Breastfeeding Behaviors by Race/Ethnicity and Foreign-Born Status in the United States: An Analysis of the U.S. National Survey of Children’s Health

Abstract

Objective:

The foreign-born population is growing in the United States, but no nationally representative statistics of breastfeeding behavior disaggregated by race/ethnicity and foreign-born status have been published in recent years. This study examines breastfeeding initiation, any breastfeeding, and exclusive breastfeeding at 3 and 6 months among foreign-born and U.S.-born Non-Hispanic (NH) Black, NH White, and Hispanic women in the United States.

Methods:

This is a cross-sectional study utilizing years 2021 and 2022 of the National Survey of Children’s Health. Sample children identified as NH White, NH Black, and Hispanic who were 6 months to 5 years old and residing with their biological or adoptive mother were included (n = 27,818).

Results:

Foreign-born women in all racial/ethnic groups (NH Black, NH White, and Hispanic) had significantly higher odds of any breastfeeding at 6 months relative to U.S.-born NH White women. However, they did not have significantly different odds of exclusive breastfeeding for 6 months relative to U.S.-born NH White women. U.S.-born Hispanic women had rates of exclusive breastfeeding for 6 months (23.2%) that were much closer to U.S.-born NH Black women (23.4%) than to foreign-born Hispanic women (29.4%) or U.S.-born White women (32.1%).

Conclusions:

The large percentage of foreign-born women who reported some breastfeeding at 6 months indicates a strong commitment to breastfeeding and may be a leverage point for future exclusive breastfeeding interventions among this group. U.S.-born Hispanic women appear to be struggling with exclusive breastfeeding and may need additional interventions.

Introduction

Breastfeeding is the preferred method of infant feeding as established by the World Health Organization (WHO),¹ the American Academy of Pediatrics,² and the United States Centers for Disease Control and Prevention (CDC).³ It is associated with a reduced risk of noncommunicable diseases that disproportionately impact racial and ethnic minority mothers (e.g., breast cancer, diabetes prevention/management, and postpartum depression)^4–6 and their offspring (e.g., respiratory diseases, type 2 diabetes, and gastrointestinal diseases)⁶ in the United States. Not surprisingly, breastfeeding disparities also exist among racial and ethnic minority groups in the United States⁷ and are attributed to social drivers of health.^8,9

Currently, there is a growing U.S. population of immigrants from Latin American and African countries.¹⁰ We know that foreign-born women who immigrate to high-income countries generally have higher breastfeeding rates than the native born population,¹¹ and previous work has estimated prevalence rates of breastfeeding indicators by racial/ethnic categories,^12–25 but these studies have several limitations. First, few of these studies utilize nationally representative datasets.^{16,19,21–23,26} Second, studies rarely report on both the duration and exclusivity of breastfeeding,^12,14,15 the two indicators that serve as the recommendations for breastfeeding by the WHO¹ and the Healthy People 2030 initiative.²⁷ Third, the literature is void of studies that have disaggregated breastfeeding exclusivity and duration by U.S.-born and foreign-born status among the three largest racial/ethnic groups in the United States—White, Hispanic, and Black.^14,15,17,18

Thus, whether foreign-born women who immigrate to the United States demonstrate distinct rates of national and global priority breastfeeding indicators (e.g., exclusivity, duration) compared with U.S.-born women is unknown. Further, it is essential that we disaggregate breastfeeding behaviors by racial/ethnic groups (e.g., Hispanic, Black) as well as foreign-born status so that we understand what patterns are distinct to racial/ethnic groups and what patterns are more influenced by foreign-born status. This information is integral for developing health equitable innovations that increase breastfeeding rates at the population level to address health disparities among vulnerable populations.

If distinct patterns of breastfeeding prevalence rates emerge by racial/ethnic group and by foreign-born status, this would be an important finding to continue to probe and learn from the social norms, policies, and cultures of countries that women immigrate from. In doing so, opportunities would emerge for cross-country collaborations on innovations that benefit the health of both countries—a research method referred to as reciprocal innovation.²⁸ This perspective aligns with a recent call to action to consider a global perspective when addressing nationally based maternal and child issues.²⁹ To advance the field, we report the rates of breastfeeding exclusivity and duration among U.S.-born and foreign-born populations from White, Black, and Hispanic racial/ethnic groups using a nationally representative dataset.

