Race and Ethnicity and Exclusive Breastfeeding Success

Abstract

Introduction:

Breast milk is the ideal food for infants. However, at 6 months of age, <25% of infants in the United States are exclusively breastfed. While racial disparities in breastfeeding have been documented, questions remain about the contributions of paternal race and ethnicity to breastfeeding.

Materials and Methods:

This single-site, prospective study investigated the association of parental characteristics and exclusive breastfeeding (EBF). EBF and non-EBF (N-EBF) infants who were >35 weeks gestational age were compared at nursery discharge and ∼30 days of age.

Results:

At nursery discharge (n = 499), mean birth weight (±standard deviation [SD]) was greater in the EBF versus N-EBF cohort (3.4 ± 0.4 versus 3.3 ± 0.5 kg, p = 0.01). When compared to the N-EBF cohort, infants in the EBF cohort were significantly more likely to have the following characteristics: (1) vaginal birth; (2) non-Hispanic parents; (3) parents with higher socioeconomic status, and (4) parents who are English-speaking (p < 0.01 for all). Similar findings persisted at 30 days. Non-Hispanic parents were 2 (95% confidence interval [CI]: 1.4–3.3) and 3.5 (95% CI: 1.5–7.9) times more likely to exclusively breastfeed than Hispanic parents at nursery discharge and 30 days, respectively. At nursery discharge, families with a Hispanic mother and non-Hispanic father were more likely to EBF than families with a Hispanic mother and father (odds ratio 2.9, 95% CI: 1.1–7.6). In multivariate model, parental ethnicity was associated with EBF at discharge (p = 0.03) and 30 days (p = 0.02).

Conclusion:

Paternal ethnicity may influence EBF. Addressing disparities in EBF may warrant investigations into culturally inclusive and family-centered interventions.

Introduction

Breastfeeding benefits the infant, mother, and community. Compared to non-breastfed infants, breastfed infants have higher neurodevelopmental scores and a decreased incidence of sudden infant death syndrome, obesity, infections, atopy, diabetes, and certain cancers.¹ Mothers who breastfeed have a lower risk of type 2 diabetes mellitus, cardiac disease, and breast and ovarian cancer.² In addition to individual benefits, the benefits of breastfeeding are appreciated at a macrosystem level. In a cost analysis, when compared to exclusive breastfeeding (EBF) for at least 6 months, non-EBF (N-EBF) was associated with an excess of ∼3,000 deaths and billions of U.S. dollars for medical and nonmedical expenses.^2,3

Although the benefits of breastfeeding are well established, there are racial and ethnic disparities in the United States. Large studies have demonstrated that after accounting for demographic variables and socioeconomic status, non-Hispanic White infants are more likely to initiate and continue breastfeeding compared to non-Hispanic Black infants.⁴ While Spanish-speaking Hispanic mothers have comparable durations for breastfeeding when compared with White mothers, English-speaking Hispanic mothers terminate breastfeeding earlier compared to White mothers.⁵

Breastfeeding interventions have focused mainly on the mother.^6–8 Studies suggest that the father's preferred method of feeding may influence the mother's decision to breastfeed,⁹ and increased paternal support is associated with increased breastfeeding rates.^10,11 Although maternally focused breastfeeding interventions are important, paternally inclusive interventions may help close the breastfeeding disparity gap.¹² Hence, this study's objective was to investigate the relationship between maternal and paternal race and ethnicity and EBF in a large, urban city in the United States (Los Angeles).

Materials and Methods

Study design

This study's primary outcome was EBF at nursery discharge. This study was a secondary analysis of a single-site, prospective study that enrolled infants with a gestational age ≥35 weeks, who were admitted to the newborn nursery immediately after birth with risk factors for severe hyperbilirubinemia.¹³ The University of California, Los Angeles (UCLA), newborn nursery is located within the Ronald Reagan Hospital in Los Angeles, CA. There are ∼1,400 admissions per year, the majority of which are full-term newborns. Exclusion criteria included missing breastfeeding and demographic data, major congenital anomalies, congenital infections, liver disorders, and maternal history of hepatitis.¹³

EBF or N-EBF infants were compared at nursery discharge and ∼30 days of age. A diet consisting of sole breast milk was defined as EBF. A diet consisting of any formula feeding was defined as N-EBF. Data at nursery discharge were collected from the electronic medical record, while data at 30 days of age were collected by an electronic or paper survey. Written informed consent was obtained from a parent or legal guardian for all subjects. The UCLA Institutional Review Board approved the study.

