Breastfeeding Support for African-American Women in Louisiana Hospitals

Abstract

Objective:

This study determined the variation in hospital breastfeeding support for African-American women in Louisiana.

Study Design:

Data from the 2007–2008 Louisiana Pregnancy Risk Assessment Monitoring System (n=2,534) were used to determine the odds of African-American women's hospital experiences with breastfeeding-related services following delivery relative to women of all other races. SAS-callable SUDDAN software was used for analyses.

Results:

African-American women were 60% less likely than women of other races to initiate breastfeeding or pump milk (odds ratio=0.40, 95% confidence interval=0.31–0.52). Compared with women of other races, African-American mothers were less likely to receive breastfeeding instruction and support from healthcare professionals while in the hospital, including being less likely to receive phone numbers for support and less likely to have their baby remain in the hospital room with them. African-American mothers were also less likely to report that they breastfed while in-hospital or breastfed exclusively while in-hospital.

Conclusion:

This study shows significant racial differences in initiation of breastfeeding and hospital experiences following delivery in Louisiana.

Introduction

In Louisiana, the percentage of women who initiate breastfeeding has consistently ranked lowest or second to lowest in the United States.¹ In addition to baseline rates that are low across all races, enormous disparities exist, with non-Hispanic white women initiating breastfeeding 59.8% of the time and only 31.8% of non-Hispanic black women initiating.² The state of Louisiana has a particularly high obesity and diabetes burden, and disparities in these chronic diseases exist, as they do for many of the southern United States.³ Given the higher rates of diseases potentially modifiable by breastfeeding in African-Americans, breastfeeding could play a particularly important role in improving the health of Louisiana's African-American women and their children.^4–7 The current Healthy People 2020 objective is to increase the proportion of mothers who breastfeed their babies to 82%.⁸ To achieve this goal in Louisiana, a better understanding of the reasons for breastfeeding disparities as well as an aggressive campaign to address them must be accomplished. Provider encouragement and social support before, during, and after pregnancy are important influences for breastfeeding mothers.^9,10 Race may influence whether a woman receives breastfeeding support during prenatal care; however, literature is scarce. Beal et al.¹¹ found that African-American women in Texas were less likely to receive breastfeeding advice from medical providers and Women, Infants and Children Special Supplemental Nutrition Program (WIC) nutritional counselors and more likely to receive formula-feeding advice from WIC counselors. Ahluwalia et al.¹² looked at hospital experiences in several states by race and found significant racial variation in hospital support practices for breastfeeding. Literature from France suggests that disparities may be an issue internationally.¹³

This study examines the Louisiana Pregnancy Risk Assessment Monitoring System (LaPRAMS) data for differences in hospital support for breastfeeding by race. We hypothesized that one potential challenge to breastfeeding for African-American women in Louisiana is that they are not receiving adequate in-hospital provider support.

Subjects and Methods

For this study we used data from the LaPRAMS, an ongoing, population-based survey that collects self-reported data about the experiences of women before, during, and shortly after pregnancy. Using Louisiana birth certificate records, a stratified random sample of postpartum mothers in Louisiana were surveyed 2–6 months after delivery. The Louisiana Department of Health and Hospitals Title V Program conducts the survey under a cooperative agreement with the Centers for Disease Control and Prevention. The annual sample size is large enough for estimating statewide risk factor proportions within 3.5% at a 95% confidence level.

Mothers are sent up to three surveys, which are followed by telephone interviews if no response is received by mail. Maternal demographic characteristics, including race, ethnicity, marital status, and years of education completed, are obtained from the birth certificate and are available through the Pregnancy Risk Assessment Monitoring System (PRAMS) dataset. The population stratification is determined by each PRAMS state, and the Centers for Disease Control and Prevention uses this information to make the results representative of all Louisiana women delivering live-born infants in the state during the study period, accounting for survey design, noncoverage, and nonresponse.¹⁴ The breastfeeding support questions asked in the LaPRAMS questionnaire reflect the World Health Organization/UNICEF Ten Steps to Successful Breastfeeding. Louisiana has a similar nonprofit program that designates hospitals as “GIFT Certified” (Guided Infant Feeding Techniques Certified) if they follow 10 steps to encourage and support breastfeeding (Table 1). This analysis combines data from the years 2007 and 2008 to improve the power to detect differences in responses by race. Data from years 2005 and 2006 were not included because of disruptions in public health surveillance in the 2 years following Hurricanes Katrina and Rita.

