Informational Sources About Breastfeeding Associated with Breastfeeding Initiation: Insights into Racial Disparities

Abstract

Background:

Breastfeeding provides essential nutrition and disease protection for infants while reducing the risk of type 2 diabetes and breast cancer in mothers. Despite these benefits, significant racial and ethnic disparities exist in breastfeeding initiation, particularly among Black women. This study examines racial differences in the receipt of breastfeeding information from varying sources and their association with breastfeeding initiation.

Methods:

Data were obtained from the Phase 8 Core Pregnancy Risk Assessment Monitoring System for 2016–2020 (n = 163,724). The analysis focused on comparing the likelihood of breastfeeding initiation (yes/no) across racial groups and the impact of receiving breastfeeding information from varying clinical (mother’s doctor/nurse/baby’s doctor, etc.) and social sources (support group/family/friends, etc.). Univariate and multivariable analysis was conducted in SAS 9.4.

Results:

Black women consistently exhibited lower odds of breastfeeding initiation compared with other racial groups, across all informational sources. The study found that while information from both clinical and social sources increased breastfeeding initiation overall, Black women remained less likely to initiate breastfeeding than White women (p < 0.0001).

Conclusion:

Systemic barriers, including racism and bias in health care, contribute to the racial disparities in breastfeeding initiation. Culturally tailored interventions and improved health care provider training are necessary to address these gaps. Future efforts should aim to bridge the divide between clinical and social breastfeeding information sources to improve breastfeeding rates among minority women.

Background

Breastfeeding is a source of nutrition and protection for infants.^1,2 Through antibodies found within breast milk, breastfeeding can lower the risk of respiratory diseases and other illnesses, such as sudden infant death syndrome.^1,2 For mothers, breastfeeding lowers the risk for type 2 diabetes and certain cancers, such as breast cancer.^1,2 Because of the myriad health benefits, Healthy People 2030 has made breastfeeding a public health priority with aims to increase prevalence of exclusive breastfeeding for the first 6 months, as well as “some” breastfeeding with food as a supplement through 1 year.³ Despite the benefits of breastfeeding, certain racial and ethnic groups still lag in breastfeeding initiation.

The American Academy of Pediatrics recommends exclusive breastfeeding for a minimum of 6 months⁴; however, approximately one in four Black mothers never initiate breastfeeding.⁵ Moreover, about two-thirds of Black mothers do not exclusively breastfeed at 6 months, and more than three-fourths do not continue breastfeeding at 1 year.⁶ Compared with other racial groups, Black women have consistently lower breastfeeding rates at 6 months and 1 year.⁶ This disparity in breastfeeding among Black women persists regardless of education level or social status, indicating that other systemic factors create barriers to breastfeeding initiation.⁷

Factors that influence breastfeeding initiation include receiving information about breastfeeding from trusted sources and having access to postpartum care as well as to maternal leave and related family-planning resources.⁸ In contrast, inaccessible postpartum care, a lack of maternal leave and related resources, and lacking support systems are immediate barriers to breastfeeding initiation.⁸ Systemic factors, such as racism, bias, and discrimination, contribute significantly to the lack of breastfeeding initiation specifically among Black women.⁷ Black women and their health care providers identified race-related stressors that took precedence over breastfeeding. However, bias and discrimination from health care providers themselves was also a factor, with Black women noting that they did not receive breastfeeding information, advice, or encouragement from their health care providers.⁷

Information about the benefits of breastfeeding is a major driver to initiate breastfeeding,⁹ and the source of the information is also important. However, many Black women do not receive quality breastfeeding information (e.g., receive insufficient breastfeeding information) from their providers.¹⁰ Moreover, Black women and women of color prefer to discuss medical information with family, friends, or social networks instead, often due to mistrust of medical professionals.¹¹ Because of this, receiving information from medical doctors and then having it reiterated by social networks or support groups of their peers may help increase breastfeeding initiation among minority groups.^10,12

Although the source of information on breastfeeding is consistently an influential factor, few studies explore racial differences in receiving information and how each source may influence breastfeeding initiation. The Pregnancy Risk Assessment Monitoring System (PRAMS) is a large, population-based surveillance system and the only national surveillance system to provide data about pregnancy and the first months after birth.¹³ PRAMS includes variables measuring social factors, including breastfeeding information sources.^14,15 Previous studies have investigated these factors but with regard to other topics, such as intimate partner violence and opioid use, but do not address racial disparities.^14,15 Although previous work has identified specific sources of information preferred by Black women, there is only one study to date that specifically used PRAMS data to assess racial differences in receipt of information about breastfeeding.¹⁶ However, since then new data have emerged prompting a need for reassessment. Assessing sources of information can be used to inform breastfeeding interventions that focus on racial and cultural differences and improve breastfeeding initiation rates by ensuring women are receiving quality information from the sources they receive information from most. Thus, the study aimed to explore racial differences, specifically between Black women and other racial and ethnic groups, in the association between sources of breastfeeding information and breastfeeding initiation.

