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n Breastfeeding Disparities Among Communities Lacking Access to Lactation Consultants During the COVID-19 Pandemic: A Theory-Guided Paper
Breastfeeding Disparities Among Communities Lacking Access to Lactation Consultants During the COVID-19 Pandemic: A Theory-Guided Paper
Cynthia Flynn, BA, RN, IBCLC and Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k
Acknowledgements
Christine Berté (MSMC School of Nursing Dean), Denise Garofalo (MSMC Librarian for Systems & Catalog Services), and Julia Flynn (MSMC Writing Center)
n Abstract
There is a significant difference in breastfeeding rates between Black and white infants, dependent upon their mother’s access to professional lactation care. According to the Centers for Disease Control and Prevention (CDC), 73.7% of Black infants are ever breastfed in comparison to 86.7% of white infants (Centers for Disease Control and Prevention [CDC], 2020a). The COVID-19 pandemic has complicated access to lactation care and illuminated the ongoing healthcare disparities in racial minority and economically marginalized populations across the United States. According to the CDC, some Black communities have higher rates of chronic diseases and also register lower breastfeeding rates. Research suggests that some chronic diseases can be mitigated by human milk consumption in infancy (Binns & Lee, 2019). In recognizing human milk’s value during infancy, the U.S. Surgeon General recommends access to international board certified lactation consultants (IBCLC) to support breastfeeding. Despite these government issued guidelines, data repeatedly demonstrates that hospitals lacking adequate lactation care in under-resourced Black communities continue to lack adequate distribution of breastfeeding information and lactation support. A literature review was performed by the authors using the databases PubMed Central®, CINAHL, Google Scholar, and ProQuest. Sources include journal articles, books, websites, and reports (2012–2021). The authors used the topics related to general healthcare disparities, breastfeeding rates, and variances, as well as barriers to breastfeeding in impoverished communities in the United States. Access to lactation consultants during COVID-19 and lactation programs that address impoverished communities was also examined. The literature review consistently notes clear discrepancies in care. At a time when nationwide healthcare policies focus on preventative solutions to improve population wellness, this lack of equality in care in communities cannot be overlooked. Nursing theorist Imogene King’s work on goal attainment may be applied to foster adaptation among interdisciplinary teams, IBCLC, and patients to increase breastfeeding rates among under-resourced Black communities. Guided by King’s Theory of Goal Attainment, this paper offers a proactive construction for an insidious public health dilemma. The purpose of this paper is to explore and disrupt inherent systematic healthcare inequities affecting Black communities by suggesting a new platform for lactation care. The application of theoretically-derived best practices will help to improve lifelong health outcomes, strengthen patient-provider relationships, and reduce healthcare spending across the lifespan of these currently underserved communities. Keywords: professional lactation care, Imogene King Theory of Goal Attainment, breastfeeding sponsor, barriers to breastfeeding
Cynthia Flynn, BA, RN, IBCLC and Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k
Mount Saint Mary College Family Nurse Practitioner Program, Newburgh, New York
Background
The COVID-19 pandemic has brought to light racial disparities in health care prevalent throughout the United States. Systemic discrimination, already prevalent in many racial minority communities due to limited funding and healthcare access, has only grown more prevalent during the global pandemic. For example, according to data from New York State, Blacks and Hispanics make up 22% and 29% of the New York City landscape, yet their COVID-19-related death rates are 28% and 34%, respectively (New York State Department of Health, 2021). A review of national data indicates that counties with higher proportions of African Americans also have higher numbers of COVID-19 cases and deaths (Peek et al., 2021). However, inequalities in healthcare delivery run deeper than the pandemic statistics of the past 2 years. These inequalities have been documented extensively in the Black, Latinx, and other medically underrepresented communities for more than 120 years by government and academic researchers (Levins, 2019). In the United States, Black men are more likely to be diagnosed and succumb to prostate cancer, yet they are disproportionately underrepresented in prostate cancer screenings (Alexis & Worsley, 2018). Data from the Pennsylvania Medicaid system showed that managed care organizations’ poor performance with minority populations has directly correlated with greater racial differences within communities served (Parekh et al., 2017).
