Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes

Abstract

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

Drivers of Inequities Seen Among US Lactation Rates

In 2021, over 1200 women died within pregnancy and the first 42 days postpartum, while 20 000 infants died before their 1st birthday in the United States [1,2], an unthinkable number of lives and life-years lost. Despite having the highest healthcare spending per capita compared to other high-income countries, and touting cutting-edge biomedical innovation, US pregnant individuals experience morbidity and mortality rates that far exceed those of most other high-income nations [3-5]. US maternal mortality rates increased by roughly 15% in 2018-19, 18% in 2019-20, and 42% in 2020-21, with over 80% of deaths considered to be preventable [1,6]. US infant mortality (ie, death before 1 year) increased for the first time in two decades between 2021-22, a rise largely driven by a marked 9% increase in the rate of death due to maternal complications [2]. This reality underscores the integrated health of a mother and child and the critical need for dyadic solutions.

Promoting breast/chest feeding among US dyads is one strategy worth strong consideration to address this crisis. Among the top drivers of maternal mortality is cardiovascular disease, and for infants, sudden unexpected infant death [7-9]. Breastfeeding has been associated with lower all-cause mortality and cardiometabolic risk for both mother and infant, as well as lower risk of sudden infant death [10-17]. A 2023 analysis of nearly 10 million US infants demonstrated that merely breastfeeding at the time of hospital discharge was associated with 33% fewer odds of infant mortality [18].

The dyadic mortality crisis disproportionately impacts communities that have been socially and economically marginalized, with non-Hispanic Black and Native American dyads experiencing the worst postpartum health outcomes [7,8,19-21]. In 2021, non-Hispanic Black and Native American women had mortality rates 2 to 3 times higher than non-Hispanic White mothers [1]. These inequities are mirrored among infants, with Native American and non-Hispanic Black infants having 2 and 2.5 times the rate of death before age 1 compared to non-Hispanic White infants, respectively [2]. These communities also have the lowest breastfeeding rates in the US [22]. Moreover, Hispanic dyads initiate breastfeeding at rates comparable to non-Hispanic White dyads (2019: 87.4% and 85.5%, respectively) [22], though are less likely to meet their personal goal of exclusive breastfeeding at 1 and 3 months postpartum [23]. There has been inequitable exposure between racial and ethnic groups over generations to breast milk’s numerous benefits, including a protective effect on childhood brain development, asthma and infection risk, as well as a lower dyadic risk of hypertension, diabetes, and cancer, all conditions prevalent among communities that have been socioeconomically marginalized [11,12,24].

To address the rise in dyadic morbidity and mortality, as well as distribute the benefits of breastfeeding more equitably, a concerted, multisystem investment in the promotion of breastfeeding is needed, particularly within populations with low lactation rates. Investment in the study and implementation of appropriate breast pump use is one potential tool to support breastfeeding among communities with the greatest barriers to reaching their infant feeding goals.

Historical Context and Policies that Drive Inequities in Lactation

Longstanding social, political, and economic marginalization of racial and ethnic minority groups in the US has resulted in inequitable health care delivery, quality, and outcomes for these communities [25-27]. Regarding breastfeeding specifically, several US policies and socioeconomic structures have both promoted formula use and failed to address barriers to breastfeeding. We must also acknowledge the broader impact of historical slavery and displacement of US racial and ethnic minority groups on present infant feeding practices. Though a brief overview of these concepts will follow, I recommend Andrea Freeman’s book Skimmed: Breastfeeding, Race, and Injustice for those seeking comprehensive historical context around the relationship between racial injustice and infant feeding practices in the US [28].

Formula use has grown to be most prevalent among communities that have been socioeconomically marginalized, in part due to highly effective, targeted marketing strategies that disseminate persuasive disinformation to families [29-31]. A February 2023 Lancet article series provides a comprehensive analysis of marketing and lobbying strategies used by corporate manufacturers to expand formula use and undermine breastfeeding—including the emerging role of personalized digital marketing [29,32,33]. The US is one of the few high-resource countries that does not strictly regulate the marketing of breast-milk substitutes, and as a result, much misguided and convincing marketing reaches families, undermining efforts to meet individual and national breastfeeding goals [34].

