The Interaction of Race and Pregnancy Intentions on Breastfeeding Initiation Rates and Duration in the United States

Abstract

Background:

Unintended pregnancy increases adverse perinatal health outcomes. Limited studies exist on the influence of pregnancy intention on breastfeeding. This study examines the interaction of Race and couples’ pregnancy intention on breastfeeding initiation and duration.

Methods:

Using the National Survey of Family Growth (2017–2019), we categorized breastfeeding into three categories (never breastfed, breastfed for 6 months or less, and breastfed for more than 6 months). Multinomial logistic regression and probability marginal effects were estimated across racial categories (Hispanics, non-Hispanic [NH] White, Black, and NH-others or multiracial).

Results:

The probability (Pr.) of never breastfeeding was the greatest among NH-Black women for all pregnancy intentions—both intended (Pr.: 0.34), mother-only (Pr.: 0.27), father-only (Pr.: 0.45), ambivalent (Pr.: 0.55), and neither intended (Pr.: 0.37). The probability of breastfeeding for 6 months or less is highest for Hispanics for both intended (Pr.: 0.41), NH-White for mother-only intended (Pr.: 0.49), Hispanics for father-only intended (Pr.: 0.56), ambivalent pregnancy intentions (Pr.: 0.60), and NH-others or multiracial for neither intended pregnancies (Pr.: 0.48). The probability of breastfeeding for more than 6 months is highest for NH-others or multiracial for both intended (Pr.: 0.50), ambivalent (Pr.: 0.49), and neither intended (Pr.: 0.36), while highest for NH-Black for mother-only intended (Pr.: 0.43).

Conclusions:

Our study demonstrates the interaction of Race and couples’ pregnancy intention on breastfeeding initiation and duration. Owing to the high volume of unintended pregnancies in the United States, the current study might help maternal and child healthcare providers understand the interaction between race and pregnancy intentions on breastfeeding initiation and duration in the United States.

Introduction

Breastfeeding is associated with improved health outcomes for both infants and mothers.¹ For infants, breastfeeding protects against infections such as lower respiratory and gastrointestinal infections, acute diarrhea disease, leukemia, inflammation, asthma, diabetes, atopy, sudden infant death syndrome,^1,2 and aids brain development.^3,4 For mothers, breastfeeding is associated with reduced risk of type 2 diabetes mellitus; breast, ovarian, and endometrial cancer; and hypertension,^1,2 cardiovascular disease, postpartum depression.^5–7 For mothers and infants to maximize the health benefits of breastfeeding, the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommended exclusive breastfeeding (breast milk only, with no water, other fluids, or solids) for 6 months after delivery, with supplemental breastfeeding continuing for 2 years and beyond.¹

However, despite the documented health benefits of breastfeeding, most families in the United States do not breastfeed for as long as they intend to.⁷ The overall prevalence of breastfeeding initiation in the United States was 84.1% in 2021 but varied by maternal race/ethnicity.⁸ Infants from Asian mothers have the highest prevalence rate of breastfeeding (92.7%), followed by non-Hispanic (NH) White mothers (86.2%), multiracial mothers (85.2%), Hispanic mothers (83.4%), and NH-Black mothers (75.4%). While the report does not provide the breastfeeding rates for Native Hawaiian/other Pacific Islander mothers or American Indian/Alaska Native mothers, it shows racial disparities in breastfeeding initiation.⁸ The prevalence of breastfeeding duration shows that 15.9% of mothers never breastfed, 59.8% breastfed for 6 months, and 39.5% breastfed for 12 months.⁸ The NH-Black mothers have the lowest breastfeeding rate of 6 months duration (51.7%).⁸ Previous studies showed existing racial disparities in breastfeeding initiation and duration and demonstrated the need to increase support for breastfeeding women of color.^9,10 Thus, efforts to address racial disparity in breastfeeding initiation and duration will offer an opportunity to achieve 6 months of exclusive breastfeeding, and 2 years of supplemental breastfeeding as recommended by AAP and WHO.