Data and Methods

The study utilizes the National Survey of Children’s Health (NSCH) years 2021–2022. The NSCH is a nationally representative survey that samples noninstitutionalized children aged 0–17 years.³⁰ It is administered annually via the internet or mail, and all questions are answered by an adult representative of the sample child.³⁰ The survey was designed by the Health Resources and Services Administration’s Maternal and Child Health Bureau and is administered by the U.S. Census Bureau.³¹ To ensure adequate sample size, we have pooled 2 years of data (2021 and 2022). Additional information regarding the design and administration of the NSCH can be accessed elsewhere.³⁰

The NSCH survey administrators imputed missing data for race/ethnicity and federal poverty level variables using hot-deck and sequential regression imputation methods, respectively.³² The analytic dataset for this study was restricted to Hispanic, Non-Hispanic (NH) White, or NH Black children aged 6 months to 5 years old living with a female biological or adopted parent. The NSCH codes age in years, but there is a dichotomous variable included in the dataset that indicates if the infant is <6 months old that was used to define our sample. The data combined biological and adoptive parents into one category. Therefore, only households with one female adoptive/biological parent were retained, because we could not reliably assess which mother would be physically able to breastfeed the child. Households without a female adoptive/biological parent were also dropped. Another 991 observations were dropped (3.4%) due to missing data, leaving us with a final sample of 27,818 observations. Of the total 991 dropped observations, 661 were NH White U.S.-born participants (67.1% of the dropped observations and 3.0% of the total NH White U.S.-born sample). Only 44 observations were lost from the NH Black foreign-born participants (4.4% of the dropped observations and 11.1% of the NH Black foreign-born sample; Appendix 1). Given the relatively small number of missing cases, we decided not to impute missing values. However, the federal poverty line variable contains imputed data that were provided by NSCH. We utilized multiple imputation estimation commands in Stata for analyses that include the poverty variable.

Breastfeeding status was measured as the following five categories: (1) ever breastfed, (2) any breastfeeding for a minimum of 3 months, (3) exclusive breastfeeding for a minimum of 3 months, (4) any breastfeeding for a minimum of 6 months, and (5) exclusive breastfeeding for a minimum of 6 months. Respondents were asked, “Was this child ever breastfed or fed breastmilk?” and could answer Yes or No. All respondents who indicated yes to ever breastfeeding were then asked, “If yes, how old was this child when he or she COMPLETELY stopped breastfeeding or being fed breast milk?” Responses were recorded in months. Women could also indicate that the infant was still breastfeeding at the time of the survey. Infants were coded as breastfeeding for 3 months if the survey respondent stated that they stopped breastfeeding in month 3 or later or if the infant was still breastfeeding at the time of the survey (all infants in our sample are at least 6 months old). Infants were coded as breastfeeding for 6 months if they stopped breastfeeding in month 6 or later or if infant was 6 months or older and was still breastfeeding. To determine if the infant was fully or partially breastfed, respondents were asked, “How old was this child when he or she was FIRST fed formula?” Responses were recorded in months. Respondents could also indicate that the child was never fed formula. Respondents were also asked, “How old was this child when they were FIRST fed anything other than breast milk or formula? Include water, juice, cow’s milk, sugar water, baby food, or anything else that your child might have been given.” In accordance with the CDC definition of exclusive breastfeeding, any intake of formula or other liquids/food during the time frame indicated (3–6 months) meant that the child was coded as not exclusively breastfeeding.³³