Table 1.

The Guided Infant Feeding Techniques Ten Steps to a Healthy, Breastfed Baby

1. All policies, interventions, and care plans directed towards the newborn, infant, or lactating woman should protect, promote, and support breastfeeding.

2. Hospital employees should receive breastfeeding education and training upon employment, with updates provided on a regular basis.

3. Promote breastfeeding as the feeding method of choice to all mothers prior to birth, following birth, and after hospital discharge.

4. Encourage mothers and newborns to breastfeed within the first two hours after birth, with the first hour being ideal.

5. Show mothers how to breastfeed and how to maintain lactation, even if separated from their infants.

6. Support the decision of mothers to breastfeed. Complementary or supplementary feedings of water or artificial infant formula will not be given to a breastfeeding infant unless specifically ordered by the physician for a clinical condition or upon parental request.

7. Encourage rooming-in both day and night.

8. Encourage mothers to breastfeed their newborns without restrictions.

9. Discourage the use of artificial nipples for normal newborns.

10. The hospital should address support for breastfeeding mothers following hospital discharge.

Survey response varied by race. Weighted response rates for African-American women were 43.5% in 2007 and 42.0% in 2008, whereas 67.3% and 61.5% of white women responded in 2007 and 2008, respectively. The percentages of women responding who were other than white or African-American race were 52.4% in 2007 and 55.5% in 2008. We did not account for Hispanic ethnicity in this analysis as no African American respondents reported also being Hispanic.

To assess the effect of prenatal counseling on initiation of breastfeeding, we used responses to the question, “During any of your prenatal care visits, did a doctor, nurse, or other healthcare worker talk with you about breastfeeding your baby?”

Breastfeeding initiation was determined by affirmative response to the following question, “Did you ever breastfeed or pump breastmilk to feed your new baby after delivery?” Respondents were asked 10 questions reflecting the policies of Louisiana's GIFT program: “Hospital staff gave me information about breastfeeding,” “My baby stayed in the same room with me at the hospital,” “I breastfed my baby in the hospital,” “I breastfed my baby in the first hour after my baby was born,” “Hospital staff helped me learn how to breastfeed,” “My baby was fed only breastmilk at the hospital,” “Hospital staff told me to breastfeed whenever my baby wanted,” “The hospital gave me a gift pack with formula,” “The hospital gave me a telephone number to call for help with breastfeeding,” and “My baby used a pacifier in the hospital.” These 10 questions were framed around the structure of the GIFT program and intended to devise level of support for breastfeeding at the hospital level.

Weighted logistic regression was used to estimate the effect of African-American race on the experience of hospital breastfeeding support. No adjustments were made to the reported confidence intervals (CIs) to account for multiple comparisons. All models included terms for the mother's race (African-American or other), age, marital status, education, rural/urban residence, WIC participation at time of pregnancy, parity, and income. These covariates were included in the models to control for confounding by sociodemographic differences that could mask the effect of race. To test differences by race in reasons stated for not initiating breastfeeding χ² tests were used. SAS-callable SUDAAN version 10.0 was used for all analyses.

Institutional Review Board approval was received by Louisiana State University, and LaPRAMS maintains Institutional Review Board approval under the Louisiana Department of Health and Hospitals and the Centers for Disease Control and Prevention.

Results

Table 2 presents numbers and weighted percentages of African-American LaPRAMS respondents and respondents of other races. African-American respondents accounted for 39.5% of weighted respondents, while the category of “other race” consists of white (57.3%), Asian (1.5%), Native American (0.6%), and other nonwhite women (1.2%).

Table 2.

