The Association Between Prenatal Food Insecurity and Breastfeeding Initiation and Exclusive Breastfeeding Duration: A Longitudinal Study Using Oregon PRAMS and PRAMS-2,2008

Abstract

Background:

In the United States, 11.1% of households experience food insecurity; however, pregnant women are disproportionately affected. Maternal food insecurity may affect infant feeding practices, for example, through being a source of chronic stress that may alter the decision to initiate and continue breastfeeding. Thus, we sought to determine whether prenatal food insecurity was associated with breastfeeding (versus not) and exclusive breastfeeding duration among Oregon women.

Method:

The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data of live births from 2008 to 2015 and the Oregon PRAMS-2 follow-up survey were used (n = 3,624) in this study. Associations with breastfeeding initiation and duration were modeled with multivariable logistic regression and accelerated failure time (AFT), respectively. Models were adjusted for maternal sociodemographic and pre-pregnancy health characteristics.

Results:

Nearly 10% of women experienced prenatal food insecurity. For breastfeeding initiation, unadjusted models suggested non-significant decreased odds (odds ratio (OR) 0.88 [confidence intervals (CI): 0.39, 1.99]), whereas adjusted models revealed a non-significant increased odds (OR 1.41 [CI: 0.58, 3.47]). Unadjusted AFT models suggested that food-insecure mothers had a non-significant decrease in exclusive breastfeeding duration (OR 0.76 [CI: 0.50, 1.17]), but adjustment for covariates attenuated results (OR 0.89 [CI: 0.57, 1.39]).

Conclusions:

Findings suggest minimal differences in breastfeeding practices when exploring food security status in the prenatal period, though the persistence of food insecurity may affect exclusive breastfeeding duration. Lower breastfeeding initiation may be due to other explanatory factors correlated with food insecurity and breastfeeding, such as education and marital status.

Introduction

Food insecurity, which is inadequate access to nutritionally acceptable food, has been increasingly recognized as a determinant of poor health, including physical and mental health, and pregnancy outcomes such as gestational diabetes mellitus and low birthweight.^1–4 Although the prevalence has been declining since its peak in 2007, recent national estimates suggest that 11.1% of United States households experience food insecurity, which may have been exacerbated as a result of the COVID-19 pandemic.^5,6 The prevalence also varies by state, race/ethnicity, and gender; racialized populations tend to be disproportionately affected, as well as pregnant persons and single mothers.⁵

From a life course perspective, food insecurity during pregnancy has the potential to influence fetal programming of poor health as a result of poor nutrition.^7,8 Food insecurity may further affect infant feeding practices in the postpartum period through different pathways, depending on its severity.^9,10 For example, gestational diabetes mellitus may impede breast milk production, which is associated with a shorter duration of breastfeeding. Given that food insecurity has been associated with an increased risk of gestational diabetes mellitus, it may make it difficult for a food-insecure mother to breastfeed longer as desired.¹¹ Food insecurity may also be a chronic stressor and may be associated with depressive and anxiety symptoms, which in turn may impair breast milk production and lower the oxytocin needed for the contraction of the breast for feeding, thereby decreasing the initiation and continuation of breastfeeding.^12,13 In addition, structural factors may be implicated in this association, such as a lack of maternity leave policies in the United States or poor living wages among food-insecure families that force women to return to work early, contributing to an inability to adhere to breastfeeding recommendations.^14,15 Because breastfeeding is theoretically a source of food security for infants, supporting mothers experiencing their own food insecurity may be important to optimize infant nutrition.¹⁶

Current recommendations call for exclusive breastfeeding for 6 months; although this figure is 40% globally, 24.9% of infants are exclusively breastfed in the United States.^17,18 Improving the prevalence and exclusivity of breastfed infants has remained an objective of Healthy People 2030, which are data-driven goals in the United States to improve population health by 2030.¹⁹ Few studies have explored how food insecurity may affect breastfeeding, and the evidence remains unclear. Qualitative and quantitative cross-sectional studies in Canada or among participants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) suggested that household food insecurity may be associated with lower breastfeeding initiation and a shorter duration of exclusive breastfeeding.^9,20,21 Limited studies have explored this association in the United States using longitudinal data, with studies either examining breastfeeding cessation categorically¹⁴ or focusing on household food insecurity as opposed to mothers specifically.²² In addition, these previous studies do not explore the temporal patterns of food insecurity, as some mothers may face food insecurity persisting into the postpartum period.²³ Therefore, we sought to determine the association between maternal experiences of food insecurity during pregnancy and breastfeeding behaviors using a longitudinal survey. We hypothesized that mothers experiencing food insecurity during pregnancy were less likely to initiate breastfeeding and have a shorter duration of exclusive breastfeeding compared with mothers who did not experience food insecurity during pregnancy.

