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. 2019 Sep 3;173(10):961–968. doi: 10.1001/jamapediatrics.2019.2645

National Trends in the Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infants

Margaret G Parker 1,✉, Lucy T Greenberg 2, Erika M Edwards 2,3,4, Danielle Ehret 2,3, Mandy B Belfort 5, Jeffrey D Horbar 2,3
PMCID: PMC6724150  PMID: 31479097

Key Points

Question

Has the provision of human milk among very low-birth-weight infants changed in the United States during the past decade, and to what extent does the provision of human milk vary by US census region and maternal race/ethnicity?

Findings

This cohort study of very low-birth-weight infants cared for in 802 US hospitals in the Vermont Oxford Network from 2008 to 2017 found that provision of human milk at hospital discharge increased overall but lags in the South and among non-Hispanic black and Native American populations.

Meaning

Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.

This cohort study describes US trends in the provision of human milk at hospital discharge for very low-birth-weight infants during the past decade according to census region and maternal race/ethnicity, including regional and state variations of any provision of human milk at hospital discharge among racial/ethnic groups.

Abstract

Importance

Human milk confers important health benefits to very low-birth-weight (VLBW) infants (≤1500 g). The extent to which the use of human milk has changed over time and the factors associated with human milk use nationally in this population are poorly understood.

Objectives

To describe US trends in the provision of human milk at hospital discharge for VLBW infants during the past decade according to census region and maternal race/ethnicity, quantify associations of census region and maternal race/ethnicity with the provision of human milk at hospital discharge, and examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups.

Design, Setting, and Participants

A cohort study was conducted of 346 248 infants, born at 23 to 29 weeks’ gestation or with a birth weight of 401 to 1500 g, who were cared for at 802 US hospitals in the Vermont Oxford Network from January 1, 2008, to December 31, 2017. The US census region was categorized as West, Midwest, Northeast, and South (reference). Maternal race/ethnicity was categorized as non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian and Pacific Islanders, and Native American.

Main Outcomes and Measures

Any provision of human milk at hospital discharge, defined as the use of human milk as the only enteral feeding or the use of human milk in combination with fortifier or formula.

Results

Of the 346 248 infants in the study (172 538 boys and 173 710 girls), 46.2% were non-Hispanic white, 30.1% were non-Hispanic black, 18.3% were Hispanic of any race, 4.7% were Asian and Pacific Islanders, and 0.8% were Native American. Any provision of human milk at hospital discharge increased steadily among all infants, from 44% in 2008 to 52% in 2017. There were increases across all US census regions and racial/ethnic groups. Any provision of human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19), compared with the South, and was higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) and lower among Hispanic (among singleton births: adjusted prevalence ratio, 0.98; 95% CI, 0.96-1.01; among multiple births: adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91), Native American (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69), and non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60), compared with non-Hispanic white mothers. These results were robust to adjustment for birth year and infant characteristics. Wide regional and state variations were found in any provision of human milk at hospital discharge.

Conclusions and Relevance

Overall prevalence of any provision of human milk at hospital discharge among VLBW infants has steadily increased during the past decade. Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.

Introduction

The rate of preterm birth has increased from 2014 to 2016,1 and is associated with myriad medical and developmental disabilities.2 Disparities in preterm birth occur among US census regions and racial/ethnic groups, in which non-Hispanic black mothers have higher rates of preterm birth compared with non-Hispanic white mothers, and where infants born in the South are more likely to be born preterm compared with other regions.1,3 The provision of human milk represents a modifiable factor that can offset many adverse health outcomes (including necrotizing enterocolitis,4,5 late-onset sepsis,6 and poorer neurodevelopment7) that occur among the most vulnerable group of preterm infants, those with very low birth weight (VLBW) (≤1500 g). It is therefore important to understand the national trends in the provision of human milk for VLBW infants among US regions and racial/ethnic groups. Evaluation of disparities that may exist can elucidate the highest-risk groups, which may inform targets for future interventions focused on increasing the provision of human milk.

