Baby-Friendly Hospital Initiative and Breastfeeding Outcomes Across Social Determinants of Health in Oklahoma, USA: A Secondary Data Analysis

BACKGROUND: Breastfeeding improves maternal and infant health, reducing risks of cancer, diabetes, cardiovascular disease, and infant mortality. Despite national gains in breastfeeding initiation, disparities persist in exclusivity and duration across social determinants of health (SDOH). The Baby-Friendly Hospital Initiative (BFHI) promotes evidence-based maternity care practices to support breastfeeding, yet its effectiveness across diverse populations remains unclear. PURPOSE: This study examined whether BFHI designation is associated with breastfeeding outcomes including initiation, exclusive breastfeeding at 8 weeks, and any breastfeeding at 8 weeks among Oklahoma mothers who delivered between 2016 and 2018, and whether these associations differ across SDOH including race, ethnicity, household income, educational attainment, marital status, maternal age, parity, and geographic location. METHODS: = 4,234) was conducted. Weighted logistic regression estimated associations between BFHI designation and breastfeeding outcomes, stratified by SDOH, and adjusted for demographic and socioeconomic factors. RESULTS: BFHI designation at birth facility was associated with higher odds of initiation among primiparous mothers (adjusted odds ratio [aOR] = 1.89, 95% confidence interval [CI]: [0.98-3.64]), Native American mothers (aOR = 1.43, 95% CI: [0.95-2.15]), and unmarried mothers (aOR = 1.34, 95% CI: [0.89-2.03]). Among mothers with moderate household income ($24,001-$48,000), BFHI designation was associated with significantly greater odds of exclusive breastfeeding at 8 weeks (aOR = 1.85, 95% CI: [1.19-2.89]); a similar, nonsignificant pattern was observed for any breastfeeding at 8 weeks (aOR = 1.63, 95% CI: [0.99-2.70]). CONCLUSIONS: BFHI demonstrates differential effects across SDOH, benefiting first-time and moderate-income mothers but not Black mothers. Culturally responsive nursing care and tailored interventions are needed to achieve breastfeeding equity.