Abstract Background: In the United States, breastfeeding initiation is reported for 75% of all live births; however, little information is available for mothers affected by severe preeclampsia (SP) who because of magnesium sulfate treatment are separated from their infants in the immediate postpartum period. This study examined feeding practices and factors associated with breastfeeding initiation in 281 women with SP and their 200 late-preterm and 81 term infants. Subjects and Methods: SP was diagnosed according to established clinical and laboratory criteria. Infant feeding preference was ascertained on admission to labor and delivery. Variables known to influence breastfeeding initiation, including maternal age, smoking, obesity, and racial and educational characteristics, were assessed. Results: All mothers received magnesium sulfate for 24 hours following delivery. Of 281 infants, 54% were admitted to the neonatal intensive care unit (NICU). All mothers and infants survived. On admission, 149 women intended to breastfeed, 73 intended to feed formula, and 59 were undecided. Four of 73 women who did not wish to breastfeed and 27 of 59 originally undecided later initiated breastfeeding. At discharge, 144 (51%) of all these mothers had successfully initiated breastfeeding. Factors associated with breastfeeding initiation failure included African American race, younger age, lower education, multiparity, smoking, and obesity. Of 149 women who intended to breastfeed, 76% were successful, and logistic regression analysis showed that intention to breastfeed was the most significant predictor of breastfeeding initiation. During the first 24 hours postpartum, 78% of infants receiving well-baby care, and 4% of those admitted to the NICU visited with their mother once. Among women who intended to breastfeed, successful breastfeeding initiation involved 85% of infants receiving routine well-baby care and 69% of those admitted to the NICU. Conclusions: In spite of the challenges created by SP, including early maternal separation, breastfeeding initiation is possible. The strongest predictor for breastfeeding success remains the intention to breastfeed, whereas race, lower level of education, and obesity are associated with breastfeeding initiation failure.