Breastfeeding Trends by Race/Ethnicity Among US Children Born from 2009-2015
by Anne Eglash MD, IBCLC, FABM
We continue to have inequity in health among various race/ethnicities due to differences in breastfeeding rates. Because of suboptimal breastfeeding, the authors of this week’s article report that black infants, in comparison to white infants, are estimated to have 1.7 times excess cases of ear infections, 3.3x excess cases of necrotizing enterocolitis, and 2.2 times excess child deaths.
This recently published study used data from the National Immunization Survey, an ongoing telephone survey by the Centers for Disease Control, to evaluate breastfeeding rates among 167,842 children born between 2009 and 2015. They asked 1) if the child was ever breastfed, 2) How old was the child when first fed formula, 3) How old was the child when starting foods other than breastmilk/formula, 4) How old was the child when they stopped breastfeeding or taking breastmilk. Infants were categorized as Hispanic or non-Hispanic, White, Black, Asian, American Indian, Alaskan Native, Hawaiian or other Pacific Islander, and 2 or more races. Other demographic data gathered included birth order, whether participating in WIC, maternal marital status, maternal educational level, and household poverty level.
Overall, the authors demonstrate that breastfeeding rates increased from 2009 to 2015 among all racial/ethnic groups, except for ever breastfeeding and 12 month rates among American Indian/Alaskan Native infants, and ever breastfeeding for Asian infants.
Breastfeeding disparity grew between black and white infants, meaning that the rate of increase in breastfeeding rates among whites was greater than among blacks. Black infants had a 6.1% rise in initiation and exclusivity, and a 9.4% rise in breastfeeding duration. These are lower rates of rise compared to white infants, who had an 8.2% rise in initiation, 10.1% for exclusivity, and 11.1% for duration. The authors cite several possible factors, including population-wide intervention strategies not working as effectively for black mothers, poorer access to community breastfeeding support programs and lactation consultants, and less access to maternity care practices supportive of breastfeeding.
- The overall US breastfeeding rate at 12 months did not change from 2009-2015. It remained at approximately 25%.
- When adjusting for other factors such as poverty level and education, breastfeeding rates were overall higher among Hispanics in comparison with non-Hispanic whites.
- Asian infants had higher initiation rates as compared to white infants in 2009-2010, but were lower than white infants by 2014-2015.
- From 2009 to 2015, differences in breastfeeding rates between American Indian/Alaskan Native infants vs white infants narrowed significantly.
- For the first time, 2015 breastfeeding rates showed no effect from education or poverty level.
See the Answer
Large racial/ethnic disparities in breastfeeding are associated with adverse health outcomes.
To examine breastfeeding trends by race/ethnicity from 2009 to 2015 and changes in breastfeeding gaps comparing racial/ethnic subgroups with white infants from 2009-2010 to 2014-2015.
Design, Setting, and Participants
This study used data from 167 842 infants from the National Immunization Survey–Child (NIS-Child), a random-digit–dialed telephone survey among a complex, stratified, multistage probability sample of US households with children aged 19 to 35 months at the time of the survey. This study analyzed data collected from January 1, 2011, through December 31, 2017, for children born between 2009 and 2015.
Child’s race/ethnicity categorized as Hispanic or non-Hispanic white, black, Asian, or American Indian or Alaskan Native.
Main Outcomes and Measures
Breastfeeding rates, including ever breastfeeding, exclusive breastfeeding through 6 months, and continuation of breastfeeding at 12 months.
This study included 167 842 infants (mean [SD] age, 2.33 [0.45] years; 86 321 [51.4%] male and 81 521 [48.6%] female). Overall unadjusted breastfeeding rates increased from 2009 to 2015 by 7.1 percentage points for initiation, 9.2 percentage points for exclusivity, and 11.3 percentage points for duration, with considerable variation by race/ethnicity. Most racial/ethnic groups had significant increases in breastfeeding rates. From 2009-2010 to 2014-2015, disparities in adjusted breastfeeding rates became larger between black and white infants. For example, the difference for exclusive breastfeeding through 6 months between black and white infants widened from 0.5 to 4.5 percentage points with a 4.0% difference in difference (P < .001) from 2009-2010 to 2014-2015. In contrast, the breastfeeding differences between Hispanic, Asian, and American Indian or Alaskan Native infants and white infants became smaller or stayed the same except for continued breastfeeding at 12 months among Asians. For example, the difference in continued breastfeeding at 12 months between Hispanic and white infants decreased from 7.8 to 3.8 percentage points between 2 periods, yielding a −4.0% difference in difference (P < .001). Because of positive trends among all race/ethnicities, these reduced differences were likely associated with greater increases among white infants throughout the study years.
Conclusions and Relevance
Despite breastfeeding improvements among each race/ethnicity group, breastfeeding disparities between black and white infants became larger when breastfeeding improvements decreased even further among black infants in 2014-2015. The reduced breastfeeding gaps among all other nonwhite groups may be associated with greater increases among white infants. More efforts appear to be needed to improve breastfeeding rates among black infants.
The US breastfeeding rate across all race/ethnicities at 12 months of age increased by 11.3% from 24.6% in 2009 to 35.9% in 2015. This research demonstrates that poverty, education, age, marital status still play very important roles in breastfeeding rates, but breastfeeding rates are not 100% dependent on these factors. In other words, race/ethnicity itself also influences breastfeeding rates, so cultural norms, opportunities and barriers need further exploration. Although some of our policies such as improving breastfeeding support at work, may have contributed to increased breastfeeding rates from 2009 to 2015, it may be that such policies work better for certain groups than others, such as higher-paid workers vs low-wage workers. Further work is needed to improve support for African American dyads, since the overall increase in breastfeeding rates was higher among whites than it was for the African American population.