Influence of Race and Ethnicity on Meeting Intention to Exclusively Breast Milk Feed at Postpartum Hospital Discharge

Abstract

Background:

Racial/Ethnic disparities in breastfeeding practices exist despite strong evidence for significant health benefits of breastfeeding for the mother–newborn dyad. Breastfeeding intentions are known to predict breastfeeding practices at hospital discharge and breastfeeding retention in the long term. Interventions during postpartum hospitalization can help mothers achieve breastfeeding intentions and reduce racial/ethnic gaps in breastfeeding on discharge. This study aims to identify racial/ethnic disparities in meeting intentions to exclusively breast milk feed (EBMF) on hospital discharge.

Methods:

This was a retrospective cohort study of mothers who intended to EBMF and their newborns delivered at term at a single academic medical center during 2022. The primary outcome was EBMF at discharge.

Results:

Participants included non-Hispanic Black (NHB) (n = 96), Hispanic (n = 97), and non-Hispanic White (NHW) (n = 955) mothers who intended to EBMF. Mothers who identified as NHB (40.6%) or Hispanic (64.9%) were significantly less likely to EBMF compared with NHW (87.5%) mothers (odds ratio [OR] = 0.14, 95%CI [0.08, 0.23] and OR = 0.37, 95%CI [0.22, 0.61], respectively) at newborn hospital discharge. Rurality, insurance type, gravidity, parity, gestational diabetes, and birth weight were not associated with breast feeding choice/practices at discharge, but increasing age was associated with an increased likelihood of EBMF (OR = 1.07, 95%CI [1.03, 1.11]), as was neonatal intensive care unit admission (OR = 2.93, 95%CI [1.18, 7.31]). Cesarean birth was associated with decreased likelihood of EBMF (OR = 0.57, 95%CI [0.38, 0.85]).

Conclusion:

Significant racial/ethnic disparities in EBMF at hospital discharge exist among those who intended to EBMF, which are not explained by differences in other examined covariates.

Introduction

The health benefits of breastfeeding for mothers/birthing people and children are widely established.¹ Breastfed infants have a reduced risk of gastrointestinal infection, otitis media, respiratory tract infection, asthma, allergies, obesity, type 1 and 2 diabetes mellitus, and sudden infant death syndrome.^2–5 In the long term, mothers/birthing people who breastfeed have a reduced risk of ovarian cancer, breast cancer, hypertension, coronary artery disease, and type 2 diabetes.^6–10 The World Health Organization recommends exclusive breast milk feeding (EBMF) for 6 months and continued breast milk feeding until 2 years or beyond.^11,12 Given that Black mothers/birthing people and infants continue to experience the highest burden related to poor maternal and infant health outcomes, breastfeeding is an especially important public health issue in Black communities.^12,13 Despite robust evidence of significant health benefits of breastfeeding for mother/birthing person and infant, racial and ethnic disparities in breastfeeding rates exist. In 2020 and 2021, the prevalence of breastfeeding initiation was 84.0% overall and varied by maternal race/ethnicity, ranging from 90.1% among infants of Asian mothers to 74.5% among infants of Black mothers/birthing people.¹⁴ However, the breastfeeding experiences of racial/ethnic minority mothers/birthing people in the United States remain understudied.¹⁵

Postpartum hospital experiences such as formula supplementation and access to quality breastfeeding support are modifiable factors positively correlated with breastfeeding long term.¹⁶ The Baby Friendly Hospital Initiative (BFHI) is an evidence-based program designed to increase breastfeeding through standardized hospital protocols.¹⁷ The “Ten Steps to Successful Breastfeeding” consists of evidence-based practices that have been shown to increase breastfeeding initiation and duration, forming the framework that guides the BFHI.¹⁷ The steps include complying with the International Code of Marketing of Breast-milk Substitutes; developing a written breastfeeding policy that is routinely communicated to all health care staff; establishing ongoing monitoring and data management systems; training all health care staff in the skills necessary to support breastfeeding; informing all pregnant people about the benefits and management of breastfeeding; facilitating immediate and uninterrupted skin-to-skin contact and supporting mothers/birthing people to initiate breastfeeding as soon as possible after birth; supporting mothers/birthing people to initiate and maintain breastfeeding and manage common difficulties; giving newborn infants no food or drink other than breast milk, unless medically indicated; practicing rooming-in; supporting mothers/birthing people to recognize and respond to their infants’ cues for feeding; counseling mothers/birthing people on the use and risks of feeding bottles, artificial nipples (teats), or pacifiers; and coordinating discharge so that parents and their infants have timely access to ongoing support and care.¹⁷