Materials and Methods

Data source and analytic sample

This study was conducted using Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data on live births from 2008 to 2015 and the Oregon PRAMS-2 data follow-up survey of mothers re-interviewed 2 years later. Birth certificate records serve as a sampling frame for PRAMS, using a stratified, random sample to identify resident women who had a live birth. Racialized women and non-Hispanic white women who deliver a low-birthweight infant are oversampled. The analytic sample consisted of women with a singleton birth between 2008 and 2011 and between 2014 and 2015 and who were followed-up in PRAMS-2 from 2010 to 2013 and 2016 to 2017. Owing to changes in the PRAMS protocol, data were not sufficiently collected for live births from 2012 to 2013 (and their follow-up in 2014–2015) and were excluded from analysis (Supplementary Fig. S1). To reflect Oregon’s population of mothers who deliver a live birth, responses were weighted for oversampling, nonresponse, and non-coverage. Additional details about the Oregon PRAMS and PRAMS-2 methodologies have been described elsewhere.²⁴ This study received an exempt determination from the University of Maryland Institutional Review Board.

Measures

The two main outcomes were breastfeeding initiation and the duration of exclusive breastfeeding. Breastfeeding initiation was determined by the question in PRAMS (“Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period of time?”) and was dichotomized as “yes” or “no.” Duration of exclusive breastfeeding was calculated using both datasets, using the breastfeeding questions asking mothers to recall their total breastfeeding length (“How old was your 2-year-old when he or she completely stopped breastfeeding or being fed breast milk?”), and the age at which other liquids and/or solids were introduced (“How old was your 2-year-old the first time he or she drank liquids other than breast milk [such as formula, water, juice, tea, or cow’s milk]?”) Exclusive breastfeeding duration was then determined by the minimum age of the infant when external liquids and/or solids were introduced.

The exposure variable, any prenatal food insecurity, was measured using the single food security question included in Oregon PRAMS (“During the past 12 months before your new baby was born, did you ever eat less than you felt you should because there wasn’t enough money to buy food?”), which is included in the U.S. Department of Agriculture’s (USDA’s) 6-item abbreviated food security module and is considered “midrange severity” because of eating patterns being disrupted, such as reduced food intake.⁵ Responses to this question were dichotomized as “yes” (food insecure) or “no” (food secure).

Potential covariates that were considered included maternal age, maternal education, maternal race or ethnicity, marital status, and pre-pregnancy body mass index (BMI), all examined categorically. Variables related to the socioeconomic status of the mother were also considered, including the number of previous live births, income according to the federal poverty level (FPL), and prenatal WIC participation. Behavioral covariates were also examined, including prenatal depression and maternal smoking before and during pregnancy (Supplementary Fig. S2).^21,25–27 These variables were considered because of their associations with both the exposure and the outcome. The survey year was examined to adjust for any differences by year.

Analysis plan

The distribution of maternal and infant characteristics within the categories of prenatal food insecurity and the prevalence of breastfeeding initiation by maternal characteristics were examined. To examine the first outcome (breastfeeding initiation), multivariable logistic regression was conducted using a tiered approach to covariates. Model 1 included demographic characteristics: maternal age, maternal education, marital status, race/ethnicity, maternal pre-pregnancy BMI, and survey year. Variables related to poverty were then added in a tiered fashion. Model 2 included the number of previous live births in addition to the covariates in Model 1. Model 3 adjusted for income according to the FPL in addition to the covariates in Model 2. Potential behavioral factors that may precede or be the result of food insecurity were examined in separate models, including prenatal WIC participation, prenatal depression, and maternal smoking. Separate models were implemented because the design of the survey could not allow us to determine whether these factors occurred before food insecurity, in which case they would be confounders, or after, in which case they would be considered mediators. In addition, because preterm birth (before 37 weeks’ gestation) may dictate the method of infant feeding to meet their nutritional needs,²⁸ all models were restricted to term births for comparison with the overall sample. Odds ratios (ORs) and 95% confidence intervals (CIs) for every breastfed infant (versus never breastfed infant) were estimated for all models.