Healthcare Disparities Beginning at Birth
According to the Office of Disease Prevention and Health Promotion (ODPHP) Healthy People 2020 national objectives for improving lives, a health disparity is a health difference that is closely linked with social, economic, or environmental disadvantage (Office of Disease Prevention and Health Promotion [ODPHP], 2020). Healthcare disparities begin in infancy and impact health throughout a person’s lifespan. Breastfeeding is where this often begins. Denying an infant the basic opportunity to breastfeed, due to its racial and socioeconomic environment, is an unconscionable injustice.
When considering a range of infant feedings, nothing comes close to the multitude of benefits that human milk provides. Human breastmilk delivers the greatest number and quality of health benefits to mother and baby, which is why it is often referred to as “superfood.” For the pair, increased bonding and reduction in postpartum depression may foster healthier emotional environment early in life. Protection against infections and chronic diseases such as diabetes (type 1 and 2), obesity, and childhood and reproductive cancers also exists (American Academy of Pediatrics [AAP], 2020). Since 2012, the American Academy of Pediatrics (AAP), in recognition of these benefits, recommends breastfeeding exclusively for newborns in the first six months of life or more. It is estimated that if 90% of people breastfed according to guidelines, the United States would save more than $13 billion in health care costs per year (U.S. Department of Health and Human Services, 2020). Because science affirms breastfeeding as the superior choice for infant feeding, the U.S. Surgeon General created a call to action recommending access to international board certified lactation consultants (IBCLC) and breastfeeding support for every mother and baby (CDC, 2019).
Breastfeeding Data
Human milk is unequivocally regarded as the best nutrition for all infants. Yet, according to data from the CDC, a percentage of Black infants are repeatedly missing this important early-stage development opportunity. Blacks historically have disproportionately higher rates of cancer, diabetes, and obesity than whites (CDC, 2017). Breastfeeding can help reduce these threats to health and wellness, and benefits of breastfeeding are lifelong. Convenient access to early intervention is the key to making and reaching breastfeeding goals.
In 2015, the CDC added several breastfeeding questions to their National Immunization Survey-Child (NIS-Child) to track the rates of breastfeeding among Blacks and non-Hispanic whites at birth, 3 months, and 6 months of age (Beauregard et al., 2019). The results of the NIS-Child revealed that breastfeeding initiation rates for Black infants were 16.5% lower than white infants of the same age. Furthermore, at 3 months of age, the consumption of any human milk for Black breastfeeding babies was 14.7% lower than for white babies. At 6 months, the disparity grew to 17.3% (Figure 1). The CDC reported that low-income families who receive the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) have lower breastfeeding rates (77%) compared with families who qualify, but don’t utilize WIC (82%) and those who do not qualify for WIC (92%) (CDC, 2020a).
Barriers to Breastfeeding
Generally, Black women who are in a low-income bracket, are less likely to breastfeed for several reasons, including language and cultural
Figure 1 Comparison of Breastfeeding Initiation and Continuation According to Race
100 90 80 70 60 50 40 30 20
86%
70% 71%
59%
10 0
% Initiated Breastfeeding % Any Breastfeeding at 3 Months 61%
45%
% Any Breastfeeding at 6 Months
Non-Hispanic White Non-Hispanic Black
Note. Figure 1 shows the variation in breastfeeding rates of initiation and continuation between non-Hispanic white and Black people. Adapted from “Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015,” by J. L. Beauregard, H. C. Hamner, J. Chen, W. Avila-Rodriguez, L. D. Elam-Evans, and C. G. Perrine, 2019, Morbidity and Mortality Weekly Report, 68(34), pp. 745–748 (https://doi. org/10.15585/mmwr.mm6834a3). In the public domain.
barriers, and a lack of support at home, work, and within healthcare systems (Leruth et al., 2017). Disparities in breastfeeding knowledge and access to lactation care are also leading concerns causing these discrepancies. In fact, less than 25% of lower-income Black women receive information on breastfeeding from public health and social service venues. Hospitals that service low-income Black communities also report lower rates of breastfeeding initiation (Beauregard et al., 2019).
