In an article being early released this week in Pediatrics, Drs. Luis Seoane Estruel and Tatiana Andreyeva from University of Connecticut examined changes in the rate of breastfeeding initiation before and during the 2022 infant formula shortage crisis and compared results across subpopulations (10.1542/peds.2024-067139).
Recall that in late 2021, pandemic-related supply chain problems impacted infant formula availability, and in February 2022 this worsened with the shutdown of Abbott Nutrition’s Michigan facility due to concern for food-borne illness; overall national out-of-stock rates rose to 32% across states, with more than a third of parents reporting difficulty getting formula.
Against this backdrop, the authors examined National Vital Statistics System birth certificate data from 2016 to 2022 for the 47 states with availability of breastfeeding initiation data.
Using statistical techniques that are clearly explained, and accounting for changes over time, policy, and geographic location, the authors found that breastfeeding initiation:
- Was stable pre-crisis at 84%,
- Increased significantly (3.2 percentage points) during the formula shortage to 87.2%,
- Declined only minimally after June 2022, averaging 87.18% July–December 2022, and
- Had the highest increases for Non-Hispanic Black mothers and those with public insurance, participating in WIC, and in the smallest counties.
A simplistic, incorrect, and unsupportable interpretation of the study results might be that women “choose” to breastfeed when formula is scarce, and hence a public health intervention to limit formula availability would increase breastfeeding rates. This flawed thinking fails to account for the impact of structural racism, racial economic inequality, the urban-rural divide, and other forms of structural inequality, defined as “disparities in wealth, resources, and other outcomes that result from discriminatory practices of institutions such as legal, educational, business, government, and health care systems.”
Individual socio-behavioral decisions, such as infant feeding, are increasingly understood as reflective not of personal effort, grit, or determination, but rather as a window on current and past societal practices, for example “redlining” (the refusal of mortgages in minority neighborhoods, outlawed in 1968), which perpetuate poverty, limit opportunity, and negatively affect health outcomes.
The word “choice” implies a freedom of personal preference that does not account for pervasive inequities that may include:
- Inadequate access to lactation help,
- Economic necessity to return to work without workplace empowerment, and
- Generational loss of breastfeeding knowledge.
What are the public health and policy approaches that can increase breastfeeding? Paid maternity leave (with longer leave duration more effective), the PUMP (Providing Urgent Maternal Protections for Nursing Mothers) Act that mandates workplace lactation protection, Nurse Home Visiting programs, and the WIC Breastfeeding Peer Counselor program are evidence-based examples of federal and state laws and programs that create positive change to counteract structural inequality and effectively increase breastfeeding across subpopulations.
There is an outstanding commentary on this article by Drs. Rita Wang, Neha S. Anand, and Heather E. Hsu from Boston Medical Center that aligns with this thread of thought (10.1542/peds.2024-068835), and don’t forget to view the authors’ video abstract for a quick take on the article itself. I encourage you to read this excellent article and think broadly about its meaning. We do more for ourselves as a society when we lift all of us up, and supporting equity for breastfeeding is one deeply impactful way to do so.
