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New ways of understanding disparities in rates of breastfeeding :

July 28, 2016

In a study released this month in Pediatrics, “Racial and Ethnic Differences in Breastfeeding”, Dr. Chelsea McKinney and colleagues examine and untangle the interconnected factors that underlie racial and ethnic differences in breastfeeding rates in the United States (US).1

In a study released this month in Pediatrics, “Racial and Ethnic Differences in Breastfeeding”, Dr. Chelsea McKinney et al. (peds.2015-2388) examine and untangle the interconnected factors that underlie racial and ethnic differences in breastfeeding rates in the United States (US).1  Generalists and breastfeeding medicine specialists alike will be fascinated (I think) because this article is a welcome reprieve from the mainstream in 2 ways.  

First, rather than (metaphorically) heaping risk factors for not breastfeeding into a giant pile and walking away, the authors elucidate and explore distinct contributing risk factors not routinely considered. Second, their methodology is clearly explained and makes sense even to those of us who lack statistical sophistication. The authors include familiar demographic factors such as poverty, education and marital status, but also examine non-demographic factors including “family history of breastfeeding” (meaning whether the mother herself was breastfed) and hospital introduction of formula.  The study results are nuanced and severalhelp explain significant disparities in rates of breastfeeding in the US.  Please read to find your own “ah-ha” moment(s) since there are so many in this article!

Two results stand out for me. Black mothers as compared to those of all other races and ethnicities were less likely to initiate breastfeeding (BF) and to plan to BF postnatally (postnatal BF intent), and had shorter durations of BF.  No surprise, unfortunately. But when comparing BF initiation and postnatal BF intent between black and white mothers, the triad of poverty, marital status and education fully mediated (explained) the differences in rates.  

Wow. This was the first result that grabbed me. At face value, this might also not seem surprising since we are used to seeing these demographic factors as increasing risk for not breastfeeding.  But what a wake-up call that demographics fully explain the racial differences in these BF rates.  What is the collective sociocultural power of marriage, education and money?  

After all, breastfeeding is essentially free and formula is expensive (setting aside WIC- the Special Supplemental Nutrition Program for Women Infants and Children- for a moment), so there must be historical, cultural, personal and perhaps neighborhood contexts that are more meaningful and explanatory than poverty alone.2 And while we can easily agree that it would be a ludicrous strategy to urge all black mothers into matrimony in order to increase BF rates, I wonder - what is the elusive and complex melding of financial, emotional and perhaps even housing stability that marriage possibly contributes to BF choice beyond “partner support?”  And how can a high school or college degree impact what is basically a parenting decision?  That the difference between black and white mothers’ BF initiation and postnatal BF intent can essentially be fully explained by poverty, educational level and marital status opens a Pandora’s box of very uncomfortable societal questions that I believe ultimately demand answers.

The second result that I found interesting is one that also intrigued the authors. In-hospital formula introduction was the biggest predictor of the shorter duration of BF among black as compared with white mothers. The authors appropriately note that this is a variable that can be impacted, and as increasing numbers of birthing hospitals become designated “Baby Friendly,” in-hospital formula supplementation for all infants and especially for minority infants may decrease, in compliance with Baby Friendly Step 6 (“Give infants no food or drink other than breast-milk, unless medically indicated” - https://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps). In-hospital formula supplementation is a visible risk factor for early BF cessation,3 targeted and measured by both the Department of Health and Human Services (DHHS) Healthy People 2020 goals (MICH-23, https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives) and the Centers for Disease Control mPINC survey (maternity Practices in Infant Care & Nutrition, https://www.cdc.gov/breastfeeding/data/mpinc/results-tables.htm). McKinney and colleagues give us evidence that providing early or limited or any formula that is not medically necessary contributes to racial disparities in breastfeeding duration, and should therefore be avoided.

In summary, “Racial and Ethnic Differences in Breastfeeding” has so much “first food” for thought that I am confident you will enjoy reading it from beginning to end for yourself!

1. Reference index article by McKinney and colleagues “Racial and Ethnic Differences in Breastfeeding” in Pediatrics.

2. Gross TT, Powell R, Anderson AK, et al “WIC peer counselors’ perceptions of breastfeeding in African American women with lower incomes.” J Hum Lact 2015; 31: 99-110.

3. Chantry CJ, Dewey KG, Peerson JM et al. “In-Hospital Formula Use increases Early Breastfeeding Cessation among First-time Mothers Intending to Exclusively Breastfeed.” J Pediatr 2014; 164: 1339-1345.

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