Battle For Breastfeeding

A debate rages in georgia over who can teach parents to nurse

By Cecilia Nowell

Art by Sharanya Durvasula

A woman bending down handling medical equipment

Mary Nicholson Jackson, a petite mother of three, has worked at Grady Memorial Hospital in Atlanta for 30 years. Over the decades, she has coached countless other Black women through the trials of breastfeeding — babies who won’t latch or settle down, sore or bleeding nipples, plugged ducts, engorgement, exhaustion. She’s also trained many of those mothers in turn to offer support to others in their communities. When Georgia passed a law in 2016 requiring that lactation consultants in clinical settings be licensed by a specific organization — a lengthy and expensive process — it threatened to put Jackson out of a job. As a Black woman who had fought to have her expertise in childbirth and child care valued, it seemed like a familiar instance of gatekeeping from the medical establishment. It felt reminiscent of the early twentieth century, when white male doctors attacked granny midwives — usually Black women who cared for white and Black families alike — as old-fashioned, dirty, and superstitious. The whole thing reeked of “that whole superior, privileged attitude,” Jackson said.

So, in 2018, Jackson sued the state of Georgia. The breastfeeding organization that she co-founded, Reaching Our Sisters Everywhere (ROSE), argued that the licensure requirement would cut Black women out of providing lactation care and harm Black patients who might not be able to access one of the few licensed providers in the state. In May of 2023, the Georgia Supreme Court agreed, overturning the Georgia Lactation Consultant Practice Act. 

Quadruplet babies
Annie Mae Fultz’s doctor named the Fultz quadruplets and sold the rights to use them in marketing campaigns to Pet Milk, a formula company that would create ads alleging that the nutritional powers of formula had saved the girls. The aftereffects of that trend are still felt today: Black women are more likely to be given formula for their babies.

Most people in the broader birth-work and reproductive rights community celebrated the win. But to hear the other side tell it, Jackson and her allies were engaged in a well-funded attack on the rights of Georgians to access lactation consultants: “a carefully crafted media and legal strategy” orchestrated by “far-right libertarian” organizations, as a board member of the National Lactation Consultant Alliance (NLCA) put it earlier this year. (This is from someone who ran for Georgia State Senate as a Republican in 2018 and runs an organization that mobilizes conservative women in suburban Atlanta.) Her conclusion: “Goliath just slayed David in Georgia.” 

It’s worth dissecting what exactly happened in Georgia because the jumble of attacks were genuinely confusing, with each party accusing the other of harming the interests of low-income women and their babies and denigrating the hard-won expertise of care workers. The Georgia fight is likely to be replicated as similar bills on lactation consultants pop up in dozens of states, and we may see the same debate happen as states decide whether to cover Medicaid reimbursements for doula work. It’s a bureaucratic battle that gets to the heart of long-standing concerns in women’s health: How to empower individuals and communities to take care of their own well-being? How to reimagine a system that condescends to women’s knowledge of their own bodies and has long pushed women healers of color out of practice? And how to accomplish anything at all within the miserable confines of the U.S. health insurance system?

Breastfeeding in the U.S., like so much else, is inextricably marked by the legacy of slavery and racism.

Since 2011, ROSE has worked to reduce breastfeeding disparities in Black communities by leading trainings and hosting gatherings for Black families across Georgia. Their example has spread across the country — leaders of the B.L.A.C.K. Course, a breastfeeding support training program focused on the experiences of Black women, and the Indigenous Breastfeeding Counselor Certification, which has trained over 600 Indigenous counselors, both cite ROSE as inspiration. 

Culturally informed programs like these are essential because breastfeeding in the U.S., like so much else, is inextricably marked by the legacy of slavery and racism. Enslaved women were forced to work as wet nurses for their white enslavers’ children; after emancipation, says Alicia Bonaparte, a sociology professor at Pitzer College and co-editor of Birthing Justice: The Politics of Black Women, Pregnancy, and Childbirth, some Black women continued supplying white families with milk to earn additional income. By the 1950s, as Black women began giving birth in segregated hospitals, infant formula companies started partnering with hospitals to sell formula to parents. In 1946, Annie Mae Fultz, a Black and Cherokee woman, gave birth to the first surviving set of identical quadruplets in the U.S. But her doctor named the four girls and sold the rights to use them in marketing campaigns to Pet Milk, a formula company that would create ads alleging that the nutritional powers of formula had saved the girls. The aftereffects of that trend are still felt today. A 2016 study published in the journal Pediatrics found that Black mothers are nine times as likely to be given formula for their babies as white mothers.

A black woman with a white baby on her lap
Even after emancipation, some Black women continued to supply white families with milk to earn additional income. In 1912, the New York magazine The Independent published an account by an anonymous Black nurse, who wrote, “perhaps a million of us… hold in our arms a million white children, thousands of whom, as infants, are suckled at our breasts — during my lifetime I myself have served as ‘wet nurse’ to more than a dozen white children.”