Many factors influence breastfeeding initiation and duration, including social support, breastfeeding self-efficacy, perceived insufficient milk supply, infant weight/health, illness/medication usage,^7,11,12 maternal smoking, vaginal delivery, multiparity, dyad separation and connection, maternal education level, breastfeeding education/support,¹³ parents as caregivers, living in urban areas, older maternal age, being married, and lower income.¹⁴ Also, immigrant women of all races were more likely to initiate and continue breastfeeding than their U.S.-born counterparts, suggesting that cultural factors are important in the decision to breastfeed.^15,16 However, information from family or friends and breastfeeding support groups influence breastfeeding initiation and duration across racial groups, but with smaller effects among Alaska Native, NH-Black, and Hispanic women.¹⁷

In addition, pregnancy intentions influence breastfeeding initiation and duration.¹⁸ For instance, the odds of never breastfeeding or breastfeeding less than 6 months are influenced by couples’ unintended or discordant pregnancy intentions.¹⁸ Also, U.S. women with unintended pregnancies are less likely to initiate breastfeeding¹¹ and to breastfeed for 8 or more weeks.¹⁹ Moreover, fathers with a mistimed pregnancy—that occurred earlier than desired²⁰ are more likely to have a child who was never breastfed or breastfed less than 6 months.²¹ Building on the existing literature that pregnancy intention influences breastfeeding outcomes,^18,21 and the existing disparities in breastfeeding rates by race/ethnicity.^9,10 We argue that there is an interaction of race and pregnancy intentions on breastfeeding initiation and duration. Understanding the interaction is important in reducing breastfeeding disparity owing to the variations in pregnancy intentions by maternal Race. For instance, NH-Black women are more likely to report an unintended birth than Hispanics or NH-White women, and they are more likely to report mistimed pregnancy than NH-White women.^22,23 Similarly, NH-Black women had the highest probability of experiencing discordant pregnancy intentions along with their male partners.²⁴ Factors contributing to the disparity in pregnancy intentions between NH-Black and NH-White women are age, relationship status, maternal age at first birth, poverty, health insurance, attitudes toward contraceptives, culture, and forces of inequality.^23,25,26 Thus, the study examines the interaction of race and pregnancy intentions on breastfeeding initiation rates and duration in the United States.

Materials and Methods

Data

This study used the 2017–2019 pregnancy and women’s file of the National Survey of Family Growth (NSFG). NSFG used trained female interviewers to sample women (15–49 years) face-to-face. On average, the interviews last 80 minutes, with a response rate of 69%.²⁷ NSFG collects data on pregnancy-related information such as gestational length, pregnancy outcome, termination date, and pregnancy intention, among others. The survey used a multistage, area probability sample from 120 Primary Sampling Units with oversamples of teenagers, African Americans, and Hispanics across the United States. The dataset documentation is publicly available; see https://www.cdc.gov/nchs/nsfg/index.htm

Sample

The unit of analysis for this study was women’s pregnancy in the NSFG. We restricted the analysis to breastfeeding information from the first pregnancy to avoid confounding factors related to breastfeeding for subsequent children.^18,28 Also, we excluded women if they were never pregnant, received help to conceive, or had missing information on pregnancy intention and breastfeeding.¹⁸ The final analysis was conducted on 4,171 women.

Variables

Breastfeeding duration, the outcome of interest, was defined as never breastfed, breastfed 6 months or less, and breastfed for more than 6 months. In the survey, breastfeeding was assessed in weeks, using self-reported survey items. If the mother reported breastfeeding between 1 and 25 weeks, we categorized her as breastfeeding 6 months or less, while if the mother reported breastfeeding 26 weeks or more, she was categorized as breastfeeding 6 months or more,²¹ which is also consistent with CDC’s national breastfeeding recommendations. A couple’s pregnancy intention for the first live birth is a joint measure of maternal and paternal pregnancy intention. Maternal and paternal pregnancy intentions have six categories, respectively, later, right time, too soon, mistimed, did not care, indifferent, unwanted, do not know, and not sure. Unintended pregnancy was defined as a pregnancy that occurred too soon (e.g., mistimed) or was unwanted. Intended pregnancy includes pregnancy that was at the right time or overdue.¹⁸ We categorized did not care, indifferent, and do not know, not sure as ambivalent intentions.²⁹ Then, we merged pregnancy intentions from both partners to create a variable with five categories—both intended, father-only intended, mother-only intended, couple ambivalent, and neither-intended. Both intended pregnancy was the reference category because previous studies have shown that intended pregnancy has better breastfeeding outcomes.^19,21

