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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: Acad Pediatr. 2022 Feb 25;22(8):1429–1436. doi: 10.1016/j.acap.2022.02.008

Racial and Ethnic Differences in Maternal Social Support and Relationship to Mother-Infant Health Behaviors

Michelle J White a, Melissa C Kay a,b, Tracy Truong c, Cynthia L Green c, H Shonna Yin d, Kori B Flower e, Russell L Rothman f, Lee M Sanders g, Alan M Delamater h, Naomi N Duke a, Eliana M Perrin i
PMCID: PMC10078964  NIHMSID: NIHMS1784007  PMID: 35227910

Abstract

Objectives:

To examine racial and ethnic differences in maternal social support in infancy and the relationship between social support and mother-infant health behaviors.

Methods:

Secondary analysis of baseline data from a multisite obesity prevention trial that enrolled mothers and their two-month-old infants. Behavioral and social support data were collected via questionnaire. We used modified Poisson regression to determine association between health behaviors and financial and emotional social support, adjusted for sociodemographic characteristics.

Results:

826 mother-infant dyads (27.3% Non-Hispanic Black, 18.0% Non-Hispanic White, 50.1% Hispanic and 4.6% Non-Hispanic Other). Half of mothers were born in the U.S.; 87% were Medicaid-insured. There were no racial/ethnic differences in social support controlling for maternal nativity. U.S.-born mothers were more likely to have emotional and financial support (rate ratio [RR] 1.14 95% confidence interval [CI]: 1.07, 1.21 and RR 1.23 95% CI: 1.11, 1.37, respectively) versus mothers born outside the U.S. Mothers with financial support were less likely to exclusively feed with breast milk (RR 0.62; 95% CI: 0.45, 0.87) yet more likely to have tummy time ≥12min (RR 1.28; 95% CI: 1.02, 1.59) versus mothers without financial support. Mothers with emotional support were less likely to report feeding with breast milk (RR 0.82; 95% CI: 0.69, 0.97) versus mothers without emotional support.

Conclusions:

Nativity, not race or ethnicity, is a significant determinant of maternal social support. Greater social support was not universally associated with healthy behaviors. Interventions may wish to consider the complex nature of social support and population-specific social support needs.

Keywords: Child obesity, social support, race and ethnicity, nativity

Introduction

Social support has been defined as the degree to which aspects of interpersonal relationships promote a sense of being valued and cared for, and facilitate an ability to engage in activities and behaviors on behalf of self and others.[1] Social support has been linked to a wide range of health behaviors and outcomes and has achieved a particular spotlight in maternal-child health due to its effects on maternal mental health, infant feeding, and infant development.[2, 3]

Parent social support may protect against the development of child obesity which may be particularly important during a child’s first year of life, a critical period for obesity prevention.[4–7] Mothers with greater social support report greater initiation and duration of breastfeeding, an important factor in obesity prevention.[8] Reduced levels of stress have also been reported with greater social support, allowing mothers to respond to infant cues and foster healthy development.[9, 10] In addition to infant feeding practices, the first year of life is also when screen time and physical activity practices start to form.[11, 12] Together, infant feeding, screen time and infant time spent playing in prone position, known as “tummy time,” are key targets for child obesity prevention.[13–15] However, few studies have examined the relationship between maternal social support and key mother-infant health behaviors during the first year of life outside of breastfeeding.[16]

The relationship between maternal social support and race and ethnicity is another important gap in the social support literature during infancy. Studies across multiple disciplines have shown that levels of social support may not be equal among racial and ethnic groups in the United States.[17] The reasons for these differences may include social isolation as a result of structural racism and recent immigration to the U.S.[18, 19] Moreover, the effects of social support on health outcomes may be different for individuals of different racial and ethnic groups. For example, a handful of studies suggest that high levels of social support for Non-Hispanic Black individuals may not have the same health-promoting effect as in Non-Hispanic White individuals.[17, 20] This difference in effect may exist because individuals from marginalized communities experience high levels of discrimination and psychosocial stressors potentially mitigating the beneficial effects of social support. Also, individuals who provide social support can be a source of social strain. Cultural expectations and multigenerational caretaking responsibilities may lead to a significant experience of social strain for Hispanic and Black individuals, even among relationships which also provide social support.[2, 21]