The national trends in the provision of human milk by US region and by racial/ethnic groups are well described among the healthy, term infant population,8,9 but are poorly understood among VLBW infants. Previous studies of VLBW infants are limited to single states10,11,12 and report lower rates of provision of human milk at hospital discharge among non-Hispanic black and Hispanic infants compared with non-Hispanic white infants. Studies examining national time trends, regional differences, or regional and state variations in racial/ethnic disparities in the provision of human milk among VLBW infants are lacking. Thus, the objectives of this study were to (1) describe US trends in provision of any human milk at hospital discharge or transfer among VLBW infants during the past decade by census region and by maternal race/ethnicity, (2) quantify associations of US census region and maternal race/ethnicity with any provision of human milk at hospital discharge, and (3) examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups.

Methods

Population

We used data from the Vermont Oxford Network, a voluntary worldwide community of practice dedicated to improving the quality, safety, and value of care through a coordinated program of data-driven quality improvement, education, and research.13 Hospitals with neonatal intensive care units contributed data on infants with a birth weight of 401 to 1500 g or who were born at 22 to 29 weeks’ gestation and who were inborn or transferred to the reporting hospital within 28 days of life. For this analysis, we included surviving infants at least 23 weeks’ gestational age at birth and cared for at 802 US hospitals from January 1, 2008, to December 31, 2017. Of these infants (N = 380 173), we excluded those discharged or transferred away from the reporting hospital within 15 days of birth (3978 [1.0%]), those with congenital anomalies (11 987 [3.2%]), with missing data on diet (273 [0.07%]), or no enteral feeding (7949 [2.1%]) at hospital discharge or transfer, those missing data on maternal race/ethnicity or race/ethnicity classified as other (7901 [2.1%]), and those with missing data on length of stay at the time of discharge home or transfer from the reporting neonatal intensive care unit (1837 [0.5%]), for a final cohort of 346 248 (91.1%). The University of Vermont institutional review board determined that the use of data from the Vermont Oxford Network Research Repository was not human subjects research and therefore did not require informed consent.

Measures

All data were collected by local staff using standard definitions.14 The main exposures were the following: (1) US census region, which was categorized as West, Midwest, South, and Northeast according to US Census Bureau classifications,15 and (2) maternal race/ethnicity, which was categorized as non-Hispanic white, non-Hispanic black, Hispanic of any race, Asian and Pacific Islanders, and Native Americans. The main outcome was any provision of human milk (the mother’s own milk and/or pasteurized breast donor milk) within 24 hours of final discharge from the reporting hospitals, where 326 411 infants (94.3%) were discharged home and 19 837 infants (5.7%) were transferred to another hospital. Any human milk included unfortified human milk only or any human milk with a fortifier or formula.16 Covariates included year of birth, infant birth weight for gestational age z score and gestational age,17 length of stay at the date of final discharge, maternal prenatal care, location of birth (inborn vs outborn), mode of delivery (cesarean vs vaginal), and plurality (singleton vs multiple).

Statistical Analysis

We determined the rates of any provision of human milk at hospital discharge by year, from 2008 to 2017, within US Census and maternal race/ethnicity categories, and used logistic regression models with year of birth to test the significance of linear trends over time within categories. To examine associations of US region and maternal race/ethnicity with any provision of human milk at hospital discharge, we used a risk-adjusted Poisson regression model with generalized estimating equations, adjusting for hospital clustering, infant year of birth, and infant-level covariates, with interaction terms for length of stay by gestational age at birth. We calculated crude and risk-adjusted prevalence ratios and 95% CIs, using the South and the non-Hispanic white groups, the largest groups, as the reference groups. We additionally excluded 651 infants (0.2%) with extreme birth weights (z scores of <–4 and >4) from risk-adjusted models. Results were stratified by singletons vs multiples because providing milk for 1 infant differs from providing milk for 2 or more infants simultaneously. To examine variability in racial/ethnic disparities between regions in any provision of human milk at hospital discharge, we examined interactions between race/ethnicity and US region in the risk-adjusted model. To examine variability in racial/ethnic disparities between states, we determined differences in black vs white, Hispanic vs white, Asian vs white, and Native American vs white disparities in crude prevalence with 95% CIs within each state. We additionally calculated the coefficient of variability in crude prevalences between states for each race/ethnicity. We performed a sensitivity analysis of our analyses, including only infants who were discharged home (vs transferred), to examine whether the inclusion of transferred infants changed our findings. We used R, version 3.4.3 (R Foundation for Statistical Computing) for data analysis. All P values were from 2-sided tests and results were deemed statistically significant at P < .05.

