control—although organizations should prioritize
ways that they can assist in addressing structural inequal-
ities that affect their workers and patients. However,
workplaces allow implicit bias to remain unchecked
when they structure employment in discriminatory ways,
when they intentionally or unintentionally conceal the
complaints and concerns of workers of color, and when
they unequally distribute positions of power and influ-
ence across an organization.
When supervisors ignore or deny racial discrimination
and cast Black workers as “angry Black women,” they
reinforce negative images of Black women and confirm
racist stereotypes about people of color. When White
workers lack meaningful connections with racial minori-
ties in other spheres of their lives (neighborhoods, reli-
gious organizations, etc.), this can have a significant
impact on worker’s implicit bias because these organiza-
tions are providing a legitimating authority to the implicit
biases that workers already hold.
To address patient discrimination, employers cannot
merely require implicit bias training. Instead, they must
also take a concerted look at their hiring and employ-
ment data, mentorship programs, education-related
reimbursement programs, educational materials that are
provided to patients, and various policies (e.g., such as
referral policies/criteria related to mental illness and sub-
stance abuse) to uncover and systemically address dis-
crimination. Organizations should not be surprised that
employees hold implicit biases—indeed, it would be sur-
prising, given the structure of inequality in the United
States, if they did not. Instead, employers should provide
evidenced-based implicit bias training, and they should
also critically consider the ways that the organization, its
culture, and the institutions that it is connected to (e.g.,
insurance agencies, law, government, and contractors)
actively uphold and maintain inequality.
One approach to this has been detailed in research on
cultural humility. Cultural humility involves a lifelong
commitment on the part of both individual practitioners and
institutions to engage in self-evaluation and self-critique, to
address inequality between patients and physicians, and to
develop nonpaternalistic partnerships with communities
(Tervalon & Murray-Garcia, 1998). Strategies used to pur-
sue these goals include patient-focused interviewing and
care, community-based care, and advocacy and institutional
consistency. This practice involves teaching practitioners to
use a less authoritative and controlling style, ensuring that a
substantial portion of clinical training has occurred at com-
munity rather than university-centered sites, and insuring
that institutions are engaging in ongoing self-criticism that
evaluates staff diversity, hiring practices, multicultural
training requirements, and the organization’s relationships
with the community (Tervalon & Murray-Garcia, 1998).
Finally, it is important to note that this study has a num-
ber of limitations. Participants in this study are all certified
IBCLCs and highly educated with the overwhelming
majority holding a bachelor’s degree or higher. Future
studies need to look at a more diverse set of participants.
This study also analyzes provider’s perceptions of racial
discrimination against mothers. This is limiting in that
providers may conceal the degree to which they engage in
discrimination against patients. Indeed, most of the pro-
viders in this study reported instances in which they wit-
nessed others - not themselves - discriminate against
patients in the course of lactation care. Similarly, this
study does not center the perceptions or experiences of the
mothers themselves. However, providers are well poised
to report not only the bias and discrimination that may go
on in front of the mother in the hospital room but also the
background comments and actions that occur when pro-
viders are in their office, at the nurse’s desk, or discussing
patients with doctors. Conversations and decisions that
occur outside of the patients view also have a significant
impact on the care that a patient and her child receive.
Despite the limitations, this study provides critical
insight by connecting implicit bias to discussions of
breastfeeding inequalities and includes a sample of
IBCLCs that span across multiple sites. Traditionally, dis-
cussions of breastfeeding inequality have focused on
Thomas 1061
individual-level factors that affect breastfeeding rates.
Researchers have similarly focused narrowly on medical
or behavioral interventions to increase breastfeeding rates.
This study has documented that lactation consultants,
like other medical professionals, are prone to discrimina-
tory beliefs and practices that affect the quantity and qual-
ity of care patients receive. These findings are consistent
with a breadth of research on discrimination in other areas
of medical care. However, because this study deals with
breastfeeding, it uniquely addresses the intersectional
nature of discrimination for women of color and the racial-
ized assumptions placed on mothers and babies before and
after birth. In documenting this, this research addresses
one of the systemic barriers to breastfeeding for people of
color—the availability of quality, nondiscriminatory lac-
tation care by a certified professional—and the ways that
patient discrimination is upheld and concealed by White
semantic moves and institutional inequality.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research,
authorship, and/or publication of this article.
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Author Biography
Erin V. Thomas completed this study as part of her dissertation
research in Sociology at Georgia State University in Atlanta,
GA. Dr. Thomas now serves as an ORISE research fellow at the
Center’s for Disease Control in Atlanta, GA. You can learn
more about her work at www.erinvthomas.com.