Characteristics of Louisiana Pregnancy Risk Assessment Monitoring System Respondents by African-American and All Other Races Combined

	African-American		Other race
Factor, level	n	Weighted %	n	Weighted %
Age (years)
<18	67	7.7	44	2.7
18–<30	630	77.5	1,075	67.5
30–<40	185	13.2	489	28.2
40+	17	1.7	27	1.6
Married
Yes	210	20.8	1,148	66.8
No	689	79.2	487	33.3
High school diploma
Yes	663	69.8	1,409	84.6
No	236	30.2	226	15.4
Nulliparous
Yes	398	42.8	884	44.4
No	501	57.2	751	55.6
Residence
Rural	350	36.9	945	52.5
Urban	549	63.1	690	47.6
Household income
<$20,000	535	61.2	460	29.7
≥$20,000	364	38.8	1,175	70.3
WIC during pregnancy
Yes	637	78.5	679	44.9
No	226	21.5	920	55.1
Ever breastfed
Yes	329	31.9	1,045	62.5
No	570	68.1	590	37.5
Total	899	100.0	1,635	100.0

WIC, Women, Infants and Children Special Supplemental Nutrition Program.

African-American women were 60% less likely than women of other races to initiate breastfeeding or pump milk (odds ratio [OR]=0.40, 95% CI=0.31–0.52) after adjustment for maternal age, marital status, education, household income, low birth weight, smoking during pregnancy, rural residence, receipt of WIC during pregnancy, and previous births. This lower odds of initiating breastfeeding persisted despite African-American expectant women reporting that they were more likely to receive prenatal counseling on breastfeeding than women of other races (OR=1.39, 95% CI=1.02–1.91). However, prenatal breastfeeding counseling was not found to be predictive of initiation for African-American women (OR=1.28, 95% CI=0.99–1.65) or for all women (OR=1.27, 95% CI=0.99–1.64).

Table 3 presents adjusted ORs and 95% CIs for the effect of African American race in predicting whether a new mother received each of 10 types of in-hospital breastfeeding support after delivery. Table 3 presents results separately for mothers who initiated breastfeeding, thus indicating an intention to breastfeed, and all mothers regardless of breastfeeding initiation.

Table 3.

Odds Ratios and 95% Confidence Intervals for African-American Race in Predicting the Experience of Each of 10 Types of Hospital-Based Support for Breastfeeding

	Mothers who breastfed
	African-American mothers responding "yes"				Mothers who did and did not breastfeed
Questionnaire item	Unweighted n	Weighted %	Odds ratio	95% CI	Odds ratio	95% CI
Hospital staff provided breastfeeding information	300	89.5	0.55	(0.28, 1.09)	0.75	(0.56, 1.01)
Hospital staff helped me learn how to breastfeed	252	74.9	0.90	(0.58, 1.39)	0.61	(0.48, 0.78)
Staff provided instruction to breastfeed on demand	194	73.5	0.75	(0.50, 1.14)	0.57	(0.44, 0.72)
Hospital provided a breastfeeding telephone information number	251	78.6	0.60	(0.38, 0.95)	0.57	(0.45, 0.72)
Hospital gave a gift pack of formula	269	84.5	0.98	(0.59, 1.61)	0.91	(0.66, 1.25)
Baby used a pacifier in the hospital	257	70.6	1.25	(0.86, 1.84)	0.94	(0.73, 1.20)
Baby stayed in the same room at the hospital	138	68.1	0.66	(0.45, 0.97)	0.72	(0.56, 0.92)
Breastfed in the first hour after delivery	99	46.5	0.95	(0.67, 1.36)	NA
Baby fed only breastmilk while in the hospital	128	34.7	0.59	(0.41, 0.86)	NA
Breastfed while in the hospital	207	78.8	0.52	(0.32, 0.83)	NA

CI, confidence interval; NA, not applicable.

African-American mothers who initiated breastfeeding reported similar experiences as mothers of other races who initiated breastfeeding for six of the 10 types of support, including breastfeeding within the first hour after delivery, hospital staff providing information about breastfeeding, hospital staff helping to teach the mother how to breastfeed, hospital staff instructing the mother to breastfeed on demand, provision of a gift pack of formula, and use of pacifiers in hospital.

The experience of African-American mothers in-hospital who initiated breastfeeding was significantly different from that of mothers of other races who initiated breastfeeding in four areas of hospital support. African-American mothers who breastfed were less likely to report that their new baby stayed in the hospital room with them, that they breastfed while in-hospital, that they breastfed exclusively while in-hospital, and that the hospital staff provided them with a telephone information number for breastfeeding support.