Results

Among 346 248 mother–VLBW infant dyads, 71 200 infants (20.6%) were born in the West, 81 094 (23.4%) in the Midwest, 51 842 (15.0%) in the Northeast, and 142 112 (41.0%) in the South. Overall, 159 984 (46.2%) of infants had mothers who were non-Hispanic white, 104 093 (30.1%) were non-Hispanic black, 63 247 (18.3%) were Hispanic, 16 236 (4.7%) were Asian and Pacific Islander, and 2688 (0.8%) were Native American. Other characteristics are described in Table 1.

Table 1. Characteristics of Mother–Very Low-Birth-Weight Infant Dyads According to Maternal Race/Ethnicity.

Characteristic Dyad, No. (%)
All (N = 346 248) Non-Hispanic White (n = 159 984 [46.2%]) Non-Hispanic Black (n = 104 093 [30.1%]) Hispanic (n = 63 247 [18.3%]) Asian and Pacific Islander (n = 16 236 [4.7%]) Native American (n = 2688 [0.8%])
US region
West 71 200 (20.6) 28 475 (17.8) 7963 (7.6) 25 923 (41.0) 7369 (45.4) 1470 (54.7)
Midwest 81 094 (23.4) 48 249 (30.2) 23 455 (22.5) 6451 (10.2) 2385 (14.7) 554 (20.6)
Northeast 51 842 (15.0) 25 118 (15.7) 14 938 (14.4) 8702 (13.8) 3038 (18.7) 46 (1.7)
South 142 112 (41.0) 58 142 (36.3) 57 737 (55.5) 22 171 (35.1) 3444 (21.1) 618 (23.0)
Any human milk at discharge 172 969 (50.0) 89 689 (56.1) 35 799 (34.4) 34 793 (55.0) 11 719 (72.2) 969 (36.0)
Infant characteristics
Birth weight, mean (SD), g 1102 (286) 1124 (280) 1062 (290) 1104 (287) 1121 (281) 1146 (279)
Gestational age at birth, mean (SD), wk 28.5 (2.7) 28.7 (2.6) 28.3 (2.7) 28.3 (2.7) 28.8 (2.7) 28.6 (2.6)
Inborn 300 072 (86.7) 137 621 (86.0) 91 759 (88.2) 54 003 (85.4) 14 555 (89.6) 2134 (79.4)
Length of stay at discharge or transfer, mean (SD), d 66 (36) 65 (34) 66 (39) 67 (35) 65 (35) 67 (35)
Discharged home at final disposition (vs transferred) 319 634 (92.3) 147 496 (92.2) 95 907 (92.1) 58 731 (92.9) 14 983 (92.3) 2517 (93.6)
Maternal characteristics
Multiple birth 94 630 (27.3) 53 627 (33.5) 22 253 (21.4) 13 364 (21.1) 4847 (29.9) 539 (20.1)
Cesarean birth 255 436 (73.8) 121 793 (76.1) 73 921 (71.0) 45 784 (72.4) 12 028 (74.1) 1910 (71.1)
Prenatal care 332 495 (96.0) 155 381 (97.1) 98 352 (94.5) 60 393 (95.5) 15 893 (97.9) 2476 (92.1)
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The prevalence of any provision of human milk at hospital discharge increased across all 4 US regions and 5 racial/ethnic groups in the last decade, from 44% in 2008 to 52% in 2017 (P < .001 for trend), but the prevalence differed by US region and by maternal race/ethnicity (Figure 1A and B). Among singletons and multiples, the adjusted prevalence of any human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and the Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19) compared with the South, and it was lower for non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60) and Native American mothers (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69) and higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) compared with non-Hispanic white mothers (Table 2). Hispanic mothers had a lower adjusted prevalence of any provision of human milk at hospital discharge compared with non-Hispanic white mothers among multiples only (adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91).