Beyond navigating personalized marketing and misinformation around infant feeding options, many low-income US families gain access to highly subsidized formula through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal supplemental nutritional program that aims to prevent food insecurity among pregnant women and young children [35]. To be sure, WIC provides vital support to US families facing high risk of food insecurity. Yet, upon WIC’s inception in 1974, rates of formula grew precipitously among low-income families. Today, WIC participants account for over 55% of all formula consumed in the US [36]. The use of formula among low-income populations across generations has left many communities with less peer and family knowledge around breastfeeding, influenced cultural infant feeding norms, and enhanced the vulnerability of these communities during national supply chain disruptions, as seen with the 2022 US Formula Shortage [31,37-40]. The rise in formula use among WIC participants over the last several decades is not driven by socioeconomic status alone, as participant breastfeeding outcomes differ by race/ethnicity [23] and between eligible participants versus eligible non-participants [41]. Additionally, non-Hispanic Black and Hispanic WIC participants are less likely to meet their breastfeeding goals at 3 months postpartum compared to non-Hispanic White participants [23], suggestive of the multifactorial and likely intersectional nature of inequitable lactation outcomes observed in the US today. To help combat this reality, WIC has invested greatly in effective breastfeeding supports in recent years, including breastfeeding peer counselors [42], pump loan programs, and enhanced nutritional supplementation for breastfeeding families. These efforts are vital to mitigating the negative impact of longstanding formula subsidies on breastfeeding outcomes among participating families and should only continue to expand if sustained behavioral change around breastfeeding is desired.

Beyond policies that indirectly and directly promote formula use, suboptimal US breastfeeding rates are driven by insufficient protective policies and supportive socioeconomic structures to address breastfeeding barriers. Early return to work and poor access to lactation expertise have been identified as prevalent barriers among all lactating individuals but are particularly prevalent among dyads of racial and ethnic minority groups [43-45].

Nearly two-thirds of US women with a child under the age of 3 participate in the workforce [46]. Lack of paid leave from work during the immediate postpartum period is among the greatest barriers to breastfeeding facing US families [47]. Much data supports that parental leave after childbirth is associated with reduced maternal and infant morbidity and mortality, as well as the establishment of exclusive breastfeeding, increased downstream earning potential and workforce retention, increased infant vaccination rates, and reduced maternal medical and mental comorbidities [48-54]. The 1993 Family Medical Leave Act (FMLA) permits families to take parental leave after the delivery of a child [47]. Yet, a mere 56% of US families qualify for federal FMLA protections today, which is unpaid and reserved for employees who have worked for their employer for a certain number of hours [55]. These restrictions leave many families financially unable or legally ineligible to take leave after a child is born, with 60% of non-Hispanic Black and nearly 67% percent of Hispanic workforce members unable to take unpaid leave [52]. Slow progress is being made, with 13 US states currently offering paid leave [56]. Nonetheless, 2023 data from The Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) demonstrated that the return to work as a reason for not initiating lactation was most prevalent among non-Hispanic Black (20.8%) and Native American (26.6%) individuals [44]. Among those who did initiate breastfeeding, the return to work was reported by 24% and 16% of non-Hispanic Black and Native American women, respectively, as the reason for breastfeeding cessation [44]. Efforts to improve lactation rates for US families, particularly among those from historically marginalized communities, must address the notable barrier of paid parental leave.

Perhaps the most common barrier for US families to meeting their breastfeeding goals is timely and affordable access to lactation expertise when encountering common lactation challenges [57]. To understand the scope of need, a nationally representative cohort of nearly 6 million women who breastfed for <10 weeks reported “not producing enough milk” (57.6%) and “baby had difficulty latching” (38.7%) as the most common reason for breastfeeding cessation [44]. These challenges are common and often addressable with timely access to lactation expertise. Yet formal lactation consultation is not currently a standard in routine obstetric or pediatric care and is not an affordable option for most families, particularly those who are uninsured or enrolled in public insurance [44,58]. As a result, many families end up mix-feeding (ie, feeding both formula and breast milk) when encountering lactation challenges [59], eventually transitioning to exclusive formula use for ease or due to unintended loss of milk supply [60].

Though barriers to meeting one’s personal breastfeeding goals are multifactorial in nature, the breast pump is one tool worthy of consideration to help mitigate these barriers and impact individual and national change.

Breast Pumps: A Critical Lactation Support Tool for Dyads Facing the Most Barriers

In addition to improved policies and practices aimed at driving a paradigm shift in healthcare around breastfeeding support, the widespread provision and optimal use of breast pumps may confer great benefit to dyads facing the most barriers to lactation.

Though latching a baby directly to breast or chest is recognized as the optimal technique for infant feeding, this is not always feasible [61,62]. The early return to work, having latch difficulties with poor access to support, separation of the dyad for medical care, infant prematurity, or not latching a baby due to cultural norms or trauma are such examples. These barriers are more common among marginalized communities, who are less likely to qualify for unpaid FMLA, have less comprehensive coverage for lactation consultation, and have less access to peer, family, or community lactation support due to generations of formula use. Additionally, women from these communities are more likely to experience bias and discrimination from their healthcare team around their infant feeding goals [27,63], as well as suffer from perinatal cardiometabolic complications that could disrupt lactation, including pre-eclampsia [57,64,65], infant prematurity [66,67], and diabetes [68-70].

