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Despite overall improvement in breastfeeding in the past 3 decades in the United States, significant and alarming social disparities persist. Adverse social determinants of health are increasingly recognized as root causes of social disparities in health outcomes, including breastfeeding initiation and continuation. We provide an overview of the evidence and mechanisms by which social determinants of health, including education, employment, food, neighborhood, and housing contribute to ongoing social disparities in breastfeeding in the United States, including current research gaps. We also review the intersection of social determinants of health with income, racism, and theory of planned behavior, a commonly used decision-making framework for breastfeeding promotion. Future interventions to address social determinants of breastfeeding should occur at the policy, community, organization, and individual levels.
Exclusive breastfeeding is recommended for all newborns until at least 1 year of age due to the array of health benefits for mothers and infants across the life course.
Unfortunately, inequities in breastfeeding according to race/ethnicity in the United States are well-known and persistent, where non-Hispanic black mothers are much less likely to initiate and continue breastfeeding compared to mothers in most other racial/ethnic groups.
Similar to social disparities in other health behaviors, the causes of racial and ethnic disparities in breastfeeding are multifactorial and rooted in an array of social, financial, and political issues (Figure). One important cause of racial/ethnic disparities in breastfeeding is social determinants of health (SDHs), defined as 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 US Department of Health and Human Services Health People 2030 strategic goals.
SDHs include education, employment, food, neighborhood, and housing. SDHs can positively or negatively impact health. Negative, or adverse, SDHs are more common among under-represented minority populations and therefore represent a root cause of racial/ethnic disparities in health outcomes. Our primary aims were to (1) summarize current evidence that elucidates the mechanisms by which adverse SDHs contribute to low breastfeeding rates and (2) clarify research gaps (Table I).
FigureCauses of racial and ethnic disparities in breastfeeding.
Table IProposed interventions targeting social determinants of breastfeeding.
Social Determinant of Health
Theory of Planned Behavior Domain
Proposed Interventions
Overall
Perceived control; subjective norms
Screening and referral for SDHs in clinical and community settings; peer navigation that connects mothers to resources as appropriate
Education
Attitude; subjective norms
Improve access to culturally appropriate lactation education (text message, peer support); target education at community-level, include partners
Employment
Percieved control
State and federal policy supporting longer duration of paid maternity leave and more extensive supports for lactation at work
Food
Percieved control
Support for local organizations providing food delivery for families with pregnant and breastfeeding mothers; policy support for food access for families with pregnant and breastfeeding mothers
Neighborhood
Attitude; subjective norms
Support policies that reduce racial segretation; support development of community-level breastfeeding support groups and delivery of breastfeeding support services
Housing
Percieved control
Support policies providing adequate housing for pregnant and breastfeeding mothers; promote breastfeeding support practices in homeless shelters
Intersection with income
Percieved control
Financial support for mothers' time spent breastfeeding; expansion of direct cash payments of child tax credit programs
Intersection with racism
Attitude; subjective norms; percieved control
Implicit bias training to health care providers giving lactation support; track breastfeeding support practices according to race/ethnicity in hospitals and other public health settings; promoting training and hiring of racially concordant lactation providers; support policies geared toward reducing neighborhood segregation
The mechanism by which this occurs is multifaceted. Higher education attainment leads to improved job mobility and wealth, which can facilitate breastfeeding through increased financial support.
For example, many mothers with higher incomes can afford private lactation consultations, breast pumps and supplies, and paid support for child care or other household duties that may facilitate breastfeeding (see further explanation in the Income and SDH section). Lactation-specific education also has been linked to breastfeeding and serves as a target of many successful interventions geared toward breastfeeding promotion among low-income, minority populations.
Effective lactation-education interventions that are focused on non-Hispanic black and Hispanic mothers target increasing knowledge on the benefits of breastfeeding and overcoming common barriers.
These studies have been delivered during the prenatal, hospital, and postpartum time periods and vary by mode of education delivery (eg, peers, lactation consultants, or nurses).
Studies have consistently shown that a shorter duration of maternity leave and a lack of work-related support for breastfeeding are negatively associated with breastfeeding.
This negative association occurs because maternity leave allows for increased mother–infant contact and frequency of nursing. Mothers who anticipate a shorter duration of time off from work have been shown to be less likely to even start breastfeeding.
A recent seminal study showed that when maternity leave was extended from 6 to 12 weeks among mothers serving in the military in 2016, exclusive breastfeeding increased from 72% to 82% at 2 months, 57% to 71% at 4 months, 47% to 60% at 6 months, and 35% to 45% at 9 months,
demonstrating the effectiveness of longer maternity leave on breastfeeding duration, and consistent with substantial evidence from other developed countries. Since 1993 in the United States, ∼50% of workers who wish to take maternity leave have been provided job protection through the Family and Medical Leave Act. However, few states require paid medical or maternity leave. In California, the first state to institute paid maternity leave, exclusive breastfeeding at 3 and 6 months was increased by 3% to 5%, and any breastfeeding at 3, 6, and 9 months was increased by 10% to 20% after paid maternal leave was implemented, when compared to the same time periods in other states.