At the same time that Black women were being sold on formula, emerging evidence showed breastfeeding boosted newborns’ immune systems, protected them from a host of illnesses, and reduced a mothers’ risk of developing certain cancers later in life. To be sure, the pressure to breastfeed in the U.S. today is immense, and in recent years, there’s been an effort to push back on the guilt-inducing “breast is best” campaign and show that babies can also thrive on formula or with a combination. But the prevailing logic among pediatricians and lactation professionals is that initiating some amount of breastfeeding is beneficial for both infant and parent. Lactation consultants can be key to helping nursing succeed. 

Libertarian non-profit represented Jackson, arguing that the breastfeeding law violated Americans’ right to earn a living

In its lawsuit, ROSE said Georgia’s law would worsen existing inequities. It would introduce state oversight of consultants and require that anyone offering clinical care — creating a treatment plan or recommending assistive devices, for example — be certified by a specific entity, the International Board of Lactation Consultant Examiners (IBLCE). Only people with that certificate would be allowed to call themselves “lactation consultants” and charge for their services. IBLCE certification is the most rigorous, but also the most expensive, available. The examination alone costs upwards of $600, and the required academic training, clinical mentorship, and continuing education can cost thousands more. According to a 2019 survey, about 90 percent of all IBLCE certified consultants are white. 

“Nobody has ever tried to pass a lactation licensure bill with the purpose of excluding people from it. But that’s systemic racism: We do things without even realizing the impact they have,” said Camie Jae Goldhammer, co-founder of the Indigenous Breastfeeding Counselor training. 

At its core, though, ROSE’s argument to the Georgia court was that the law was “blocking people from jobs,” Jackson told me, and that’s where the libertarians come in. The Institute of Justice, a libertarian nonprofit, public interest law firm, represented Jackson pro bono, while the Goldwater Institute and other conservative and libertarian organizations filed briefs in support, arguing that the law violated Americans’ right to earn a living. The Institute has represented various professionals in licensing disputes across the country, like death doulas in California and hair braiders in Louisiana; in a recent case in Florida, the firm represented a health coach who had been fined for giving dietary advice without being a licensed dietician. In its final ruling, Georgia’s Supreme Court said that the law violated Jackson’s and other consultants’ right to due process because “it precludes them from practicing their lawful, chosen profession.” 

Nurses surrounding a pregnant patient laying on a stretcher
Maude Callen, a nurse midwife, conducts a class at the State Board of Health’s Midwife Institute at Frogmore, in South Carolina.

“You’ve got people like the Institute of Justice parading around the country opposing all types of health care licensing,” Marsha Walker, one of the original authors of the IBLCE exam, told me. Her organization, the National Lactation Consultant Alliance, formed as a nonprofit specifically promoting licensure after other major breastfeeding organizations reversed course and took ROSE’s side. Walker and her colleagues, a mix of lactation experts, consultants, and attorneys with varying politics, believe that they’d been outflanked, steamrollered by lofty rhetoric around racial equity. (The group is clearly conscious that their board skews white; under an “equity” section on their website they offer scholarships for the licensing exam.) Licensing would bring more consultants into the insurance system, which rarely covers their services outside of the hospital. While some parents do fine with in-hospital coaching alone, most are discharged before their milk comes in and need follow-up appointments — which can range from $100 to $400 per session — to tackle issues with milk supply or pain.

How to reimagine a system that condescends women’s knowledge of their own bodies and has long pushed women of color healers out of practice?

The decision “turns back the clock in Georgia — back to a time when anyone can call themselves a ‘lactation consultant’ irrespective of education or training which sows confusion for families and employers,” NLCA said in a statement on the Supreme Court decision. Another NLCA board member, nurse and attorney Merrilee Gober, told me, “The state needs to vet the people who are doing more than education. If you’re asking a woman to undress and you’re asking to take her baby and do a physical assessment on that baby, and you’re creating a care plan, that’s clinical care. And that can be very dangerous.” Leah Aldridge, the NLCA member who talked about David and Goliath, has also said that it was insulting to those who had gone through the IBLCE process to equate it with other programs for which “not even a high school diploma” is required. It’s easy to see how someone trained by a community-minded group like ROSE could find that patronizing and retrograde. 

Jackson says she’s not entirely opposed to licensure, especially if it helps families on Medicaid access care, but wishes Georgia’s law had included consultants with other certificates, not just those certified by the IBLCE. “The problem with that language is that you’re naming a particular company,” she said. She also wasn’t convinced consultants certified by the IBLCE actually wanted to serve Medicaid families.

As Black women were being sold formula, white women started coming together in the 1950s and ’60s in groups like La Leche League to advocate for breastfeeding. Emerging evidence showed breastfeeding boosted newborns’ immune systems and protected them from a host of illnesses, and reduced a mothers’ risk of developing certain cancers later in life.

“I believe 100 percent” that people certified by IBLCE are not the only ones who can provide lactation support, Goldhammer said. “I know that to be true.” It touches a nerve, when women who care for their own communities have been sidelined or even criminalized for generations — from granny midwives to the mothers helping their daughters self-manage their own abortions today. With licensure bills pending in dozens of states, like Tennessee, Texas, and Massachusetts, the question remains: How can we care for one another with, or without, the support of the health care system? 

Cecilia Nowell is a freelance reporter focused on gender, health, and environmental stories in the Americas.

This article was supported by the Economic Hardship Reporting Project and the Journalism and Women Symposium Health Journalism Fellowship, with the support of The Commonwealth Fund.