The moderating variable was the maternal race/ethnicity (Hispanics, NH-White, NH-Black, NH-others, or multiracial). The category of the NH-others, or multiracial included American Indian or Alaska Native, Asian, Native Hawaiian, or other Pacific Islander women or multiracial mothers. The potential confounders were selected based on the results from previous studies and availability in NSFG.^18,21,30,31 The sociodemographic variables selected were maternal age (24 years or less, 25–29 years, 30–34 years, and 35 years and above), paternal age (18–24 years; 25–49 years), marital status at child delivery (married; not married), poverty level (0–99; 100–199; 200–299; and 300 or more percent), highest maternal education attainment (less than high school; high school; some college or more), maternal prepregnancies body mass index (BMI) (normal weight, overweight, and obese), while undefined BMI was excluded from the analysis. Other factors were the mother’s foreign-born status (yes; no) and current religious affiliation (no religion; catholic; protestant; others).

Statistical analysis

The statistical analysis was conducted using Stata 16 software. The study sample was described with unweighted frequency and weighted percentages. Multinomial logistic regression was used to determine other factors associated with breastfeeding duration. The influence of couples’ pregnancy intention on breastfeeding initiation and duration was estimated using the multinomial logistic regression, both at the unadjusted and parsimonious model. The parsimonious model included the interaction term of couple pregnancy intention and maternal Race for an accurate probability prediction in the probability margin.³² Clustered robust standard errors were used for both unadjusted and parsimonious models because pregnancy information was nested in women.³³ Subsample analysis was computed for the relationship between pregnancy intention and breastfeeding using maternal racial/ethnic groups through predicted probability marginal effects. The predicted probabilities test for the interaction effects in the natural metric of the dependent variables while holding other variables constant.³² The University of Florida Institutional Review Board approved the study as nonhuman research (NH00021956).

Results

Background characteristics of the respondents

Thirty-nine percent of women breastfed for 6 months, 51.8% reported both-intended pregnancy, and 7.1% stated mother-only intentions. While 46.6% of the women were NH-White, 54.9% were married, 53.7% had some college education, 56.8% were 35 years and above, 59.9% had a partner of the ages of 25 and 49 years, 38.7% were obese, 29.6% were below 100 poverty level, 77.8% were born within the United States, 54% have private health insurance, and 44.9% were protestant (Table 1).

Table 1.

Unweighted Distribution and Weighted Percentages of Background Characteristics

Variables	Frequency (%) n = 4,147
Breastfeeding
Never breastfeeding	1,231 (26.46)
Breastfeeding 6 months or less	1,567 (39.41)
Breastfeeding more than 6 months	1,229 (34.13)
Couples’ pregnancy intention
Both intended	2,055 (51.83)
Mother only	280 (7.09)
Father only	439 (8.13)
Ambivalent	360 (8.93)
Neither intended	1,013 (24.02)
Race
Hispanic	1,491 (29.73)
NH-White	1,454 (46.6)
NH-Black	898 (14.42)
NH-Others or multiracial	304 (9.25)
Marital status at child delivery
Married	1,815 (54.91)
Not married	2,332 (45.09)
Education
Less than high school	821 (17.04)
High school	1,315 (29.23)
Some college	2,011 (53.73)
Maternal age
24 years or less	279 (4.41)
25–29	772 (14.06)
30–34	1,211 (24.73)
35+	1,885 (56.8)
Paternal age
18–24	1,038 (40.24)
25–49	1,491 (59.76)
Body mass index
Underweight/normal weight	1,160 (33.57)
Overweight	1,030 (27.69)
Obese	1,626 (38.74)
Poverty level
0–99	1,553 (29.56)
100–199	1,120 (27.87)
200 −299	665 (16.55)
300 or more	809 (26.02)
Born outside the United States
Yes	975 (22.23)
No	3,164 (77.77)
Health insurance status
Private	1,808 (54.01)
State-sponsored health plan	1,373 (23.92)
Other government health care	203 (4.70)
None	763 (17.37)
Religion
No religion	831 (21.02)
Catholic	1,126 (25.43)
Protestant	1,904 (44.89)
Other	286 (8.66)

Factors of breastfeeding initiation and duration

The other factors significantly associated with breastfeeding initiation and duration are maternal Race, marital status at conception, BMI, education, born outside the United States, health insurance status, and religion, at a p < 0.05 (Table 2).