Statistical methods and analysis

Data are represented as mean ± standard deviation (SD). Significance was determined using chi-square analysis, t test, or Kruskal-Wallis test. Univariable and multivariable logistic regression models for EBF were run using a four-level ethnicity variable (both Hispanic, only father, only mother, or neither Hispanic). Odds ratios (ORs) with 95% confidence intervals (CIs) were computed with both parents identifying as Hispanic as the reference group. Statistical analyses and comparisons were conducted using IBS SPSS V25 (Armonk, NY). p-Values <0.05 were considered statistically significant.

Results

Five hundred and seventy-three subjects were enrolled between June 2014 and July 2016. Seventy-four subjects were excluded because of missing data. At nursery discharge, there were 499 subjects (n = 346 in the EBF group and n = 153 in the N-EBF group). At 30-day follow-up, there were 205 subjects (n = 135 in the EBF group and n = 70 in the N-EBF group). When infants who followed up at 30 days were compared to those who were lost to follow-up, there was no difference in demographics or other neonatal variables (data not shown).

At nursery discharge, mean birth weight (±SD) and gestational age were greater in the EBF versus the N-EBF cohort (3.4 ± 0.4 versus 3.3 ± 0.5 kg, p = 0.01 and 40 ± 1.1 versus 39 ± 1.3, p = 0.003, respectively). In the N-EBF group, 72% were predominantly fed breast milk, 20% were predominantly fed formula, and 8% were exclusively fed formula. When compared to the N-EBF cohort, infants in the EBF cohort were more likely to have been born vaginally and have non-Hispanic and English-speaking parents with a higher socioeconomic status (SES) (p < 0.01 for all). However, when the EBF group was compared to the N-EBF group, maternal and paternal race were similar (p = 0.28 and p = 0.77, respectively). Despite a similar number of lactation consults (68% versus 66%, p = 0.5), the EBF group had a higher average latch score on day 2 of age when compared to the N-EBF group (8.9 ± 1.2 versus 8.3 ± 1.4, p < 0.001) (Table 1). Similar findings persisted at 30 days for the EBF and N-EBF group (Table 1). When the EBF group was compared to the group who received predominately formula at nursery discharge (n = 43) and 30 days (n = 70), similar findings were observed (data not shown).

Table 1.

Parental and Neonatal Characteristics in Exclusive Breastfeeding and Nonexclusive Breastfeeding Groups at the Time of Discharge from the Hospital and at 30 Days After Discharge

	At discharge		At 30 days
	EBF (n = 346)	N-EBF (n = 153)	EBF (n = 135)	N-EBF (n = 70)
Maternal age (years)	32 ± 5	32 ± 5	32 ± 4	32 ± 5
Vaginal delivery	76%	56%^a	79%	67%
Gravida	2.2 ± 1.34	2.4 ± 1.53	2.1 ± 1.3	2.0 ± 1.1
Para	1.7 ± 1.0	2.0 ± 1.1^a	1.7 ± 1.0	1.6 ± 0.8
Gestational age (weeks)	39.6 ± 1.1	39.3 ± 1.3^a	39.6 ± 1.1	39.2 ± 1.2^a
Birth weight (kg)	3.4 ± 0.4	3.3 ± 0.5^a	3.5 ± 0.4	3.3 ± 0.5
Gender (male)	54%	50%	54%	61%
1-Minute Apgar	8.0 ± 1.43	8.2 ± 1.25	8.1 ± 1.1	8.0 ± 1.5
5-Minute Apgar	8.9 ± 0.56	8.9 ± 0.29	8.9 ± 0.3	8.9 ± 0.4
Weight loss at day 2 (%)	−5.6 ± 1.83	−3.8 ± 3.12	−5.7 ± 2.2	−5.7 ± 2.1
Weight loss at discharge	−5.1 ± 2.60	−5.4 ± 3.57	−5.0 ± 2.7	−5.7 ± 3.1
Average Latch Score 1	8.0 ± 1.22	7.6 ± 1.28^a	8.0 ± 1.1	7.7 ± 1.2
Average Latch Score 2	8.9 ± 1.20	8.3 ± 1.44^a	9.0 ± 1.1	8.4 ± 1.2
Gestational diabetes	6%	10%	5%	9%
Pregnancy-induced hypertension	5%	5%	4%	7%
Maternal race
African American	5%	6%	3%	0%
American Indian/Alaska Native	1%	0%	1%	1%
Asian	14%	22%	16%	27%
Native Hawaiian/Pacific Islander	0%	1%	0%	9%
White	78%	71%	80%	69%
More than one Race	1%	1%	0%	0%
Other	1%	0%	0%	3%
Non-Hispanic Maternal Ethnicity	74%	63%	84%	67%
Paternal race^a
African American	8%	7%	4%	1%
American Indian/Alaska Native	1%	1%	0%	0%
Asian	12%	16%	11%	24%
Native Hawaiian/Pacific Islander	0%	0%	0%	0%
White	76%	75%	81%	70%
More than one Race	2%	1%	2%	3%
Other	1%	0%	3%	1%
Non-Hispanic Paternal Ethnicity	76%	63%^a	85%	70%
Maternal education
Less than a high school diploma	3%	7%^a	3%	0%
High school diploma	7%	9%	2%	6%
Associate's degree	10%	16%	6%	13%
Bachelor's degree	33%	30%	37%	14%
Graduate degree	43%	23%	48%	59%
Primary language
English	95%	86%^a	99%	94%
Spanish	5%	14%	1%	6%

Data are represented as mean ± standard deviation. Significance was determined using chi-square analysis, t test, or Kruskal-Wallis test.

p < 0.05.