In addition to duration of maternity leave, barriers to breastfeeding in the work environment are substantial contributors to breastfeeding cessation. Work-related breastfeeding-promotion practices include accommodating time and space for milk expression, providing a sanitary place for milk storage, and allowing breastfeeding in public and private locations. Several laws across many states have been passed in support of such practices and have been associated with modest increases in breastfeeding outcomes.
Overall, state policies to support breastfeeding and paid leave have increased in the past 1 to 2 decades. However, many policy gaps remain. Many states lack such policies, while other states have policies that apply to only large businesses; furthermore, the extent to which these policies are followed is unclear. Therefore, addressing employment-related barriers remains a high priority to further promote breastfeeding in the United States.
Food
Studies have found associations between household food insecurity and earlier breastfeeding cessation.
Racial and ethnic differences in reasons for breastfeeding cessation among women participating in the special supplemental nutrition program for women, Infants, and Children.
The mechanisms of this association are multifactorial. Food insecurity is a marker of poverty, which itself has been associated with family stress and many other adverse SDHs that contribute to decreased breastfeeding. Mothers with food insecurity have reported concerns about their milk quantity and quality, leading to mothers' decisions to supplement with formula and stop breastfeeding.
Metabolic disorders such as gestational diabetes and morbid obesity have been associated with low milk production, and thus poor food access may have a direct physiologic link to breastfeeding outcomes.
It is also possible that decreased quality or quantity of maternal energy intake may impact milk production, but further studies are needed to examine this possibility.
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a source of food benefits for low-income families. Pre-/post-design studies reported higher rates of breastfeeding after WIC food benefits were increased in 2019.
While it is possible that increased receipt of food contributed to improved milk production and longer durations of breastfeeding, this mechanism is less likely due to the way the policy was designed. Only mothers who were exclusively breastfeeding received the increased food benefit, compared to partially breastfeeding or formula-feeding mothers. Therefore, the policy incentivizing breastfeeding was more likely the explanation for increased breastfeeding among mothers receiving more food benefits, rather than a direct impact of the food itself.
Neighborhood
Neighborhood has been shown to be associated with breastfeeding.
geocoded and linked birth-certificate data to census tracts and reported the extent to which neighborhood disadvantage, an index derived from various markers of household poverty, and neighborhood affluence, an index derived from occupation, education, and home value, were associated with breastfeeding within racial/ethnic groups. Neighborhood disadvantage was associated with lower exclusive breastfeeding rates among Asians, Hispanics, and non-Hispanic blacks, but not non-Hispanic whites. Neighborhood affluence was associated with higher exclusive breastfeeding rates among Hispanics and non-Hispanic whites.
Furthermore, living in a primarily non-Hispanic black (ie, more racially segregated) neighborhood has also been associated with decreased breastfeeding initiation and duration among non-Hispanic blacks.
Neighborhoods provide several possible supports for breastfeeding. Neighborhoods contain local breastfeeding support resources, such as baby cafes, WIC centers, or other medical facilities that facilitate access to breastfeeding education and support. These supports are not equitably distributed. A recent study that geocoded breastfeeding support services reported that these services were more likely to be located in suburban, high-income areas composed predominantly of non-Hispanic white populations.
Beyond direct breastfeeding supports, neighborhoods also provide social and cultural support, which represent additional determinants of breastfeeding continuation.
which contribute to reduced breastfeeding initiation and continuation. Homeless mothers are also less likely to attend prenatal care and well-child visits, limiting their access to breastfeeding-related education.
These practices included staff education and training; provision of water and snacks for breastfeeding mothers at night; provision of clean, private, and safe spaces for breastfeeding or pumping, and breast pumps; support of nursing at group classes; and facilitating access to community breastfeeding support.
Research is needed to examine the extent to which the implementation of these practices may impact breastfeeding among mothers living in homeless shelters.
Theory of Planned Behavior as a Framework for Understanding the Impact of SDH on Breastfeeding Behaviors
The theory of planned behavior (TPB) is a well-established framework used to examine health behaviors, including breastfeeding.
Decisions about health-related behaviors such as breastfeeding, as described in the TPB, are determined by attitudes (perceptions about a behavior), perceived control (how much someone believes they have control of the behavior), and subjective norms (what someone believes other people think about whether they should engage in the behavior).