Methods

Data

Data from the Phase 8 Core PRAMS Core Research File (2016–2020) were analyzed for this study. These data were collected in two waves from 2016 to 2017 and from 2018 to 2020, with a participation rate of 50% and 55% in each wave, respectively.¹³ A stratified sample was drawn monthly from current birth certificate files. Participants were then recruited through paper mail and, if there was no response, researchers followed up via telephone.¹³ PRAMS uses complex stratified sampling to recruit participants and sampling weights to generate nationally representative estimates.¹³ More details about PRAMS data collection are available on the Centers for Disease Control and Prevention’s website.¹³ The PRAMS sample included 202,939 women who gave birth in the past 2–6 months and had a birth certificate on file within their local jurisdiction.¹³

Measures

The dependent variable was breastfeeding initiation. The question associated with this variable is “Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period of time?” with response options of yes or no.¹³ The independent variables included the mother’s race and informational sources about breastfeeding. The respondent’s race was self-reported, and response options included (1) Black, (2) White, (3) Japanese, (4) Filipino, (5) Chinese, (6) Other Asian, (7) American Indian, (8) Alaska Native, (9) Mixed Race, (10) Other Non-White, and (11) Hawaiian. Due to the distribution of responses, these were recoded to six racial categories as follows: Black, American Indian and Alaska Native (AIAN), White, Asian American and Native Hawaiian (AANH), Other, and Mixed Race.

Informational sources about breastfeeding were measured by asking, “Before or after your new baby was born, did you receive information about breastfeeding from any of the following sources?” with yes and no check boxes for each of the following answer choices: (1) my doctor, (2) a nurse, midwife, or doula, (3) a breastfeeding or lactation specialist, (4) my baby’s doctor or health care provider, (5) a breastfeeding support group, (6) a breastfeeding hotline or toll-free number, (7) family or friends, and (8) other with an open-ended text box.¹³ Each response option was used as stand-alone dependent variables. In addition, these variables were combined into two recoded variables as follows: clinical sources and social sources. Clinical sources included their doctor, a nurse, midwife, or doula, a breastfeeding or lactation specialist, and their baby’s doctor or health care provider. Social sources included breastfeeding support groups, a breastfeeding hotline or toll-free number, family or friends, and an “other” response option where women could denote an information source not listed. “Other” response options mostly included internet searches or YouTube videos.

The following sociodemographic factors were identified as potential confounders of associations between race and breastfeeding outcomes. Specifically, previous research has shown that maternal age, education, and socioeconomic status are associated with breastfeeding initiation.^17,18 Moreover, these factors are often variables in breastfeeding promotion interventions as they are influential in parents’ breastfeeding decisions.¹⁹ The first confounding variable was the mother’s education, and the answer choices are (1) Less than High School, (2) Some High School, (3) High School or GED, (4) Bachelor’s Degree, and (5) Graduate Degree. The referent group was bachelor’s degree. The second potential confounding variable is the mother’s age, calculated from the question “What is your date of birth?” with a text box to enter the month/day/year of the mother’s birth.¹³ This question was calculated by PRAMS, and mother’s age was grouped by less than 17–39 and older than 40. The referent group was the 40+ age-group. Socioeconomic status was denoted by the federal poverty level (FPL) and was categorized by 0–100% FPL, 101–200% FPL, 201–300% FPL, and >300% FPL.

Statistical analyses

A complete case analysis was conducted; women who completed the survey and did not have missing data for my variables of interest were included in the study sample. The final sample size when excluding missing data was 163,724. Survey weights were applied to all analyses to generate nationally representative estimates, except for California, Idaho, and Ohio as they did not participate during the 2016–2020 waves. Descriptive statistics were displayed for breastfeeding initiation, race, education, and socioeconomic status. Chi-squared tests were used to examine unadjusted associations between informational sources on breastfeeding and (1) sociodemographic factors and (2) breastfeeding initiation. Multivariable logistic regression models were constructed to examine associations between breastfeeding informational sources and breastfeeding initiation, adjusting for sociodemographic factors and other potential confounders. Interaction effects and stratified analysis between race and breastfeeding informational sources and their associations with breastfeeding initiation were also conducted. Odds ratio (OR), 95% confidence intervals (CIs), and p-values were computed to assess the association between race and breastfeeding sources. p-Values less than 0.05 and 95% CI not including the null value of 1 were considered significant. SAS version 9.4 was used for all statistical analyses.

