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

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Purpose Overall, breastfeeding initiation in the U.S. has increased over the past two decades, yet initiation rates vary by several sociodemographic and psychosocial factors. We examined prenatal demographic, behavioral, and psychosocial factors associated with breastfeeding initiation in the U.S. Methods Data from 16,452 participants in the Environmental influences on Child Health Outcomes (ECHO) program on breastfeeding initiation (ever vs. never) were assessed through maternal self‑report. Generalized estimating equation regression models estimated adjusted risk ratios (RRs) for initiating breastfeeding. The primary model included maternal age, race/ethnicity, partnership status, country of origin, education, gestational weight gain, and prenatal smoking. Additional subsample models examined associations between breastfeeding initiation and prenatal sleep characteristics, reported discrimination, and maternal mental health. Results Overall, 81% of mothers initiated breastfeeding. In adjusted analyses, mothers self-identifying as non‑Hispanic Black were statistically significantly less likely to initiate breastfeeding than non‑Hispanic White mothers (RR=0.86, 95% CI 0.81–0.92). Having a partner (RR=1.06, 95% CI 1.03–1.09) and higher levels of educational attainment (RR=1.23–1.30) were positively associated with breastfeeding initiation; prenatal smoking was inversely associated (RR=0.87, 95% CI 0.82–0.92). 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). Conclusion Breastfeeding initiation is shaped by social, structural, and behavioral factors. Racial inequities, education qualifications, the influence of partnership status, and prenatal smoking underscore the need for structural interventions, culturally responsive lactation support, and integrated prenatal services. These findings provide a critical foundation for future research and policy efforts aimed at promoting comparable breastfeeding initiations across diverse U.S. populations.