The independent variables for this study are sample child’s race/ethnicity, mother’s foreign-born status, mother’s age, mother’s marital status, mother’s education, preterm birth, birth order, and household federal poverty level. Mother’s race/ethnicity was not asked, so the child’s race is used as a proxy. The race, ethnicity, and foreign-born status variables were combined to make the following categories: “US-born Non-Hispanic White,” “US-born Non-Hispanic Black,” “US-born Hispanic,” “Foreign-born Non-Hispanic White,” “Foreign-born Non-Hispanic Black,” and “Foreign-born Hispanic.” Mother’s marital status is coded dichotomously as “married” or “Cohabiting/never married/divorced/separated/widowed.” Preterm birth is also coded dichotomously. Mother’s education is categorical and reported as follows: “Less than High School,” “High School Graduate,” “Vocational Degree or Some College,” “College Graduate,” “Graduate School Degree.” Mother’s age was reported continuously in the NSCH and then grouped into categories: “18–20,” “21–24,” “25–29,” “30–34,” “35–39,” and “40 plus.” Preterm birth was determined by a question asking, “Was this child born more than 3 weeks before their due date?” with yes answers coded as preterm. Birth order is coded as “Only child or oldest child,” “second child,” “third child,” and “fourth child or greater.” The federal poverty level was calculated by the NSCH. All analyses were run using Stata 17 and weighted to be nationally representative according to NSCH recommendations.³² Both bivariate and multivariate logistic regression models were executed for the analysis. This study was determined by the Indiana University Institutional Review Board to be not human subjects research #19571.

Results

Table 1 displays the descriptive statistics for the study population. In our weighted analytical sample, the rate of ever breastfeeding was 83%. At 3 months, the rate of any breastfeeding was 70%, and the rate of exclusive breastfeeding was 48%. At 6 months, around 59% were breastfeeding, and only 30% reported exclusive breastfeeding. The sample consisted of around 58% U.S.-born NH White mothers, whereas 9% were U.S.-born NH Black mothers and 16% were U.S.-born Hispanic mothers. The sample also included 4% NH White foreign-born mothers, 3% NH Black foreign-born mothers, and 10% Hispanic foreign-born mothers. The majority of the women were between the ages of 25–29 years and 30–34 years at the time of the survey (25% and 35%, respectively). Nearly 13% of the mothers were under the age of 25 years, and only 5% of the mothers were above 40 years or older. The majority of the mothers were married at the time of the survey (77%). More than half of the mothers had a college degree or higher level of education (51%), whereas around a quarter of the mothers were either high school graduates or less than that (24%). Twelve percent of the infant births were preterm. More than a third of the respondents lived in households with family income below 200% of the federal poverty line (37%).

Table 1.

Descriptive Statistics for the Study Sample (N = 27,818)

Variables	Unweighted number in sample	Weighted percent in sample	95% CI
Breastfeeding prevalence
Ever breastfed	23,986	83.4	82.4	84.4
Any breastfeeding for 3 months	20,282	70.3	69.0	71.4
Exclusive breastfeeding for 3 months	14,164	47.5	46.2	48.8
Any breastfeeding for 6 months	17,383	59.0	57.7	60.3
Exclusive breastfeeding for 6 months	8,799	29.5	28.4	30.7
Sample child’s race/ethnicity and mother’s foreign-born status
U.S.-born NH White	21,468	57.8	56.5	59.1
U.S.-born NH Black	1,163	9.2	8.4	10.1
U.S.-born Hispanic	2,464	15.5	14.4	16.6
Foreign-born NH White	1,105	4.4	3.9	5.0
Foreign-born NH Black	354	2.7	2.3	3.2
Foreign-born Hispanic	1,264	10.3	9.3	11.5
Year of survey
2021	14,374	50.9	49.6	52.2
2022	13,444	49.1	47.8	50.4
Mother’s age
18–20	698	3.6	3.1	4.2
21–24	2,317	9.5	8.7	10.3
25–29	7,273	24.6	23.7	25.7
30–34	10,272	35.1	33.8	36.3
35–39	5,962	22.0	20.9	23.1
40+	1,296	5.2	4.6	5.9
Mother’s marital status
Currently not married	4,650	23.2	22.0	24.5
Currently married	23,168	76.8	75.5	78.0
Mother’s highest level of education
<12 years	738	9.2	8.2	10.4
High school graduate	2,869	15.3	14.4	16.4
Vocational/some college	6,721	24.2	23.2	25.3
College degree	9,505	28.1	27.1	29.2
Graduate school	7,985	23.0	22.1	24.0
Preterm birth
No	24,835	88.4	87.5	89.2
Yes	2,983	11.6	10.8	12.5
Birth order of sample child
1	14,485	38.6	37.5	39.8
2	9,614	35.2	34.0	36.4
3	2,955	19.0	17.8	20.1
4+	764	7.2	6.4	8.2
FPL^a
<100% FPL	2,833	17.1	15.9	18.4
100%−199% FPL	3,955	19.5	18.3	20.8
200%−399% FPL	8,594	28.4	27.2	29.7
400%+ FPL	12,435	34.9	33.7	36.1