Studies have shown benefits of the BFHI for increasing breastfeeding rates among racially diverse/low-income populations.^18,19 There is a dose–response relationship between the number of BFHI steps mothers/birthing people and their newborns are exposed to and the likelihood of improved breastfeeding outcomes.²⁰ In Iowa, the implementation of the BFHI steps differs across locations, with only two of the state’s 56 birthing hospitals currently receiving the “Baby-Friendly” designation.^21,22 This award is granted after an external evaluation to determine whether a facility has fully implemented all the 10 steps.¹⁹ Even when BFHI is implemented, racial disparities in breastfeeding exist, highlighting the need to explore additional barriers.²³

While many pregnant people intend to exclusively breastfeed, they face a multitude of challenges that influence the realization of their breastfeeding goals. Racial and ethnic disparities in breastfeeding initiation and long-term success stem from a wide range of interconnected historical, cultural, social, economic, political, and psychosocial factors.²⁴ Systemic and structural barriers, such as racism, bias, and inequitable access to lactation resources and support, continue to be issues in the United States.²⁵

Breastfeeding disparities are well documented for non-Hispanic Black (NHB) mothers/birthing people and their infants, despite similar rates of prenatal intention to breastfeed.²⁶ EBMF on discharge from postpartum hospitalization has been shown to have decreased risk of breastfeeding cessation.²⁷ While earlier studies have explored the impact of race/ethnicity on breastfeeding intention and initiation, they have not explicitly addressed its influence on meeting self-identified breastfeeding goals during the postpartum hospital stay, a period that has been shown to influence breastfeeding outcomes in the longer term. The long-term goal of this study is to characterize racial/ethnic disparities in breastfeeding practices in a Midwestern comprehensive academic medical center. We hope that the outcomes of this study will inform the development of meaningful, evidence-based, patient-centered, and culturally responsive interventions to increase rates of EBMF rates among NHB and Hispanic mothers/birthing people who experience breastfeeding challenges/barriers.

The study aims to characterize the relationship between race/ethnicity and infant feeding decisions during postpartum hospitalization. The study will test the primary hypothesis that NHB and Hispanic mothers/birthing parents who intended to EBMF are less likely to be EBMF on discharge compared with non-Hispanic White (NHW) mothers/birthing people.

Methods

This was a retrospective cohort study consisting of mother–newborn dyads who were delivered at term at University of Iowa Health Care (UIHC) during 2022 with a documented intention to EBMF. The study was approved by the University of Iowa Institutional Review Board (#202306436). Subjects were separated into three groups each consisting of at least 90 mother–newborn dyads self-identifying as NHW, NHB, or Hispanic race/ethnicity as recorded in the electronic health record (EHR). A power analysis showed that this sample size would detect a difference in realizing breastfeeding goals with a power of 80% and significance of 0.05.

UIHC is an 800-bed comprehensive academic medical center and regional referral center in the Midwest region of the United States. The Obstetrics and Gynecology and Family Medicine departments perform approximately 3,000 deliveries per year. UIHC does not have a Baby-Friendly designation.

