Relationship Between Race and Meeting Breastfeeding Intentions
by Anne Eglash MD, IBCLC, FABM
Racial differences in breastfeeding rates exist in the USA, where non-Hispanic Black women have had significantly lower breastfeeding rates compared to Non-Hispanic Whites for decades. This difference in breastfeeding rates has led to assumptions among health care professionals and other community supporters that Black women have a lower intention to breastfeed.
The research article for this week’s CQW is a longitudinal cohort study among women and children enrolled in the WIC Infant and Toddler Feeding Practices Study 2 (ITFPS-2). This study, which has enrolled individuals from 80 WIC sites around the USA since 2013, is designed to explore information on feeding practices and nutritional outcomes in this population. Among all enrollees, 2070 pregnant women who intended to breastfeed were included in this analysis, and their intentions to provide only breastmilk at 1 month and 3 months postpartum were recorded. Thirty-two % of the subjects were non-Hispanic White, 21% were non-Hispanic Black, and 41 % were Hispanic.
The researchers also collected demographic and health data that would affect breastfeeding rates (confounding factors) such as age, education status, history of breastfeeding, mode of delivery, preterm status, poverty level, and whether the partner lived in the same home.
They found that the intention to breastfeed, and to provide only breastmilk at 1 month and 3 months postpartum was higher among Hispanics, and did not differ significantly among non-Hispanic Blacks and non-Hispanic Whites. On average, nine in 10 women intended to try breastfeeding, 6/10 intended to provide only breastmilk at 1 month, while 5/10 intended to provide only breastmilk at 3 months.
- Approximately 90% of all women in the study initiated breastfeeding, with Hispanic women having higher initiation rates than non-Hispanic Whites and non-Hispanic Blacks.
- Among women who intended to provide only breastmilk at 1 month, Hispanic women were more likely to meet their intention as compared to non-Hispanic White and non-Hispanic Black women.
- Among all women who intended to provide only breastmilk at 3 months, approximately 30% on average met their intention.
- Despite having similar intentions to breastfeed, non-Hispanic Whites had higher breastfeeding rates at 1 month and 3 months postpartum as compared to non-Hispanic Blacks.
- Although Hispanic women had higher intention to provide only breastmilk at 1 and 3 months postpartum, non-Hispanic Whites had higher rates of providing breastmilk at 1 and 3 months.
See the Answer
Prenatal breastfeeding intentions impact breastfeeding practices. Racial/ethnic disparities exist in breastfeeding rates; it is unknown if prenatal intentions and meeting intentions differ by race/ethnicity. A longitudinal cohort of USDA's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) which enrolled participants beginning in 2013 were used to estimate prenatal intentions for breastfeeding initiation, exclusive breast milk feeds at 1 and 3 months by race/ ethnicity (n = 2070). Meeting intentions were determined by reported breast milk consumption at birth, 1 month and 3 months. Multivariable logistic regression was used to determine the association of race/ethnicity with meeting intentions. There were no differences in prenatal breastfeeding intentions between non-Hispanic White and non-Hispanic Black women (initiation: 86.9% and 87.2%; Month 1: 52.3% and 48.3%; Month 3: 43.8% and 40.9%; respectively), but a higher percentage of Hispanic women intended to breastfeed at all time points (95.5%, 68.3% and 56.4%; respectively, P < 0.05). Among women who intended to breastfeed at Month 1, non-Hispanic Black and Hispanic women had significantly lower odds of meeting intentions compared with non-Hispanic White women after adjusting for covariates (aORs: 0.63 [95% CI: 0.41, 0.98]; 0.64 [95% CI: 0.44, 0.92], respectively). Similar findings were seen for Month 3. Despite no differences in breastfeeding intentions, non-Hispanic Black women were less likely to meet their breastfeeding intentions than non-Hispanic White women. Hispanic women were more likely to intend to breastfeed yet were less likely to meet their intentions. This suggests that non-Hispanic Black and Hispanic women face challenges to meeting their longer breastfeeding intentions. Understanding how racism, bias and discrimination contribute to women not meeting their breastfeeding intentions may help efforts to reduce breastfeeding disparities.
This study demonstrated that non-Hispanic Whites and non-Hispanic Blacks had the same intention to initiate breastfeeding and to provide only breastmilk at 1 and 3 months postpartum. However, 56% of non-Hispanic Whites met their intentions at 1 month as compared to 41.5% of non-Hispanic Blacks. At 3 months, 45% of non-Hispanic Whites met their intentions as compared to 26% of non-Hispanic Blacks.
Hispanic women had higher intentions to initiate breastfeeding and to provide only breastmilk at 1 and 3 months as compared to non-Hispanics, but only 42% and 28% of Hispanic mothers met their intentions at 1 and 3 months respectively.
The authors point out that several factors differ by race/ethnicity, contributing to inequity in breastfeeding success, namely experiences in birth hospitalization, the receipt of lactation services, family support, community support, affordable childcare, and breastfeeding support at work. Ironically the lower rates of breastfeeding among women of color has created a catch-22, creating implicit bias among many that has contributed to their insufficient breastfeeding support. In other words, if women of color are observed to not breastfeed for very long, they are less likely to be offered lactation services immediately postpartum, and may receive less information about the impact of early postpartum contraception on breastfeeding.
Raising awareness of such implicit bias, educating communities on the reality of breastfeeding intention among women of color, and identifying these barriers in our communities are central to designing support programs for breastfeeding dyads at risk of not reaching their goals.