Can hospital support reduce racial/ethnic disparities in exclusive breastfeeding? An assessment using mediation analysis

Background:  Despite American Academy of Pediatrics recommendations, only 11% of Illinois infants are exclusively breastfed for the first six months of life and there is substantial variation across racial/ethnic groups.  Through practices like the “Ten Steps to Successful Breastfeeding”, hospitals can support breastfeeding, but differential access to or effectiveness of hospital practices could exacerbate racial/ethnic disparities in breastfeeding.

Methods: 2004–2008 Illinois Pregnancy Risk Assessment Monitoring System (PRAMS) data were used to assess women's reported experience of six breastfeeding-supportive hospital practices (no formula gift pack, breastfeeding in the first hour, rooming-in, breastfeed on-demand, no pacifier, and receiving a telephone support number) and whether exclusive breastfeeding was terminated before six weeks among women who initiated breastfeeding.  The number of hospital support practices experienced were dichotomized into “high support” (≥4) or “low support” (<4). Using logistic regression, counterfactual mediation analysis was used to estimate the natural direct effect (NDE) and natural indirect effect (NIE) of race/ethnicity on exclusive breastfeeding at six weeks, considering hospital support as a mediator.  

Results:  Among breastfeeding initiators in Illinois, 53.4% of non-Hispanic white women, 68.5% of non-Hispanic black women and 68.2% of Hispanic women stopped exclusive breastfeeding prior to six weeks and disparities remained after adjustment for confounders (black-white aOR=1.73 [1.41-2.12]; Hispanic-white aOR=1.88 [1.61-2.18]).  Non-Hispanic black and Hispanic women were also less likely to experience high hospital support than non-Hispanic white women (black-white aOR=0.59 [0.48-0.73]; Hispanic-white aOR=0.67 [0.57-0.79]).   High hospital support was a significant mediator of the black-white disparity in exclusive breastfeeding termination (OR-NIE= 1.10 [1.04-1.16]), but not the Hispanic-white disparity (OR-NIE=1.03 [1.00-1.06]).  If non-Hispanic black women were to experience high hospital support at the same level as non-Hispanic white women, the black-white disparity in exclusive breastfeeding termination before six weeks would be slightly reduced (OR-NDE=1.66 [1.33-2.07]), but remain significant.

Conclusions:  Racial/ethnic disparities exist in exclusive breastfeeding and in the hospital support provided to breastfeeding mothers.  However, differential access to hospital support accounts for little of the observed black-white disparity and none of the Hispanic-white disparity in exclusive breastfeeding termination before six weeks.  While hospital support is important for improving breastfeeding at the population-level, improving access to high hospital support is not likely to eliminate disparities in exclusive breastfeeding.  More research about the factors that cause and maintain disparities in breastfeeding is necessary to inform targeted interventions.