Data were collected from the Intergenerational Health Knowledgebase derived from the EHR of mother–newborn dyads who met the inclusion criteria of intention to EBMF.^28–30 For this study’s purpose, EBMF was defined as breastfeeding, breast pumping, bottle feeding with pumped breast milk, and/or bottle feeding with donor breast milk without the intention to supplement with formula. Subjects were excluded if the gestational age at birth was <37 weeks, if data on feeding type at discharge were not available in the EHR, if the mother/birthing person was <18 years old, or if the mother/birthing person was admitted to the intensive care unit. Data on primary outcome (EBMF yes/no) and co-variables, including demographic factors (maternal age, race, ethnicity, gravidity, parity, body mass index [BMI], rurality, and insurance information), obstetric comorbidities (gestational diabetes and hypertensive disorders of pregnancy), and obstetric/neonatal factors (mode of delivery, quantity of blood loss intrapartum, hemoglobin results, depression screening results, Apgar score at 1 and 5 minutes, infant birth weight, length of hospital stay, and admit nursery) were automatically extracted from UIHC’s Maternal Child Knowledgebase and manually extracted from the EHR.²⁸ Rurality was determined by postal code and corresponding Rural–Urban Commuting Area Codes. Study data were collected and managed using REDCap electronic data capture tools hosted at University of Iowa.^29,30

The data were analyzed using IBM SPSS Statistics (Version 29). Descriptive statistics were used to examine distributions of study variables and to summarize participant characteristics. Bivariate associations between the dependent variable and each of the independent variables, as well as each of the covariates, were tested. Chi-squared tests, one-way Analysis of variance (ANOVA) tests, or Kruskal–Wallis tests were used to test the association between variables and racial/ethnic groups. A binomial logistic regression was performed to ascertain the effects of race/ethnicity on the likelihood that mothers/birthing people who intended to breastfeed will feed exclusive breast milk versus combination (breast milk and formula combination) or exclusive formula feeding after discharge and to control for the potential confounding variables. Alpha = 0.05 for all analyses.

Results

Overall, 1,267 mother–newborn dyads were identified in 2022 who intended to EBMF. Of these, 113 dyads were excluded due to gestational age <37 weeks and 5 dyads were excluded due to maternal age <18 years. In addition, one dyad was excluded due to unknown feeding decision at discharge, and one dyad was excluded due to maternal intensive care unit admission (Fig. 1). Of the 1,148 subjects included in the study, 96 identified as NHB, 97 identified as Hispanic, and 955 identified as NHW.

FIG. 1.

Flowchart diagram of subject selection.

Demographic and Obstetric/Neonatal characteristics were compared by racial/ethnic group (NHB, Hispanic, or NHW) (Table 1). A one-way between subjects ANOVA was conducted to compare the effect of race/ethnicity on maternal age (years), maternal BMI (kg/m²), discharge hemoglobin level (g/dL), quantity of blood loss during delivery (mL), maternal length of hospital stay (days), and neonatal birth weight (grams). One-way ANOVA test identified significant differences between groups in mean maternal age (years) (F[2, 1145] = 13.351, p < 0.001), discharge hemoglobin level (g/dL) (F[2, 1132] = 5.218, p = 0.006), and neonatal birth weight (grams) (F[2, 1145] = 11.803, p < 0.001). Kruskal–Wallis tests were performed on the gravidity, parity, Patient Health Questionnaire scores, and Apgar scores of the three groups. The differences between the mean rank totals of gravidity (H[2] = 9.773, p = 0.008) and parity (H[2] = 23.449, p < 0.001) were significant. Chi-squared tests of independence were executed to evaluate the relationship between race/ethnicity and obstetric/neonatal characteristics, including mode of delivery, gestational diabetes, preeclampsia, neonatal intensive care unit (NICU) admission, rurality, and insurance type. Observed frequencies are reported in Table 1. The chi-square test yielded significant results for gestational diabetes (χ²[2] = 6.621, p = 0.036), rurality (χ²[2] = 37.218, p < 0.001), and insurance type (χ²[12] = 151.282, p < 0.001). NHB mothers/birthing people more often had cesarean births (26, 27.1%) compared with Hispanic mothers/birthing people (23, 23.7%), and NHW mothers/birthing people (275, 24.0%) and newborns of NHB mothers/birthing people were more likely to be admitted to the NICU (6, 6.3%) compared with Hispanic mothers/birthing people (5, 5.2%) and NHW mothers/birthing people (66, 5.7%); however, these differences were not significant. All other characteristics were found to be similar between groups.