Results

Sample characteristics

Table 1 shows that the majority of the sample was non-Hispanic White (71%), and 15% of the sample were non-Hispanic Black. Most participants used both clinical and social sources (66%). Over one-third of participants (39%) had a bachelor’s or higher (master’s, doctorate, or professional degree). Participants who were in the 25–29 (29%) and 30–34 (30%) age-groups comprised most of the sample (Table 1).

Table 1.

Weighted Characteristics of 2016–2020 Participants of the Pregnancy Risk Assessment Monitoring System (n = 163,724)

Characteristics	Weighted frequency	%
Race
Non-Hispanic Black	1,275,857	15.12
Non-Hispanic White	5,991,904	71.02
American Indian and Alaska Native	76,623	0.91
Asian and Native Hawaiian	434,910	5.16
Mixed Race	248,909	2.95
Other Race	408,458	4.84
Source of information
Clinical only	2,347,442	27.82
Social only	195,040	2.31
Both	562,052	66.67
Neither	269,126	3.19
Education
Less than 8th grade	176,141	2.09
9–12th grade, no diploma	606,754	7.19
High school graduate/GED	2,000,682	23.71
Some college/no degree/associate degree	2,342,919	27.77
Bachelor’s/Master’s/Doctorate/Professional	3,310,166	39.24
Maternal age
≤17	66,920	0.79
18–19	228,288	2.71
20–24	1,510,256	17.90
25–29	2,483,649	29.44
30–34	2,585,779	30.65
35–39	1,285,669	15.24
40+	276,100	3.27
FPL
0–100%	2,553,999	30.27
101–200%	1,838,808	21.80
201–300%	1,566,480	18.57
>300%	2,477,373	29.36
Ever breastfed
Yes	7,452,686	88.34
No	983,974	11.66
Ever breastfed by race
Yes
Non-Hispanic Black	1,007,553	78.97
Non-Hispanic White	5,373,747	89.68
American Indian and Alaska Native	65,461	85.43
Asian and Native Hawaiian	407,879	93.78
Mixed Race	222,997	89.59
Other Race	375,049	91.82
No
Non-Hispanic Black	268,304	21.03
Non-Hispanic White	618,157	10.32
American Indian and Alaska Native	11,161	14.57
Asian and Native Hawaiian	27,031	6.25
Mixed Race	25,912	10.41
Other Race	33,409	8.18

FPL, federal poverty level.

Table 1 displays that 88% of women initiated breastfeeding. Black (79%) and AIAN (83%) women were less likely to initiate breastfeeding compared with other racial groups (85–93%), and Black women had significantly lower breastfeeding initiation rates compared with all other racial groups (p < 0.0001). Table 2 shows the main logistic regression model with breastfeeding initiation as the outcome variable.

Table 2.

Main Effects from Logistic Regression If Ever Breastfed: Pregnancy Risk Assessment Monitoring System Phase 8, 2016–2020

Effect	Point estimate	95% confidence limits
Race
Black versus White	0.59	0.55	0.63
AIAN versus White	1.13	0.98	1.30
AANH versus White	1.37	1.20	1.56
Mixed Race versus White	1.23	1.07	1.42
Other Race versus White	1.97	1.69	2.31
Education
<8th grade versus Bachelor’s Degree or Higher	0.25	0.22	0.28
9–12th grade versus Bachelor’s Degree or Higher	0.47	0.39	0.57
High School Graduate/GED versus Bachelor’s Degree or Higher	0.31	0.28	0.34
Some College/Associate’s versus Bachelor’s Degree or Higher	0.49	0.45	0.53
Maternal age
≤17 versus 40+	0.82	0.62	1.10
18–19 versus 40+	1.13	0.92	1.38
20–24 versus 40+	1.04	0.89	1.22
25–29 versus 40+	1.05	0.90	1.23
30–34 versus 40+	1.08	0.93	1.26
35–39 versus 40+	1.06	0.90	1.25
FPL
0–100% FPL versus >300% FPL	0.48	0.44	0.53
101–200% FPL versus >300% FPL	0.74	0.67	0.82
201–300% FPL versus >300% FPL	0.87	0.79	0.96
Source of information
Clinical only versus neither	2.74	2.46	3.06
Social only versus neither	4.44	3.64	5.42
Both versus neither	6.53	5.82	7.28

FPL, federal poverty level.

