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Pediatrics. 2019 Feb;143(2). pii: e20181897. doi: 10.1542/peds.2018-1897. Epub 2019 Jan 18.

Addressing Racial Inequities in Breastfeeding in the Southern United States.

Author information

Division of General Pediatrics, Boston Medical Center, Boston, Massachusetts;
Reaching Our Sisters Everywhere, Inc, Lithonia, Georgia.
Division of General Pediatrics, Boston Medical Center, Boston, Massachusetts.
Division of General Pediatrics, Boston University, Boston, Massachusetts.
College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
Blue Cross & Blue Shield of Mississippi, Flowood, Mississippi.
Mississippi State Department of Health, Jackson, Mississippi.
Center for Interprofessional Studies and Innovation, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts; and.
Department of Pediatrics, Children's Regional Hospital at Cooper, Cooper Medical School, Rowan University, Camden, New Jersey.



Race is a predictor of breastfeeding rates in the United States, and rates are lowest among African American infants. Few studies have assessed changes in breastfeeding rates by race after implementing the Ten Steps to Successful Breastfeeding (hereafter referred to as the Ten Steps), and none have assessed the association between implementation and changes in racial disparities in breastfeeding rates. Our goal was to determine if a hospital- and community-based initiative in the Southern United States could increase compliance with the Ten Steps, lead to Baby-Friendly designation, and decrease racial disparities in breastfeeding.


Hospitals in Mississippi, Louisiana, Tennessee, and Texas were enrolled into the Communities and Hospitals Advancing Maternity Practices initiative from 2014 to 2017 and received an intensive quality improvement and technical assistance intervention to improve compliance with the Ten Steps. Community partners and statewide organizations provided parallel support. Hospitals submitted monthly aggregate data stratified by race on breastfeeding, skin-to-skin care, and rooming in practices.


The disparity in breastfeeding initiation between African American and white infants decreased by 9.6 percentage points (95% confidence interval 1.6-19.5) over the course of 31 months. Breastfeeding initiation increased from 66% to 75% for all races combined, and exclusivity increased from 34% to 39%. Initiation and exclusive breastfeeding among African American infants increased from 46% to 63% (P < .05) and from 19% to 31% (P < .05), respectively. Skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only.


Increased compliance with the Ten Steps was associated with a decrease in racial disparities in breastfeeding.

[Indexed for MEDLINE]

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