The FPL variable has missing values. The raw data are given in the unweighted sample N, and the weighted data are calculated using the multiply imputed data given to us by the NSCH (mi estimate commands were used in Stata).

CI, confidence interval; NH, Non-Hispanic; FPL, federal poverty line; NSCH, National Survey of Children’s Health.

Table 2 shows the background characteristics of the analytical sample by race/ethnicity and foreign-born status. Around 7.8% of the NH Black U.S.-born mothers were under the age of 20 years, and only 0.5% of the NH Black foreign-born mothers were in the same age bracket. Similarly, 7% of the Hispanic U.S.-born mothers were under the age of 20 years, and only 3% of the Hispanic foreign-born mothers were in the same age bracket. NH Black foreign-born mothers were married at similar rates compared with the NH White U.S.-born mothers (79% versus 86%), whereas only 38% of NH Black U.S.-born mothers were married. Almost a third of Hispanic foreign-born mothers had under 12 years of education (34%) compared with 14% of NH Black foreign-born mothers, and <10% of the mothers from all other groups had the same level of education. Around 12% of the births were preterm for NH Black foreign-born mothers compared with 18% of preterm births among NH Black U.S.-born mothers. Nearly 27% of the NH Black foreign-born mothers were below 100% of the federal poverty line compared with 10% of the NH White U.S.-born mothers, 33% of the foreign-born Hispanic mothers, and 37% of the NH Black U.S.-born mothers.

Table 2.

Descriptive Statistics^* by Race/Ethnicity and Foreign-Born Status

Variables	NH White U.S. born (n = 21,468)	NH Black U.S. born (n = 1,163)	Hispanic U.S. born (n = 2,464)	NH White immigrant (n = 1,105)	NH Black immigrant (n = 354)	Hispanic immigrant (n = 1,264)	p Value^***
Mother’s age
18–20	2.6	7.8	7.0	0.7	0.5	2.7	<0.001
21–24	8.3	12.5	15.7	2.8	5.0	8.1
25–29	25.7	26.7	24.3	20.8	20.0	20.3
30–34	38.7	29.7	28.2	33.7	34.1	30.4
35–39	20.8	16.8	19.9	32.8	34.4	28.7
40+	3.9	6.5	4.9	9.2	6.1	9.8
Mother’s marital status
Currently not married	14.2	62.3	33.3	8.2	21.5	30.6	<0.001
Currently married	85.8	37.7	66.7	91.9	78.5	69.4	<0.001
Mother’s highest level of education
<12 years	4.7	9.6	9.0	8.4	13.6	33.8	<0.001
High school graduate	11.7	21.0	21.3	12.7	18.1	22.2
Vocational/some college	21.9	35.0	31.9	16.2	20.1	20.6
College degree	33.9	16.1	21.8	33.6	28.4	13.8
Graduate school	27.8	18.4	16.0	29.2	19.8	9.7
Preterm birth
No	89.1	82.2	88.6	91.1	87.7	88.8	0.011
Yes	10.9	17.8	11.4	8.9	12.3	11.2	0.011
Birth order of sample child
1	40.9	38.7	36.1	40.3	34.8	29.5	0.002
2	35.1	33.2	38.4	31.3	32.4	34.8
3	17.7	17.9	18.3	18.5	23.4	27.1
4+	6.3	10.2	7.2	10.0	9.5	8.5
FPL^**
<100% FPL	9.7	37.2	21.4	15.1	26.8	33.0	<0.001
100%−199% FPL	15.4	24.1	23.8	18.1	29.9	30.2
200%−399% FPL	30.8	21.7	27.6	27.2	27.1	23.4
400%+ FPL	44.2	16.9	27.2	39.6	16.2	13.5

All data are presented as weighted %.

