Understanding the Challenges of Breastfeeding

Improving breastfeeding rates has the potential to significantly reduce health disparities in the United States. The number of U.S. mothers who breastfeed their infants has grown over the last 50 years. Still, rates remain low by international standards with substantial racial, income, and educational disparities.

Breastfeeding has many well-documented benefits for both infants and their birthing parents. Benefits for infants include reduced risk of sudden infant death syndrome, asthma, ear infections, childhood obesity, and gastrointestinal infections. Another benefit is the reduced risk of severe inflammation affecting the digestive tract (i.e., necrotizing enterocolitis), most often found in preterm babies. Maternal benefits include decreased risk of hypertension, type 2 diabetes, ovarian cancer, and breast cancer. Breastfeeding also releases oxytocin, a hormone that causes the uterus to contract. This helps the uterus to return to normal size more quickly and reduces bleeding after birth.

To better understand barriers impeding breastfeeding in the U.S., we analyzed population-weighted data from 2016 to 2019 from the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS collects information about birthing parents’ behaviors and experiences before and during pregnancy, as well as after delivery.

We compared breastfeeding duration across 43 states and the District of Columbia. We were particularly interested in understanding the likelihood of never initiating breastfeeding by age, race and ethnicity, language, marital status, household income, educational attainment, parity or the number of live births, and insurance status. We also compared sources of information and education for respondents who never breastfed to those who breastfed up to 6 months or longer.

The large income, education, and racial disparities in breastfeeding initiation and duration should be the focus of major public health and clinical policy initiatives.

We found that, among 142,643 new mothers, 12.6% never breastfed, 60.4% reported breastfeeding at 3 months, and 54.7% at 6 months. While 75.8% of college graduates reported breastfeeding at 3 months, the same was true for only 37.8% of respondents who had a high school education or less. Teenage (25.5%) and Black participants (36.3%) had the lowest six-month breastfeeding rates.

Respondents whose delivery was paid for by Medicaid were 25% more likely to have never breastfed than those with private insurance. And those reporting household income below $20,000 were 57% more likely to have never breastfed compared to those whose income was over $85,000.

In terms of breastfeeding information, 64.1% of respondents who were breastfeeding at 6 months reported receiving information from their doctor. Among respondents who never breastfed, only 13% reported receiving information from their doctor.  

Beyond the well-documented short-term benefits of breastfeeding, evidence shows that breastfeeding may also reduce obesity and inflammation in the long-term. Indeed, the large increase in obesity in the U.S. in the 1980s and 1990s may be associated with the low breastfeeding rates among those born in the 1960s and 1970s, when less than 25% of mothers were ever breastfeeding. However, more research is needed about these long-term effects.

The large income, education, and racial disparities in breastfeeding initiation and duration should be the focus of major public health and clinical policy initiatives. These campaigns need to include culturally sensitive education before and after childbirth, with mental health support and close follow-up care from obstetrics and primary care providers. Health plans should support home, community-based in-person, and telephone or other virtual lactation consulting services. Public policies, such as paid family and medical leave and workplace accommodations, will also be critical.

Breastfeeding for at least three months or more can improve infant immune defenses and the health of infant digestive systems. Given the large short-term and potentially very large long-term benefits, increasing breastfeeding rates should be a much more important public health priority in the United States.