A breast pump could be the difference between meeting—or not meeting—one’s breastfeeding goals for dyads facing the above lactation challenges, biases, or gaps in care delivery. Examples include requiring a pump to maintain lactation after returning to work, using a pump to increase or maintain one’s milk supply while awaiting lactation support to help address pain or poor latch, extracting milk while a mother or baby is admitted to the hospital postpartum, or choosing to exclusively pump due to personal preference.

The Impact of Legislative Efforts to Expand Pump Access on Lactation Outcomes

The Patient Protection and Affordable Care Act (ACA) required coverage of breast pumps by private insurers and Medicaid enrollees in 2012 and 2014, respectively [71]. As a result, breast pumps have become nearly ubiquitous among breastfeeding families, with over 85% of lactating parents reporting pump use at some point in time [72,73]. A 2017 study demonstrated that the greatest increase in breastfeeding initiation after this mandate was appreciated among non-Hispanic Black and American Indian/Alaskan Native women, those with less formal education, and unmarried mothers, all populations that experience low breastfeeding rates [74]. Additionally, a 2008 study of WIC enrollees demonstrated that families who received an electric pump upon request sought formula at 8.8 months postpartum on average compared to an average of 4.8 months for families placed on a pump waitlist (p<0.001) [75]. These studies suggest that pumps may confer an augmented benefit to dyads facing increased barriers to their lactation goals.

The widespread distribution of pumps following the ACA mandate has been accompanied by a rise in exclusive pumping [76-78]. A 2011 study found that women of lower socioeconomic status (education of some college or less; income less than $35,000/year) were more likely to have never latched to the breast and exclusively pumped [77]. Though exclusive pumping can be an elective decision for some, its prevalence underscores larger racial, ethnic, and sociodemographic disparities in infant prematurity. Relevant factors include lack of available and affordable lactation support for early latch difficulties, access to paid leave from work, and accountability on the part of payers and health systems to ensure the provision of quality breastfeeding care and support for all families [79,80].

Pump Provision Does Not Guarantee Appropriate Use: More Research is Needed

It must be noted that pumps are not without hazard or risk, and if used inappropriately can cause injury and may unnecessarily interrupt normal physiologic breastfeeding [81-83]. There is currently limited and mixed evidence regarding the association between breast pump use and breastfeeding success [73,74,84-92]. Given the ubiquity of pump use among breastfeeding individuals today, understanding the ideal timing, frequency, and application of breast pump use is essential to avoid parental harm and develop evidence-based protocols in medicine. Future research is needed to build this understanding, including the ideal device required for a family’s individual situation (manual, electric, hands free, hospital grade, etc.), as well as indications for and optimal timing of pump use to augment—and not hinder—breast milk supply. Studies are also needed to describe and examine pump use within specific subpopulations, such as those suffering from preeclampsia, diabetes, and infant prematurity, as well as working parents.

Despite successfully increasing pump access through federal policy, our nation’s systems have fallen short of equipping patients and healthcare professionals with the knowledge necessary to ensure their appropriate use. A 2012 study found lower odds of breastfeeding past 2 months postpartum among mothers who received pump education from a physician or physician assistant (OR 0.58, 95% CI 0.36-0.93), and conversely, higher odds of breastfeeding beyond 2 months among those who learned about pumps from friends and relatives, or took a class (OR 1.70, 95% CI 1.13-2.55; OR 1.85, 95% CI 1.24-2.76, respectively) [93]. Health systems currently need evidence-based protocols for pump use to ensure their appropriate implementation, protect against their inappropriate overuse and patient harm, and standardize patient and provider pump education.

Ultimately, there is a timely and critical need for evidence-based, person-centered protocols and educational curricula around breast pump use given their ubiquity among US families, potential for harm if used inappropriately, and most importantly, their potential to facilitate more equitable breastfeeding outcomes for dyads with the lowest breastfeeding rates and highest health risk.

Conclusions and Next Steps

There is a maternal and infant health crisis within the US, with rising morbidity and mortality rates seen among all mother-infant dyads. Socially and economically marginalized communities, particularly non-Hispanic Black and Native American women, are disproportionately impacted by this rise in dyadic mortality. Breastfeeding promotion could prove highly effective at improving health outcomes for these high-risk groups, as it is known to be associated with a reduced risk of several conditions that drive dyadic mortality, including cardiovascular disease and sudden infant death. Though limited and conflicting data exists on the relationship between breast pumps and lactation outcomes overall, breast pumps have been shown to support breastfeeding exclusivity and duration among dyads from marginalized communities. There is an emerging need for research to inform health policy, practice, and education around appropriate pump use to achieve equitable lactation outcomes for all mother-infant dyads.

Glossary

WIC

Special Supplemental Nutrition Program for Women Infants, and Children

ACA

the Patient Protection and Affordable Care Act

FMLA

Family Medical Leave Act