The potential for racial and ethnic differences in access to social support and its effects on mother-infant behaviors is significant when considered in concert with racial and ethnic differences in mother-infant health behaviors and disparities in child obesity.[22, 23] Identifying mothers for whom the provision of social support may foster healthy behaviors may inform interventions which aim to mitigate early life obesity risk. To better elucidate the relationship between social support and mother-infant health behaviors we pursued 3 aims. First, we compared levels of maternal social support by race and ethnicity, controlling for maternal nativity. Second we tested the association between maternal social support and three mother-infant health behaviors which are important for obesity prevention during the first year of life[13]: feeding with breast milk, tummy time, and television (TV) time. Finally, we assessed whether race and ethnicity moderate the relationship between maternal social support and mother-infant health behaviors. We hypothesized that Hispanic and Non-Hispanic Black mothers would have less emotional and financial social support versus Non-Hispanic White mothers and that greater availability of social support would be associated with healthy mother-infant behaviors regardless of maternal race or ethnicity.

Methods

Study Design

We conducted a cross-sectional assessment of social support and three mother-infant feeding- and activity-related behaviors: tummy time, infant feeding with breast milk, and TV time. Data collection for this study occurred at baseline (when infants were approximately two months old) as part of the Greenlight study, a randomized childhood obesity prevention trial at 4 pediatric clinics in Miami, FL; Nashville, TN; New York, NY and Chapel Hill, NC from 2010–2014. Detailed methodology for Greenlight have been previously described.[24] Mothers provided written and verbal consent according to institutional review board protocols approved at each of the four study sites. The clinical trial was registered as NCT01040897 at clinicaltrials.gov.

Study Population

Infants enrolled in the study were between 6–16 weeks of age and had a mother or guardian who spoke either Spanish or English. Infants who were born prior to 34 weeks gestation, weighed less than 1500g at birth, or had a diagnosis that could affect growth were excluded from the study. For the present analysis, fathers and other male caregivers (N = 39) who were enrolled with their infants at the 2-month visit were excluded from the analysis due to potential differences in the function and perception of social support in males versus females.[25] Study data were collected by trained research coordinators at each site according to the study protocol.

Measures

Social Support.

Following prior frameworks describing the application of social support to health behaviors, we assessed the adequacy and availability of maternal emotional support and the availability of maternal financial support.[2, 26] Social support was assessed using three validated questions from the National Health and Nutrition Examination Survey (NHANES) designed to describe both emotional social support (i.e., the provision of advice or expression of care), and financial or instrumental support (i.e., the provision of material aid).[27] To assess the availability of emotional support, mothers were asked “Can you count on anyone to provide you with emotional support such as talking over problems or helping you make a difficult decision?” To assess the adequacy of their emotional support, mothers were asked “In the last 12 months, could you have used more emotional support than you received?” We analyzed these questions as separate items because social support may be perceived as available (is it present?) or adequate (is it sufficient?), each with differing impacts on health outcomes.[26] Response options for both emotional support questions were “yes,” “no,” “don’t know,” and “don’t need help.” To permit clear interpretation, only caregivers who answered “yes” or “no” were included in analyses. All other answers were coded as missing (N=16 for availability of emotional support and N=40 for adequacy of emotional support). To assess the availability of financial support, mothers were asked “If you need some extra help financially, could you count on anyone to help you; for example, by paying any bills, housing costs, hospital visits, or providing you with food or clothes?” Response options were “yes,” “no,” “offered help but wouldn’t accept it” and “don’t know”. Only caregivers who answered “yes” or “no” were included in analyses. All other answers were coded as missing (N=36).

Mother-infant behaviors.

