ThruLines is a DC Health data brief series designed to inform the public about ongoing public health challenges.
The series aims to take insights gleaned from analysis of local data to inspire evidence-based policies and programs that improve health in the District.

Breastfeeding in the District of Columbia

Breastfeeding provides many health benefits for both infants and mothers. Children who were breastfed have reduced risk of allergic rashes, gastrointestinal infections, ear infections, necrotizing enterocolitis (NEC), obesity, type 1 diabetes, severe lower respiratory tract infections, asthma, and sudden infant death syndrome.¹ Mothers who breastfed have lower risk of breast cancer, type 2 diabetes, and ovarian cancer. ²

The Centers for Disease Control and Prevention (CDC) recommends exclusive breastfeeding for the first six months of life, followed by continued breastfeeding alongside solid foods until a child’s second birthday.

This ThruLines analyzes data on breastfeeding among District residents from two national surveys and a breastfeeding needs assessment specific to the District.

A large and increasing fraction of mothers initiated breastfeeding

Between 2015 and 2023, the percentage of District resident infants that breastfed slightly increased from 82% to 85%. Breastfeeding initiation rates in DC were comparable to national rates and similar to other municipalities surveyed in 2015 : New York City (88%), Chicago (79%), and Houston (79%).

Breastfeeding initiation rates were lower among some subgroups

In more recent years, compared to the District overall, breastfeeding initiation was significantly lower among residents who were younger, non-Hispanic black, had a high school education or less, were unmarried, had lower incomes, or ever participated in the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program.

Mothers’ education was the factor most strongly associated with breastfeeding initiation

Maternal education was the demographic characteristic most strongly associated with breastfeeding initiation. High school graduates and non-graduates were 17 percentage points less likely than those with more education to begin breastfeeding (data not shown).

Disparities in breastfeeding initiation by race/ethnicity and marital status narrowed—or disappeared entirely—when focusing solely on mothers who graduated from college. Overall, there was a 23-percentage point gap in breastfeeding initiation between non-Hispanic white and non-Hispanic Black infants, and a 5-percentage point gap between non-Hispanic white and Hispanic infants (figure above). However, among college-educated mothers, these differences shrank to 5 percentage points and zero, respectively, with neither remaining statistically significant (figure below). Similarly, the overall gap between married and unmarried mothers was 20 percentage points, but among college graduates, it decreased to 7 percentage points (although remained significant). These findings suggest that disparities in breastfeeding initiation reflect broader inequities in educational access and the advantages that education confers.

District infants breastfed at higher rates during the first nine months of life than nationally

Many mothers stop breastfeeding within a couple of months. Among mothers who started breastfeeding, the percent who continued for nine months was significantly higher in the District than nationally. Approximately three out of four District infants were still being breastfed at six months, and about two out of five continued through their first year. It should be noted, however, that only one in three of District infants met the CDC’s recommendation for exclusive breastfeeding through the first six months post-partum.

Education was also most strongly linked to how long District infants were breastfed

Maternal education was the demographic characteristic most strongly associated with breastfeeding duration: mothers without a college degree breastfed on average about six weeks less than those with a college degree. This gap began to widen about one month after birth and grew more pronounced after eight weeks, shortly after the end of the District’s paid parental leave period . In fact, nearly one third of mothers surveyed in the DC Breastfeeding Needs Assessment reported stopping breastfeeding earlier than they had intended, citing the demands of returning to work or school as the primary barrier to continue (data not shown).

As with breastfeeding initiation, breastfeeding duration varied by race/ethnicity, but the differences nearly disappeared among college-educated mothers. Unmarried mothers also breastfed nearly six weeks less than married mothers (data not shown).

Although overall breastfeeding rates were higher in the District than nationally, this was primarily driven by college-educated District mothers, who breastfed at significantly higher rates than their peers nationwide (data not shown). In comparison, District mothers without a college degree matched national breastfeeding duration rates.

Breastfeeding education occurred through a variety of channels after delivery, with very little instruction provided during the prenatal period

According to the DC Breastfeeding Needs Assessment, which included both survey and focus group data, 40% of respondents reported experiencing breastfeeding difficulties after leaving the hospital. While most mothers (71%) initially intended to exclusively breastfeed, more than half (60%) altered that plan (data not shown). The most frequently cited reasons included perceived insufficient milk production, breastfeeding-related pain, and challenges with infant latching—factors that are closely tied to gaps in breastfeeding education.

Most women in focus groups highlighted the lack of a systematic or standardized experience for receiving breastfeeding education both before and after delivery. Many women mentioned receiving little to no breastfeeding information from their medical providers in the prenatal period:

After delivery, focus group participants reported a wide range of different experiences in receiving breastfeeding information or assistance, with some receiving guidance from WIC staff or lactation consultants or nurses or from no one at all.