Figure 1. Prevalence of Any Provision of Human Milk at Hospital Discharge From 2008 to 2017.

Figure 1.

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A, Prevalence according to US region. Increases in estimated prevalence per year were West, 0.7%; Northeast, 1.6%; Midwest, 0.9%; and South, 1.2%. B, Prevalence according to maternal race/ethnicity. Increases in estimated prevalence per year were Asian and Pacific Islanders, 0.8%; non-Hispanic white, 0.9%; Hispanic, 1.1%; Native American, 1.2%; and non-Hispanic black, 1.3%. Linear trends by year: P = .003 for Native Americans and P < .001 for all other groups.

Table 2. Adjusted Prevalence Ratios of Any Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infantsa.

Characteristic Prevalence Ratio (95% CI)
Singletons Multiples
Crude Adjusted Crude Adjusted
US region
West 1.49 (1.48-1.51) 1.32 (1.25-1.39) 1.42 (1.40-1.44) 1.28 (1.21-1.35)
Midwest 1.08 (1.07-1.09) 1.03 (0.98-1.10) 1.13 (1.11-1.15) 1.06 (1.00-1.12)
Northeast 1.21 (1.19-1.22) 1.11 (1.04-1.19) 1.22 (1.20-1.24) 1.11 (1.04-1.19)
South 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Maternal race/ethnicity
Non-Hispanic white 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
Non-Hispanic black 0.65 (0.64-0.66) 0.67 (0.65-0.70) 0.55 (0.54-0.56) 0.57 (0.54-0.60)
Hispanic 1.03 (1.02-1.04) 0.98 (0.96-1.01) 0.91 (0.90-0.93) 0.88 (0.86-0.91)
Asian and Pacific Islander 1.34 (1.32-1.36) 1.21 (1.18-1.25) 1.20 (1.18-1.22) 1.12 (1.09-1.15)
Native American 0.67 (0.64-0.71) 0.64 (0.59-0.70) 0.60 (0.54-0.67) 0.59 (0.50-0.69)
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a

Models adjusted for infant year of birth, birth weight for gestational age z score, gestational age, length of stay, and interaction terms for length of stay by gestational age at birth; maternal prenatal care, mode of delivery, location of delivery (inborn vs outborn), and plurality; and clustering by hospital. We excluded infants with extreme birth weights (z scores of <−4 and >4).

When we examined regional variations in racial/ethnic disparities, we found that Asian mothers had the highest prevalence of any provision of human milk at hospital discharge within all US regions (Figure 2). Prevalences varied from 50% to 68% for non-Hispanic white mothers, from 48% to 62% for Hispanic mothers, from 28% to 52% for Native American mothers, and from 30% to 48% for non-Hispanic black mothers (Figure 2). After adjusting for infant characteristics and hospital clustering, the P value for the interaction between race/ethnicity and US Census region was less than .001, indicating that prevalences of any provision of human milk at hospital discharge within race/ethnicity groups differed between regions. We examined the difference in the prevalence of any provision of human milk at hospital discharge between minority groups and non-Hispanic white groups within states, and we ranked states with at least 5 infants in each racial/ethnic category from lowest to highest in Figure 3. A value of 0 represents no disparities, a negative value represents lower prevalence of any provision of human milk among a minority group, and a positive value represents higher prevalence of any provision of human milk, compared with the non-Hispanic white group. We found wide variations among states in the degree of racial/ethnic disparities in the prevalence of any provision of human milk at hospital discharge (Figure 3). Native American groups had the highest coefficient of variation in prevalence between states (0.52), followed by non-Hispanic black groups (0.38), non-Hispanic white groups (0.20), Asian individuals (0.20), and Hispanic groups (0.18). To inform improvement initiatives within smaller US regions, we determined crude prevalences in any provision of human milk at hospital discharge according to race/ethnicity within 9 US regions in the past decade, as shown in the eFigure in the Supplement. A list of participating hospitals is in the eTable in the Supplement. In our sensitivity analysis, results were similar among infants who were discharged home compared with the entire cohort of infants who were discharged home or transferred to another hospital.