Table 1.

Demographic and Obstetric/Neonatal Characteristics by Racial/Ethnic Group and Total Subject Population

	NHB (n = 96)	Hispanic (n = 97)	NHW (n = 955)	Total (n = 1,148)	p
Maternal age (years) (mean ± SD)	28.9 ± 5.6	27.7 ± 5.2	30.1 ± 4.8	29.8 ± 4.9	<0.001 ^a
Maternal BMI (kg/m²) (mean ± SD)	32.7 ± 7.1	33.3 ± 6.5	33.1 ± 7.3	33.1 ± 7.2	0.882 ^a
Gravidity [median (IQR)]	3 (2)	2 (2)	2 (2)	2 (2)	0.008 ^b
Parity [median (IQR)]	1 (3)	1 (2)	1 (1)	1 (2)	<0.001 ^b
Mode of delivery
Vaginal	64 (66.7%)	68 (70.1%)	675 (70.7%)	807 (70.3%)	0.949 ^c
Cesarean	26 (27.1%)	23 (23.7%)	226 (23.7%)	275 (24.0%)
VBAC	6 (6.3%)	6 (6.2%)	55 (5.7%)	66 (5.7%)
Gestational age (weeks) (mean ± SD)	38.9 ± 1.2	38.9 ± 1.1	39.0 ± 1.1	39.0 ± 1.1	0 . 648 ^a
Hemoglobin (g/dL) (mean ± SD)	10.0 ± 1.2	10.0 ± 1.3	10.3 ± 1.3	10.3 ± 1.3	0.006 ^a
QBL (mL) (mean ± SD)	544 ± 499	577 ± 451	528 ± 491	533 ± 488	0.627 ^a
Gestational diabetes	17 (17.7%)	11 (11.3%)	90 (9.4%)	118 (10.3%)	0.036 ^c
Preeclampsia	9 (9.4%)	6 (6.2%)	59 (6.2%)	74 (6.4%)	0.475 ^c
PHQ-9 score at hospital discharge (mean ± SD)	2.6 ± 3.9	2.6 ± 3.0	2.3 ± 2.7	2.3 ± 2.8	0.222 ^b
Maternal length of hospital stay (days) (mean ± SD)	2.9 ± 1.2	2.8 ± 1.1	2.9 ± 4.3	2.9 ± 3.9	0.083 ^a
Neonatal birth weight (grams) (mean ± SD)	3,283 ± 518	3,332 ± 417	3,484 ± 462	3,454 ± 468	<0.001 ^a
Apgar 1 minute [median (IQR)]	8 (2)	8 (2)	8 (2)	8 (2)	0.158 ^b
Apgar 5 minute [median (IQR)]	9 (0)	9 (0)	9 (0)	9 (0)	0.143 ^b
NICU admission	6 (6.3%)	5 (5.2%)	55 (5.8%)	66 (5.7%)	0.947 ^c
Lives in rural area	8 (8.3%)	45 (46.4%)	356 (37.3%)	409 (35.6%)	<0.001 ^c
Insurance type
Medicaid	62 (64.6%)	61 (62.9%)	199 (20.8%)	322 (28.0%)	<0.001 ^c
Private/Commercial	33 (34.4%)	33 (34.0%)	730 (76.4%)	796 (69.3%)
Medicare	0 (0.0%)	0 (0.0%)	3 (0.3%)	3 (0.3%)
Veteran care	0 (0.0%)	1 (1.0%)	4 (0.4%)	5 (0.4%)
TRICARE	1 (1.0%)	2 (2.1%)	12 (1.3%)	15 (1.3%)
No insurance	0 (0.0%)	0 (0.0%)	7 (0.7%)	7 (0.6%)

One-way ANOVA test for significant differences by racial group.

