Racial, Ethnic and Nativity Disparities In Breastfeeding: Examining the Impact of Racial Discrimination

Background/Purpose: Racial/ethnic and nativity disparities in breastfeeding persist in the United States despite recommendations set forth by national organizations. Examining maternal/birthing parent responses to racial discrimination is a novel approach to identify potentially modifiable factors associated with breastfeeding. Overall, the relatively scarce research shows discrimination is associated with lower rates of breastfeeding but largely focuses on indirect forms of racial discrimination such as health care funding and disparities in lactation services and support, or interpersonal discrimination such as health professional attitudes. A few studies show associations between racial discrimination and increased breastfeeding, with proposed mechanisms of cultural resistance, resilience, and strength serving as buffers against personal and institutionalized racism.

Our study examined associations between emotional, stress, and physical responses to discrimination and breastfeeding initiation and duration across race/ethnicity and nativity, and tested whether the responses to discrimination attenuated any of the observed inequities in breastfeeding by race/ethnicity and nativity.

Methods: Data and samples: We used Massachusetts Pregnancy Risk Assessment Monitoring System survey data (2016-2022) linked with birth certificate records (n=8,175) in bivariate and multivariate analyses.

Measures:

Outcome: Breastfeeding was assessed with dichotomous questions (Y/N) asking about whether they breastfed/pumped breastmilk for any amount of time (initiation), and how long they breastfed/pumped breastmilk categorized as >8 weeks (duration).

Predictors: The primary predictor variables reflected responses to racial discrimination modeled dichotomously (Y/N) and were measured with three questions about feeling emotional, stress, or physical symptom responses based on treatment due to racial/ethnic background in the 12 months before birth. With data from the infant birth certificate, we categorized maternal race, ethnicity and nativity as US and foreign-born non-Hispanic white, non-Hispanic Black, Hispanic/Latina, Asian/Pacific Islander and Other race/ethnicity.

Results: Overall, foreign-born mothers had higher rates of breastfeeding initiation (95.2% vs. 89.5%) and duration (82.6% vs. 67.0%) compared to their US-born counterparts. The prevalence of emotional, stress, and physical responses to discrimination varied across race/ethnicity and nativity with highest prevalence among US-Born Non-Hispanic Black mothers. In fully adjusted models, emotional responses to discrimination were associated with almost 3-fold odds of breastfeeding initiation (aOR=2.70, 95% CI [1.48-4.93]) and 2-fold odds of breastfeeding duration of at least 8 weeks (aOR=1.99, 95% CI [1.54, 2.58]). Physical related responses to discrimination doubled the odds of breastfeeding duration (aOR=1.96, 95% CI [1.30-2.96]). Although discrimination responses were associated with breastfeeding initiation and duration, they only partially accounted for the differences in breastfeeding initiation or duration across racial/ethnic and nativity groups.

Conclusions and Implications: While we unequivocally acknowledge the pernicious impact of discrimination, our unexpected findings require us to consider the factors that predict positive health behaviors in response to perceived discrimination, while simultaneously naming the responsible social and historical contexts. This counters the deficit perspectives that perpetuate victimization and allows for a holistic understanding of the myriad ways that racial/ethnic minoritized groups have navigated discrimination. Health care social workers should be informed about the sociocultural factors that impact breastfeeding perceptions and behaviors, as well as the agency shown in the face of oppression.