Figure 2. US Regional Variations in Any Human Milk at Discharge According to Maternal Race/Ethnicity.

Figure 2.

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The vertical lines indicate 95% CIs.

Figure 3. US State Variation in Any Provision of Human Milk at Discharge According to Maternal Race/Ethnicity.

Figure 3.

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US states and Washington, DC, were ranked from lowest to highest with respect to difference in prevalence of any provision of human milk at discharge among minorities vs white mothers with 95% CIs. A value of 0 represents no difference in the prevalence of any provision of human milk among racial/ethnic groups, a negative value represents a lower prevalence of any provision of human milk among a minority group compared with white mothers, and a positive value represents a higher prevalence of any provision of human milk among a minority group compared with white mothers. Significant racial/ethnic disparities are indicated by an error bar that does not cross the center line. Only states with at least 5 infants in each racial/ethnic category are shown.

Discussion

In a US population study of nearly 350 000 VLBW infants, we found that any provision of human milk at neonatal intensive care unit discharge has increased during the last decade. However, substantial regional and racial/ethnic disparities exist; VLBW infants born in the South have the lowest prevalence of human milk provision at discharge and VLBW infants born in the West have the highest prevalence of human milk provision at discharge, whereas non-Hispanic black infants and Native American infants have the lowest prevalence of human milk provision at discharge and Asian and Pacific Islander infants have the highest prevalence of human milk at discharge. Furthermore, the degree of racial/ethnic disparities within regions and states varies considerably, suggesting that regional or statewide improvement efforts focused on reduction of disparities may be a successful strategy to address this important issue.

The continuation of breastfeeding among term infants has steadily increased during the past decade8 after major public health interventions such as the Surgeon General’s Call to Action to Support Breastfeeding 201118 and the World Health Organization’s Baby-Friendly Hospital Initiative.8,19,20 Our study demonstrates that improvements occurred among VLBW infants, a medically vulnerable population for which the provision of human milk has a substantial health benefit. National public health campaigns geared toward generally healthy infants have increased awareness of the importance and benefits of human milk, which has likely led to additional improvements within the VLBW infant population. For instance, hospitals that are designated as “Baby-Friendly,” meaning that they implemented hospital breastfeeding support practices focused mainly on healthy term infants, are also more likely to have higher provision of mother’s milk and donor milk among the VLBW infant population.21,22

Similar to national trends among term infants,8,23 our study demonstrated that disparities by US region and race/ethnicity exist and have not improved during the last decade among VLBW infants. Regarding region, we identified that mothers with VLBW infants born in the South were least likely to provide any human milk at hospital discharge, even when accounting for demographic factors such as race/ethnicity, and medical vulnerabilities, such as birth weight and gestational age. This finding is particularly concerning given that preterm birth is highest in the South compared with other US regions.3 In the absence of the protective health effects of human milk, infants born in the South are potentially at higher risk of the sequelae of preterm birth. The reasons for regional disparities in breastfeeding are multifactorial and include poverty24; participation in the Supplemental Nutrition Program for Women, Infants, and Children25; hospital, community, and workplace breastfeeding support practices26,27; insurance access28,29; parental leave policies30,31; and public opinion and attitudes.32 These factors vary by region and can determine whether a mother continues to breastfeed. Public health initiatives and policies focused on addressing these issues in the South may represent promising strategies to increase human milk provision for VLBW infants.

In addition to policy-level initiatives, examination of the extent of regional and statewide variations in human milk disparities is important because this examination elucidates opportunities for clinical quality improvement approaches. Racial/ethnic disparities in neonatal care delivery is being increasingly recognized.12,33,34,35,36 The reasons for these disparities are multifactorial and may involve the lower quality of care provided at hospitals that disproportionally serve minorities,33,34 implicit bias among neonatal intensive care unit staff,37 and/or other factors. Several states have conducted statewide quality improvement breastfeeding initiatives focused on the VLBW infant population38,39 and reducing racial/ethnic disparities in breastfeeding during hospitalization.40,41 State and regional quality initiatives that have focused on reducing disparities have also focused on staff training, adopting evidence-based breastfeeding support practices, and addressing barriers to ongoing family engagement.40,41 Our study found variations in racial/ethnic disparities within states and regions; therefore, in addition to policy approaches, regional and state-based quality improvement initiatives to address clinical practices represent potential opportunities to address disparities in the provision of human milk.