To further understand the impact that the healthcare industry has on breastfeeding rates, the CDC created the Maternity Practices in Infant Nutrition and Care (mPINC), a national survey for maternity wards meant to help hospital administrators celebrate existing strengths and target areas for improvement in their practices and policies that affect infant feeding. Every two years, the CDC invites hospitals to fill out the mPINC survey. In 2018 alone, 2,045 hospitals participated and were asked about early postpartum care practices; feeding practices; education and support of mothers and caregivers; staff and provider responsibilities and training; and hospital policies and procedures. Organized into six main areas of care called subdomains, policies and practices are then scored and comprise each state’s total mPINC score (CDC, 2020b). In 2011, the CDC began correlating mPINC scores with U.S. Census data by ZIP codes to identify trends in maternity care and breastfeeding promotion and guidance equity. A CDC Morbidity and Mortality Weekly Report (Figure 2) revealed that hospitals were less likely to meet five of the 10 recommended mPINC indicators if they were in ZIP codes where the Black population was greater than the national average. The indicators included early initiation of breastfeeding (46.0% compared with 59.9%), limited use of breastfeeding supplements (13.1% compared with 25.8%), rooming-in (27.7% compared with 39.4%), limited use of pacifiers (30.5% compared with 37.9%), and post-discharge support (23.9% compared with 29.9%) (Lind et al., 2014). Survey findings revealed that the hospitals in question lacked common practices that typically promote lactation. Practices such as breastfeeding attempts in the first hour after birth, skin-to-skin contact, and avoidance of glucose water and infant formula when not medically indicated were inadequately implemented.
Often, despite the U.S. Surgeon General’s recommendations, these hospitals were not staffed with IBCLCs and/or staff training to support breastfeeding is inadequate (Beauregard et al., 2019). Research by Patel (2017) demonstrates the direct correlation between access to IBCLCs and
Figure 2 mPINC Scores Related to Racial Composition of Patient Populations Served by Hospitals
70
60%
48%
13% 27%
12% 12% 40%
28%
11% 38%
30%
8% 30% 33%
8%
Early initiation of breastfeeding: 20% of healthy, full-term, breastfed infants initiate breastfeeding within 1 hour of uncomplicated vaginal birth. Limited use of breastfeeding supplements: <10% of healthy, full-term, breastfed infants are supplemented with formula, glucose water or water. Rooming-in >90% of healthy, full-term infants, regardless of feeding method, remain with their mother for at least 23 hours per day during the hospital stay. Limited use of paci ers: <10% of healthy, full-term, breastfed infants are given paci ers by maternity care sta members.
% Blacks < 12.2 % Blacks > 12.2 % Point Di erence Post-discharge support: hospital routinely provides three modes of post-discharge support to breastfeeding mothers (physical contact, active reaching out, and referrals).
Note. Figure 2 shows that as the percentage of Blacks in a population increases, the mPINC scores for the population’s ZIP code decreases. The mPINC score of a hospital is based on a 10-point survey that addresses the utilization of best practices for breastfeeding initiation and continuation. Adapted from “Racial disparities in access to maternity care practices that support breastfeeding – United States, 2011,” by J. Lind, C. Perrine, R. Li, K. Scanlon, and L. Grummer-Strawn, 2014, Morbidity and Mortality Weekly Report (https://www.cdc. gov/mmwr/preview/mmwrhtml/mm6333a2.html). In the public domain.
increased rates of initiation and continuation of exclusive breastfeeding in the first month of life. This data confirms that disparities in access to quality breastfeeding assistance exist in Black communities that are in a low-income bracket, which negatively affects breastfeeding rates.
COVID-19 Effects on Breastfeeding
The COVID-19 pandemic has further complicated infancy for new mothers. During a pandemic, as with natural crises like devastating hurricanes and earthquakes, the value of breastfeeding becomes clearer. In a state of uncertainty, human milk is one form of nutrition that mothers can count on. Families never need to concern themselves with finding substitutes in their local markets or worry that their water sources for preparation are contaminated or inaccessible. An Australian study (Hull et al., 2020) that examined the needs and concerns of breastfeeding mothers during the height of the COVID-19 pandemic found that mothers commonly expressed feelings of isolation, stress, and the need for professional lactation intervention. Many could not access their healthcare provider face-to-face, either because of fear of contracting COVID-19 or lack of appointments available, according to the study. Decreased access to care was common throughout the United States during the first surge of the pandemic. Existing Models
Increased access to IBCLCs is supported by Sanchez et al. (2019). This work revealed that a comprehensive support structure providing ongoing, professional guidance can help to improve breastfeeding outcomes. Additionally, when access to health care is limited and internet service is unavailable (as is more likely the case in communities in a low-income bracket), mobile clinics are often used. However, infection control and social distancing concerns in mobile clinics arose during the COVID-19 pandemic, further complicating processes and solutions.