Mothers who initiated breastfeeding were more likely to receive information from lactation consultants or their social circle

Mothers who successfully initiated breastfeeding, compared to those who did not, were significantly more likely to receive help from lactation specialists (87% vs. 62%) or their social circle of family and friends (66% v 43%). Non-college graduates were significantly more likely to receive information from doctors and less likely to receive information from lactation specialists or their social circle (data not shown).

The Takeaway

In the District of Columbia, as in much of the U.S., while many mothers begin breastfeeding, few exclusively breastfeed for the recommended first six months, and many stop entirely within just a couple of months. Many District mothers cited reasons for why they did not exclusively breastfeed that were closely tied to gaps in breastfeeding education, while others reported the demands of returning to work or school as reasons for ending breastfeeding early.

Breastfeeding requires time, support, and guidance—particularly during the demanding postpartum period, which is marked by exhaustion and significant physical and emotional demands. Research shows that successful breastfeeding is more likely when mothers receive education and support from trusted sources (e.g. family and friends ³, ⁴ as well as lactation consultants⁵) before and after delivery⁶, along with paid parental leave that allows mothers to breastfeed for longer durations⁷. In the District, breastfeeding support appears to occur through a patchwork of channels after delivery and is very uncommon during pregnancy.

Education level also appears to play an important role in whether District mothers initiate and continue breastfeeding. Education often influences the types of jobs mothers hold, which in turn affects access to paid leave, healthcare, and workplace accommodation. Moreover, access to lactation consultants is often limited for mothers with fewer resources due to cost, insurance gaps, or lack of transportation to appointments with a newborn.

To ensure meaningful breastfeeding support in the District, policies must prioritize paid family leave and standardized, evidence-based education and assistance for mothers both before and after delivery, especially for mothers with lower levels of education.

WHAT CAN BE DONE:

DC Health will:

• Support prenatal care providers to promote breastfeeding education during the prenatal period.
• Support hospitals and birthing facilities to implement culturally responsive lactation policies and practices.
• Support Medicaid insurance reimbursement for lactation support services and promote to mothers and lactation support professionals.
• Continually enhance breastfeeding services to support mothers enrolled in the Women, Infants, and Children (WIC) program.
• Convene multi-sector partners to make recommendations for improving breastfeeding through legislative, programmatic, and policy approaches.

Policymakers should:

• Implement an infant and toddler human milk feeding policy for lactating inmates at DC Department of Corrections facilities regardless of time being served.
• Require birthing hospitals to prioritize human milk feeding as the best standard of infant feeding by developing and reporting policies to DC Health that outline clinical guidance and patient engagement strategies.
• Establish a requirement for providers and nurses that interact with pregnant or lactating parents to complete at least four (4) hours minimum of lactation specific training annually.

Healthcare systems and providers should:

• Adopt organizational guidelines for prenatal, labor, and delivery care practices that support breastfeeding beginning in pregnancy (i.e. Baby Friendly USA) with emphasis on mothers who may face higher barriers.
• Complete Maternity Practices in Infant Nutrition and Care (mPINC™) Survey annually.
• Connect all pregnant women and new mothers to breastfeeding education and lactation support providers, in particular in the first week after delivery.
• Incorporate lactation check-ins as part of well-baby visit at 3-5 days, 2 weeks, and 1 month postpartum.
• Eliminate all formula marketing practices, such as accepting free or discounted formula supplies and promotional materials from manufacturers, and store formula products away from patients’.
• Refer all potentially eligible pregnant women and mothers of infants and young children to the WIC program for breastfeeding support services at no cost.

Health plans should:

• Cover and promote lactation support including breastfeeding counseling and supplies as a reimbursable service.
• Offer technical assistance to lactation support providers on insurance coding and billing.

Employers should:

• Implement organizational policies to support breastfeeding employees, as summarized in the District of Columbia Workplace Breastfeeding Support Toolkit,
• Ensure the worksite environment follows federal and District lactation accommodation laws

Community-based organizations can:

• Refer residents to community breastfeeding support services.
• Provide training to all direct service staff to improve their lactation support skills and ensure skills are culturally responsive.
• Participate in District-wide breastfeeding promotion activities that normalize and create a culture of breastfeeding as normal and the preferred way of feeding babies.

Residents can:

• Reach their breastfeeding goals and support family members and friends who breastfeed. For more information visit the DC Health Breastfeeding Program page
• Participate in District-wide breastfeeding promotion activities that normalize and create a culture of breastfeeding as normal and the preferred way of feeding babies.

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