Racial differences in breastfeeding information on breastfeeding initiation

Table 3 shows that regardless of the source of breastfeeding information, Black women consistently have lower odds of ever breastfeeding compared with White women, with ORs ranging from 0.40 (95% CI: 0.35–0.47, support group) to 0.63 (95% CI: 0.59–0.67; mother’s doctor). The odds of ever breastfeeding for other races by information source are somewhat variable. AIAN women show higher odds with sources like ‘other’ sources (OR = 1.65; 95% CI: 1.19–2.29) or their doctor (OR = 1.21; 95% CI: 1.06–1.39), but lower odds with a support group (OR = 0.60; 95% CI: 0.45–0.81) compared with White women. AANH, Mixed Race, and Other Race women generally have higher odds of ever breastfeeding compared with White women across several sources (Table 3).

Table 3.

Odds Ratio of Ever Breastfed Interaction Effects Between Race and Source of Breastfeeding Information Pregnancy Risk Assessment Monitoring System Phase 8, 2016–2020

Race	Mother’s doctor	Nurse/ midwife/doula	Lactation specialist	Baby’s doctor	Support group	Hotline	Family/friends	Other
Received information from this source
White (ref)	—	—	—	—	—	—	—	—
Black	0.63 (0.59–0.67) ^*	0.55 (0.51–0.59) ^*	0.45 (0.41–0.50) ^*	0.52 (0.48–0.56)^*	0.40 (0.35–0.47) ^*	0.55 (0.46–0.67) ^*	0.54 (0.49–0.58) ^*	0.59 (0.49–0.70)^*
AIAN	1.21 (1.06–1.39)	0.98 (0.85–1.13)	0.74 (0.60–0.90)	1.02 (0.88–1.19)	0.60 (0.45–0.81)	0.88 (0.64–1.21)	1.05 (0.87–1.28)	1.65 (1.19–2.29)
AANH	1.47 (1.27–1.69)*	1.27 (1.095–1.475)	1.04 (0.86–1.24)	1.29 (1.10–1.50)	0.77 (0.60–1.00)	0.97 (0.70–1.35)	1.16 (0.97–1.39)	1.11 (0.75–1.65)
Mixed Race	1.29 (1.11–1.51)	1.21 (1.01–1.44)	1.06 (0.86–1.31)	1.06 (0.89–1.27)	1.03 (0.72–1.46)	1.23 (0.76–2.01)	1.18 (0.98–1.43)	1.36 (0.84–2.21)
Other Race	2.11 (1.79–2.51) ^*	1.85 (1.55–2.20) ^*	1.18 (0.97–1.44)	1.87 (1.56–2.25)	1.22 (0.93–1.59)	1.68 (1.19–2.36)	1.55 (1.26–1.91)	2.17 (1.38–3.41)

Indicates significance at the p < .0001 level, bold indicates significance at the p < 0.05 level.

AANH, Asian American and Native Hawaiian; AIAN, American Indian and Alaska Native.

Overall, all races and ethnicities have higher odds of initiating breastfeeding if they receive breastfeeding information compared with no information at all (Table 4). Generally, social sources result in higher odds compared with clinical sources except for Asian women (OR = 3.37; 95% CI: 1.28–7.87, clinical sources) (Table 4). Receiving breastfeeding information from a combination of both sources is associated with higher odds of breastfeeding initiation among all groups, except Asian women (Table 4).

Table 4.

Association Between Breastfeeding Initiation and Breastfeeding Information Sources Stratified by Race

Race	Clinical sourcesOR (95% CI)	Social sourcesOR (95% CI)	Both sourcesOR (95% CI)	Neither sourcesOR (95% CI)
White (N = 98,333)	2.94 (2.59–3.34) ^*	5.10 (3.95–6.58) ^*	7.83 (6.90–8.89) ^*	Ref
Black (N = 29,884)	1.97 (1.50–2.59) ^*	3.07 (2.04–4.62) ^*	4.02 (3.08–5.25) ^*	Ref
AIAN (N = 7,169)	2.12 (1.09–4.10)	4.63 (1.97–10.85)	3.86 (1.99–7.49) ^*	Ref
Asian (N = 11,184)	3.37 (1.98–5.71) ^*	3.17 (1.28–7.87)	5.10 (3.06–8.51) ^*	Ref
Mixed Race (N = 9,705)	3.53 (1.93–6.45) ^*	5.05 (1.84–13.86)	7.95 (4.43–14.22) ^*	Ref
Other Race (N = 7,449)	1.81 (0.98–3.33)	2.08 (0.86–5.01)	3.01 (1.67–5.40)	Ref

Indicates significance at the p < .0001 level, bold indicates significance at the p < 0.05 level. AIAN, American Indian and Alaska Native; CI, confidence interval; OR, odds ratio.