Table 2.

Multinomial Logistic Regression Showing the Factors Associated with Breastfeeding Initiation and Duration Among U.S. Mothers

	Odds ratio (95% CI)
Variables	Never breastfed versus breastfed more than 6 months	Breastfed 6 months or less versus breastfed more than 6 months
Maternal age (ref: 20–24 years)
25–29	1.49 (0.57–3.86)	1.41 (0.62–3.21)
30–34	0.75 (0.30–1.89)	0.78 (0.35–1.72)
35+	1.09 (0.44–2.71)	0.71 (0.32–1.56)
Paternal age (ref: 18–24 years)
25–29	0.84 (0.66–1.08)	0.90 (0.73–1.10)
Race (ref: NH-Blacks)
Hispanic	0.50 (0.32–0.78)**	1.14 (0.76–1.70)
NH-White	0.64 (0.43–0.96)*	0.92 (0.63–1.33)
NH-others or multiracial	0.55 (0.31–0.97)*	0.99 (0.61–1.61)
Marital status (ref: married)
Not married	2.09 (1.59–2.74)***	1.36 (1.06–1.73)*
BMI (ref: normal weight)a
Overweight	1.36 (0.99–1.87)	1.22 (0.95–1.56)
Obese	2.09 (1.57–2.79)***	1.61 (1.27–2.04)***
Poverty level (ref: 0–99)
100–199	0.92 (0.66–1.28)	0.81 (0.61–1.08)
200–299	1.20 (0.81–1.77)	0.79 (0.56–1.10)
300 or more	0.79 (0.52–1.18)	0.77 (0.55–1.08)
Education (ref: less than high school)
High school	1.12 (0.75–1.67)	1.46 (1.02–2.10)*
Some College	0.47 (0.32–0.70)***	1.18 (0.83–1.67)
Born outside the United States (ref: yes)
No	2.91 (2.02–4.17)***	1.83 (1.39–2.40)***
Health insurance status (ref: private)
State-sponsored health plan	1.76 (1.25–2.49)**	1.09 (0.81–1.49)
Other government health care	1.56 (0.87–2.79)	1.01 (0.60–1.69)
None	1.32 (0.92–1.90)	0.98 (0.72–1.34)
Religion (ref: protestants)
No religion	0.80 (0.56–1.14)	1.38 (1.02–1.86)*
Catholic	0.83 (0.61–1.14)	1.29 (0.98–1.69)
Other religions	0.44 (0.27–0.74)***	0.61 (0.40–0.92)*

Ref: breastfed 6 months more than 6 months.

p < 0.05; **p < 0.01; ***p < 0.001.

BMI, Body Mass Index.

CI, confidence interval; Ref, the reference category.

Association of pregnancy intentions and breastfeeding duration

The unadjusted analysis indicated that couples with a mother-only intended pregnancy compared to both intended pregnancies are more likely to breastfeed for 6 months or less (odds ratio [OR]: 1.47) relative to breastfeeding for more than 6 months. However, couples with father-only intended pregnancies compared to both intended pregnancies are more likely never to breastfeed (OR: 2.65) and to breastfeed for 6 months or less (OR: 2.56), relative to breastfeeding for more than 6 months. Couples with ambivalent pregnancy intentions, compared to both intended, are more likely never to breastfeed (OR: 2.76) and breastfeed for 6 months or less (OR: 2.11). Similarly, couples with neither intended pregnancy compared to both intended are more likely never to breastfeed (OR: 2.53) or breastfeed for 6 months or less (OR: 1.74), relative to breastfeeding for more than 6 months (Table 3). After adjusting for maternal age, paternal age, BMI, race, poverty, marital status, education, foreign-born status, health insurance, religion, and the interaction term between pregnancy intention and maternal race in the parsimonious model, couples with father-only intended pregnancy compared to both intended pregnancies are more likely to breastfeed for 6 months or less (OR: 2.45), relative to breastfeeding for more than 6 months. Similarly, couples with ambivalent pregnancy intentions, compared to both intended pregnancies, are more likely to breastfeed for 6 months or less (OR: 2.66) relative to breastfeeding for more than 6 months. However, couples with neither pregnancy intentions compared to both intended are more likely never to breastfeed (OR: 2.07) or breastfeed for 6 months or less (OR: 1.57), relative to breastfeeding for more than 6 months (Table 3).