Three mother-infant health behaviors were analyzed: tummy time, TV time, and feeding with breast milk. These behaviors are highlighted as key behaviors within the first year of life for obesity prevention by the World Health Organization and American Academy of Pediatrics.[13, 14] Each behavior was assessed using a questionnaire at the two-month well child visit. Questionnaire items were adapted from validated measures including the Infant Feeding Style Questionnaire (IFSQ).[28] To assess infant feeding practices, mothers were asked what type of milk they were feeding their child with choices of breast milk only, formula only, or both. Mother-infant feeding practices were described as exclusive breast milk use, use of some breast milk and use of formula only. Tummy time was determined by mothers’ answers to the following question in minutes: “On most days, how much total time does [child’s first name] typically spend being active on his/her tummy while awake each day?” Tummy time was operationalized categorically as less than 12 minutes or 12 minutes or more based on recommendations from the American Academy of Pediatrics and evidence that daily tummy time of 12 minutes or more may protect against rapid infant weight gain.[29, 30] To determine TV time, mothers were asked: “How much is the television on each day when [child’s first name] is in the room (even if [child’s first name] is not watching).” TV time was operationalized as a continuous variable in minutes.

Demographic Data.

Enrolled mothers completed a detailed demographic questionnaire which included child sex, mother’s age, mother’s education, maternal nativity (born outside the U.S.), whether they were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), number of children in household, number of adults in household, household income and preferred language (English or Spanish). Center for Epidemiologic Studies Depression Scale (CES-D) score was also collected to assess for depression, where a score of 16 or greater was considered consistent with maternal depression.[31]

Statistical Analysis

Demographic characteristics were summarized using mean (standard deviation, SD), median (25th −75th percentiles, Q1-Q3), or frequency (percentage) for the study cohort. Breast milk only, both breast milk and formula, and tummy time were modeled using modified Poisson regression. TV time was treated as a continuous outcome and modeled using negative binomial regression with results presented using the rate ratio (RR) with 95% confidence interval (CI). For each outcome, a model with social support, race/ethnicity, and their interaction terms were fit and compared to a model without the interaction terms using a Wald test. If the overall interaction effect was significant (p < 0.05), contrast statements were used to assess the association between social support and the outcome for each level of race/ethnicity. If the interaction effect was not significant, a main effect model with only social support was fit. The same procedure was followed for both unadjusted and adjusted analyses. Covariates in adjusted analyses included child sex, maternal age, maternal education, WIC enrollment, significant symptoms of depression (CES-D score ≥ 16), number of children in household, number of adults in household, preferred language and study site. All analyses were performed in R 4.0.0 (R Core Team, 2020) at two-tailed significance level of 0.05.[32]

Results

Demographic Characteristics

There were 826 mothers included in the analysis. Half of mothers identified as Hispanic, and 27.3% identified as Non-Hispanic Black (Table 1). Non-Hispanic Other race classification included mothers who identified as Asian, Native American and Other. Non-Hispanic Other mothers comprised 4.6% of mothers. Approximately half of mothers (49.6%) were born in the U.S. Maternal mean age was 27.5 years (SD 5.7), and mean infant age 9.3 weeks (SD 1.8). Fifty-two percent of infants were female. Mothers reported a range of educational attainment. The cohort was overall low-income with 84.3% reporting a household income of less than $40,000 per year; 85.5% were enrolled in WIC. The mean number of children and adults per household was 2.1 (SD 1.0) and 2.5 (SD 1.1), respectively. Only 9% of infants were receiving out-of-home childcare at the time of their two-month well visit.

Table 1.