An excellent model for care already exists in the work done by Leruth et al. (2017). In this study, healthcare providers increased breastfeeding rates in a vulnerable population by partnering with a local hospital to provide intensive one-to-one education and ongoing support. By integrating inpatient and outpatient resources in hospitals that serve Black communities in a lowincome bracket, more mothers were enabled to breastfeed. The authors suggest combining ideas from Leruth et al.’s (2017) Chicago clinic with COVID-19 pandemic adjustments taken into consideration. We also suggest an additional level of support, guided by the Theory of Goal Attainment by Imogene King as described in the text, “Nursing Theories and Nursing Practice” by Marlaine Smith (2020). King’s theory is a framework by which providers can deliver modern, ongoing and effective care and focusing on incremental progress to be made by setting and achieving goals.
Developing Solutions
Addressing the barriers to breastfeeding for Black women is one of the keys to improving care for future generations of families in America. The data describes variances in breastfeeding rates between Black and white infants in disadvantaged communities in the United States. According to a report by the American Civil Liberties Union (ACLU) Women’s Right Project, Black women face physical, emotional, and cultural obstacles to breastfeeding, many of the constraints owing to limited financial resources. Black women’s labor participation rate of 60.2% is higher than the rate for women of all other races. Additionally, Black women are oftentimes the primary economic support for their families, with 70.7% of Black mothers as sole breadwinners and 14.7% as co-breadwinners (Echols, 2019). Many Black women experience economic pressures that motivate them to return to the workplace earlier after giving birth than women of any other race. This paper highlights critical deficiencies found in the health systems of Black communities in low income brackets and the lack of lactation consultant programs and support. To disrupt this entrenched inequality, the authors propose an anticipatory approach, guided by Imogene King’s Theory of Goal Attainment. Now, more than ever, it is of utmost importance that all families have access to equitable resources that support the mother-baby dyad in breastfeeding and that families have access to tools to help them set and reach their breastfeeding goals.
A comprehensive support structure providing ongoing, professional guidance can help to improve breastfeeding outcomes. Application of Nursing Theory
King’s Theory of Goal Attainment begins with the concept of capturing the essence of nursing in the form of face-to-face transactions (Smith, 2020). The theory emphasizes the value of the nurse-patient relationship in communicating, setting goals, and moving both nurse and patient together to achieve goals. When used in an interdisciplinary setting, goals are achieved by the patient when each member of the team realizes and accepts their role and function in reaching chosen goals. Each member brings a specific purpose to the group, and individualized tasks are accomplished by the teammates according to their role and expertise. Communication within the group is ongoing, fluid, patient-centered, and it includes the patient as an active participant. This process promotes adaptation of the patient and team as one.
The Nurse Practitioner Leads a Multidisciplinary Team to Address Gaps in Care
In a breastfeeding model of care, applying King’s theory would entail exchanging information on breastfeeding and assisting the client in establishing a commitment to, and an initial goal for, breastfeeding. The process would begin during pregnancy and continue through infant weaning. As the process unfolds, further, measurable goals can be set in a stepwise or gradual fashion. Each goal should be accompanied by a means to attain the goal in the form of a nursing care plan. The care plan would be implemented using lactation resources through the hospital-based breastfeeding office, which would allow providers to capture newborns at birth.