Kruskal–Wallis test for significant differences by racial group.

Chi-square test for Independence by racial group.

BMI, body mass index; IQR, interquartile range; NHB, Non-Hispanic Black; NHW, Non-Hispanic White; NICU, neonatal intensive care unit; PHQ-9, Patient Health Questionnaire; SD, standard deviation; QBL, quantity of blood loss during delivery; VBAC, vaginal birth after cesarean. Bold and italics values are statistically significant.

To assess the relationship between race/ethnicity and EBMF on discharge, we performed a chi-squared test of independence. Among the NHB group, 39 individuals were EBMF in contrast to 57 who were not. Comparably, in the Hispanic group, 63 were EBMF, whereas 34 were not. Finally, within the NHW group, 938 were EBMF, whereas 210 were not (Table 2). The chi-square test yielded significant results, χ²(2) = 148.362, p < 0.001.

Table 2.

Frequencies and Percentages of Exclusive Breast Milk Feeding by Race/Ethnicity and Total Population

	NHB (n = 96)	Hispanic (n = 97)	NHW (n = 955)	Total (n = 1,148)	χ²	df	p
EBMF at discharge
Yes	39 (40.6%)	63 (64.9%)	836 (87.5%)	938 (81.7%)	148.362	2	<0.001
No	57 (59.4%)	34 (35.1%)	119 (12.5%)	210 (18.3%)	148.362	2	<0.001

EBMF, exclusive breast milk feeding; df, degrees of freedom; NHB, Non-Hispanic Black; NHW, Non-Hispanic White.

A logistic regression was performed to ascertain the effects of race/ethnicity on the likelihood of mothers/birthing people who intended to EBMF versus combination (breast milk and formula) or exclusive formula feeding after discharge and to control for the potential confounding effect of age, gravidity, parity, gestational diabetes, discharge hemoglobin, neonatal birth weight, rurality, insurance type, mode of delivery, and NICU admission (Table 3). The logistic regression model was statistically significant, (χ²[13, n = 1148] = 163.971, p < 0.001). The model explained 21.9% (Nagelkerke R²) of the variance in breastfeeding and correctly classified 83.2% of cases. NHB and Hispanic mothers/birthing people were significantly less likely to EBMF compared with NHW mothers/birthing people (odds ratio [OR] = 0.14, 95%CI [0.08, 0.23] and OR = 0.37, 95%CI [0.22, 0.61], respectively). Rurality, insurance type, gravidity, parity, gestational diabetes, and birth weight were not associated with breastfeeding choice, but increasing age was associated with an increase in the likelihood of EBMF (OR = 1.07, 95%CI [1.03, 1.11]), as was NICU admission (OR = 2.93, 95%CI [1.18, 7.31]). Cesarean birth was associated with decreased likelihood of EBMF (OR = 0.57, 95%CI [0.38, 0.85]).

Table 3.

Logistic Regression Analysis Predicting the Effect of Race/Ethnicity, Age, Gravidity, Parity, Gestational Diabetes, Discharge Hemoglobin, Neonatal Birth Weight, Rurality, Insurance Type, Mode of Delivery, and NICU Admission on Exclusive Breast Milk Feeding on Discharge

