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]

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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