10/26/17 DISCLOSURES LEARNING OBJECTIVES MY JOURNEY INTO BREASTFEEDING ADVOCACY BEYOND ATTITUDES AND INTENTION:

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1 10/26/17 DISCLOSURES BEYOND ATTITUDES AND INTENTION: SOCIAL AND STRUCTURAL DETERMINANTS OF U.S. BREASTFEEDING OUTCOMES I have no financial conflicts of interest to disclose. LESLIE KUMMER, MD ACADEMIC PEDIATRICS FELLOW AND MPH CANDIDATE, UNIVERSITY OF MINNESOTA MINNESOTA BREASTFEEDING COALITION ANNUAL MEETING NOVEMBER 3, 2017 LEARNING OBJECTIVES Discuss current disparities in breastfeeding rates in Minnesota Identify individual, social and community-level factors that influence breastfeeding outcomes Discuss key features of successful community-based programs for promoting breastfeeding among high-risk populations MY JOURNEY INTO BREASTFEEDING ADVOCACY Early

2 10/26/17 MY JOURNEY INTO BREASTFEEDING ADVOCACY MY JOURNEY INTO BREASTFEEDING ADVOCACY Autumn 2011 Summer 2014 BACKGROUND U.S. breastfeeding below national goals Significant disparities exist 2

3 10/26/17 3

4 10/26/17 Social Ecological Model of Health Promotion 4

5 OBJECTIVE Are interpersonal and community contexts in which families live associated with breastfeeding outcomes, independent of individual-level factors? National Survey of Children s Health (NSCH) Nationally representative Telephone-based periodic survey N = 27,511 Parents/guardians of children ages 6 months to 5 years 5

6 OUTCOMES Breastfeeding Initiation Exclusive Breastfeeding to 6 months Mother s age Mother s education level Nativity status (native or foreign born) Child s race/ethnicity Household poverty status Mother s age Mother s education level Nativity status (native or foreign born) Child s race/ethnicity Household poverty status 1. Family structure 2. Presence of emotional support person 3. Live in socially supportive neighborhood Mother s age Mother s education level Nativity status (native or foreign born) Child s race/ethnicity Household poverty status 4. Number of neighborhood amenities (parks, playgrounds, libraries, etc) 5. Neighborhood safety 6. Identifies personal doctor or nurse (PCP) 6

7 RESULTS FAMILY STRUCTURE Progress Toward Healthy People 2020 Goals aor BF Initiation aor EBF to 6 mo BF Initiation EBF to 6 mo NSCH 2011 Healthy People 2020 Goal Two parent (bio/adoptive) Two parent (step) Single mother Other ref ref PRESENCE OF AN EMOTIONAL SUPPORT PERSON LIVING IN A SUPPORTIVE NEIGHBORHOOD aor aor BF Initiation EBF to 6 mo No ref ref aor aor BF Initiation EBF to 6 mo No ref ref Yes Yes 7

8 NEIGHBORHOOD AMENITIES NEIGHBORHOOD SAFETY aor aor BF Initiation EBF to 6 mo None ref ref 1 amenity 2 amenities 3 amenities 4 amenities Never or Sometimes Usually or Always aor BF Initiation ref - aor EBF to 6 mo ref IDENTIFIES PERSONAL DOCTOR OR NURSE (PCP) aor BF Initiation aor EBF to 6 mo No ref ref PRESENCE OF AN EMOTIONAL SUPPORT PERSON aor aor BF Initiation EBF to 6 mo No ref ref Yes Yes 8

9 LIVING IN A SUPPORTIVE NEIGHBORHOOD NEIGHBORHOOD AMENITIES aor aor BF Initiation EBF to 6 mo No ref ref aor aor BF Initiation EBF to 6 mo None ref ref Yes 1 amenity 2 amenities 3 amenities 4 amenities CONCLUSIONS CONCLUSIONS After controlling for individual-level factors Interpersonal support neighborhood amenities Neighborhood safety having a PCP independently associated with breastfeeding initiation and 6 month exclusivity Previous associations between race/ethnicity, educational level, income level and breastfeeding outcomes may be better explained by Systemic inequities in access to resources 9

10 CONCLUSIONS LIMITATIONS Future research to examine the roles of community, health system and policy factors Opportunities to promote and protect breastfeeding by targeting social and built environment of new parents Cross-sectional study Potential for parental recall bias, reporting bias Neighborhood context assessed via parental perception, rather than objective measures STRENGTHS First study to examine associations between social and neighborhood context and breastfeeding outcomes using nationally-representative data 10