Table 3.

Multinomial Logistic Regression Showing the Association Between Couple Pregnancy Intention and Breastfeeding Duration: NSFG 2017–2019

	Unadjusted model COR (95% CI)		Parsimonious model^a AOR (95% CI)
Pregnancy intentions	Never breastfed	Breastfed 6 months or less	Never breastfed	Breastfed 6 months or less
Both intended	Reference		Reference
Mother only	1.36 (0.97–1.90)	1.47 (1.08–2.00)*	1.11 (0.42–2.93)	1.32 (0.68–2.54)
Father only	2.65 (1.93–3.65)***	2.56 (1.68–3.02)***	2.00 (0.94–4.27)	2.45 (1.39–4.38)**
Ambivalent	2.76 (1.96–3.88)***	2.11 (1.52–2.91)***	1.65 (0.57–4.76)	2.66 (1.03–6.91)*
Neither intended	2.53 (2.02–3.155)***	1.74 (1.42–1.09)***	2.07 (1.16–3.70)*	1.57 (1.01–2.44)*

Parsimonious model controlling for maternal age, paternal age, BMI, race, poverty, marital status, education, born outside the United States, health insurance, religion, and the interaction term between pregnancy intentions and maternal race. Clustered robust standard errors were used for both unadjusted and parsimonious models.

p < 0.05; **p < 0.01;***p < 0.001.

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; NSFG, National Survey of Family Growth.

Predictive probabilities of breastfeeding duration by couple pregnancy intention and race

For both intended pregnancies, the probability of never breastfeeding was the greatest among NH-Black women for both intended pregnancies (probability [Pr.]: 0.34), breastfeeding for 6 months or less was greatest for Hispanics (Pr.: 0.41), and breastfeeding for more than 6 months was greatest for NH-others or multiracial. For couples with mother-only intended pregnancies, the probability of never breastfeeding was the greatest for NH-Black (Pr.: 0.27), breastfeeding for 6 months or less was greatest for NH-White (Pr.: 0.49), breastfeeding for more than 6 months was greatest for NH-others or multiracial. For couples with father-only intended pregnancies, the probability of never breastfeeding was the greatest for NH-Black women (pr.: 0.45), breastfeeding for 6 months or less was greatest for Hispanics (Pr.: 0.56), and breastfeeding for more than 6 months was greatest for NH-others or multiracial (Pr.: 0.45).

Similarly, for couples with ambivalent pregnancy intentions, the probability of never breastfeeding was greatest for NH-Black (Pr.: 0.55), breastfeeding for 6 months or less was greatest for Hispanic women (Pr.: 0.60), and breastfeeding for more than 6 months was greatest for NH-others or multiracial (Pr.: 0.49). For couples with neither pregnancy intentions, the probability of never breastfeeding was greatest for NH-Black (Pr.: 0.37), breastfeeding for 6 months or less (Pr.: 0.48), and breastfeeding for more than 6 months (Pr.: 0.36), was greatest for NH-others or multiracial (Pr.: 0.36) (Table 4).

Table 4.

Predictive Probability (Marginal Effects) of Breastfeeding Duration, by Couple Pregnancy Intention and Maternal Race: NSFG 2017–2019