Studies have shown that negative attitudes, lack of perceived control, and lack of subjective norms regarding breastfeeding among non-Hispanic black mothers, as compared to non-Hispanic white mothers, are key contributors to decreased breastfeeding
What has rarely been acknowledged in past studies examining TPB domains is the intersection with SDH. The TPB can serve as a useful framework for operationalizing intervention targets of adverse SDHs that affect breastfeeding. For example, attitudes are informed by the belief that breast milk is healthy and nutritious, concepts that are often delivered through improved access to health education. Perceived control is impeded by the perception of support for breastfeeding at work, access to breast pumps and lactation support in a community or neighborhood, child care, and other competing demands in the home. Subjective norms are driven by both advice from health care providers and the experience of family and friends living in a community or neighborhood. Future interventions using the TPB domains as mechanistic targets toward breastfeeding promotion should consider the intersection with SDHs Table I.
Intersection of Income and SDHs
Income level and SDH are interrelated and both contribute to decreased breastfeeding (Figure). For example, lower education attainment and inconsistent or lower-paying employment are linked to lower household income and a subsequent increased risk for housing and food insecurity. In addition to the aforementioned mechanisms linking adverse SDHs to decreased breastfeeding, direct financial support is also related to breastfeeding. Mothers with higher incomes are more likely to pay for private lactation consultation and breastfeeding supplies, for example. These mothers are more easily able to pay for support related to household duties (eg, cleaning, food preparation) and childcare to facilitate more time to breastfeed. Despite the fact that employment has been associated with barriers to breastfeeding, higher-income mothers are more likely to hold full-time employment that allows for more breastfeeding support in the workplace compared to lower-income mothers who are more likely to work part-time jobs and/or jobs without such support.
In addition to the financial support that enables time and access to breastfeeding support, emerging evidence suggests that small cash incentives can be used to incentivize breastfeeding. In a recent cluster randomized controlled trial from the United Kingdom, in which mothers were randomly assigned to receive a small financial incentive (50 USD) versus no incentive, breastfeeding was modestly increased in the first 6 to 8 weeks postpartum.
In a qualitative analysis conducted alongside the trial, designed to elucidate the mechanisms of the increase, mothers who received the financial incentive reported that they felt valued for their effort and compensated for their difficulties.
These findings suggest that small cash incentives may promote self-efficacy, or a belief in one's ability to breastfeed, and provide value to this behavior.
Intersection of Racism and SDHs
Structural racism, or racial bias among institutions and across society,
is a well-known cause of SDH. Structural racism impacts equitable access to housing and neighborhoods, which in turn impacts access to education and employment. A recent study of mothers in the Black Women's Health Study, using data from 1995–2005, reported on experiences of racism in the work environment
A recent review of data from qualitative and quantitative studies on this topic reported that health providers held biased assumptions that non-Hispanic black mothers would not breastfeed, and that this bias led to decreased support offered to them. Furthermore, fewer referrals and lower-quality lactation support were received by non-Hispanic black mothers compared to mothers in other racial/ethnic groups.
Black, Hispanic, and other minoritized mothers have few opportunities to receive racially concordant lactation support: Only 1.6% of surveyed International Board Certified Lactation Consultants identify as non-Hispanic black, and 4.7%, as Hispanic.
Recognition of international board certified lactation consultants by health insurance providers in the United States: results of a national survey of lactation consultants.
There have not yet been interventional studies targeting personally mediated racism as a mechanism of improving equitable lactation support for minority mothers.
Next Research and Policy Steps
SDHs are crucial determinants of breastfeeding in the United States and contribute significantly to existing racial/ethnic disparities. Future strategies to address social determinants of breastfeeding should optimally combine interventions at the policy, community, organization, and individual levels (Table). Interventions should target different types of SDHs that are drivers of breastfeeding outcomes, and address the intersection of poverty, racism, and theory of planned behavior domains.
Conclusions
Breastfeeding is recognized as a modifiable health-related behavior, with substantial short- and long-term benefits to mothers and infants. Addressing the persistence in social disparities in breastfeeding in the United States is crucial for offsetting health-related inequities and is recognized as a public health priority. Evidence shows that SDHs are a crucial driver of social disparities in breastfeeding. Future interventions should target improvements in education, employment, food access, housing, and neighborhoods.
Disclosure
The authors have indicated that they have no conflicts of interest with regard to the content of this article.
Author Contributions
Dr. Parker drafted and reviewed the manuscript. Dr. Standish reviewed the manuscript critically for content.
Racial and ethnic differences in reasons for breastfeeding cessation among women participating in the special supplemental nutrition program for women, Infants, and Children.
Recognition of international board certified lactation consultants by health insurance providers in the United States: results of a national survey of lactation consultants.
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