		β	SE β	Wald χ²	df	p	e ^β(Odds ratio)	95% CI
Variable	Reference	β	SE β	Wald χ²	df	p	e ^β(Odds ratio)	Lower	Upper
Race/ethnicity				62.232	2	<0.001
NHB	NHW	−2.004	0.264	57.781	1	<0.001	0.135	0.08	0.226
Hispanic	NHW	−0.998	0.255	15.368	1	<0.001	0.369	0.224	0.607
Insurance type
Private/Commercial (True)	False	0.805	0.761	1.119	1	0.29	0.447	0.101	1.987
Medicaid (True)	False	1.124	0.765	2.155	1	0.142	0.325	0.073	1.457
Rural (True)	False	0.048	0.188	0.066	1	0.798	0.953	0.659	1.378
Gestational diabetes (True)	False	0.24	0.264	0.823	1	0.364	0.787	0.469	1.321
Cesarean (True)	False	0.564	0.204	7.659	1	0.006	0.569	0.381	0.848
NICU	Newborn Nursery	1.076	0.466	5.337	1	0.021	2.933	1.177	7.309
Age	—	0.067	0.021	10.36	1	0.001	1.069	1.027	1.114
Gravidity	—	−0.042	0.1	0.177	1	0.674	0.959	0.789	1.166
Parity	—	−0.227	0.142	2.571	1	0.109	0.797	0.603	1.052
Hemoglobin	—	0.031	0.07	0.193	1	0.66	1.031	0.899	1.182
Birth weight	—	0	0	0.531	1	0.466	1	1	1.001
Constant	—	0.535	1.407	0.145	1	0.704	1.708

df, degrees of freedom; NICU, neonatal intensive care unit; NHB, Non-Hispanic Black; NHW, Non-Hispanic White; SE, standard error. Bold values are statistically significant.

Discussion

This study investigated the effects of race/ethnicity on meeting intentions to EBMF and found that NHB and Hispanic mothers/birthing people were significantly less likely to meet their intentions to EBMF at hospital discharge than NHW mothers/birthing people. Even though maternal age, gravidity, parity, gestational diabetes, discharge hemoglobin, neonatal birth weight, rurality, and insurance type differed significantly between the racial/ethnic groups studied, these factors did not explain the racial/ethnic disparities in EBMF at discharge from postpartum hospitalization identified in our study. In addition to race/ethnicity, maternal age, cesarean birth, and NICU admission were identified as factors that influence EBMF at hospital discharge among our study population.

Racial/ethnic disparities in breastfeeding outcomes are well documented. Fryer et al. hypothesized that the difference in breastfeeding rates among Hispanic and NHB women of similar socioeconomic status resulted from differences in social support or other psychosocial factors. However, after adjustment for each of the statistically significant psychosocial and demographic covariates, including age, income, using federal supplemental nutrition, education, planned pregnancy, gestational age at delivery, birth weight, baseline depression score, and history of sexual abuse, Hispanic women continued to have higher odds of breastfeeding compared with NHB women immediately postpartum.³¹ Similarly, our findings suggest that differences in demographic and obstetric/neonatal factors identified in our sample do not fully account for the racial/ethnic disparities in EBMF immediately postpartum. Robinson et al. suggest that health care providers’ biased assumption that NHB women would not breastfeed affects the quality of breastfeeding support provided to them, such as fewer referrals for lactation support and more limited assistance when problems develop.¹⁶ Breastfeeding problems requiring lactation support are common in the early postpartum period. These experiences can influence a mother’s/birthing person’s breastfeeding decisions.³² The approach to addressing breastfeeding problems in the early postpartum period can affect a mother’s self-confidence in breastfeeding and subsequent breastfeeding success.³³

Similarly, prior studies have identified age-related disparities in implementation of hospital practices that promote breastfeeding, with younger mothers/birthing people less likely to experience these practices.³⁴ This is aligned with the findings of our study that increasing age was associated with increased likelihood of EBMF on discharge. Of note, NHW mothers/birthing people were significantly older than NHB and Hispanic mothers/birthing people on average in our study. However, when adjusted for age and other potential confounding factors, race/ethnicity remained significantly associated with EBMF on discharge, indicating that age differences between groups do not entirely explain the racial/ethnic disparities in breastfeeding outcomes in our study.