Considering all mothers regardless of whether they initiated breastfeeding, African-American race was significantly associated with lower odds of receiving four kinds of in-hospital breastfeeding support: the baby remaining in the hospital room with the mother, the hospital staff helping the mother learn to breastfeed, the hospital staff instructing the mother to breastfeed on demand, and the hospital staff providing the mother with a breastfeeding telephone help line number. There was no significant difference in in-hospital support for African-American mothers among all mothers regardless of breastfeeding initiation with regard to the staff providing breastfeeding information, receipt of formula gift packs, or pacifier use.

Among mothers who did not initiate breastfeeding, African-American mothers differed in some of the reasons for not breastfeeding compared with mothers of other races (Table 4). African-American mothers were more likely to state that they did not breastfeed because they did not like breastfeeding than mothers of other races (45% vs. 39%; χ² p=0.0440). African-American mothers were statistically significantly less likely than mothers of other races to cite being ill, the demands of other children, and embarrassment as reasons for not initiating breastfeeding.

Table 4.

Reasons for Not Initiating Breastfeeding by Mother's Race Showing Weighted Percentages and χ² Significance Levels

	Weighted %
Reason for not breastfeeding	African-American	Other race	χ² p value
Baby was too ill	2.00	2.80	0.4603
Mother was too ill	11.30	16.10	0.0410
Other children too demanding	16.00	24.00	0.0028
Too many household duties	9.20	13.30	0.0532
Didn't like breastfeeding	45.30	38.50	0.0440
Didn't want to be tied down	8.10	9.90	0.3408
Embarrassing	4.10	7.60	0.0255
Return to school or work	22.10	17.30	0.0778
Wanted body to self	0.00	0.00	1.0000

Discussion

African-American women have reported receiving less counseling during prenatal care on topics that could improve their health and that of their babies such as smoking cessation, alcohol use, and breastfeeding when compared with white women.¹⁵ Our study found that although African-American women were more likely to have discussed breastfeeding with a health professional prior to delivery, they were less likely to have hospital support for breastfeeding once they had already initiated breastfeeding.

The immediate postpartum period presents an opportunity for hospital physicians and staff to promote breastfeeding practices before demands of home and work further influence a mother's decision to breastfeed. Hospital settings are arguably the most supportive and easiest in which to breastfeed because of the presence of support staff. We found that African-American mothers did not receive the same level of in-hospital breastfeeding support as women of other races. Even those African-American mothers who demonstrated an intention to breastfeed by initiating breastfeeding did not receive as much breastfeeding support as women of other races. Therefore, addressing racial disparities in in-hospital breastfeeding support may be an important modifiable factor in increasing breastfeeding rates and encouraging mothers who do breastfeed to practice correct methods.

Our study also found that African-American LaPRAMS respondents were more likely than women of other races to cite not liking breastfeeding as a reason for not initiating breastfeeding. Although this answer is fairly nondescriptive, finding more specific reasons for “not liking” the practice is an opportunity for research and social media campaigns to address expectant mother's concerns. Our findings that African-American women who initiated breastfeeding were less likely to breastfeed in the hospital may mean that women are breastfeeding immediately after delivery but not during the rest of the hospital stay, but further research is needed to better understand this discrepancy.

Several limitations exist with LaPRAMS data. LaPRAMS is self-reported, and recall bias is possible because women respond after their infant's birth. Also, the Louisiana PRAMS data may not be generalizable to other states. The response rate to LaPRAMS post-Katrina has been lower than our desired 70%. Although post-Katrina PRAMS response rates have been lower, when comparing responses before and after Katrina, the sampled population has not demonstrated statistically different answers to sampled survey questions that have remained stable across survey years.

Currently, only 23% of delivery hospitals in Louisiana have comprehensive breastfeeding policies, including all model breastfeeding policy components recommended by the Academy of Breastfeeding Medicine.¹⁶ Forty-three percent of African-Americans delivering in Louisiana deliver in GIFT-certified hospitals, compared with 51% of white women. This difference may partially explain why African-American babies are less likely to stay in the room with the mother. It is likely that access to lactation consultants and other support services is lacking at non–GIFT-certified hospitals. However, other hospital-level factors such as length of stay or nurse-staffing ratios may be different as well but are not captured in our data and may be a further area of research interest.