Our finding that non-Hispanic black mothers have a lower prevalence of human milk provision for VLBW infants compared with non-Hispanic white mothers has been described previously.10,11,12,42,43,44,45,46 Non-Hispanic black mothers face many barriers to continued production of milk, including lack of access to breastfeeding support and education, lack of cultural acceptance, and the need for an early return to work after childbirth.47,48,49,50 Previous studies have demonstrated that the black vs white disparity in breastfeeding is also driven by social determinants of health, such as maternal education, employment level, and income,51,52 measures that we did not collect in our study. Because of our national population cohort, we were able to examine Asian groups and Native American groups, which are the 2 minority groups that are often removed or grouped as “other” among studies with smaller sample sizes.10,11,44,46,53 Asian mothers had the highest prevalence of human milk provision overall within US regions and most states compared with other racial/ethnic groups. Cultural beliefs and family support have been described as strong facilitators of breastfeeding support among Asian American mothers.54 In contrast, Native American mothers had a lower prevalence of human milk provision, which varied substantially by region. Native American mothers are more likely to experience morbidities of pregnancy and adverse birth outcomes, including preterm birth,55 compared with non-Hispanic white mothers, such that improved provision of human milk may be a considerable health benefit for this minority group. However, to date, little is known about the barriers and facilitators to milk production among Native American mothers of VLBW infants and how these may differ by US region. Further investigation is needed to tailor interventions for minority groups.

Strengths and Limitations

The strengths of this study include its generalizability because we examined a national population-level cohort. We had sufficient sample sizes to examine relatively small racial/ethnic groups. A limitation is our reliance on human milk use at a single point during hospitalization, final discharge, which underestimates the consumption of human milk during the entire hospitalization. Most mothers of all racial/ethnic groups with VLBW infants initiate breastfeeding and continue to provide milk for the first 3 to 4 weeks of hospitalization, at which point racial/ethnic disparities in ongoing human milk provision emerge.10 Measurement of human milk only at the final point of hospital discharge does not capture data on mothers who provided human milk earlier in the hospitalization but stopped prior to hospital discharge. We did not differentiate between mother’s milk and donor milk in our composite measure of human milk, although most hospitals transition from donor milk to formula as a supplement to mother’s milk when mother’s milk is no longer available prior to hospital discharge.56,57 Therefore, we believe that our measure of “any human milk” likely represents “any mother’s milk” in most cases. We were not able to account for socioeconomic, cultural, or social and demographic factors, such as maternal age, known to be associated with the provision of mother’s milk for VLBW infants. We accounted for prenatal care, but this may not have been an adequate proxy for socioeconomic, cultural, and social and demographic factors.58 We did not have access to data on the maternal receipt of hospital-based breastfeeding support practices such as family education, early initiation of milk expression, skin-to-skin care, and pump type and frequency. However, we accounted for clustering by hospital, and these practices likely tracked within hospitals.

Conclusions

The provision of human milk for VLBW infants represents a modifiable means to offset the sequelae of preterm birth. Despite improvements in the provision of human milk for VLBW infants in the last decade overall, regional and racial/ethnic disparities in the provision of human milk for VLBW infants persist. Variations in racial/ethnic disparities at the regional and state level suggest that policies and programs focused within these units may represent optimal strategies to address this important issue.

Supplement.

eFigure. Prevalence of Any Human Milk at Discharge Among VLBW Infants in 9 US Regions

eTable. Participating US Hospitals in the Vermont Oxford Network

Click here for additional data file. (612.9KB, pdf)

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Associated Data

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Supplementary Materials

Supplement.

eFigure. Prevalence of Any Human Milk at Discharge Among VLBW Infants in 9 US Regions

eTable. Participating US Hospitals in the Vermont Oxford Network

Click here for additional data file. (612.9KB, pdf)

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