For the outcome of exclusive breastfeeding duration, restricted to women who initiated breastfeeding, Kaplan–Meier curves were constructed to visually inspect the differences between food-insecure and food-secure women. Accelerated failure time (AFT) model was used to examine the relationship, which is an alternative to the Cox proportional hazards model, is easier to interpret, and requires fewer assumptions.^29,30 Because of the survey structure of the data, the appropriate distribution for the model was selected based on adjusted Wald tests fit on a generalized gamma distribution model. Women were right-censored at 6 months’ (26.07 weeks) duration and given recommendations for exclusive breastfeeding.^17,31 Covariates were added in a tiered approach similar to the breastfeeding initiation analysis. With AFT model, time ratios (TRs) and 95% CIs were estimated. A time ratio of >1 was interpreted as a longer duration of exclusive breastfeeding, while a time ratio of <1 indicated a shorter duration of exclusive breastfeeding. Similarly, the models were also restricted to term births for comparison to the overall sample.

Because food insecurity may persist into the postpartum period, we also conducted a sensitivity analysis examining the effect of temporary (prenatal only) and prolonged food insecurity (women experiencing food insecurity in both the perinatal and postpartum periods, using the same question in the follow-up PRAMS-2 survey two years postpartum [“In the past 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food?”]) specifically on the outcome of exclusive breastfeeding duration. Women who responded “yes” to only the question in Oregon PRAMS were categorized as having experienced food insecurity in the prenatal period only, whereas women who responded “yes” to both questions in Oregon PRAMS and PRAMS-2 were categorized as having persistent food insecurity. Women who responded “no” to both questions were categorized as food secure. Similar modeling procedures described above were used when examining food insecurity status categorically with exclusive breastfeeding duration.

All analyses were conducted using the Stata 15 survey data analysis command, using weights to account for the complex sampling design of PRAMS-2. A p value of <0.05 was used to determine significance (i.e., 95% CI of OR/TR crossing 1); however, where significance was not met, we commented on patterns and magnitudes of effects seen, according to best practices from the American Statistical Association.³²

Results

A final unweighted analytic sample of n = 3,624 women from 2008 to 2015 was included for analyses. The weighted prevalence of prenatal food insecurity was 9.8% (unweighted n = 332). Table 1 presents select maternal and infant characteristics by maternal food security status, weighted to represent the population of Oregon mothers during this period. Most women were between 24 and 34 years, non-Hispanic white, and delivered at term. Food-insecure women were more likely to be younger, non-white, have a high school education or less, be under 100% of the FPL, have a delivery paid for by Medicaid, and participate in prenatal WIC compared with food-secure mothers. In addition, food-insecure mothers had similar breastfeeding initiation but appeared to have a lower median exclusive breastfeeding duration than food-secure mothers.

Table 1.

Unweighted Percent Distribution of Selected Maternal and Infant Characteristics by Prenatal Food Insecurity Status: Oregon PRAMS Data, 2008–2015^*

	Total N (unweighted)	Food insecure^a	Food secure^a
Maternal characteristics at time of birth
Maternal age at birth (years)	n = 3,624	n = 3,32	n = 3,292
<20	145	7.6	3.6
20–24	599	34.9	17.5
25–29	1,043	30.5	32.4
30–34	1,107	18.3	28.2
35–39	596	6.6	14.7
≥40	134	2.1	3.6
Maternal race/ethnicity	n = 3,612	n = 331	n = 3,281
non-Hispanic white	1,068	62.3	68.7
non-Hispanic black	256	2.4	1.8
Hispanic	815	26.9	18.8
Other^b	1,473	8.3	10.6
Marital status	n = 3,621	n = 332	n = 3,289
Not married	998	56.9	28.5
Married	2,623	43.1	71.5
Maternal educational attainment	n = 3,611	n = 330	n = 3,281
No high school diploma or GED	522	21.7	13.9
High school diploma or GED	653	40.8	22.5
Some college	1,060	30.9	27.1
Bachelor’s degree or higher	1,376	6.5	36.5
Median FPL (%)	201 [87, 349]	82 [48, 128]	214 [99, 396]
FPL	n = 3,466	n = 316	n = 3,150
0–99%	991	62.4	25.2
100–185%	679	28.1	19.6
≥186%	1,796	9.4	55.2
Insurance pre-pregnancy	n = 3,490	n = 329	n = 3,161
Medicaid	561	20.2	16.3
Other	2,128	30.5	61.8
Self-pay	801	49.3	22.0
Payment source at delivery	n = 3,606	n = 330	n = 3,276
Medicaid	1,450	73.4	37.9
Private	2,034	22.1	59.5
Other	51	2.1	1.4
Self-pay	71	2.4	1.1
Prenatal WIC participation	n = 3,562	n = 325	n = 3,188
Not eligible (FPL > 185)	373	15.6	10.8
Eligible but not (FPL ≤ 185)	1,597	4.8	49.2
Yes	1,543	79.6	40.0
Prenatal care sought	n = 3,435	n = 313	n = 3,122
No	8	0.0	0.3
Yes	3,427	100.0	99.7
Pre-pregnancy BMI	n = 3,549	n = 321	n = 3,228
Underweight	114	1.8	2.9
Normal	1,784	441.0	49.5
Overweight	851	23.4	24.2
Obese	800	12.4	23.4
Smoking during pregnancy	n = 3,569	n = 325	n = 3,244
Never	3,011	59.5	83.8
Before only	339	20.4	9.6
Before and/or during	219	20.1	6.6
Prenatal depression	n = 3,557	n = 323	n = 3,234
No	3,240	79.5	92.3
Yes	317	20.5	7.7
Route of Delivery	n = 3,261	n = 326	n = 3,235
Spontaneous vaginal	2,393	67.8	69.4
Assisted vaginal	137	2.5	3.5
Cesarean section	1,031	29.7	27.1
Infant characteristics at birth
Previous live births	n = 3,621	n = 332	n = 3,289
None	1,587	44.9	41.7
1	1,173	25.2	34.5
2	510	16.7	14.2
≥3	351	13.2	9.5
Gestational week at birth	n = 3,624	n = 332	n = 3,292
<37 weeks (preterm)	208	4.6	5.8
≥37 weeks	3,416	95.4	94.2
Sex	n = 3,624	n = 332	n = 3,292
Male	1,881	54.1	53.8
Female	1,743	45.9	46.2
Low birthweight	n = 3,624	n = 332	n = 3,292
No	3,464	95.8	96.0
Yes	160	4.2	4.0
Admission to NICU or infant transferred	n = 3,591	n = 328	n = 3,263
No	3,315	92.9	92.7
Yes	276	7.1	7.3
Ever breastfed infant	n = 3,264	n = 332	n = 3,292
No	127	4.5	4.0
Yes	3,497	95.5	96.0
Median total breastfeeding duration (weeks)	52.1 [26.1, 73.9]	52.1 [26.1, 69.5]	52.1 [26.1, 78.2]
Median exclusive breastfeeding duration (weeks)	21.7 [8.7, 30.4]	17.4 [4.3, 28.0]	21.7 [8.7, 30.4]