Discussion

This study was the second to use PRAMS data to investigate racial disparities in receipt of breastfeeding information and its association with breastfeeding initiation.¹⁶ Unlike the previous study that utilized data from 2016 to 2019, the current study used data from 2016 to 2020. We found that Black women and AIAN women had the lowest breastfeeding initiation rates compared with all other racial and ethnic groups. Black women, specifically, had the lowest breastfeeding initiation rate that was below 80% compared with all other groups. This aligns with previous literature that has found similar racial disparities in breastfeeding rates.^16,20

Overall, the data suggest that breastfeeding information, particularly from combined clinical and social sources, generally increases the likelihood of breastfeeding initiation across all racial groups, although the magnitude of this effect varies by race. Specifically, among Black women, we see that regardless of the source of information they are still less likely to breastfeed compared with White women. The majority of participants received information from both clinical and social sources, with clinical sources only (i.e., mother’s doctor, baby’s doctor) following close behind. This may mean that even though Black women are receiving information from similar sources as their counterparts, other factors are at play. This is in line with previous research that has discussed the difficulties with breastfeeding among Black women and women of color.^11,21,22 This could be because breastfeeding is not a highly discussed topic in the Black community due to historically negative connotations surrounding breastfeeding in this population.²³ The psychosocial effects over time from wet nursing, medical racism, and discrimination that have occurred have contributed to decreased breastfeeding rates, specifically in the Black community.²³ This consistent pattern emphasizes the need to bridge the gap between clinical and social sources of information.

This study aligns with previous literature that have emphasized the importance of getting information from both clinical and social sources.²⁴ Because medical racism and discrimination often cause lapses in information from clinical sources,²⁵ physicians should be trained on cultural competency and diversity when caring for their Black patients. Moreover, based on the results of this study, social sources are an important facet to breastfeeding information and need more investigation into what social sources are crucial to the breastfeeding process for Black women and other racial and ethnic minorities.

Breastfeeding is an important public health topic and has garnered increasing attention in recent years, especially concerning racial disparities among racial minority groups such as Black and AIAN populations. Identifying where parents are receiving breastfeeding information from can aid in tailoring breastfeeding promotional interventions to meet their specific needs and improve the acceptance of breastfeeding information. Future studies should look to develop and implement culturally tailored material, including those that bridge the gap between clinical sources and racial minorities’ familial information sources, into breastfeeding interventions. Since this study did not have information available about the quality of information provided by sources, future research should focus on the quality of breastfeeding information provided by health care professionals and how social sources can better relay breastfeeding information.

The cross-sectional and self-reported nature of the PRAMS data means that temporality cannot be ascertained and there may be inaccuracy of reported behaviors, specifically with breastfeeding information categories such as “other” that included self-reported sources, such as the internet. Despite these limitations, the study has numerous strengths. PRAMS is a nationally representative dataset and the largest dataset of its kind for investigating pregnancy and early postbirth months. In addition, the data are designed to be weighted to obtain estimates representative of the general population. Finally, robust statistical analyses were conducted including post hoc tests and sensitivity analyses, and findings were consistent across models.

This study explored racial disparities in receipt of breastfeeding information and its association with breastfeeding initiation. Overall, we found that regardless of source for Black women, specifically, they had significantly lower odds of initiating breastfeeding. Black and AIAN women have disparities in breastfeeding initiation; however, implementing the knowledge from this study with health care providers could be a starting point to establish culturally appropriate care for Black and AIAN women. This information could also be used as a baseline to implement training of social sources to recommend breastfeeding during the prenatal and perinatal periods, since minority groups prefer to receive medical information from social sources. Doing this will lead to improved maternal and child health outcomes among these groups and overall.

Footnotes

Acknowledgment

The authors thank Dr. Matthew Rossheim (University of North Texas Health Science Center) for useful discussions and assistance with this article.

Authors’ Contributions

K.C.J.: Conceptualization, methodology, formal Analysis, writing—original draft, and writing—review and editing. R.B.B.: Formal Analysis, writing—original draft, and writing—review and editing. I.N.A.: Writing—original draft and writing—review and editing. S.B.G.: Writing—original draft and writing—review and editing.

Disclosure Statement

The authors report there are no competing conflicts of interest to declare.

Funding Information

The authors report there are no funding sources to declare.

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