***

p value from chi-square test.

NH, Non-Hispanic; FPL, federal poverty line; NSCH, National Survey of Children’s Health.

Breastfeeding rates varied greatly by race/ethnicity and foreign-born status of the mothers (Fig. 1). Breastfeeding initiation rates were highest among NH White foreign-born mothers (92%) followed by NH White U.S.-born mothers (86%), foreign-born NH Black mothers (86%), Hispanic foreign-born mothers (85%), U.S.-born Hispanic mothers (80%), and lowest among U.S.-born Black mothers (69%; Fig. 1). The disparity in any breastfeeding by race/ethnicity and nativity status remained for breastfeeding rates at 3 months; however, the pattern in exclusive breastfeeding rates was different. The exclusive breastfeeding rates at 3 months were highest among NH White foreign-born mothers (55%) followed by NH White U.S.-born mothers (51%), Hispanic foreign-born mothers (43%), NH Black foreign-born mothers (41%), Hispanic U.S.-born mothers (40%), and lowest for NH Black U.S.-born mothers (38%). This heterogeneity in exclusive breastfeeding by race/ethnicity and nativity status remained for exclusive breastfeeding at 6 months.

FIG. 1.

Breastfeeding prevalence by race/ethnicity and foreign-born status.

Table 3 presents adjusted odds of breastfeeding initiation and duration by race/ethnicity and foreign-born status (See Table A2. for unadjusted results). These results are adjusted for mother’s age, mother’s education, mother’s marital status, child’s birth order, household poverty level, year of survey administration, and whether the birth was preterm. Compared with U.S.-born NH White women, foreign-born NH White mothers had 1.96 times the higher odds of ever breastfeeding (odds ratio [OR]: 1.96; 95% confidence interval [CI]: 1.29, 2.96) and foreign-born Hispanic women had 1.70 times higher odds of ever breastfeeding (OR: 1.70; 95% CI: 1.22, 2.35). For any breastfeeding at 3 months, both foreign-born NH Black women and foreign-born Hispanic women had significantly higher odds of breastfeeding as compared with the U.S.-born NH White women [OR: 2.38; 95% CI: 1.48, 3.82 and OR: 1.90; 95% CI: 1.45, 2.47), respectively]. For any breastfeeding at 6 months, both U.S.-born NH Black and U.S.-born Hispanic women had significantly lower odds of breastfeeding (OR: 0.76 and OR: 0.84, respectively); however, both these results were only marginally significant (p < 0.05). In contrast, both foreign-born NH Black and foreign-born Hispanic women had significantly higher odds of breastfeeding at 6 months (OR: 2.44 and OR: 1.54, respectively), and these results were significant at p < 0.001 and p < 0.01 levels, respectively. The odds of exclusive breastfeeding at both 3 months and 6 months were significantly lower for U.S.-born Hispanic women than those of U.S.-born NH White mothers (OR: 0.78 and OR: 0.76, respectively).

Table 3.

Multivariable Logistic Regressions Examining Odds of Breastfeeding by Race/Ethnicity and Foreign-Born Status (N = 27,818)

