Disparities in Breastfeeding Among U.S. Black Mothers: Identification of Mechanisms

Abstract

Objective: Disparities in U.S. breastfeeding rates persist among Black mothers according to birth country and between Black and White mothers, necessitating further investigation of modifiable mediating factors to inform interventions. This study seeks to examine the extent that social, maternal, infant factors and Theory of Planned Behavior (TPB) domains (attitudes, perceived control, and subjective norms) mediate the association of maternal race/birth country and breastfeeding continuation. Methods: A national cohort of 2,050 mothers self-identifying as U.S.-born non-Hispanic Black (n = 689), foreign-born non-Hispanic Black (n = 139), and U.S.-born non-Hispanic White (n = 1,222) was analyzed. Using logistic regression, associations of race/birth country and any/exclusive breastfeeding at 2-6 months were examined. Structural equation modeling was used to determine whether social, maternal, and infant factors and TPB domains mediate these relationships. Results: 40.0% of U.S.-born Black, 82.2% of foreign-born Black, and 57.3% of U.S.-born White mothers reported any breastfeeding at 2-6 months. Compared with U.S.-born Black mothers, odds of any breastfeeding were sevenfold higher among foreign-born Black mothers (odds ratio [OR] = 7.04 95% confidence interval [CI] = 4.80-10.31), which was explained partly by social/maternal/infant factors and TPB domains. Compared with U.S.-born White mothers, any breastfeeding was lower (OR = 0.54, 95% CI = 0.40-0.73) among U.S.-born Black mothers and higher (OR = 3.81, 95% CI = 2.48-5.87) among foreign-born Black mothers; these differences were also mediated by the aforementioned factors. Conclusions: Among Black mothers in the United States, breastfeeding continuation varied substantially by birth country. Promotion of interventions targeting positive attitudes, perceived control, and subjective norms may reduce disparities among Black and between Black and White mothers.

Keywords: Black mothers; breastfeeding continuation; racial disparities.

FIG. 1.

Conceptual framework depicting mediation pathways between maternal race/birth country and breastfeeding continuation. Color images are available online.

FIG. 2.

Associations of maternal race/birth country and any breastfeeding at 2–6 months are shown. Panel (a) shows results of foreign-born Black versus US-born Black, panel (b) shows US-born Black versus US-born White and panel (c) shows foreign-born Black versus US-born White. Black lines indicate positive and red lines indicate negative associations (p < 0.05). Thickness of line indicates strength of the association. ORs reflecting significant values in the relationships between both the predictor and mediator as well as mediator and outcome variables are presented. OR, odds ratio. Color images are available online.

FIG. 3.

Associations of maternal race/birth country and exclusive breastfeeding at 2–6 months are shown. Panel (a) shows results of foreign-born Black versus US-born Black, panel (b) shows US-born Black versus US-born White and panel (c) shows foreign-born Black versus US-born White. Black lines indicate positive and red lines indicate negative associations (p < 0.05). Thickness of line indicates strength of the association. ORs reflecting significant values in the relationships between both the predictor and mediator as well as mediator and outcome variables are presented. Color images are available online.