Weighted proportion.

Includes Asian/Pacific Islander, American Indian or Alaska Native, Other, and Hispanic origin unknown or not stated.

Births from 2012–2013 were excluded.

BMI, body mass index; FPL, federal poverty level; PRAMS, pregnancy risk assessment monitoring system; WIC, Women, Infants, and Children; GED, General Educational Diploma; FI, food insecurity.

Table 2 presents the unweighted N and weighted prevalence of breastfeeding by maternal characteristics and exposure to prenatal food insecurity. Breastfeeding initiation was very similar across maternal characteristics; however, mothers who were non-Hispanic black, were not married, had less than a high school education, were below 100% of the FPL, participated in prenatal WIC, and who smoked had a lower prevalence of initiating breastfeeding.

Table 2.

Prevalence of Ever Breastfed Infant by Maternal Characteristics and Exposure: Oregan PRAMS Data, 2008–2015^*

	Ever breastfed infant
	Overall
Total number of births	n	Percent^a
Exposure
Prenatal food insecurity
No	3,187	96.0
Yes	310	95.5
Maternal demographics
Maternal age at birth (years)
Under 20	138	95.8
20–24	578	96.2
25–29	1,014	97.6
30–34	1,067	95.5
35–39	570	93.5
40+	130	94.0
Maternal race/ethnicity
non-Hispanic white	1,032	95.9
non-Hispanic black	239	93.0
Hispanic	789	96.9
Other^b	1,426	95.5
Marital status
Not married	939	92.3
Married	2,555	97.6
Maternal educational attainment
No high school diploma or GED	488	92.3
High school diploma or GED	613	94.0
Some college	1,024	96.8
Bachelor’s degree or higher	1,360	98.5
Federal poverty level
0–99%	931	92.7
100–185%	658	97.6
≥186%	1,757	97.5
Prenatal WIC participation
Not eligible (FPL > 185)	1,567	97.7
Eligible but not (FPL ≤ 185)	364	97.0
Yes	1,455	93.7
Prenatal care sought
No	8	100.0
Yes	3,308	96.0
Pre-pregnancy BMI
Underweight	111	95.2
Normal	1,733	97.0
Overweight	816	95.6
Obese	767	94.9
Smoking during pregnancy
Never	2,924	96.9
Before only	328	95.8
Before and/or during	191	86.0
Prenatal depression
No	3,128	96.2
Yes	306	94.0

Weighted proportion.

Includes Asian/Pacific Islander, American Indian or Alaska Native, Other, and Hispanic origin unknown or not stated.

Births from 2012 to 2013 were excluded.

