NYMC Student Theses and Dissertations

Date of Award

7-22-2025

Document Type

Doctoral Dissertation - Restricted (NYMC/Touro only) Access

Degree Name

Doctor of Public Health

Department

Public Health

First Advisor

Dr. Adam Block

Second Advisor

Heather L. Brumberg, MD, MPH, FAAP

Third Advisor

Shetal Shah MD FAAP

Abstract

Introduction: Preferred language other than English is associated with preventable adverse health outcomes. While Foreign-Birth status is linked to higher odds of breastfeeding, limited research examines how Foreign-Birth status, language preference, and self-identified ethnicity intersect to influence intention to breastfeed (ITBF).

Problem Statement & Purpose: Breastfeeding disparities exist across Foreign-Birth status, race/ethnicity, and preferred language, with a limited understanding of how these factors are linked. The Theory of Planned Behavior proposes that intention predicts behavior and is influenced by attitudes, subjective norms, and perceived behavioral control (Ajzen, 1991). This study evaluates ITBF and the impact of Foreign-Birth status, accounting for language preference, race/ethnicity, clinical conditions, and social determinants of health (SDOH).

Methods:

This was a cross-sectional analysis (2016-2025) of birth certificates merged with self-reported survey data administered to all consenting mothers (≥18 years) of singleton live-born infants in the Hudson Valley, NY Region. The primary outcome was ITBF. The preferred language (English or Spanish) was defined as the language in which the survey was completed. Subgroup analyses included 1. Self-reported Hispanic mothers & 2. Self-reported Non-Hispanic mothers.

Bivariate & multivariate regression analyses were performed examining ITBF in relation to Foreign-Birth status for the entire population as well as the two subgroups. Models were adjusted for maternal demographics, language, clinical conditions, and social determinants of health.

Results:

Of 1390 mothers, 932(67%) Domestic-Born mothers, 832 (89%) preferred English and 1011 (0.11%) preferred Spanish. Of the 307 (33%) Hispanic Domestic-Born mothers, 229 (75%) intended to breastfeed, and of the 625 (67%) non-Hispanic Domestic-Born mothers, 406 (65%) intended to breastfeed. Of the 458 (33%) Foreign-Born, 356 (78%) preferred English, and102 (22%) preferred Spanish. Of the 294 (64%) Hispanic Foreign-Born mothers, 298 (81%) intended to breastfeed. Of the 164 (36%) non-Hispanic Foreign-Born mothers, 125 (77%) intended to breastfeed. Among all mothers, those who were Foreign-Born exhibited higher ITBF rates than Domestic-Born (85% vs 71% respectively, p< 0.001). In both subgroup analyses, Foreign-Born mothers compared with Domestic-Born exhibited higher rates of ITBF, whether among Hispanic mothers (84% vs 76%, p< 0.010) or among Non-Hispanic mothers (87% vs 69% respectively, p< 0.001). Preferred language was not associated with ITBF among all mothers (76% English, 77% Spanish, p=0.580), mothers who only identified as Hispanic (80% English, 82% Spanish, p=0.637), and not with mothers who identified as Non-Hispanic (73% English, 70% Spanish, p=0.689). Logistic regression demonstrated Foreign-Born mothers had higher adjusted odds of ITBF compared to Domestic-Born mothers (OR 1.92, 95% CI 1.29-2.85), irrespective of preferred language. Similarly, among Non-Hispanic mothers, Foreign-Birth status was associated with higher adjusted odds of ITBF compared to Domestic-Born mothers (OR 2.48, 95% CI 1.35-4.55). However, among Hispanic mothers, nativity was not associated with ITBF.

Conclusions: This study is among the first to examine the relationship between Foreign-Birth status, race/ethnicity, preferred language, and ITBF while accounting for SDOH. We found Foreign-Birth status is associated with higher odds of ITBF among all mothers as well as among the Non-Hispanic subgroup. Yet, Foreign-Birth was not associated with ITBF among the Hispanic subgroups. These results suggest cultural influences, either by Foreign-Birth status/Non-U.S. country of origin or related ethnicity, may influence ITBF. These cultural influences may exert a more direct effect on ITBF than language or SDOH. We speculate nativity does not influence ITBF in our analysis among the Hispanic population because there may be commonalities and cultural norms related to breastfeeding across countries which denote Hispanic origin. In contrast, we surmise that among Non-Hispanic, Foreign-Born, cultural norms related to Breastfeeding may differ significantly compared to the United States, potentially explaining our findings. Culturally appropriate education and support, regardless of preferred language, may improve ITBF rates.

Keywords: Intent to Breastfeed, Breastfeeding, Foreign-Birth, Preferred language, Social Determinants of Health, Health Disparities, Maternal Health, Neonatal Nutrition

Additional Files
Bonnie Reyna Dissertation Approval Form signed.pdf (150 kB)
Dissertation approval form signed Bonnie Reyna

Disciplines

Medicine and Health Sciences

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Available for download on Friday, January 01, 2027

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