Research Review: Evidence of Racial Disparities in Access to Human Milk in the NICU

By Tara Coffin, MEd, CLE, PhDc

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Today's research review is by my colleague Tara Coffin - who examines a new study, Disparities in Hospital-Reported Breast Milk Use in Neontal Intensive Care Units - United States, 2015 that demonstrates that babies of color in the NICU have less access to both their own parent's breast/chestmilk but also less access to donor milk.  Since babies of color are more likely to be born prematurely and/or need NICU care, the lack of human milk can play a significant role in their ability to grow and thrive and get released from the NICU sooner and fully healthy.  The inequities that people of color face every day in receiving care during pregnancy, labor/birth and postpartum birth continue to affect their babies after birth if they need NICU care. - Sharon Muza, Community Manager, Science & Sensibility.

Human milk is critical for premature infants, who often spend their early days in the neonatal intensive care unit (NICU). Prior research indicates that infants who receive more than 50% of their lactating parent’s milk, in the two weeks following birth, have a significantly decreased risk of necrotizing enterocolitis, a condition that is often fatal (Maffei & Schanler, 2017). When the gestational parent’s milk is unavailable, the American Academy of Pediatrics supports the use of donor human milk for high-risk infants (American Academy of Pediatrics). Breast/chest feeding policies, like the Baby-Friendly Hospital Initiative, have sought to improve breast/chest feeding rates in the United States, in hopes of improving access to human milk for healthy term infants and premature infants alike (Merewood et al., 2003). Despite these efforts, however, racial disparities in access to human milk persist, and in some cases have even grown over the past decade, as seen in table 1 (CDC, 2017)

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Non-Hispanic black parents, for example, who are at an increased risk for preterm labor, also have some of the lowest breastfeeding rates. Now a recent CDC study suggests that these disparities may also exist in the context of NICU breast milk use, where access to human milk can quite literally be the difference between life and death (Boundy et al., 2017).

Using data from the CDC’s 2015 Maternity Practices in Infant Nutrition and Care survey, researchers found that hospitals located in zip codes with a higher percentage of black residents were less likely to use human milk in their NICU. They explored this not just from the perspective of breast/chest feeding initiation, but the access to any human milk—from the lactating parent or from a donor milk bank. Of the 602 hospitals equipped with a NICU who also reported zip code-level data about race, 222 of them were located in zip codes with a percentage of black residents that exceeded the national average (12.3%). The other NICUs were located in zip codes with a below-average percentage of black residents. NICUs in zip codes with an above average percentage of black residents reported that 72% of infants received milk from their lactating parent, compared to 80% in NICUs located in zip codes with below-average percentage of black residents. This trend was observed in the context of donor milk as well, where only 5% of infants received donor milk in zip codes with higher percentages of black residents, versus 10% of infants in zip codes with lower percentages. In other words, hospitals that were more likely to serve black families reported lower update of human milk, when compared to other hospitals.

An earlier study found that the family’s ability to pay does not seem to influence access to donor milk (Brownell et al., 2016). So there’s likely something else going on here. The difference observed between zip codes with higher and lower percentage black residents could be due to any number of reasons and warrants additional research. But there is no question about the deeply troubling lack of appropriate perinatal care observed across non-Hispanic black communities. For example, a joint report by the Texas Department of State Health Services’ Maternal Mortality and Morbidity Task Force reported a substantial increase in maternal mortality among black mothers, noting that while black mothers accounted for only 11.4% of Texas births in 2011 and 2012, they accounted for nearly one-third (28.8%) of pregnancy-related deaths (Department of State Health Services, 2016). Now it appears that the same factors worsening perinatal outcomes for black parents may also negatively impact access to human milk in the NICU.


American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Pediatrics 2012;129:e827–41. https://doi. org/10.1542/peds.2011-3552

Boundy, E. O., Perrine, C. G., Nelson, J. M., & Hamner, H. C. (2017). Disparities in Hospital-Reported Breast Milk Use in Neonatal Intensive Care Units—United States, 2015. MMWR. Morbidity and mortality weekly report, 66(48), 1313.

Brownell, E. A., Smith, K. C., Cornell, E. L., Esposito, P. A., Wiley, C. C., Wang, Z., ... & Hagadorn, J. I. (2016). Five-year secular trends and predictors of nonconsent to receive donor milk in the neonatal intensive care unit. Breastfeeding Medicine, 11(6), 281-285.

CDC (2017). Racial Disparities Remain in Breastfeeding Rates. JAMA. 2017;318(8):691. doi:10.1001/jama.2017.10454

Department of State Health Services. (2016). Maternal Mortality and Morbidity Task Force and Department of State Health Services: Joint Biennial Report.

Maffei, D., & Schanler, R. J. (2017, February). Human milk is the feeding strategy to prevent necrotizing enterocolitis!. In Seminars in perinatology (Vol. 41, No. 1, pp. 36-40). WB Saunders

Merewood, A., Philipp, B. L., Chawla, N., & Cimo, S. (2003). The baby-friendly hospital initiative increases breastfeeding rates in a US neonatal intensive care unit. Journal of Human Lactation, 19(2), 166-171.

tara coffin headshot 2016.jpgAbout Tara Coffin

Tara Coffin MEd, CLE, PhDc, is a mom, a lactation educator, and a public health researcher. She studies research dissemination in the arena of genetics and maternal and child health issues, with a focus on connecting the community with meaningful health research. With experience with educational technology, she is passionate about improving public health research dissemination and education in the virtual setting. Tara blogs about issues related to epigenetics, lactation, and public health at Milk and Genes.

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