EBF, exclusive breastfeeding; N-EBF, nonexclusive breastfeeding.

Non-Hispanic parents were 2.1 (95% CI: 1.4–3.3, p = 0.001) and 3.5 (95% CI: 1.5–7.9) times more likely to EBF than Hispanic parents at nursery discharge and 30 days, respectively. Families with Hispanic mothers and non-Hispanic fathers were 2.9 (95% CI: 1.1–7.6, p = 0.03) times more likely to EBF than families with Hispanic parents at nursery discharge. At 30 days, this finding was no longer significant (OR 2.1, 95% CI: 0.6–7.6, p = 0.3). The likelihood of EBF was similar when families with non-Hispanic mothers and non-Hispanic fathers were compared to families with Hispanic parents at nursery discharge (OR 1.8, 95% CI: 0.7–5.1, p = 0.3) and 30 days (OR 1.4, 95% CI: 0.3–6.8, p = 0.7). In a multivariate analysis, parental Hispanic ethnicity was associated with EBF at nursery discharge (p = 0.03) and 30 days (p = 0.02). At nursery discharge only, parental ethnicity, along with the mode of delivery and parity status, was associated with EBF (Table 2).

Table 2.

Parental Characteristics and the Odds of Exclusively Breastfeeding at Time of Discharge from the Hospital and 30 Days After Discharge in a Multivariate Analysis

	At discharge	At 30 days
	OR (95% CI)	OR (95% CI)
Ethnicity
Neither Hispanic versus both Hispanic	2.0 (1.3–3.3)^a	3.7 (1.6–8.8)^a
Father Hispanic versus both Hispanic	1.8 (0.6–5.3)	1.8 (0.4–9.2)
Mother Hispanic versus both Hispanic	2.5 (0.9–7.0)	2.2 (0.6–8.0)
Gravida	1.2 (0.9–1.5)	1.0 (0.7–1.5)
Para	0.7 (0.5–0.9)^a	1.1 (0.7–2.0)
Gestational diabetes	0.6 (0.3–1.2)	0.8 (0.2–2.5)
Cesarean	0.3 (0.2–0.5)^a	0.5 (0.3–1.0)
Pregnancy induced hypertension	1.1 (0.5–2.8)	0.7 (0.2–2.9)

Data are represented as ORs with 95% CIs.

p < 0.05.

CI, confidence interval; OR, odds ratio.

The EBF group had a shorter length of stay in the hospital than the N-EBF group (47 ± 17 versus 65 ± 28 hours, p < 0.001). Ten N-EBF infants were transferred from the nursery to a higher level of care, while only one EBF infant was transferred from the nursery to a higher level of care. The EBF group was less likely to undergo a 48-hour sepsis rule-out and receive phototherapy for severe hyperbilirubinemia when compared to the N-EBF group (8% versus 13%, p = 0.048 and 7% versus 16%, p = 0.001, respectively). Rates for scheduled outpatient follow-up at nursery discharge with a health care professional were similar when the two groups were compared (90% in the EBF group versus 84% in the N-EBF group, p = 0.062).

Discussion

This study highlights breastfeeding disparities in a cohort of infants born to mothers who were cared for at an academic hospital in a large, cosmopolitan U.S. city. Infants of parents who identified as Hispanic, had lower SES, and were Spanish-speaking were less likely to be exclusively breastfed than parents who identified as non-Hispanic, had a higher SES, and were English-speaking. While maternal young age, low-income status, lower educational level, and being unmarried are social determinants of breastfeeding initiation and continuation, they cannot wholly account for persistent breastfeeding disparities in the United States.^2,4,14

Obstacles to breastfeeding are numerous. These barriers include economic hardship, lack of counseling and education, cultural attitudes and ideologies, and formula introduction.² Families lack maternity and paternity leave benefits and may need to return to work. Many workplaces do not accommodate breastfeeding mothers, and childcare poses a physical barrier to breastfeeding. Less support at home and lack of access to high-quality food and health care, particularly lactation specialists, influence a family's decision to breastfeed. Complicating matters, in the United States, the breast is sexualized, and public nursing is often considered taboo. All of the above factors, combined with the implicit bias of health care professionals, continue to contribute to breastfeeding disparities in the United States.^2,5,14,15