Pregnancy intentions	Never breastfed	Breastfed 6 months or less	Breastfed more than 6 months
Both intended
Hispanics	0.18 (0.14–0.22)***	0.41 (0.36, 0.46)***	0.41 (0.36, 0.47)***
Non-Hispanics White	0.22 (0.18–0.26)***	0.36 (0.32, 0.40)***	0.42 (0.37, 0.46)***
Non-Hispanic Black	0.34 (0.23–0.46)***	0.34 (0.22, 0.45)***	0.32 (0.22, 0.42)***
Non-Hispanic others or multiracial	0.19 (0.11–0.27)***	0.31 (0.22, 0.40)***	0.50 (0.41, 0.60)***
Mother-only intended
Hispanics	0.17 (0.05–0.30)**	0.47 (0.32, 0.62)***	0.36 (0.24, 0.49)***
Non-Hispanics White	0.17 (0.09–0.25)***	0.49 (0.36, 0.61)***	0.34 (0.22, 0.46)***
Non-Hispanic Black	0.27 (0.07–0.47)**	0.29 (0.08, 0.50)**	0.43 (0.24, 0.63)***
Non-Hispanic others or multiracial	0.17 (−0.06, 0.40)	0.43 (0.13, 0.73)**	0.40 (0.09, 0.71)**
Father-only intended
Hispanics	0.20 (0.11, 0.28)***	0.56 (0.46, 0.67)***	0.24 (0.15, 0.34)***
Non-Hispanics White	0.29 (0.17, 0.41)***	0.49 (0.36, 0.63)***	0.21 (0.10, 0.33)***
Non-Hispanic Black	0.45 (0.27, 0.63)***	0.34 (0.16, 0.52)***	0.21 (0.07, 0.35)**
Non-Hispanic others or multiracial	0.33 (0.10, 0.52)**	0.22 (0.00, 0.44)	0.45 (0.15, 0.74)**
Ambivalent
Hispanics	0.16 (0.05, 0.27)**	0.60 (0.42, 0.78)***	0.24 (0.09, 0.39)**
Non-Hispanics White	0.27 (0.17, 0.37)***	0.41 (0.31, 0.51)***	0.33 (0.22, 0.43)***
Non-Hispanic Black	0.55 (0.37, 0.73)***	0.31 (0.11, 0.52)**	0.14 (−0.02, 0.29)
Non-Hispanic others or multiracial	0.05 (−0.06, 0.17)	0.45 (0.12, 0.79)**	0.49 (0.15, 0.83)**
Neither intended
Hispanics	0.25 (0.18, 0.32)***	0.45 (0.37, 0.53)***	0.30 (0.23, 0.37)***
Non-Hispanics White	0.29 (0.22, 0.36)***	0.38 (0.31, 0.45)***	0.33 (0.26, 0.40)***
Non-Hispanic Black	0.37 (0.24, 0.50)***	0.40 (0.25, 0.55)***	0.23 (0.11, 0.36)***
Non-Hispanic others or multiracial	0.16 (0.03, 0.29)*	0.48 (0.32, 0.63)***	0.36 (0.22, 0.50)***

p < 0.05; **p < 0.01; ***p < 0.001.

Discussion

The current study found that there is an interaction between race and couples’ pregnancy intention on breastfeeding initiation and duration. Specifically, the probability of never breastfeeding was greatest for NH-Black women in all the pregnancy intentions (both intended, mother-only intended, father-only intended, ambivalent, and neither intended), more than other racial groups. The probability of breastfeeding for 6 months or less is highest for Hispanic women in all the pregnancy intentions except when the pregnancy was neither intended. However, NH-others or multiracial women were more likely to breastfeed their baby for more than 6 months in all the pregnancy intentions.

While there are no studies that examined the interaction of race and pregnancy intentions on breastfeeding initiation and duration, the results are consistent with previous literature on the racial differences in breastfeeding initiation and duration. Specifically, studies have shown that NH-Black women have the lowest breastfeeding rate for 6 months duration.¹⁰ Also, Asian mothers (who formed part of the NH-others or multiracial in the current study) have the highest prevalence rate of breastfeeding in the United States.⁹

Also, the current study is consistent with the previous literature that showed that couples’ pregnancy intention influences breastfeeding initiation and duration. Specifically, babies are more likely to never breastfeed or breastfeed for less than 6 months if the father intends the pregnancy but is unintended by the mother or unintended by both couples.¹⁸ Also, fathers with mistimed pregnancies,²¹ mothers with unintended pregnancies¹⁹ are more likely to never breastfeed or breastfeed for less than 6 months. However, the study expanded upon previous literature that showed that pregnancy intention influences breastfeeding duration,^18,19,21 by showing the interaction of Race and pregnancy intention on breastfeeding initiation and duration.

