Racial and Ethnic Disparities in Breastfeeding Initiation in the USA 2019
by Anne Eglash MD, IBCLC, FABM
The Centers for Disease Control and Prevention (CDC) tracks breastfeeding rates using different survey tools for different time periods postpartum. Infant nutrition prior to hospital discharge is an item on birth certificates for 48/50 states in the USA, the District of Columbia, Guam, Northern Mariana Islands and Puerto Rico. Birth certificates also include self-reported maternal race/ethnicity.
Therefore, US CDC breastfeeding initiation data in association with race/ethnicity is taken from birth certificates. The 2019 data was analyzed from 3,129,646 births.
The overall US breastfeeding initiation rate in 2019 was 84.1%, but rates varied greatly by race/ethnicity, with the degree of disparity varying in each state.
For example, the overall breastfeeding initiation rate was highest at 94.8% in Oregon, and lowest at 64.7% in Mississippi. The largest racial/ethnic disparity in breastfeeding initiation was 37.6% in North Dakota (Asian mothers compared to American Indian/Alaska Native mothers), whereas the lowest racial/ethnic disparity was 6.6% in Vermont (higher for infants of Black and Asian mothers compared to White mothers).
The authors state that because the disparities in breastfeeding rates vary so much from state to state, programs funded to address these disparities should be designed according to the state’s needs.
- Racial/ethnic disparities in breastfeeding initiation were higher in states with higher breastfeeding rates.
- Six states exceeded a disparity in breastfeeding initiation rates of over 30%.
- In 26 states, the breastfeeding initiation rate was lowest among Black mothers.
- The largest disparities in breastfeeding initiation rates were observed between Black and White mothers.
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Breastfeeding is the optimal source of nutrition for most infants (1). Although breastfeeding rates in the United States have increased during the past decade, racial/ethnic disparities persist (2). Breastfeeding surveillance typically focuses on disparities at the national level, because small sample sizes limit examination of disparities at the state or territorial level. However, birth certificate data allow for assessment of breastfeeding initiation among nearly all newborn infants in the United States both nationally and at the state and territorial levels. To describe breastfeeding initiation by maternal race/ethnicity, CDC analyzed 2019 National Vital Statistics System (NVSS) birth certificate data for 3,129,646 births from 48 of the 50 states (all except California and Michigan†), the District of Columbia (DC), and three U.S. territories (Guam, Northern Mariana Islands, and Puerto Rico). The prevalence of breastfeeding initiation was 84.1% overall and varied by maternal race/ethnicity, ranging from 90.3% among infants of Asian mothers to 73.6% among infants of Black mothers, a difference of 16.7 percentage points. Across states, the magnitude of disparity between the highest and lowest breastfeeding rates by racial/ethnic groups varied, ranging from 6.6 percentage points in Vermont to 37.6 percentage points in North Dakota, as did the specific racial/ethnic groups with the highest and lowest rates. These state/territory-specific data highlight the variation that exists in breastfeeding disparities across the United States and can help public health practitioners and health departments identify groups on which to focus efforts. Targeting breastfeeding promotion programs on populations with lower breastfeeding rates might help reduce racial/ethnic disparities in breastfeeding initiation and improve infant nutrition and health.
The states with the lowest breastfeeding rates have the greatest racial/ethnic disparities in initiation rates. The six states that have the highest disparity rates are Wisconsin, North Dakota, Louisiana, Alabama, Arkansas, and North Carolina. The largest disparities in breastfeeding initiation rates are between Asian Americans and Blacks.
The authors of this study add that many health outcomes affected by breastfeeding, such as necrotizing enterocolitis, sudden infant death syndrome, childhood obesity, ovarian cancer, breast cancer, maternal hypertension, vascular disease, are more prevalent in the Black and American Indian/Alaska Native populations, which also happen to have lower breastfeeding rates. Therefore, closing the gap in breastfeeding rates among various racial/ethnic groups is a very important first step in resolving inequities in health outcomes.