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CME / ABIM MOC / CE

Are Mothers With Disabilities Less Likely to Initiate Breastfeeding?

  • Authors: News Author: Louise Gagnon; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 2/17/2023
  • Valid for credit through: 2/17/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, obstetricians/gynecologists, nurses, nurse practitioners, physician assistants, and other clinicians who care for women preparing for childbirth.

The goal of this activity is for members of the healthcare team to be better able to evaluate how maternal disability can affect access to best practices for breastfeeding after delivery.

Upon completion of this activity, participants will:

  • Analyze benefits and barriers of breastfeeding for infants
  • Evaluate how maternal disability can affect access to best practices for breastfeeding after delivery
  • Outline implications for the healthcare team


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News Author

  • Louise Gagnon

    Freelance writer, Medscape

    Disclosures

    Louise Gagnon has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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CME / ABIM MOC / CE

Are Mothers With Disabilities Less Likely to Initiate Breastfeeding?

Authors: News Author: Louise Gagnon; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/17/2023

Valid for credit through: 2/17/2024, 11:59 PM EST

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Clinical Context

Breastfeeding is associated with numerous salutary outcomes for infants, and the authors of the current study provide an overview of these benefits as well as best practices to promote breastfeeding after delivery. Breastfeeding is important in protecting infants and children from infection, including otitis media and respiratory tract infections. Breastfeeding also reduces the risk for infant mortality and is associated with better cognitive outcomes. Later in life, infants who were breastfed have lower risks for obesity and type 2 diabetes. Finally, breastfeeding is associated with lower risks for breast and ovarian cancer for mothers.

The authors of the current study also endorse established means to promote breastfeeding in the newborn period, including skin-to-skin contact as soon as possible after birth, assistance with breastfeeding during the hospital stay, and exclusive breastfeeding before discharge of the mother and infant; however, despite these efforts in many centers, only about half of infants in North America are exclusively breastfed at age 3 months. Risk factors for failing to breastfeed through 6 months included young parental age, smoking, and poverty.

Fewer women with chronic illness breastfeed, but the role of disability in breastfeeding remains under-researched. The current study by Brown and colleagues addresses this issue.

Study Synopsis and Perspective

Mothers with intellectual or developmental disabilities are less likely to initiate breastfeeding and to receive in-hospital breastfeeding support than mothers without a disability, new data suggest.

In a population-based cohort study of more than 600,000 mothers, patients with an intellectual or developmental disability were about 18% less likely to have a chance to initiate breastfeeding during their hospital stay.

"Overall, we did see lower rates of breastfeeding practices and supports in people with intellectual and developmental disabilities, as well as those with multiple disabilities, compared to people without disabilities," study author Hilary K. Brown, PhD, assistant professor of health and society at University of Toronto Scarborough in Ontario, Canada, told Medscape Medical News.

The study was published in the January issue of The Lancet Public Health.

Disparities in Breastfeeding

"There hasn't been a lot of research on breastfeeding outcomes in people with disabilities," said Brown, who noted that the study outcomes were based on the World Health Organization (WHO)-United Nations International Children's Emergency Fund (UNICEF) Baby Friendly Hospital Initiative guidelines. "There have been a number of qualitative studies that have suggested that they do experience barriers accessing care related to breastfeeding and different challenges related to breastfeeding. But as far as quantitative outcomes, there has only been a handful of studies."

To examine these outcomes, the investigators analyzed health administrative data from Ontario, Canada. They included in their analysis all birthing parents aged 15 to 49 years who had a single live birth between April 1, 2012 and March 31, 2018. The researchers identified patients with a physical disability, sensory disability, intellectual or developmental disability, or 2 or more disabilities using diagnostic algorithms and compared them with individuals without disabilities with respect to the opportunity to initiate breastfeeding, to engage in in-hospital breastfeeding, to engage in exclusive breastfeeding at hospital discharge, to have skin-to-skin contact, and to be provided with breastfeeding assistance.

The investigators considered a physical disability to encompass conditions such as congenital anomalies, musculoskeletal disorders, neurologic disorders, or permanent injuries. They defined sensory disability as hearing loss or vision loss. The researchers defined intellectual or developmental disability as having autism spectrum disorder, chromosomal anomaly, fetal alcohol spectrum disorder, or other intellectual disability. Patients with multiple disabilities had 2 or more of these conditions.

The study population included 634,111 birthing parents, of whom 54,476 (8.6%) had a physical disability, 19,227 (3%) had a sensory disability, 1048 (0.2%) had an intellectual or developmental disability, 4050 (0.6%) had multiple disabilities, and 555,310 (87.6%) had no disability.

The investigators found that patients with intellectual or developmental disabilities were less likely than patients without a disability to have an opportunity to initiate breastfeeding (adjusted relative risk [aRR] 0.82), to engage in any in-hospital breastfeeding (aRR 0.85), to be breastfeeding exclusively at hospital discharge (aRR 0.73), to have skin-to-skin contact (aRR 0.9), and to receive breastfeeding assistance (aRR 0.85) compared with patients without a disability.

They also found that individuals with multiple disabilities were less likely to have an opportunity to initiate breastfeeding (aRR 0.93), to engage in any in-hospital breastfeeding (aRR 0.93), to be exclusively breastfeeding at hospital discharge (aRR 0.9), to have skin-to-skin contact (aRR 0.93), and to receive breastfeeding assistance (aRR 0.95) compared with patients without a disability.