Mother and Infant Demographics N=826

Characteristics Full cohort (N = 826)
Race/Ethnicity
 Hispanic 413 (50.1%)
 Non-Hispanic Other 38 (4.6%)
  American Indian/Alaskan Native 1 (0.2%)
  Asian 19 (0.2%)
  Other 18 (2.2)
 Non-Hispanic Black 225 (27.3%)
 Non-Hispanic White 148 (18.0%)
Mother - born in US
 No 413 (50.4%)
 Yes 407 (49.6%)
 Missing 6 (0.7%)
Mother age (years)
 Mean (SD) 27.5 (5.7)
 Missing 6 (0.7%)
Mean Infant Age in Weeks (SD) 9.3 (1.8)
Infant sex
 Male 396 (47.9%)
 Female 430 (52.1%)
Infant insurance
 Medicaid 710 (86.6%)
 Private 86 (10.5%)
 None 24 (2.9%)
Special Supplemental Nutrition Program for Women, Infants, and Children
 No 119 (14.5%)
 Yes 701 (85.5%)
 Missing 6 (0.7%)
Mother education
 College graduate or higher 141 (17.2%)
 Some college 192 (23.4%)
 High school graduate 272 (33.2%)
 Less than high school 215 (26.2%)
Household income
 < $10,000 257 (32.5%)
 $10,000–19,999 220 (27.8%)
 $20,000–39,999 189 (23.9%)
 >= $40,000 124 (15.7%)
Children in household
 Mean (SD) 2.1 (1.2)
 Missing 6 (0.7%)
Adults in household
 Mean (SD) 2.5 (1.1)
 Missing 6 (0.7%)
Any out-of-home childcare
 No 746 (91%)
 Yes 74 ( 9.0%)
 Missing 6 (0.7%)
Center for Epidemiologic Studies Depression Scale
Evidence of maternal depression (≥16) 145 (17.6%)
Missing 22 (2.7%)
Site
 Nashville, TN 225 (27.2%)
 New York, NY 222 (26.9%)
 Chapel Hill, NC 241 (29.2%)
 Miami, FL 138 (16.7%)
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Social Support

Most (90.4%) mothers reported having emotional support available with significant differences across groups of race and ethnicity in unadjusted analyses (p < 0.001) (Table 2). Specifically, larger proportions of Non-Hispanic White (97.9%) and Non-Hispanic Black (95.1%) mothers reported having available emotional support versus Hispanic (85.7%) and Non-Hispanic Other (84.2%) mothers. Only 57.9% of mothers overall reported having adequate emotional support, with no significant differences between racial and ethnic groups observed (p = 0.156). Approximately three quarters of mothers reported having financial support available with significant differences across groups of race and ethnicity (p < 0.001). Only 69.8% of Hispanic mothers reported having financial support available versus >80% for each of the other groups.

Table 2.

Unadjusted Social Support by Race and Ethnicity N=826

Exposure/Outcomes Hispanic (N = 413) Non-Hispanic Other (N = 38) Non-Hispanic Black (N = 225) Non-Hispanic White (N = 148) Total (N = 826) P-value1
Social Support
Available emotional support 348
(85.7%)		 32
(84.2%)		 212
(95.1%)		 140
(97.9%)		 732
(90.4%)		 <0.0001
 Missing 7 - 2 5 16
Adequate emotional support 211
(54.2%)		 20
(54.1%)		 139
(62.9%)		 85
(61.2%)		 455
(57.9%)		 0.156
 Missing 24 1 4 9 40
Available financial support 275
(69.8%)		 30
(81.1%)		 184
(83.3%)		 122
(88.4%)		 611
(77.3%)		 <0.0001
 Missing 19 1 4 10 36
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1

P-value from Chi-square test represents comparison of exposures and outcomes across racial/ethnic groups

After controlling for maternal nativity, racial and ethnic differences in available emotional and financial support were no longer statistically significant (Table 3). Overall, mothers born in the U.S. were significantly more likely to report available emotional and financial support (RR 1.14 95% CI: 1.07, 1.21; p <0.001 and RR 1.23 95% CI: 1.11, 1.37; p<0.001 respectively). Adequacy of emotional support remained similar across maternal race and ethnicity and nativity.

Table 3.

