Social Determinants of Breastfeeding in the United States

In 1972, only 22% of all infants in the U.S. were breastfed. Just 8.2% of these babies were Black. This nadir has reversed over the last five decades due to public health programs and growing evidence of the myriad benefits of breastfeeding. Nevertheless, significant and alarming social disparities in breastfeeding persist. As in 1972, in 2015 Black women and those with less education were less likely to breastfeed than white and more educated women. For both infant and mother, the immediate and long-term health benefits of breastfeeding counteract health problems that disproportionately affect Black Americans – including infant mortality, hypertension, and breast cancer.

Adverse social determinants of health are recognized as root causes of disparate infant feeding practices, including breastfeeding initiation and continuation, and health outcomes. Social determinants of health are the “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality-of-life outcomes and risks,” according to the U.S. Department of Health and Human Services Healthy People 2030 strategic goals. These social factors can positively or negatively impact health.  Negative or “adverse” determinants are more common among underrepresented minority populations and therefore are among the root causes of racial/ethnic disparities in health outcomes.

We recently published an overview of the evidence and mechanisms by which social determinants of health contribute to on-going breastfeeding disparities in the U.S. Key themes include:

Education: Higher educational attainment is associated with increased breastfeeding via both the financial support from job mobility and wealth that education affords, and lactation-specific education.

Employment: Many studies have shown that a an earlier return to work, particularly within 3 months, is negatively associated with breastfeeding initiation and duration. Evidence regarding the impact of paid maternity leave is mixed and deserves further exploration to inform future public policy. After return to work, barriers to breastfeeding in the work environment such as facilities and allotted time for pumping, are also substantial contributors to breastfeeding cessation

Food: The association between household food insecurity and early breastfeeding cessation may be due to maternal concerns about food intake and milk production. Breastfeeding has been shown to increase among mothers who participate in supplemental food programs.

Neighborhood: Neighborhood disadvantage is associated with lower breastfeeding among residents, which may be mediated through availability or not of breastfeeding resources and social networks in those neighborhoods.

Housing: Homelessness and housing instability have been associated with lower breastfeeding initiation and duration. Homeless mothers are less likely to attend prenatal and well-child visits where breastfeeding education is given, and shelters may not accommodate breastfeeding mothers.

Racism: Racism intersects with other social determinant to negatively affect health by creating and maintaining health disparities. Structural racism has created disparities in both health and income. Experience of workplace racism is associated with lower rates of breastfeeding among Black women. And biased assumptions held by some health care providers have led to poor breastfeeding support services for Black and Hispanic mothers.

We can address these challenges by recognizing the mechanisms by which social determinants effect breastfeeding. Understanding the root causes of racial disparities in health outcomes will allow us to develop strategies to reverse these phenomena. Interventions to support breastfeeding should target social determinants of health and, optimally, combine interventions at the policy, community, organization, and individual levels.

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