In this study, parental ethnicity was associated with EBF. On the univariate analysis, Hispanic mothers whose partner was non-Hispanic were more likely to EBF than Hispanic mothers whose partner was also Hispanic. However, this association was not observed with the multivariable analysis. This may suggest a more complex relationship and sample size limitation. Cultural attitudes and historical practices of the father and father's family toward breastfeeding, along with structural limitations imposed on specific groups, may also contribute to a mother's decision to breastfed and continue to breastfeed. Studies have demonstrated that fathers are less likely to be informed about the benefits of breastfeeding.^9,10 In a randomized controlled study in Italy, infants of fathers who were educated about breastfeeding issues and how to manage these problems were more likely to be breastfed at 12 months of age compared to infants of fathers who lacked this information.¹⁶ Current antenatal and postnatal care, along with the U.S. Baby-Friendly Hospital initiative, do not address the paternal role in breastfeeding and specific barriers and stereotypes unique to fathers and non-White, non-Hispanic mothers.¹¹

Some literature suggests that Hispanic parents have similar, if not higher, rates of EBF than non-Hispanic parents.¹ In some of these studies, Hispanic parents with higher rates of EBF were often immigrants who predominately self-identified as Spanish-speaking.^1,17 In this study, more than 90% of participants were English-speaking. One study showed that each additional year of U.S. residency decreased the odds of breastfeeding by 4%.¹⁷ Studies addressing paternal race, ethnicity, nativity, and language preference are needed to decipher these relationships better. Interestingly, in this study, there was no difference between the two cohorts in terms of race. These results may be because the majority of parents identified as White or Asian, and Black parents represented <10% of the study population.

In addition to the influence of ethnicity and SES on EBF, this study also confirms results from other studies.^2,5,14,15 It is well appreciated that full-term infants and infants delivered vaginally are more likely to EBF than premature infants and infants born through Cesarean delivery.¹⁸ Higher birth weights and gestational ages and vaginal deliveries are associated with healthy pregnancies and infants. Disparities in access to prenatal care and the subsequent disparities in prenatal outcomes may contribute to these findings, which may, in turn, affect breastfeeding initiation and continuation.^2,5

The N-EBF group was more likely to undergo a 48-hour sepsis rule-out and require phototherapy, and be admitted to the neonatal intensive care unit or pediatric floor. This may be because mothers in the N-EBF cohort had suboptimal prenatal care. In this study, the incidence of pregnancy-induced hypertension, gestational diabetes, and small for gestational age was similar between the two groups. It is also possible that these infants may have been perceived as “sicker.” Admission to the intensive care unit is associated with decreased breastfeeding rates for a multitude of reasons.^19,20 First, mothers cannot room-in with their infant. Second, maternal stress and illness lead to decreased breast milk production. Third, lack of access to lactation supplies and transporting breast milk after maternal discharge may be problematic.

We recognize our study's limitations. First, this is a single-site study at an academic university. As a result, racial and socioeconomic diversity are limited. Subjects in this study likely reflect the racial and ethnic distribution within Los Angeles itself and the hospital's surrounding area. As per the 2019 census data from the U.S. Census Bureau, Los Angeles County is 26% White, 8% Black, 47% Hispanic or Latino, 15% Asian, 1.5% American Indian/Alaska Native, 0.4% Native Hawaiian or other Pacific Islander, and 3% two or more races. In contrast, the United States is 60% White, 13% Black, 18% Hispanic or Latino, 6% Asian, 1.3% American Indian/Alaska Native, 0.2% Native Hawaiian or other Pacific Islander, and 2.7% two or more races. Second, the follow-up period was short and may not reflect breastfeeding practices at 6 or 12 months of age. Third, more than half of the study sample was lost to follow-up at 30 days. Finally, paternal data such as income, level of education, SES, and primary language were not available and limited our understanding of the impact of paternal demographics on EBF.

Conclusions

This study highlights that paternal ethnicity may play a role in breastfeeding. To address disparities in EBF, culturally inclusive, family-centered, and prenatally initiated interventions that include the father are warranted.

Footnotes

Acknowledgments

We would like to thank the Neonatology faculty and Newborn Nursery at the UCLA for their support of this study. We would also like to express our sincere gratitude to the families and infants who participated in this study, along with Valencia P. Walker for her feedback on this study.

Disclosure Statement

KLC serves as a consultant for Fresenius Kabi and serves on an advisory board for Prolacta.

Funding Information

This research was funded, in part, by the Gerber Foundation (grant No. 3881 to K.L.C.) and Short-term Training Program at UCLA (to A.D.). Statistical analyses for this research were supported by NIH National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant number UL1TR001881.

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