Race/ethnicity and foreign-born status	Ever breastfed		Any breastfeeding for 3 months		Exclusive breastfeeding for 3 months		Any breastfeeding for 6 months		Exclusive breastfeeding for 6 months
Race/ethnicity and foreign-born status	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
U.S.-born NH White	ref		ref		ref		ref		ref
U.S.-born NH Black	0.71^**	[0.55, 0.92]	0.91	[0.71, 1.15]	0.85	[0.66, 1.09]	0.76^*	[0.60, 0.97]	0.92	[0.69, 1.21]
U.S.-born Hispanic	1.00	[0.77, 1.29]	0.94	[0.77, 1.15]	0.78^**	[0.65, 0.93]	0.84^*	[0.70, 1.00]	0.76^**	[0.63, 0.92]
Foreign-born NH White	1.96^**	[1.29, 2.96]	1.80^*	[1.09, 2.96]	1.23	[0.94, 1.61]	1.58^*	[1.09, 2.27]	1.06	[0.81, 1.38]
Foreign-born NH Black	1.31	[0.79, 2.18]	2.38^***	[1.48, 3.82]	0.79	[0.53, 1.67]	2.44^***	[1.62, 3.68]	0.87	[0.56, 1.35]
Foreign-born Hispanic	1.70^**	[1.22, 2.35]	1.90^***	[1.45, 2.47]	1.05	[0.83, 1.34]	1.54^**	[1.21, 1.97]	1.13	[0.87, 1.48]

Note: Adjusted for mother’s age, mother’s education, mother’s marital status, child’s birth order, household poverty level, year of survey administration, and whether the birth was preterm.

p < 0.05.

p < 0.01.

***

p < 0.001.

OR, odds ratio; CI, confidence interval; NH, Non-Hispanic.

Discussion

Despite increasing immigration from African and Latin American countries to the United States, the field lacks current, nationally representative, breastfeeding prevalence estimates that are disaggregated by U.S. or foreign-born status. Our findings demonstrate distinct relationships by foreign- and U.S.-born status across NH Black, NH White, and Hispanic groups. Foreign-born women had significantly higher rates of any breastfeeding at 3 and 6 months across all racial/ethnic groups relative to U.S.-born NH White women. When adjusted for confounders, U.S.-born Hispanic mothers were the only group significantly less likely to exclusively breastfeed for both 3 and 6 months relative to U.S.-born NH White women. These findings add to the body of knowledge on breastfeeding in the United States and are critical for informing the development and assessment of future breastfeeding interventions. The breastfeeding behaviors of U.S.-born Hispanic and NH Black women contrast sharply with the breastfeeding behaviors of foreign-born NH Black, NH White, and Hispanic women who had higher breastfeeding rates at 3 and 6 months relative to U.S.-born White women. These results align with earlier work finding high rates of breastfeeding initiation and duration among foreign-born women who immigrate to high-income countries.¹¹

As for exclusivity, previous literature has identified NH Black children as being less likely to be exclusively breastfed for 6 months compared with NH White children.³⁴ Exclusive breastfeeding rates for Hispanic children are consistently low in nationally representative studies but not significantly different from White children.^7,35 This lack of significance is notable, because smaller scale quantitative studies^36,37 and qualitative work^38,39 show that Hispanic women struggle with exclusive breastfeeding. Hispanic women often report feeding their infants with both formula and breast milk, known as “las dos cosas,” as a way to address issues related to milk supply and pumping at work.^38,39 Our results synthesize the disconnect between large-scale, nationally representative quantitative studies and qualitative work by analyzing foreign-born women separately rather than simply entering foreign-born status as a control in the model. In the United States, 32% of the Hispanic population is foreign-born,¹⁰ and it has been consistently documented that foreign-born Hispanic women have longer breastfeeding durations relative to U.S.-born Hispanic women.⁴⁰ However, foreign-born women are not always separated out in studies examining differences in breastfeeding behaviors by race/ethnicity.^12,27,41 To this end, the finding that foreign-born women, across all races/ethnicities, had higher rates of any breastfeeding highlights an opportunity to learn from other African and Latin American countries and cultures where breastfeeding rates are high, especially as we think through how to support women who are new immigrants transitioning into the United States from such foreign countries.

