Documented In-Hospital Lactation Support and Exclusive Breastfeeding During the Postpartum Stay

Importance: Exclusive breastfeeding (EBF) during the postpartum hospital stay is associated with longer breastfeeding duration. Electronic health record (EHR) data can be used to uncover patterns in missed and inequitable breastfeeding care that may be associated with persistent breastfeeding disparities. Objectives: To assess the association of documented postpartum in-hospital breastfeeding care with EBF and test differences in documented care by feeding intention and demographic and clinical characteristics. Design, Setting, and Participants: This cross-sectional study of EHR data from a single academic hospital network in Minnesota included 22 857 patients who intended to provide breastmilk and delivered singleton infants born at 37 weeks' or more gestation between January 1, 2018, and December 31, 2022. Data preparation was completed between September 2023 and May 2024; analyses were completed between June and December 2025. Exposures: Ratio of the number of documented lactation support events per 8-hour nursing shift to the number recommended during the postpartum stay (breastfeeding support ratio [BSR]). Current guidelines recommend a BSR of 1.00 or more. Main Outcomes and Measures: Multivariable logistic regression with restricted cubic splines was used to estimate the probability of EBF during the hospital stay and to estimate the relative risk (RR) of a BSR less than 1.00. Results: The sample included 22 857 dyads (mean [SD] maternal age, 31.0 [5.1] years; mean [SD] gestational age, 39.4 [1.1] weeks), with feeding intentions of 91.1% EBF (n = 20 826) and 8.9% breastmilk and formula (n = 2031). There was a nonlinear positive association between BSR and the probability of EBF, with a probability of 0.49 (95% CI, 0.44-0.54) for a BSR of 0.00, a probability of 0.78 (95% CI, 0.76-0.80) for a BSR of 1.00, and a probability of 0.91 (95% CI, 0.90-0.92), with a plateau in the association above a BSR of 2.00. The positive association of BSR with EBF was weaker, with a higher RR of a BSR less than 1.00, among American Indian or Alaska Native patients (adjusted RR, 1.94; 95% CI, 1.26-2.62); Asian, Native Hawaiian, and Other Pacific Islander patients (adjusted RR, 2.35; 95% CI, 2.08-2.62); and Black or African American patients (adjusted RR, 1.83; 95% CI, 1.60-2.07) than among White patients. There were further disparities in documented breastfeeding support identified, with higher risk of a BSR less than 1.00, by breastfeeding intention (both breastmilk and formula: adjusted RR, 4.65; 95% CI, 4.25-5.05), need for an interpreter (adjusted RR, 1.52; 95% CI, 1.32-1.72), age younger than 25 years (adjusted RR, 1.33; 95% CI, 1.14-1.51), marital status (single: adjusted RR, 1.34; 95% CI, 1.21-1.48), health insurance type (public health insurance: adjusted RR, 1.25; 95% CI, 1.06-1.45), body mass index of 30 or more (adjusted RR, 1.40; 95% CI, 1.25-1.56), current tobacco smoking (adjusted RR, 2.09; 1.72-2.47), cesarean delivery (adjusted RR, 1.16; 95% CI, 1.04-1.28), gestational age of 37 to 38 weeks (adjusted RR, 1.26; 95% CI, 1.14-1.38), and low-birth-weight status (<2500 g; adjusted RR, 1.87; 95% CI, 1.42-2.32). Conclusions and Relevance: This cross-sectional study found that, in a large EHR-based postpartum patient sample, the frequency of documented breastfeeding support was positively associated with EBF during the hospital stay, an early predictor of breastfeeding duration. However, there were numerous disparities in the level of support documented. More frequent in-hospital breastfeeding support, above currently recommended levels, could help reduce gaps in breastfeeding outcomes.