BMI, body mass index; FPL, federal poverty level; PRAMS, pregnancy risk assessment monitoring system; WIC, Women, Infants, and Children.

Unadjusted and adjusted ORs for the relationship between prenatal food insecurity and breastfeeding initiation are presented in Table 3. Magnitudes of the unadjusted model results revealed that compared with mothers who were food secure during pregnancy, prenatal food insecurity was associated with decreased breastfeeding initiation, though non-significant (OR 0.88 [95% CI 0.39, 1.99]). Upon adjustment for sociodemographic variables, the direction of the effect reversed, showing food insecurity associated with increased odds of initiating breastfeeding (adjusted OR 1.46 [95% CI 0.60, 3.60]), with maternal education and marital status being primarily responsible for reversing the effect of prenatal food insecurity from less likely to initiate breastfeeding to more likely to initiate breastfeeding. The magnitude slightly increased with the addition of confounders and potential behavioral mediators (i.e., WIC participation, prenatal depression, and maternal smoking). When restricted to term births, similar findings were seen, though the magnitudes were slightly smaller.

Table 3.

Unadjusted and Adjusted OR^a of Prenatal Food Insecurity and Ever Breastfed Overall and by Term Births: Oregan PRAMS Data, 2008–2015^*

	Prenatal Food Insecurity
	Overall	Term births (37+)
	OR (95% CI)	OR (95% CI)
Breastfeeding initiation
Unadjusted	0.88 (0.39, 1.99)	0.87 (0.37, 2.02)
Confounder-adjusted models
Model 1	1.34 (0.57, 3.13)	1.23 (0.50, 3.00)
Model 2	1.31 (0.56, 3.05)	1.18 (0.49, 2.84)
Model 3	1.41 (0.58, 3.47)	1.24 (0.49, 3.10)
Model 4	1.46 (0.60, 3.60)	1.30 (0.51, 3.28)
Models adjusted for potential mediators
Model 5	1.42 (0.56, 3.56)	1.24 (0.48, 3.20)
Model 6	1.56 (0.61, 4.00)	1.32 (0.50, 3.46)

Model 1 adjusted for maternal age, maternal education, maternal race/ethnicity, maternal BMI, marital status, and survey year; Model 2 includes Model 1 + number of previous live births; Model 3 includes Model 2 + federal poverty level; Model 4 includes Model 3 + WIC use; Model 5 includes Model 4 + prenatal depression; Model 6 includes Model 5 + maternal smoking.

Data from 2012 to 2013 were excluded.

BMI, body mass index; CI, confidence interval; OR, odds ratio; PRAMS, pregnancy risk assessment monitoring system; WIC, Women, Infants, and Children.

Figure 1 depicts the Kaplan–Meier curve of exclusive breastfeeding duration by food insecurity status. Food-insecure mothers appeared to have a lower duration of exclusive breastfeeding than food-secure mothers. In unadjusted and adjusted TRs modeling, the outcome of exclusive breastfeeding duration is presented in Table 4. Adjusted Wald tests indicated that the log-normal distribution was the most appropriate fit, consistent with previous studies using AFT models for breastfeeding duration.³³ Unadjusted results indicated that compared with mothers who were food secure during pregnancy, mothers who experienced food insecurity reported a shorter exclusive breastfeeding duration, though non-significant (TR 0.76 [95% CI 0.50, 1.17]). Adjusted models moved estimates closer to the null, but TR estimates did not change upon the addition of each confounder and potential mediator. Similar patterns were also seen when restricted to term births; however, adjusted models appeared to show no difference in exclusive breastfeeding duration.

FIG. 1.

Kaplan–Meier curve of the proportion of women who remained exclusively breastfeeding their infant. The dashed black line indicates food-secure women, whereas the gray line indicates food-insecure women.

Table 4.

Unadjusted and Adjusted TR^a of Prenatal Food Insecurity and Exclusive Breastfeeding Duration Overall and by Term Births: Oregon PRAMS Data, 2008–2015^*

	Prenatal Food Insecurity
	Overall	Term births (37+)
	TR (95% CI)	TR (95% CI)
Exclusive breastfeeding duration
Unadjusted	0.76 (0.50, 1.17)	0.82 (0.53, 1.25)
Confounder-adjusted models
Model 1	0.90 (0.59, 1.38)	0.98 (0.64, 1.50)
Model 2	0.90 (0.59, 1.39)	0.98 (0.64, 1.51)
Model 3	0.89 (0.57, 1.39)	0.95 (0.61, 1.48)
Model 4	0.90 (0.58, 1.41)	0.96 (0.61, 1.49)
Models adjusted for potential mediators
Model 5	0.90 (0.57, 1.41)	0.96 (0.61, 1.52)
Model 6	0.91 (0.58, 1.44)	0.99 (0.62, 1.57)

Model 1 adjusted for maternal age, maternal education, maternal race/ethnicity, maternal BMI, marital status, survey year; Model 2 includes Model 1 + number of previous live births; Model 3 includes Model 2 + federal poverty level; Model 4 includes Model 3 + WIC use; Model 5 includes Model 4 + prenatal depression; Model 6 includes Model 5 + maternal smoking.