Breastfeeding is a cultural norm for many foreign-born women who immigrate to the United States from Africa,⁴² the Middle East,⁴³ and Spanish-speaking countries,^44,45 which potentially explains a large portion of our results. However, while this trend is consistent, we should be careful not to overlook heterogeneity within racial/ethnic groups. Previous work has shown that breastfeeding behaviors of foreign-born Hispanic women vary considerably by country of origin.⁴⁴ This is especially true for exclusive breastfeeding, which is partly influenced by cultural beliefs regarding prelacteal feeding that can vary greatly by country of origin.^43,45,46 Exclusive breastfeeding can also be influenced by the lack of social support for immigrant women living apart from family^42,47 as well as concerns regarding breastfeeding in public places^47,48 and pumping at work.^42,46 What is unique about minority racial/ethnic groups in the United States are the cultural norms, values, beliefs, and historical contexts that shape such peoples. Unlike Latino populations who have been shown to have high rates of breastfeeding rates (except for exclusive breastfeeding), Black populations have demonstrated very low breastfeeding rates overall, part of which has been attributed to the historical and generational traumas faced by the Black community in the United States (e.g., wet nursing during slavery).⁴⁹ What is common among both Black and Hispanic groups is the disproportionate burden of social risk factors and unmet social needs that have been associated with low breastfeeding rates and high formula use, including food insecurity, low familial support, housing instability, acculturation, and transportation issues, among others.^8,50 In addition, policies, such as the PUMP Act,⁵¹ have been helpful in the workforce,⁵² but more work is needed to inform policies that support mothers and their basic right to breastfeed. These multifaceted socioecological influences on breastfeeding behaviors among a mother–infant dyad will undoubtedly warrant holistic, transagency, multilevel, and life course approaches that take these factors into consideration.

This work should be read with the understanding that we are not estimating breastfeeding rates for specific years. The data were collected in 2021 and 2022, but our sample includes children aged 6 months to 5 years old and is meant to serve as a recent snapshot of breastfeeding behavior. This study is also limited by the lack of information on country of origin, as breastfeeding behaviors may vary greatly by country. The relatively low number of observations for NH foreign-born Black women compared with other groups made it difficult to ascertain time trends within this group, so we do not know if our estimates are stable or changing over time. In addition, the race and ethnicity of the mother were not ascertained, so the sample child’s race was used as a proxy, which may introduce a margin of error into our estimates. We are also unable to control for other important variables shown to affect breastfeeding such as cesarean birth or mother’s employment status. The survey did not inquire about cesarean section births, and the employment questions were not precise enough to assess if the woman was employed while pregnant and/or postpartum.

However, to our knowledge, this study contains the only nationally representative estimates of extended and exclusive breastfeeding behaviors that disaggregate results by foreign-born and U.S.-born status for the three largest ethnic groups in the United States (NH White, NH Black, and Hispanic) utilizing data collected in the last 5 years.⁵³ As the foreign-born population in the United States grows,⁵⁴ it is important that we understand the different breastfeeding patterns in these groups. We demonstrate that foreign-born populations of all race/ethnicities have significantly higher rates of any breastfeeding at 3 and 6 months relative to U.S.-born White women but not necessarily exclusive breastfeeding. We also find that, when analyzed separately from foreign-born Hispanic women, U.S.-born Hispanic women have significantly reduced odds of exclusive breastfeedings for 6 months relative to NH U.S.-born White women. Utilizing reciprocal innovation methods²⁸ to design interventions that take into account the cultural contexts and specific barriers faced by foreign-born women in the United States could support this group to achieve the exclusive breastfeeding goals outlined in Healthy People 2030.²⁷

Footnotes

Authors’ Contributions

A.G.C. conceptualized the research question, coding, and analysis, cowrote the original draft, and edited and approved the final version of the article. S.N. assisted with coding and analysis, created tables and figures, cowrote the original draft, edited original draft, and edited the final version of the article. A.P. cowrote the original draft, edited the original draft, and edited and approved the final version of the article. All authors approved the final article as submitted and agree to be accountable for all aspects of the work.

Ethical Approval

This study was approved by Indiana University Institutional Review Board (IRB) as not human subjects research (IRB Protocol #19571).

Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

The authors received the following financial support for the research, authorship, and/or publication of this article: This work was funded, in part, by the Health Equity Advancing through Learning health system Research Collaborative, a partnership between IU Health’s Office of Health Equity Research and Engagement and the Indiana University School of Medicine, generously funded by a Cook Group Incorporated Advances in Medicine award and NIMHD R01MD017961-03S1. The funder had no role in the design and conduct of the study.

Appendix 1

Table A1.