Social Support by Race and Ethnicity Adjusting for Maternal Nativity N=826

Available emotional support Adequate emotional support Available financial support
Variables RR (95% CI) P RR (95% CI) P RR (95% CI) P
Hispanic1 Reference Reference Reference
Non-Hispanic Other1 0.96 (0.83, 1.11) 0.569 1.00 (0.73, 1.36) 0.992 1.11 (0.94, 1.33) 0.219
Non-Hispanic Black/African American1 1.01 (0.95, 1.08) 0.725 1.17 (0.97, 1.40) 0.099 1.03 (0.92, 1.15) 0.644
Non-Hispanic White1 1.04 (0.99, 1.10) 0.099 1.14 (0.93, 1.38) 0.211 1.09 (0.98, 1.22) 0.097
U.S. born2 1.14 (1.07, 1.21) <0.001 0.99 (0.84, 1.17) 0.908 1.23 (1.11, 1.37) <0.001
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1

P value for logistic regression controlling for maternal nativity (born in the U.S. yes or no)

2

Unadjusted Risk Ratio (RR) for U.S. born mothers versus mothers born outside the U.S.

Social Support and Mother-Infant Health Behaviors

Adjusted for relevant sociodemographic maternal and child factors, mothers reporting available financial support were less likely to report exclusive infant feeding with breast milk at 2 months compared to mothers who lacked available financial support (RR 0.62; 95% CI: 0.45, 0.87; p=0.005) (Table 4). Mothers reporting available emotional support were less likely to report any infant feedings with breast milk versus mothers without available emotional support (RR 0.82; 95% CI: 0.69, 0.97; p=0.022). Adequate emotional support was not associated with exclusive infant feedings with breast milk or any infant feedings with breast milk (RR 0.86; 95% CI: 0.64, 1.15; p=0.312 and RR 0.93; 95% CI: 0.83, 1.05; p=0.253, respectively). While neither the available nor adequate emotional support were associated with achieving at least 12 minutes tummy time daily, mothers with available financial support were more likely to reach this amount of tummy time compared to those who reported having no financial support available (RR 1.28; 95% CI: 1.02, 1.59; p=0.030). Neither emotional (availability or adequacy) nor available financial support were associated with TV time.

Table 4.

Adjusted Association Between Social Support and Mother Infant Behavior N=8621

Exclusive infant feedings with breast milk RR (95% CI) P-value2
Available emotional support 0.71 (0.46, 1.09) 0.118
Adequate emotional support 0.86 (0.64, 1.15) 0.312
Available financial support 0.62 (0.45, 0.87) 0.005
Any infant feedings with breast milk RR (95% CI) P-value2
Available emotional support 0.82 (0.69, 0.97) 0.022
Adequate emotional support 0.93 (0.83, 1.05) 0.253
Available financial support 0.90 (0.78, 1.03) 0.110
Tummy Time >= 12 min RR (95% CI) P-value 2
Available emotional support 1.11 (0.81, 1.54) 0.519
Adequate emotional support 0.96 (0.81, 1.11) 0.554
Availability financial support 1.28 (1.02, 1.59) 0.030
Television Time RR (95% CI) P-value 2
Available emotional support 0.92 (0.66, 1.24) 0.585
Adequate emotional support 0.94 (0.78, 1.13) 0.525
Available financial support 1.12 (0.89, 1.39) 0.321
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1

Adjusted for child sex, maternal age, maternal education, WIC enrollment, maternal depression (CES-D ≥16), number of children in household, number of adults in household, preferred language, and study site

2

P-value represents association between mother-infant behavior and social support characteristic using modified Poisson regression for breast milk outcomes and tummy time and negative binomial regression for television time.

Moderation by Race and Ethnicity

The relationships between each social support variable and mother-infant health behaviors were assessed for moderation by race and ethnicity. Only the relationship between exclusive infant feeding with breast milk and available emotional support demonstrated evidence of moderation (p < 0.001). Controlling for sociodemographic factors, racial and ethnic subgroup analyses revealed no statistically significant relationships (Supplementary Table 5). Notably, we were unable to calculate a race-stratified risk ratio for mothers identifying as Non-Hispanic White because all Non-Hispanic White mothers in our sample who exclusively fed with breast milk reported having available emotional support.