Data from 2012 to 2013 were excluded.

BMI, body mass index; CI, confidence interval; FPL, federal poverty level; PRAMS, pregnancy risk assessment monitoring system; TR, time ratio; WIC, Women, Infants, and Children.

Additional analyses examining the effect of women who experienced food insecurity prenatally only and women experiencing food insecurity that persisted into the postpartum period on exclusive breastfeeding duration are presented in Table 5 and the Kaplan–Meier curve in Supplementary Figure S3. Women who only experienced prenatal food insecurity were more likely to have a shorter exclusive breastfeeding duration, though non-significant, and did not vary upon the addition of sociodemographic covariates and potential mediators compared with food-secure mothers. However, among women who experienced food insecurity that persisted into the postpartum period, magnitudes reversed in adjusted models and they appeared to have a slightly longer duration of exclusive breastfeeding than food-secure mothers. Similar patterns were seen when restricted to term births, though the magnitudes were slightly stronger among women experiencing persistent food insecurity.

Table 5.

Sensitivity Analysis of Unadjusted and Adjusted TR^a of Maternal Food Insecurity and Exclusive Breastfeeding Duration Overall and by Term Births: Oregon PRAMS Data, 2008–2015^*

	Maternal Food Insecurity
	Overall	Term births (37+)
	TR (95% CI)	TR (95% CI)
Exclusive breastfeeding duration
Unadjusted
Prenatal FI	0.62 (0.35, 1.13)	0.68 (0.37, 1.26)
Persistent FI	0.88 (0.48, 1.60)	0.94 (0.53, 1.68)
Confounder-adjusted models
Model 1
Prenatal FI	0.72 (0.40, 1.31)	0.81 (0.44, 1.49)
Persistent FI	1.11 (0.62, 2.01)	1.21 (0.68, 2.12)
Model 2
Prenatal FI	0.72 (0.40, 1.33)	0.81 (0.43, 1.50)
Persistent FI	1.10 (0.60, 1.99)	1.19 (0.67, 2.10)
Model 3
Prenatal FI	0.68 (0.37, 1.27)	0.74 (0.39, 1.40)
Persistent FI	1.08 (0.59, 2.01)	1.18 (0.65, 2.12)
Model 4
Prenatal FI	0.69 (0.37, 1.28)	0.75 (0.40, 1.40)
Persistent FI	1.10 (0.59, 2.05)	1.19 (0.65, 2.15)
Models adjusted for potential mediators
Model 5
Prenatal FI	0.69 (0.37, 1.30)	0.77 (0.40, 1.47)
Persistent FI	1.10 (0.58, 2.08)	1.20 (0.65, 2.21)
Model 6
Prenatal FI	0.69 (0.36, 1.32)	0.77 (0.40, 1.49)
Persistent FI	1.18 (0.62, 2.23)	1.28 (0.68, 2.83)

Births from 2012 to 2013 were omitted.

CI, confidence interval; BMI, body mass index; FPL, federal poverty level; PRAMS, pregnancy risk assessment monitoring system; TR, time ratio; WIC, Women, Infants, and Children.

Discussion

In this pregnant population, who gave birth in 2008–2011 and 2014–2015, there were 9.8% of women experiencing food insecurity. This individual-level prevalence is lower than national estimates of household food insecurity (12.6–14.6%) and state estimates during this time period according to the USDA’s official measure (13.7–16.1%); however, estimates range from 10% among couples with children to 20% to 30% for single mothers or single women, highlighting the difference in this sample and the measurement of food insecurity.⁵ Though non-significant, unadjusted analyses from this study suggested that women experiencing prenatal food insecurity were less likely to initiate and sustain exclusive breastfeeding. However, much of this was explained by other underlying factors related to food insecurity, particularly when adjusting for maternal education and marital status, which suggested a non-significant increase in the odds of initiating breastfeeding among food-insecure mothers. We found minimal differences in the duration of exclusive breastfeeding between food-insecure and food-secure mothers after adjustment, though non-significant. However, when examining food insecurity by its persistence, findings suggested an increased duration of exclusive breastfeeding among mothers experiencing food insecurity in both the prenatal and postpartum periods compared with food-secure mothers, while findings suggested an earlier cessation among mothers experiencing temporary food insecurity during pregnancy only.