Descriptive Statistics of Dropped Observations (N = 991)

Variables	Unweighted number in sample	Weighted percent in sample	95% CI
Sample child’s race/ethnicity and foreign-born status
U.S.-born NH White	661	41.2	34.2	48.6
U.S.-born NH Black	79	15.7	9.9	24.0
U.S.-born Hispanic	107	14.7	10.6	20.1
Foreign-born NH White	37	6.4	4.0	10.0
Foreign-born NH Black	44	10.8	6.0	18.8
Foreign-born Hispanic	63	11.1	7.7	15.8
Year of survey
2021	478	53.1	47.9	58.3
2022	513	46.9	41.7	52.1
Mother’s age
18–20	26	2.7	1.5	5.0
21–24	55	12.0	7.5	18.7
25–29	174	22.9	17.9	28.8
30–34	239	36.0	27.1	45.9
35–39	139	20.9	13.1	31.7
40+	38	5.5	3.2	9.3
Mother’s marital status
Currently not married	174	28.5	22.4	35.5
Currently married	613	71.5	64.5	77.6
Mother’s highest level of education
<12 years	54	18.7	12.2	27.6
High school graduate	150	19.2	15.0	24.3
Vocational/some college	239	16.7	13.3	20.6
College degree	276	22.8	16.5	30.6
Graduate school	231	22.6	16.1	30.9
Preterm birth
No	719	89.3	84.3	92.9
Yes	90	10.7	7.1	15.7
Birth order of sample child
1	477	29.5	25.4	34.0
2	364	38.1	30.9	45.8
3	111	21.9	15.5	30.0
4+	39	10.5	6.8	15.8
FPL
<100% FPL	189	30.4	22.0	38.7
100%−199% FPL	176	19.5	12.6	26.5
200%−399% FPL	254	24.3	16.3	32.4
400%+ FPL	372	25.8	20.9	30.6

N varies due to missing data within dropped sample.

For the FPL variable, the raw data are given in the unweighted sample N, and the weighted data are calculated using the multiply imputed data given to us by the NSCH (mi estimate commands were used in Stata).

CI, confidence interval; NH, Non-Hispanic; FPL, federal poverty line; NSCH, National Survey of Children’s Health.

Appendix 2

Table A2.

Logistic Regressions Examining Odds of Breastfeeding by Race/Ethnicity and Foreign-Born Status: Unadjusted Results (N = 27,818)

Race/ethnicity and foreign-born status	Ever breastfed		Any breastfeeding for 3 months		Exclusive breastfeeding for 3 months		Any breastfeeding for 6 months		Exclusive breastfeeding for 6 months
Race/ethnicity and foreign-born status	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
U.S.-born NH White	ref		ref		ref		ref		ref
U.S.-born NH Black	0.37^***	[0.30, 0.46]	0.49^***	[0.40, 0.61]	0.58^***	[0.46, 0.72]	0.43^***	[0.35, 0.53]	0.65^**	[0.50, 0.84]
U.S.-born Hispanic	0.65^**	[0.51, 0.84]	0.64^***	[0.53, 0.78]	0.63^***	[0.54, 0.75]	0.59^***	[0.49, 0.70]	0.64^***	[0.53, 0.77]
Foreign-born NH White	1.97^**	[1.34, 2.89]	1.77^*	[1.07, 2.77]	1.17	[0.88, 1.55]	1.61^*	[1.11, 2.32]	1.05	[0.79, 1.39]
Foreign-born NH Black	0.99	[0.59, 1.67]	1.72^*	[1.07, 2.77]	0.65^*	[0.45, 0.94]	1.88^**	[1.25, 2.82]	0.77	[0.51, 1.18]
Foreign-born Hispanic	0.94	[0.70, 1.26]	1.09	[0.84, 1.41]	0.73^**	[0.57, 0.92]	0.98	[0.78, 1.24]	0.88	[0.67, 1.15]

Data are weighted to be nationally representative.

p < 0.05.

p < 0.01.

***

p < 0.001.

OR, odds ratio; CI, confidence interval; NH, Non-Hispanic.

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