Online Program

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

Monday, November 2, 2015

Amanda Bennett, PhD, School of Public Health, University of Illinois at Chicago, Chicago, IL
Deborah Rosenberg, PhD, Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL
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.

Learning Areas:

Conduct evaluation related to programs, research, and other areas of practice
Social and behavioral sciences

Learning Objectives:
Compare hospital experiences and exclusive breastfeeding behaviors across racial/ethnic groups in Illinois. Assess the extent to which improving hospital breastfeeding support may reduce racial/ethnic disparities in exclusive breastfeeding.

Keyword(s): MCH Epidemiology, Breastfeeding

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I obtained my PhD in maternal and child health epidemiology from the University of Illinois at Chicago School of Public Health. I have worked as an epidemiologist for state health departments since 2007. This research was conducted in partnership with the Illinois Pregnancy Risk Assessment Monitoring System.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.