An Understudied Population

Commenting on the study for Medscape, Lori Feldman-Winter, MD, MPH, professor of pediatrics at Cooper Medical School of Rowan University in Camden, New Jersey, said that one of its strengths is that it included patients who may be excluded from studies of breastfeeding practices. The finding of few differences in breastfeeding practices and support for persons with physical and sensory disabilities compared with persons without disabilities was positive, she added.

"This is an understudied population, and it is important to call out that there may be practices related to breastfeeding care that suffer, due to implicit bias regarding persons with intellectual and multiple disabilities," said Feldman-Winter. "The good news is that other disabilities did not show the same disparities. This study also shows how important it is to measure potential gaps in care across multiple sociodemographic and other variables, such as disabilities, to ensure equitable and inclusive care."

Healthcare professionals need to be aware of disparities in breastfeeding care, she added. They need to be open to exploring potential biases when it comes to providing equitable care.

R. Douglas Wilson, MD, president of the Society of Obstetricians and Gynaecologists of Canada and professor emeritus of obstetrics and gynecology at the University of Calgary in Alberta, Canada, noted that the size of the cohort represents a strength of the study and that the findings suggest the possible need for closer follow-up of a new mother who is breastfeeding and who has an intellectual disability or multiple disabilities.

"You might keep that patient in hospital for an extra day, and then the home care nurse may look in on them more frequently than they would for someone who does not need that extra oversight," said Wilson.

When their patients are pregnant, members of the healthcare team can find out whether their patients intend to breastfeed and put them in touch with nurses or lactation consultants to assist them, he added.

The study was funded by the National Institutes of Health and the Canada Research Chairs Program. Brown, Feldman-Winter, and Wilson reported no relevant financial relationships.

Lancet Public Health. 2023;8:e47-e56.[1]

Study Highlights

  • Researchers drew study data from 2 population health databases in Ontario, Canada. There are approximately 140,000 births annually in this province.
  • One database provided diagnosis data for all residents, and the other database focused on obstetric outcomes. The current study focuses on singleton deliveries between 2012 and 2018.
  • Researchers compared mothers with a history of physical, sensory, intellectual/developmental, or multiple disabling conditions with mothers without these conditions. The main study outcome was adherence to breastfeeding support care advocated by the WHO.
  • The investigators adjusted study results to account for demographic variables and other chronic health conditions.
  • 634,111 birthing parents were included in the study: 8.6% had a physical disability, and 3% and 0.2% had a sensory and intellectual/developmental disability, respectively; 0.6% of mothers had multiple causes of disability.
  • Disability was associated with higher rates of poor mental health and substance use disorder. Persons with intellectual/developmental or multiple disabilities were more likely to live in low-income neighborhoods compared with women without disability.
  • Intellectual/developmental disability was associated with worse birth outcomes, such as preterm labor and admission to the neonatal intensive care unit.
  • Compared with women without a disability, women with intellectual/developmental disability had a lower aRR of opportunity to initiate breastfeeding (aRR 0.82 [95% CI: 0.76, 0.88). The respective aRR for any in-hospital breastfeeding was 0.85 (95% CI: 0.81, 0.88), the respective aRR for breastfeeding at hospital discharge was 0.73 (95% CI: 0.67, 0.79). Finally, women with intellectual/developmental disability were less likely to receive skin-to-skin contact after delivery (aRR 0.9 [95% CI: 0.87, 0.94]) and breastfeeding assistance (aRR 0.85 [95% CI: 0.79, 0.91]).
  • Women with multiple disabilities were also at significant disadvantage compared with mothers without disability in the following study outcomes:
    • Opportunity to initiate breastfeeding (aRR 0.93 [95% CI: 0.91, 0.96])
    • Any in-hospital breastfeeding (aRR 0.93 [95% CI: 0.92, 0.95])
    • Exclusive breastfeeding at hospital discharge (aRR 0.9 [95% CI: 0.87, 0.93])
    • Skin-to-skin contact after delivery (aRR 0.93 [95% CI: 0.91, 0.95])
    • Breastfeeding assistance (aRR 0.95 [95% CI: 0.92, 0.98])
  • In contrast, mothers with sensory or physical disability generally did not have reduced breastfeeding practices compared with the control group.
  • Limiting the study analysis only to low-risk births and women who intended to breastfeed significantly attenuated disparities between the disability and control groups. Only exclusive breastfeeding at hospital discharge remained lower for women with intellectual/developmental and multiple disabilities.
  • Women with intellectual/developmental and multiple disabilities were more likely to have mother not involved in infant care listed as a reason for not breastfeeding.

Clinical Implications

  • Breastfeeding is important in protecting infants and children from infection, including otitis media and respiratory tract infections. Breastfeeding also reduces the risk for infant mortality and is associated with better cognitive outcomes. Later in life, infants who were breastfed have lower risks for obesity and type 2 diabetes. Finally, breastfeeding is associated with lower risks for breast and ovarian cancer for mothers; however, approximately half of infants are exclusively breastfed at age 3 months. Risk factors for failing to breastfeed through 6 months included young parental age, smoking, and poverty.
  • In the current study by Brown and colleagues, mothers with intellectual/developmental disability and multiple forms of disability were less likely to receive breastfeeding support in the hospital after delivery and less likely to exclusively breastfeed at discharge, but sensory and physical disability were generally not associated with reduced breastfeeding practices.
  • Implications for the healthcare team: The healthcare team should ensure that they are providing equitable treatment in promoting breastfeeding for new parents across multiple sociodemographic groups to ensure equitable and inclusive care.

 

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