Our finding of increased magnitudes of breastfeeding initiation appears to be consistent with the limited evidence from other quantitative and qualitative studies exploring food insecurity and breastfeeding. Investigators in Canada found that mothers living in food-insecure households had similar likelihoods of initiating breastfeeding compared with mothers living in food secure households.²¹ Within the U.S. context, a recently published multi-state cross-sectional analysis using PRAMS data, which also included Oregon, found that after adjusting for sociodemographic characteristics, food-insecure women had a non-significantly increased magnitude of breastfeeding, a reversal that was similar to our findings.¹⁴ Since maternal education and marital status appeared to be responsible for the reversed effect in our tiered analysis, and given their association with both food insecurity and breastfeeding (as well as their relationship to socioeconomic status), future studies should explore this relationship further, including qualitative investigations.^5,34

Other evidence on breastfeeding initiation remains inconsistent, with studies suggesting no difference in breastfeeding among food-insecure households¹⁰ or decreased breastfeeding initiation.^35,36 A qualitative study also found that mothers breastfeed less due to their perceived poor diet.⁹ However, these studies assessed household rather than individual or maternal food insecurity, like our analysis, and therefore may not capture maternal experiences of food insecurity. Nonetheless, caution should be taken with these interpretations, as our estimates were imprecise due to the small sample size of mothers experiencing prenatal food insecurity. Furthermore, research has also indicated that in times of household food insecurity, vulnerable household members, such as children, may be shielded from food insecurity by other household members, and it is unclear whether pregnant women may also be shielded, which warrants further exploration.³⁷

Regarding associations between food insecurity and exclusive breastfeeding duration, the evidence is somewhat mixed. In the previous multi-state PRAMS study, authors found that food-insecure women were more likely to cease breastfeeding by the 4- to 6-week mark compared with food-secure women who breastfed for ≥10 weeks.¹⁴ However, the authors used a multinomial analysis and did not have a longitudinal component like our study, nor did they explore exclusive breastfeeding duration. Authors of another study found no association between household prenatal food insecurity during pregnancy and breastfeeding duration; however, household food insecurity postpartum was associated with breastfeeding at 3 and 6 months compared with food-secure mothers.³⁵ Household food insecurity experienced by Canadian mothers was associated with ceasing exclusive breastfeeding earlier, but household food insecurity may not represent individual experiences.²¹ In addition, it is unclear whether our finding, when restricted to term births, may be because of the specialized nutritional needs that some preterm infants require for optimal growth.^28,38

Paradoxically, breastfeeding offers a sense of food security for families, as resources do not need to be spent on infant formula;³⁹ however, studies among Canadian food insecure women describe having fewer resources to spend on food to begin with, regardless of the infant feeding method.²⁰ Nonetheless, support from programs such as WIC may be helpful for food-insecure mothers, and yet we found that women who participated in prenatal WIC had a lower prevalence of breastfeeding. Adding WIC to the model appeared to strengthen the magnitudes seen for breastfeeding initiation, and it may be possible that women who go on to participate in WIC intend not to breastfeed, possibly due to the infant formula benefit that the program offers.⁴⁰ Alternatively, breastfeeding may contribute to further food insecurity as it may deter mothers from (re)entering the workforce if they are trying to adhere to recommendations, particularly in settings where maternity leave is unavailable or where workplace policies do not provide lactation support.³⁹ Therefore, it is unclear whether those experiencing prolonged food insecurity breastfed longer because they were unable to return to work (reporting continued food insecurity from lower incomes) or whether women experiencing prenatal food insecurity only had a shorter duration because they returned to work sooner (reporting no food insecurity in the postpartum period due to an increase in income) and may have had more workplace barriers to breastfeeding.

Family-centered policies have the potential to help food-insecure women overcome any breastfeeding barriers. Because WIC includes breastfeeding education, incentives, peer counselors, and referral services, it uniquely serves food insecure mothers, provided that they are culturally tailored and should be leveraged to help improve breastfeeding rates, as not all mothers are aware of its breastfeeding supports, including education, peer counselors, and lactation consultants.^14,41 Cash assistance programs have the opportunity to help food insecure women, as pandemic-related supports helped to alleviate food insecurity; however, this option may not be equitable as it does not address structural or social determinants that face historically marginalized communities.⁴² Examining workplace and family leave policies may be another way to help all breastfeeding women, including food-insecure women, such as by increasing lactation rooms and expanding current family leave laws to provide paid leave.⁴³ For example, California’s paid maternity leave has shown to increase the duration of breastfeeding, and as of 2022, only 13 states have recently implemented paid medical leave, including Oregon.^44,45 Given the important benefits of breastfeeding to both mother and infant, further quantitative and qualitative research may be warranted on how such policies and interventions could be beneficial for mothers experiencing food insecurity.