Discussion

Among this sample of racially and ethnically diverse mothers, the overwhelming majority of mothers (over 90%) reported having emotional support available, with fewer mothers endorsing adequate emotional support or available financial support. Statistically significant racial and ethnic differences in social support were noted prior to the inclusion of nativity in our models. However, racial and ethnic differences in social support were no longer statistically significant after controlling for nativity. Mothers born outside the U.S. were less likely to report available emotional and financial support. In our analysis of the association between maternal social support and mother-infant health behaviors, mothers with available emotional support were less likely to feed their infants breast milk. Mothers with available financial support were less likely to report exclusive feeding with breast milk yet more likely to achieve daily tummy time recommendations. While there was evidence of moderation of the association between exclusive feeding with breast milk by race and ethnicity, there were no statistically significant relationships noted in subgroup analyses. Cumulatively these findings illustrate a dearth of social support among mothers born outside the U.S. and a complex relationship between social support and mother-infant health behaviors whereby social support is not universally correlated with healthy mother-infant behaviors.

Our findings around social support and infant feeding with breast milk were surprising and likely reflect characteristics of mothers’ social networks beyond social support. Emotional social support for breastfeeding can appear through role modeling, encouragement, and supportive information, and financial support can include broader financial assistance with household expenses and childcare or the provision of breastfeeding supplies.[33] While these types of support may promote breastfeeding it is possible that the individuals providing emotional or financial support may also be influencing mother-infant behaviors in other ways. Normalization of breastfeeding, both from family and other social support networks, is important for maternal self-efficacy and ultimately a mother’s ability to successfully breastfeed her children. Thus, a mother’s social network, from which she derives emotional and financial support, can significantly impact her breastfeeding goals, in both positive and negative ways.[34] Cultural beliefs and societal influences regarding breastfeeding may specifically deter breastfeeding in Black and Hispanic families due to the influence of historic and current systemic institutional and structural racist practices, including formula companies’ race-targeted marketing and the inequitable distribution of supportive breastfeeding policies and maternity care.[35–39] Our findings reflect the need for broader assessments of the influence of maternal social environments and social network characteristics on mother-infant health behaviors.

Few studies have directly compared maternal social support levels by race or ethnicity. Our current understanding of how maternal social support varies by race and ethnicity largely derives from other periods in the life course. A lack of social support may be particularly detrimental during the critical period of infancy.[40, 41] Social support levels may differ by race or ethnicity due to relative social isolation as a result of segregation and racism.[18, 19] One study using a nationally representative sample showed that Non-Hispanic Black and Hispanic mothers of children and adolescents reported less social support for parenting than whites.[42] Additional examination of maternal social support by race and ethnicity reveals that racial and ethnic groups may not differ in the overall number of people providing social support, but by the sources and quality of social support.[43] These studies and ours indicate the relationship between maternal social support and race and ethnicity is complex, and conclusions drawn may differ if key factors such as maternal nativity are not taken into account.

Our data suggest that nativity is a better predictor of the presence of financial and emotional social support for mothers of infants than race or ethnicity. Prior studies have shown that nativity outside the U.S. may be associated with lower levels of social support.[44, 45] Recent immigrant status can lead to social isolation and limit access to financial resources and healthcare.[46] Maternal social support interventions during infancy may be particularly beneficial for mothers born outside the U.S.

The relationship between tummy time and financial support is a novel finding. There are racial and ethnic differences in tummy time.[22] An intervention providing social support via parenting support groups and health education to low-income Hispanic families increased participant tummy time supporting a potential relationship between social support and tummy time.[47] Financial support may help facilitate tummy time because mothers with available financial support are more likely to have access to financial resources which permit time, safe space, and adequate supervision to achieve more tummy time with their infant. The potential relationship between financial support and tummy time indicates that further research is needed to identify financial barriers to tummy time and infant physical activity.

