Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices

ABSTRACT Background Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to two health-promoting infant care practices: supine placement and breastfeeding. Methods We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed U.S. mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding. Results Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was OR 1.31 (95%CI 1.11-1.54) and OR 2.82 (95%CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95%CI 9.00-39.92; breastfeeding: aOR 3.86, 95%CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95%CI 4.52-9.89; breastfeeding: aOR 5.17, 95%CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the two practices. Conclusions The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.