Identifying Barriers to Mother's Milk Feeding in Early Preterm Black Infants in an Urban Neonatal Intensive Care Unit

Background: Greater use of mother’s own milk (MM) is associated with improved outcomes for preterm infants admitted to neonatal intensive care units (NICUs). Healthcare disparities exist in the provision of MM and further research is needed to better identify modifiable barriers in high-risk populations. Our urban Level IV NICU in Baltimore, Maryland serves a patient population who are 60% non-Hispanic Black, allowing us to better study this important demographic. The objective of this study was to evaluate incidence and predictors of MM provision to early preterm non-Hispanic Black infants.

Methods: We performed a retrospective medical record review of non-Hispanic Black infants (race identified by their mother) born early preterm <34 weeks gestational age (GA), between 9/2014 – 12/2020 in an urban Level IV NICU. We performed bivariate analyses of clinical and demographic variables comparing: 1) maternal characteristics of infants who did vs. did not receive MM at any point during NICU admission, and 2) neonatal characteristics and outcomes based on exposure to any MM vs. none. Chi-square, T-test, Wilcoxon Rank Sum Tests were performed as appropriate.

Results: We identified 422 early preterm, non-Hispanic Black infants during the study period, of whom 332 (79%) received MM during their NICU admission. Maternal factors associated with infants NOT receiving MM during admission included higher maternal gravidity (p=0.0011), increased parity of term deliveries (p < 0.0001), increased number of living children (p < 0.0001). Maternal age and medical comorbidities such as pre-eclampsia, HELLP syndrome, chronic hypertension, and diabetes did not have a significant impact on provision of MM. Infants of mothers with bipolar disorder were less likely to receive MM (p=0.0068) while those of mothers with anxiety diagnosis were more likely to receive MM (p=0.0245). There were no differences in provision of MM for infants whose mothers had pre-existing depression or who screened positive for post-partum depression. The mothers who provided MM were significantly more likely to have received lactation consultation during NICU admission (74% vs. 20%, p<0.001). Infants who received no MM were less premature (p=0.0002), had higher birth weights (p < 0.0001), were less likely to require a ventilator during their admission (p=0.0219), and were less likely to have an oxygen requirement once corrected to 36 weeks (p=0.0239).

Conclusion: Identifying significant barriers to MM provision for non-Hispanic Black infants will improve our ability to focus educational and supportive interventions. Interestingly, significant maternal predictors of NOT providing MM included having more term deliveries and more living children, indicating that increasing home responsibilities may limit ability to pump and/or breast feed. Interventions that provide NICU mothers with home and childcare assistance may improve their availability to pump and provide MM. Inpatient lactation consultation had one of the strongest associations, therefore enhancing access to inpatient lactation consultation may also significantly increase MM provision.