A nurse practitioner would direct the service and be responsible for assessing, diagnosing, prescribing, admitting, and referring out the most complicated breastfeeding cases. To promote fiscal responsibility, IBCLCs and certified lactation counselors (CLC) can be utilized to reiterate breastfeeding best practices and help resolve varying levels of breastfeeding
A breastfeeding sponsor would also function as a contemporary companion who could provide an outlet during the fragile and emotionally charged weeks of early motherhood.
challenges. This proposed service would operate out of the local hospital and push into the community in the form of home health visits. These visits would provide individualized care, be socially distanced, and also adhere to standard infection control practices. Care would begin in the third trimester of a pregnancy, and pinpointed care would occur at crucial times along the breastfeeding timeline such as at birth, in the first 2 weeks at home, during growth spurts and teething, as well as during a mother’s return to work, the introduction of solid foods, and weaning. Evaluation of the plan would occur weekly in early infancy, and as breastfeeding is further established, evaluations would continue monthly for the duration of the breastfeeding relationship.
Breastfeeding Sponsorship: A Fresh Concept
There is noted success in the literature to indicate that that peer breastfeeding sponsorship could translate for use with Black mothers to increase their breastfeeding success (Kim et al., 2017). According to the report, researchers who studied an Illinois WIC office recommended providing emotional and informational support to Black women by establishing support circles that are otherwise lacking. Adding this supportive and social aspect would contribute to increasing both breastfeeding initiation and duration rates for Black women, whose cultural background may have deterred breastfeeding. Some Black women have seen breastfeeding as reverting to “slavery days” when feeding a child by breast was the only option, according to a report in Minority Nurse (Johnson, 2016). With the introduction of baby formulas in the 1800s, campaigns led many women to believe breastfeeding was a choice only for lower-income mothers.
As an aid to addressing many of these stigmas, a breastfeeding sponsor would also function as a contemporary companion who could provide an outlet during the fragile and emotionally charged weeks of early motherhood. Mirroring other successful sponsorship programs, a one-on-one peer breastfeeding sponsor can serve as a close family member or friend for those who don’t have familial support when breastfeeding. Members of the community who have personal experience with breastfeeding can act as sponsors, thereby providing new mothers a “chain” of support that includes a breastfeeding sponsor, IBCLC or CLC, and nurse practitioner. In keeping with the essence of King’s theory, each member in such a support team will be focused on the common goal set by the patient and her care team.
Progress, any changes, as well as the achievement of goals would be communicated within the team to allow for continued development and holistic adaptation. Professional lactation care would be accessible in the home, which will keep newborns and their mothers out of hospitals and offices and away from exposure to diseases such as COVID-19. Consideration will have been made for the use of telehealth for lactation consultations and video phone calls for sponsor support during the height of the COVID-19 pandemic, when telephones and internet services are available. A review of literature by Ferraz dos Santos et al. (2020) shows the use of telehealth as a viable option for providing lactation consultations when in-person care is not feasible. Illness and disease that are avoidable with breastfeeding could be reduced with improved breastfeeding outcomes from such measures.
Conclusion
Human milk, often touted as “liquid gold” for its beneficial health properties, is the simplest and purest of human infant needs. Although on the surface this superfood is available to all infants, data shows this isn’t always the case due to any number of factors. Applying an action-based approach to this public health call by fortifying Black communities that are in a low-income bracket with additional breastfeeding support and resources would prove beneficial in radically reducing breastfeeding and its related health discrepancies between various racial communities in the United States. Rather than relying on infant formula due to numerous environmental, cultural, and job-related obstacles, the measures discussed in this paper would support both the child’s and mother’s health, as well as a family’s financial wellness if resources focused on increased rates of breastfeeding to cut down on both formula and medical expenses. Subsidized lactation care would reduce the burden of disease due to increased adherence to the established breastfeeding guidelines. Healthcare dollars saved by decreased rates of illness could be reinvested in lactation care to allow for continued services. Applying the concepts developed originally by Imogene King allows caregivers to work as a team to help persons in need establish and meet their breastfeeding goals. Through continuous care, documentation, and evaluation of achieved goals, the proposed approach would succeed. Education and preventative, proactive work to address deficiencies in the current models of breastfeeding delivery to underserved Black communities would begin to provide equity in resources and results in breastfeeding goals as established by the CDC. Providing a structured lactation service that underscores humans caring for humans in peer networks and communities is the backbone of King’s work. Implementation of the proposals offered by this paper would enhance health and wellness for underserved black communities.
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