Why Are the Breastfeeding Rates in Rural America So Low?

A mom from Appalachia shares her thoughts.

In 2011, moms across the country protested Target, staging “nurse-ins” and refusing to shop there after a breastfeeding mother was threatened with legal action for nursing in the women’s clothing section. I was a television reporter in my home state of West Virginia then and covered this story, admittedly and embarrassingly a little skeeved out. I was in my early twenties, and remember wondering why someone would want to breastfeed in public anyway.

Born and raised in Appalachia, I had no exposure to breastfeeding. I wasn’t breastfed, nor were any of my younger family members. There were a lot of babies in the church I went to growing up, but I don’t remember seeing a single mother nurse her child. It wasn’t until I moved away from the mountains of West Virginia that I realized breastfeeding was actually quite common.

Across the country, as many as 82 percent of mothers breastfeed their babies for some amount of time. In rural areas, the numbers are lower, with 68 percent of women starting out breastfeeding. In rural Appalachia, the dichotomy is at its most extreme, with only 57 percent of mothers even attempting to nurse.

Appalachia is comprised of thirteen states, many of which are some of the most economically depressed states in the country and rank near the bottom when it comes to both median household income and breastfeeding rates.

In West Virginia, for example, the median income is $43,000, and less than 35 percent of mothers are breastfeeding by the time their child hits the six month mark.

As someone from Appalachia, I’m as sick as every other Appalachian is of hearing how sad and depressed and poor my beloved home state is. I roll my eyes at lists that rank West Virginia at the bottom, yet again. But you can’t have a conversation about breastfeeding statistics without talking about income. They’re that tied together.

Dr. Susanna Kapourales is a pediatrician in Teays Valley, West Virginia, just a few minutes away from the state capital of Charleston. She grew up in the town of Williamson, where nearly half of the three thousand residents live below the poverty line.

“My mom was the only person in her community who breastfed at all,” Dr. Kapourales said. “She had no support whatsoever; she learned how to breastfeed by a book. She had absolutely no help in the area because nobody breastfed. But she knew that it was better for her babies.”

Kapourales’ mother moved to Williamson as an adult; and for many native West Virginian and other rural Appalachians, the aversion to breastfeeding is deep-rooted.

Though the American Academy of Pediatrics recommends breastfeeding until twelve months, Dr. Kaporales says that most of her patients nurse for about six months and switch to formula. “A lot of people will get to that six months and then either from work restraints with pumping or something else, they just find it easier to use formula.”

The Federal Family Medical Leave Act, which pertains to all fifty states, only applies to employers with at least fifty employees and doesn’t guarantee paid time off. In fact, the United States is still the only developed country that doesn’t offer paid leave for new mothers, something that could really aid in setting good breastfeeding practices into place.

Federal law does also require employers to provide “reasonable daily unpaid breaks” to pump, but the conditions or the culture aren’t always encouraging. If you have an office you can close the door to, it’s a little easier, but what if you work at Red Lobster? Where do you go to pump? For many mothers, pumping at work just isn’t an option.

“Most of the time, they are so exhausted when they get home and they don’t have enough support,” Dr. Kaporales said.

Of course, there are many other factors beside someone’s income that can deter mothers from breastfeeding — lactation or latching issues, issues with the baby’s weight or even medication the mother needs to take. But perhaps the most profound reason moms don’t nurse, in my experience, is that the act of breastfeeding itself is at odds with cultural norms, leaving them without the support of their family and friends.

Dr. Kaporales said, “some families have been raised to think that it’s weird — and then others, come hell or high water, do not want to give their babies formula. I see both, and I really think it has to do with their family.”

Cigarette smoking and drug use also play a big part in preventing mothers from breastfeeding.

In West Virginia specifically, 29 percent of residents admit to smoking regularly, and drug use is rampant. At the hospital system Dr. Kapourales works for alone, there are 2,900 births per year — babies from Ohio, Kentucky and West Virginia. Of those tiny infants, one fifth were exposed to drugs in the womb, and 400 had to be medicated after birth to help combat withdrawal symptoms that leave them screaming and shaking uncontrollably.

In hope to raise the breastfeeding rates across the country, hospitals have adopted a certification system that list them as “baby friendly.” At “baby friendly” hospitals, breastfeeding is encouraged by giving the newborn to the mother right away, foregoing nurseries by leaving the newborn with the mother the entire stay, and providing lactation support before discharge. West Virginia has just one such hospital.

That kind of support, Dr. Kapourales said, is crucial in educating, encouraging and sustaining breastfeeding. It should probably even start during pregnancy.

“In the community, if people don’t have enough support, they get discouraged with it and quit,” she said. “Those first three weeks are hard, and people feel helpless and like they can’t get through it. And if you don’t have that support system to do it, it’s hard.”

But breastfeeding rates won’t rise in these rural areas, Dr. Kapourales said, until breastfeeding is normalized. And the only way to normalize breastfeeding is to do it. In public. All the time. At the grocery store, at your older kids’ soccer practice — even at Target.

Photography by Belle Savransky for Well Rounded.

Hanna Nakano

Hanna Nakano

HANNA NAKANO is the News Editor at Well Rounded. She's a D.C. based journalist + writer, and mama to Mila Yayoi. She's married to a medical doctor with a culinary degree; you can find their recipes and ramblings at Chef Meets Girl. Say hi on Instagram.

Comments {3}

  1. Great article! Such an important topic, we need to enable and support all mothers who choose to breastfeed. It’s not enough to promote the benefits, we need to support the lifestyle required to make it work!

    Veronica Horner
  2. Hi, I would like to forward useful articles to my friend via facebook but the facebook icon goes to the WellRounded facebook page. Is there anyother way of forwarding articles besides copying the link?

    Thank you for acknowledging breastfeeding is a bit of a luxery when time and money are short

    Erin Mullaney
    1. Thanks for your comment Erin! We’d love for you to share on FB! If you’re on the desktop version, there should be social sharing icons that pop up on your left side of the article when you scroll. On mobile, the share buttons will pop up on the top once you start scrolling down.

      Jessica Pallay

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