Strengths & limitations

To our knowledge, this is the first study to have explored individual-level experiences of maternal food security status (as opposed to household food security status) on breastfeeding outcomes. In addition, Oregon PRAMS and PRAMS-2 are state-level population-based data, and given the longitudinal nature of the linked datasets, this allows for establishing temporality between exposure and outcome. These data are also generalizable to mothers in Oregon, due to the sampling structure and weighting of the survey.

With respect to limitations, most importantly, there was only one question used to measure food insecurity, which may explain the lower prevalence of food insecurity in this sample. Although this question is also incorporated in the USDA measure of food insecurity, it does not capture all dimensions of food insecurity, such as affordability and availability of nutritious meals or sufficiency of groceries. Therefore, we are unable to determine the true extent of food insecurity that the mothers experienced compared with using validated food security modules. However, population-based data with information on food insecurity and infant feeding practices are limited, with PRAMS being one such dataset, and other studies have also used this 1-item question.^14,46 Nonetheless, future PRAMS surveys and/or studies should consider incorporating the full food insecurity module or even a 2-item measure that has been validated in both interview and survey methods.^47,48

Second, the sample size for the exposure was small, which may account for the imprecision of the estimates. Third, the question on the retrospective nature of the breastfeeding duration may introduce the possibility of social desirability and recall bias, where women may exaggerate the length of breastfeeding; however, the evidence suggests that maternal recall of overall breastfeeding duration is usually accurate within three years of birth.⁴⁹ Although recall of exclusive breastfeeding duration is found to be less accurate and overestimated,⁴⁹ we avoided maternal recall by calculating exclusive breastfeeding duration using the question asked on when solids or liquids other than breast milk were introduced to the infant, in line with other studies that have explored exclusive breastfeeding with the same data source.²⁴ Fourth, although benefits such as WIC and other safety-net benefits, such as the Supplemental Nutrition Assistance Program (SNAP), may also be beneficial in improving food security status or diet quality, we did not have enough numbers to meaningfully examine the effects of WIC, nor were we able to ascertain the effects of SNAP using these data. Additional research on how these policies currently support food-insecure mothers is warranted. Finally, our findings may not be generalizable beyond the state of Oregon, as compared with the United States, Oregon reports higher breastfeeding initiation (87.2% versus 83.2%, respectively) and exclusive breastfeeding (34.2% versus 24.9%), and has a different demographic make-up.¹⁸ As racialized populations are disproportionately affected by food insecurity and differ in breastfeeding rates,⁴¹ national data are needed to fully ascertain the association of maternal food security status on breastfeeding outcomes.

Conclusions

Our study suggests that maternal food insecurity in the prenatal period does not appear to affect breastfeeding initiation or exclusive breastfeeding duration; however, the persistence of maternal food insecurity in the postpartum period may affect exclusive breastfeeding duration. Other confounding factors are more likely to complicate this relationship, such as maternal education and marital status. Further studies, including a nationally representative sample and a more detailed assessment of food insecurity, may be helpful in understanding this association. Research on policies that consider the economic and caregiving responsibilities of food-insecure mothers so that they are supported to feed themselves and their infants is warranted. This information can be used to further understand barriers and facilitators to breastfeeding practices.

Author Contribution Statment

D.A.D. conceived the idea for the study, with input from M.E.T., E.A.A., J.K., and M.T.L. D.A.D. carried out the analysis and wrote the first draft of the article. M.E.T., E.A.A., J.K., and M.T.L. provided content expertise, and all the authors contributed to the writing and approval of the final article.

Ethical Standards Disclosure

This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the University of Maryland Institutional Review Board. Written informed consent was waived for this study due to the nature of this data source; however, written informed consent was obtained from all respondents at the time of survey administration.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No financial disclosures were reported by the authors of this article.

Supplementary Material

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Supplementary Material

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The Association Between Prenatal Food Insecurity and Breastfeeding Initiation and Exclusive Breastfeeding Duration: A Longitudinal Study Using Oregon PRAMS and PRAMS-2,2008–2015

Abstract

Background:

Method:

Results:

Conclusions:

Introduction

Materials and Methods

Data source and analytic sample

Measures

Analysis plan

Results

Discussion

Strengths & limitations

Conclusions

Author Contribution Statment

Ethical Standards Disclosure

Footnotes

Disclosure Statement

Funding Information

Supplementary Material

References

Supplementary Material