Thus, the association between pregnancy intentions and breastfeeding initiation and duration can be explained through maternal race. Previous studies have shown that race impacts pregnancy intention,^22–24 through culture, social inequality, attitudes toward contraceptives, poverty, and marital status.^23,25,26 Also, breastfeeding rates vary by race^9,10 through cultural factors, support from family and friends, and breastfeeding support groups.^15–17

While pregnancy intentions vary among different races, the meaning and interpretation may also be different among different racial groups.^34–36 A qualitative study of 17 young adult U.S.-born Hispanic women argued that the meaning of pregnancy intentions differed based on the women’s pregnancy resolution decision; many felt the term placed the blame on women and was stigmatizing. Some of the Hispanic women in the study argued that pregnancies should not be planned; in doing so, they are going against fate.³⁴ Another study among NH-White and Hispanic women showed that women may show excitement at unintended pregnancy due to deeply held emotions of a child being a blessing or a gift. The foreign-born Hispanic women, however, show excitement due to social pressures despite having negative feelings.³⁵ However, among NH-Black women, pregnancy intentions may be viewed in six viewpoints, namely, actively desiring to become pregnant; avoiding pregnancy forever; lack of reproductive control or ambivalence toward pregnancy; planned future pregnancy; avoiding pregnancy due to its impacts on the family; the woman has reproductive control and partner is also avoiding pregnancies.³⁶ The breastfeeding experience of African American women could be affected by the lack of breastfeeding support from family, peers, and community; misconceptions, personal factors, prejudice, racism, home environment, income level, sexuality issues, lack of breastfeeding role models, employment policies, family involvement, and lack of supportive health care system, and supportive health care professionals toward breastfeeding success.³⁷ Also, the emotional cost of unintended or father-only intended pregnancies may lead to a lack of desire among mothers to breastfeed their infants.^38,39 Furthermore, the absence of strategic planning and the lack of physical and mental preparation that accompanies unintended pregnancies may lead mothers to adopt behaviors that are unfavorable for breastfeeding, such as inadequate nutrition, poor dietary habits,³⁹ substance use, and noncessation of drug usage.⁴⁰

Despite the strengths of the study, it has certain limitations which affect the generalizability of the result. First, in the NSFG dataset, the father’s and mother’s pregnancy intentions were reported by the mother, which could be subject to recall bias and measurement error. However, it has been shown that a partner’s pregnancy intentions reported by the mother are strongly associated with their partner’s reports.⁴¹ Second, potential confounding variables related to the father (except for the father’s age) that could affect the association between the predictor and outcome were not available in the NSFG. Third, the NSFG did not reveal whether breastfeeding continuation was exclusive or nonexclusive. Fourth, the category of the NH-others or multiracial in the NSFG included American Indian or Alaska Native, Asian, Native Hawaiian, or other Pacific Islander, and multiracial women, which might lead to loss of nuanced information or inaccurate generalizations. Despite the limitations, our study not only sheds light on how pregnancy intention among couples can affect breastfeeding initiation and duration but also provides important insights into how it varies among different racial/ethnic groups in the United States. Future studies could focus on providing qualitative insights into the meaningfulness of pregnancy intentions and factors associated with it across racial groups.

Conclusions

The study demonstrates that there is a definite relationship between pregnancy intentions and breastfeeding initiation and duration. Even after controlling for covariates, NH-Black women have the highest probability of never breastfeeding their babies, irrespective of their pregnancy intentions. NH-others or multiracial are likely to breastfeed their babies for more than 6 months for all pregnancy intentions, except mother-only intended. Owing to the high volume of unintended pregnancies in the United States, the current study might help lactation consultants understand the influence of pregnancy intentions on breastfeeding initiation and duration among racial/ethnic groups in the United States. This understanding could help them tailor the messages to initiate and sustain exclusive breastfeeding among women of different races.

Footnotes

Authors’ Contributions

S.M.A.: Conceptualization, study startup, writing—original draft preparation, formal analysis, and review and editing. J.T.W.: Study startup and writing—original draft preparation. M.V.: Writing—original draft preparation. D.S.V.: Reviewing and editing. A.L.J.: Supervision, reviewing, and editing.

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

This research received no funding.

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