11 2011 SURGEON GENERAL S CALL TO ACTION Lack of knowledge Lactation problems Poor family and social support Social norms Embarrassment Employment and Child care Health services 2011 SURGEON GENERAL S CALL TO ACTION Develop programs to educate fathers and grandmothers about breastfeeding 2011 SURGEON GENERAL S CALL TO ACTION Develop programs to educate fathers and grandmothers about breastfeeding Strengthen programs that provide mother-to-mother support and peer counseling 2011 SURGEON GENERAL S CALL TO ACTION Develop programs to educate fathers and grandmothers about breastfeeding Strengthen programs that provide mother-to-mother support and peer counseling Use community-based organizations to promote and support breastfeeding 11

12 2011 SURGEON GENERAL S CALL TO ACTION Develop programs to educate fathers and grandmothers about breastfeeding Strengthen programs that provide mother-to-mother support and peer counseling Use community-based organizations to promote and support breastfeeding Use social marketing to promote breastfeeding 2011 SURGEON GENERAL S CALL TO ACTION Develop programs to educate fathers and grandmothers about breastfeeding Strengthen programs that provide mother-to-mother support and peer counseling Use community-based organizations to promote and support breastfeeding Use social marketing to promote breastfeeding Develop systems to guarantee continuity of skilled support for lactation between hospitals and community health care settings 2011 SURGEON GENERAL S CALL TO ACTION AFRICAN AMERICAN BREASTFEEDING NETWORK MILWAUKEE, WI Develop programs to educate fathers and grandmothers about breastfeeding Strengthen programs that provide mother-to-mother support and peer counseling Use community-based organizations to promote and support breastfeeding Use social marketing to promote breastfeeding Develop systems to guarantee continuity of skilled support for lactation between hospitals and community health care settings Expand use of programs in the workplace that allow lactating mothers to have direct access to their babies Dalvery Blackwell, BA, IBCLC Community Breastfeeding Gatherings Father-to-Father Peer Groups Outpatient Lactation Services 12

13 AFRICAN AMERICAN BREASTFEEDING NETWORK MILWAUKEE, WI ST. JOHN MOTHER NURTURE PROJECT DETROIT, MI Inclusion of family members and friends in education and support Connection tool to identify and engage circles of support Capitalizing on community strengths and assets Paula Schreck, MD, IBCLC Partnership with Black Women s Breastfeeding Association in Detroit Identified disparity in breastfeeding initiation rates in local hospital compared to state ST. JOHN MOTHER NURTURE PROJECT DETROIT, MI Expanded inpatient lactation care Outpatient lactation clinic Baby-Friendly Accreditation Prenatal Peer Counselor Program Mother Nurture Club Mother Nurture Lactation College WHAT INNOVATIONS FOR SOCIAL OR STRUCTURAL SUPPORT ARE BEING IMPLEMENTED WHERE YOU WORK, LIVE AND PLAY? 13

14 PEARLS FOR CREATING COMMUNITY-BASED BREASTFEEDING SUPPORT PROGRAMS Promote breastfeeding as the cultural norm Peer support critical seeing LCs and allies who look like you Engage community members in program development Capitalize on community strengths and assets WHERE DO WE GO FROM HERE? Take a minute to think of one action you can take in your own community to support breastfeeding mothers Write it down Make a commitment to take action Use Baby Friendly as evidence-based model for equitable care REFERENCES THANK YOU! Blackwell, D. Personal communication, August 3, Burdette, A.M. Neighborhood context and breastfeeding behaviors among urban mothers. (2013). J Hum Lact 29(4); p Culhane, J.F and Elo, I.T. (2005). Neighborhood context and reproductive health. Am J Obst Gyn 192: S22-9. Seals Allers, K. The Big Letdown: How Medicine, Big Business, and Feminism Undermine Breastfeeding. 1 st ed. New York: St. Martin s Press, Schreck, P. Personal communication, July 11, U.S. Department of Health and Human Services. The Surgeon General s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, Van Dyck, P.C. (2010). Celebrating 75 years of Title V (Maternal and Child Health) and re-exploring our roots. J Mat Child Health 14(6); p Leslie Kummer, MD Fellow, Academic Pediatrics MPH Candidate University of Minnesota morr0285@umn.edu 14

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