Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity

The United States is facing a crisis in maternal and child health. Parents of color and their infants face two to four times the risk of preterm birth, pregnancy complications, and infant death, and that risk is steadily rising. Breastfeeding can significantly reduce the risk of lifetime disease and disability, especially for families experiencing poor birth outcomes. Breastfeeding provides immune protection and support for brain and gut development for infants, and reduces the risk for heart disease, and ovarian and breast cancers in breastfeeding parents. The American Pediatric Association and the Centers for Disease Control and Prevention recommend that infants receive only breastmilk for the first six months of life, and continue to receive breastmilk alongside table foods for at least the first 12-24 months of life. Yet significant disparities in breastfeeding persist in the United States, with Black and Latinx parents breastfeeding at reduced intensity (smaller proportion of infant’s diet is breastmilk) and for shorter duration (fewer total weeks providing breastmilk to infant) than non-Black and Latinx parents. Reduced breastfeeding intensity and duration among Black and Latinx families results in 1.5-3.5 times higher risk of illness and death among Black and Latinx infants compared to white infants, and contributes to more than 3,340 excess maternal deaths annually.

Breastfeeding Peer Counseling (BPC) was designed to reduce disparities in breastfeeding by using culturally relevant education and direct support to address barriers to breastfeeding faced by Black, Latinx, and low-income families. BPC recognizes that social networks of peers have traditionally provided the basis for infant feeding practices, knowledge, and breastfeeding help and encouragement. BPC is delivered by salaried lay health workers who have breastfed an infant, and have received basic training in breastfeeding support. Community-based BPC is available in all 50 states, administered to tens of thousands of birthing families every year, and is consistently associated with improved breastfeeding intensity and duration for Black and Latinx families.

A significant limitation of community-based BPC is the lack of continuity with clinical care. More than 98 percent of birthing parents in the United States receive prenatal, delivery, and postpartum care in clinical settings, and these clinical settings present an important opportunity for enhancing breastfeeding education during pregnancy and hands-on breastfeeding help after delivery. Clinically integrated BPC (Ci-BPC) is a practice that, much like doula care, supports the patient and the clinical team by delivering non-clinical, culturally relevant education and support that enhances patient experience. Ci-BPC has the potential to dramatically reduce breastfeeding disparities by enriching breastfeeding care at precisely the time patients need it most, yet there is limited research on ci-BPC. In particular, three key questions must be answered to identify the utility of ci-BPC to reduce disparities: (a) Can ci-BPC during prenatal, delivery admission, and postpartum care be used as a general breastfeeding support strategy to reduce breastfeeding disparities for Black and Latinx patients? (b) How does ci-BPC care improve breastfeeding outcomes? And finally, (c) What are the factors that influence the effectiveness of ci-BPC in the clinical setting?

Engaging with patients, community organizations, and clinical teams, the project team will test whether the addition of ci-BPC during prenatal, delivery admission, and postpartum care to standard inpatient breastfeeding support from nursing staff is associated with reduced disparities in breastfeeding outcomes for Black and Latinx families. The team will randomly assign patient volunteers to either standard breastfeeding care or standard breastfeeding care plus ci-BPC and follow these participants from pregnancy through six months postpartum to evaluate differences in breastfeeding outcomes across the two groups and determine whether Black and Latinx participants see greater improvement in their breastfeeding outcomes. The team will also evaluate what components of ci-BPC care are most important to support improved breastfeeding outcomes. Finally, the team will assess how effectively the program was implemented, and identify factors critical to program success. This study is important because the vast majority of parents desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest study of ci-BPC in the United States, this project will improve the quality of evidence available for patients and stakeholders to determine the benefits of ci-BPC for all patients, especially Black and Latinx patients. These findings can support expansion of the ci-BPC model more broadly.