Incomplete Data Drives Flawed Conclusions About AANHPI Breastfeeding Rates

August 15, 2021

Asian mothers in the U.S. have excellent breastfeeding rates!

True or False?

If you’ve read the Centers for Disease Control’s recent Morbidity and Mortality Weekly Report (MMWR), Racial and Ethnic Disparities in Breastfeeding Initiation (May 2021), you likely believe that statement is true based on the claim that 90.3% of Asian mothers initiate breastfeeding.

Except for one little problem: The report, which uses numbers from the National Vital Statistics (NVS) system, excludes California. The Golden State doesn’t report its breastfeeding initiation data to the NVS. The 68,000-plus live births to Asian mothers are not accounted for in the national report (Maternity Care in California, 2019).

Tonya Lang — chair of the Asian, Southeast Asian, Pacific Islander (ASAP!) Task Force in Alameda County — will tell you this is just the tip of a very dangerous iceberg.

“How can you say Asian breastfeeding rates are great when you’ve excluded states with high AANHPI populations?,” she queried. “An MMWR report has influence. When the CDC says our breastfeeding initiation rates are great, the conclusion is there is no need for help. No need for funding, time, resources or attention.”

But the iceberg is deeper than the most recent MMWR report. The real challenge here for Asian American, Native Hawaiian and Pacific Islander (AANHPI) communities is aggregate data.

Government agencies and non-governmental organizations often lump together all Asian Americans, Native Hawaiians and Pacific Islanders in a single category.

Lang is an CHES-certified IBCLC with a Master’s in Public Health. She also serves as co-chair of the Alameda County Breastfeeding Coalition, and is a long-time La Leche League leader in Oakland. 

She understands the communities she serves, geographic and cultural, well enough to see the gaps that need filling, such as linguistic isolation and high rates of early formula supplementation. Filling those gaps starts with disaggregating data to get a clear picture of lactation needs throughout the AANHPI population.

Disaggregation has helped Alameda County officials discover that though AANHPI birthing parents have the highest rate of breastfeeding initiation, they also have the lowest exclusive breastfeeding rates.

A contradiction highlighting the need to dig deeper.

Are there clinical factors at work here? East Asians have a higher risk of jaundice cases (ABM Protocol No. 22, 2017). Is that leading to early formula supplementation?

Or is it a communication issue?

Educational brochures with information on how to handle common lactation challenges are usually only available in English and Spanish, presenting a clear barrier to AANHPI parents who aren’t literate in those languages.

Over 100 languages are spoken at home across Alameda County, with a relatively high number of Chinese, Hindi, and Tagalog speakers. Alameda County has ~19% of the population over 5 years old who speak an Asian or Pacific Islander language – twice the rate of California Asian or Pacific Islander speakers (9%). Approximately 82% of Asian infants and 48% of Pacific Islander infants were born to foreign-born mothers.

More than 50 percent of AANHPI individuals in Alameda County consider themselves linguistically isolated, which means they think they speak English “less than well.” They speak a rich variety of languages, such as Cantonese and Mandarin Chinese, Vietnamese, Korean, and Marshallese — only to name a few.

The iceberg goes even deeper.

“We are not a monolith,” Lang said. “We have incredible diversity within our communities. The problem is our diversity is masked when AANHPI data is lumped together, feeding into the ‘model minority’ myth.”

The myth of the model minority is based in stereotypes, Lang said.

“AANHPIs are characterized as a polite, law-abiding group who have achieved a higher level of success than the general population due to inborn talent and a pull-yourselves-up-by-your-bootstraps immigrant mentality.

And like all stereotypes, the model minority myth ignores the diversity of AANHPI communities. It portrays AANHPIs as a group that can succeed just as well as Whites while also being viewed as perpetual foreigners. It masks racism against AANHPIs. The perceived success of AANHPIs is weaponized against other communities of color, which ultimately harms the goal of achieving racial justice in our society.”

Lang’s point is that until we know how each segment of the AANHPI community (Chinese vs. Japanese vs. Vietnamese vs. Filipino, etc.) is doing with breastfeeding initiation and exclusive breastfeeding through the first six months, we don’t actually know how the community as whole is doing.

“We don’t have answers because we’re not asking the right questions,” she said. “And we’re not asking the right questions because decision-makers aren’t looking critically at the data. We have a lot of assumptions but we still don’t know what we don’t know.”

To further discussion on the diversity within the AANHPI communities, ASAP! is hosting Cultural Dimensions of Lactation Support, a free webinar series focused on how cultural traditions support breastfeeding and the importance of culturally congruent care. The series format will take a conversational approach and present cultural norms as strengths to support quality care instead of barriers for health care providers to tolerate or overcome.

The first webinar in the series, focused on the East Asian community, takes place on Thursday, Aug. 19, from 8 to 9:30 a.m. Pacific. You can register here. The event is free and registered attendees will get access to the session recording.

“We’d be doing a disservice if we tried to cover the dimensions of all AANHPI communities in a single webinar,” Lang said. “There is so much diversity within our communities and differences in traditions regarding birth, breastfeeding and the postpartum period. You can’t even generalize to a specific country, because practices vary so widely.”