Limitations and Strengths

We used a common, validated measure of social support, but also one that is not specific to maternal-infant health behaviors. Thus, we may have failed to identify the specific types of support which are most important within the mother-infant context, particularly for the health behaviors of interest. Similarly, because social support is shaped by cultural norms, differences in levels of social support by race and ethnicity may reflect sociocultural differences in perceptions of social support rather than differences in access to social support. Also, we note that the cultural and ethnic diversity of our cohort is not fully captured by racial or ethnic categories. There may be significant variability in social support within the racial and ethnic categories used in the present study. Unfortunately, the adequacy of financial support was not assessed in the parent study; thus, we were unable to include this information in our analyses. However, emotional social support has been most frequently linked to health behaviors and outcomes.[2] Notably, due to the cross-sectional nature of data, the causal direction of these associations cannot be addressed in the current study. For example, the decision to exclusively feed with breast milk could shape a mother’s perceptions of social support due to the specific types of support required for breastfeeding.[48] Our assessment of screen time was limited to television time, however at the time of the study (2010–2014) televisions were the primary source of screen time. We were not able to include data describing maternal parity which may influence mother-infant health behaviors. Finally, our study also may not be generalizable to samples with higher proportions of Non-Hispanic White mothers or higher income households.

Our study strengths include a large racially and ethnically diverse cohort spread across four U.S. cities permitting the assessment of social support and health behaviors among groups who experience a disproportionate prevalence of child obesity. Not only have few studies assessed social support during early postpartum, few have done so in such a diverse population with extensive sociodemographic data including data describing nativity, preferred language and maternal depression. Additionally, rather than assess social support as a single construct, we were able to individually assess three specific social support domains and their association with key health behaviors.

Conclusions for Practice

In a diverse sample of mothers of infants, there were no racial or ethnic differences in maternal social support controlling for maternal nativity. Mothers born outside the U.S. were less likely to report available emotional or financial support. Additionally, mothers with available financial support were less likely to exclusively feed with breast milk and mothers with available emotional support were less likely to report any feedings with breast milk. Mothers with financial support available were more likely to meet tummy time recommendations. These results reflect the complexity of maternal support networks. Relationships which provide social support may support or hinder healthy behaviors. The impact of relationships which hinder healthy behaviors and cultural norms should be considered alongside behavior-specific social support in future studies to inform interventions.

Supplementary Material

2

Significance.

What is already known on the subject?

Levels of social support may vary by maternal characteristics. Maternal social support may influence family health behaviors.

What this study adds?

Mothers born outside the U.S. may lack emotional and financial social support. Social support is associated with multiple mother-infant health behaviors.

Declarations Statements

• Funding (information that explains whether and by whom the research was supported)

Funding source

This work was supported by the National Institutes of Health grants: NIH/NICHD R01 HD049794 (Yin, Rothman, Sanders, Delamater, Perrin), National Center for Advancing Translational Sciences 1KL2TR002554 (White), Loan Repayment Program L40 HD099880 (Kay), and by the Duke Center for Research to Advance Healthcare Equity (REACH Equity), which is supported by the National Institute on Minority Health and Health Disparities under award number U54MD012530 (Kay). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Duke Biostatistics, Epidemiology, and Research Design Methods Core’s support of this project was made possible in part by CTSA Grant (UL1TR002553) from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research (Truong and Green).

• Conflicts of interest/Competing interests (include appropriate disclosures)

Abbreviations:

TV

television

U.S

United States

WIC

Special Supplemental Nutrition Program for Women, Infants, and Children

Footnotes

Declaration of Competing Interest

The authors have no conflicts of interest relevant to this article to disclose.

• Ethics approval (include appropriate approvals or waivers)

This research was approved by Institutional Review Boards at the participating institutions.

• Consent to participate (include appropriate consent statements)

Mothers provided written and verbal consent according to institutional review board protocols approved at each of the four study sites.

• Consent for publication (consent statement regarding publishing an individual’s data or image) Not applicable.

• Availability of data and material (data transparency)

Data is available upon request.

• Code availability (software application or custom code)

Code is available upon request.

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