Conclusions

African-American women in Louisiana have lower rates of breastfeeding initiation and, even when initiating breastfeeding, have differing hospital experiences of breastfeeding support. One possible strategy would be to increase the number of GIFT-certified hospitals, which may help close some of the breastfeeding gaps in Louisiana by ensuring all women receive the option to obtain the full gamut of breastfeeding support services. More research is needed, however, on the differences between hospitals and how GIFT certification informs hospital-level experience. Ongoing research to evaluate the effectiveness of breastfeeding programs in Louisiana's birthing facilities should specifically address barriers encountered by African-American women and the success of policy changes in overcoming those barriers.

Footnotes

Acknowledgments

We are grateful for the assistance of Dr. Lyn Kieltyka, Senior Maternal and Child Health Epidemiologist, and Ms. Lillian Funke, both from the Louisiana Department of Health and Hospitals. This research was made possible through funding from the Norman Gant Fellowship from the Institute of Medicine. Support for this project was provided to R.E.G. through a career development grant from the Institute of Medicine.

Disclosure Statement

No competing financial interests exist.

References

Centers for Disease Control and Prevention. Breastfeeding Report Card, United States 2011: Outcome indicators. www.cdc.gov/breastfeeding/data/reportcard2.htm. 2012 July 15.

Centers for Disease Control and Prevention. Racial and ethnic differences in breastfeeding initiation and duration, by state—National Immunization Survey, United States, 2004–2008. MMWR Morb Mortal Wkly Rep, 2010; 59:327–334.

The Henry

. Kaiser Family Foundation. statehealthfacts.org www.statehealthfacts.org/comparebar.jsp?ind=501&cat=10. 2012 July 15.

Horta

, Bahl

, Martinés

et al. Evidence on the Long-Term Effects of Breastfeeding: Systematic Reviews and Meta-Analyses. Department of Child and Adolescent Health, World Health Organization: Geneva, 2007.

U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. Office of the Surgeon General, U.S. Department of Health and Human Services: Washington, DC, 2011.

, Chung

, Raman

et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep), 2007; 153:1–186.

Office of Minority Health. HHS Fact Sheet, Minority Health Disparities at a Glance. 2007. http://minorityhealth.hhs.gov/templates/content.aspx?ID=2139. 2011 July 27.

U.S. Department of Health and Human Services. Objective MICH-21.1. Healthy People 2020. U.S. Department of Health and Human Services: Washington, DC http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. 2012 July 15.

, Lange

, Slusser

et al. Provider encouragement of breastfeeding: Evidence from a national survey. Obstet Gynecol, 2001; 97:290–295.

10.

Raj

, Plichta

. The role of social support in breastfeeding promotion: A literature review. J Hum Lact, 1998; 14:41–45.

11.

Beal

, Kuhlthau

, Perrin

. Breastfeeding advice given to African American and white women by physicians and WIC counselors. Public Health Rep, 2003; 118:368–76.

12.

Ahluwalia

, Morrow

, D'Angelo

et al.

Maternity care practices and breastfeeding experiences of women in different racial and ethnic groups: Pregnancy Risk Assessment and Monitoring System (PRAMS)

Matern Child Health J, 2012; 28:167–173.

13.

Bonet

, Kaminski

, Blondel

. Differential trends in breastfeeding according to maternal and hospital characteristics: Results from the French National Perinatal Surveys. Acta Paediatr, 2007; 96:1290–1295.

14.

Adams

, Shulman

, Bruce

et al. The Pregnancy Risk Assessment Monitoring System: Design, questionnaire, data collection, and response rates. PRAMS Working Group. Paediatr Perinat Epidemiol, 1991; 5:333–346.

15.

Kogan

, Alexander

, Kotelchuck

et al. Comparing mothers' reports on the content of prenatal care received with recommended national guidelines for care. Public Health Rep, 1994; 109:637–646.

16.

Centers for Disease Control and Prevention. National Survey of Maternity Care Practices in Infant Nutrition and Care (mPINC) Centers for Disease Control and Prevention: Atlanta, 2009. http://www.cdc.gov/breastfeeding/data/mpinc/index.htm. 2012 July 15.