Race, Partner Status, Education and Smoking Shape Breastfeeding Initiation in ECHO Cohort

Most new mothers in the United States now begin breastfeeding, but who does and who does not still depends heavily on social circumstances, according to a large analysis from the Environmental influences on Child Health Outcomes (ECHO) program. Drawing on self-reported data from 16,452 participants, researchers examined how prenatal demographic, behavioral and psychosocial factors related to whether mothers ever initiated breastfeeding. Overall, 81 percent of the mothers in the cohort reported initiating breastfeeding, a figure consistent with the rise in U.S. initiation rates over the past two decades, yet the analysis revealed persistent gaps across groups.

The study, published as an open-access article in Archives of Gynecology and Obstetrics, used generalized estimating equation regression models to estimate adjusted risk ratios (RRs) for breastfeeding initiation, defined as ever versus never breastfeeding by maternal self-report. The primary model accounted for maternal age, race and ethnicity, partnership status, country of origin, education, gestational weight gain and prenatal smoking. Additional subsample models tested associations with prenatal sleep characteristics, reported discrimination and maternal mental health.

The starkest disparity was racial. Mothers who self-identified as non-Hispanic Black were statistically significantly less likely to initiate breastfeeding than non-Hispanic White mothers, with an adjusted risk ratio of 0.86 (95% CI 0.81–0.92). In contrast, having a partner was positively associated with initiation (RR 1.06, 95% CI 1.03–1.09), as was higher educational attainment, with risk ratios ranging from 1.23 to 1.30 across education levels. Prenatal smoking was inversely associated with initiation (RR 0.87, 95% CI 0.82–0.92), marking it as one of the behavioral factors linked to a lower likelihood of starting to breastfeed.

Among the psychosocial measures, higher levels of discrimination scores were associated with a very small increase in the probability of initiating breastfeeding (RR 1.004, 95% CI 1.002–1.007) — an association the authors characterize as minimal in magnitude. The subsample analyses of sleep characteristics and maternal mental health were reported as additional models, but the abstract highlights the sociodemographic and behavioral findings as the dominant signals in the data.

The authors conclude that breastfeeding initiation is shaped by social, structural and behavioral factors, and that the observed racial inequities, differences by education, the influence of partnership status and the role of prenatal smoking point to the need for structural interventions, culturally responsive lactation support and integrated prenatal services. They position the findings as a foundation for future research and policy efforts aimed at making breastfeeding initiation comparable across diverse U.S. populations. As an early-release, peer-reviewed accepted article, the version is subject to further edits before the final Version of Record appears.

Subject of Research: Prenatal demographic, behavioral and psychosocial factors associated with breastfeeding initiation in the U.S. ECHO cohort

Article Title: Maternal behavioral and psychosocial factors associated with breastfeeding initiation in the ECHO cohort

Article References: Mutaru, A.-M., Maldonado, I., Knapp, E. A., Bakre, S., Wajner, B., Natale, R., Perez, J. M., Garcia, K. C., Rivero, G. G., Comstock, S. S., Shipp, G. M., Aschner, J. L., McCormack, L. A., Keim, S. A., Cowell, W., Young, K. C., Northrup, T. F., Zhu, Y., Dabelea, D., … Smith, L. M. (2026). Maternal behavioral and psychosocial factors associated with breastfeeding initiation in the ECHO cohort. Archives of Gynecology and Obstetrics. https://doi.org/10.1007/s00404-026-08593-y

Image Credits: AI Generated

DOI: 10.1007/s00404-026-08593-y

Keywords: breastfeeding initiation, ECHO cohort, maternal health, racial disparities, prenatal smoking, educational attainment, partnership status, psychosocial factors, risk ratios, public health, Maternal, behavioral