While our study did not identify a significant difference in rate of cesarean births between racial/ethnic groups in the cohort studied, prior research suggests that nationally, racial differences in cesarean births exist and Black mothers/birthing people are significantly more likely to experience cesarean births than White mothers/birthing people.³⁵ In our sample, cesarean birth was negatively associated with EBMF. This finding is consistent with prior research suggesting that mothers/birthing people who experience cesarean births are less likely to EBMF postpartum and are more likely to require formula supplementation.³⁶ Singh et al. suggest that increased breastfeeding difficulties such as low milk supply and infant behavioral/health difficulties may contribute to disparities in breastfeeding outcomes for mothers/birthing people who experience cesarean births compared with vaginal births.³⁷ Racial/ethnic differences in NICU admission have been documented in prior research; however, differences identified in our study were not significant. Given that our study did not include preterm neonates, our sample had a relatively small number of NICU admissions and was likely not powered to detect a significant difference between racial/ethnic groups. However, in our sample of term neonates, those admitted to NICU were more likely to be EBMF on discharge. Due to the strong body of research documenting various benefits of human milk in the NICU for the short and long-term health and neurological development of very low birth weight (VLBW) infants, the American Academy of Pediatrics recommends that all VLBW infants receive human milk in the NICU.³⁸ Even though not all NICU babies are VLBW, the UIHC NICU has easier access to donor milk through the milk bank run by the institution and has better processes for lactation support. Thus, it would be expected that parents of neonates admitted to the NICU in the studied cohort experience increased support for breastfeeding.

Given the study design, we were limited to assessing variables available in the EHR. As a result, our study did not include data on socioeconomic status (other than insurance status), income, marital status, prior experience with breastfeeding, breastfeeding self-efficacy, exposure to immediate skin-to-skin contact, pacifier use, maternal education, and familial support, all of which have been shown in previous studies to influence infant feeding decisions. While this study was conducted in an academic medical center and the only tertiary institution in the state with a wide service area, it may not be possible to generalize the findings to other types of birthing facilities or to institutions in other states. In addition, the generalizability of our study findings is limited to NHB, Hispanic, and NHW racial/ethnic groups as there was only a small number of patients of other races/ethnicities in the sample population.

Postnatal unit experiences have previously been associated with exclusive breastfeeding during postpartum hospitalization.³⁹ A Center for Disease Control and Prevention report suggests that state and territorial health departments should consider developing culturally relevant initiatives to better target populations that disproportionately experience or report breastfeeding barriers.⁴⁰ When considering interventions to facilitate breastfeeding, it is important to not only consider how varying cultural beliefs may influence a lactating parent’s perceptions and attitudes toward breastfeeding but also to center their experiences, addressing systemic and structural barriers hindering the realization of their breastfeeding goals.²⁴ Future research should focus on identifying and exploring aspects of the mother’s/birthing person’s experiences, perceptions, and attitudes that influence their newborn feeding decisions. In addition, consideration could be given to implicit bias assessment and training by providers and hospital staff to identify and address unconscious biases that might affect the management of patients in the postpartum period.

Conclusion

Significant racial/ethnic disparities in meeting breastfeeding goals at hospital discharge exist among those who intended to EBMF, which are not explained by differences in other examined covariates. While our study did not assess all the complex sociodemographic factors that influence neonatal feeding decisions, it is important to realize that race and ethnicity are markers for racial and ethnic bias that may contribute to disparities in breastfeeding support and implementation of hospital practices. Further understanding of how parents’ experiences during postpartum hospitalization influence their infant feeding decisions will help us develop interventions to support families to achieve their breastfeeding goals and reduce racial/ethnic disparities in breastfeeding.

Footnotes

Authors’ Contributions

S.C.: Conceptualization, methodology, formal analysis, investigation, data curation, writing—original draft, and visualization. D.S.: Formal analysis, resources, data curation, and writing—review and editing. T.A.: Conceptualization and writing—review and editing. N.B.: Conceptualization, methodology, resources, writing—review and editing, supervision, and project administration.

Disclosure Statement

No competing financial interests exist.

Funding Information

Research reported in this publication was supported by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UM1TR004403. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This study was also supported by Iowa Public-Private Partnership funding.

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