This study examined the relationship between hospital practices and mothers' ability to exclusively breastfeed according to their intentions. The researchers analyzed data from a national survey of over 1500 mothers who gave birth in 2005. They found that primiparas (first time mothers) reported a substantial gap between their intention to exclusively breastfeed (70%) and actually doing so at 1 week postpartum (50%). Primiparas reported hospital practices like supplementation (49%) and pacifier use (45%) that conflict with the Baby-Friendly Hospital Initiative's Ten Steps. Primiparas who delivered at hospitals implementing 6-7 of the Ten Steps were 6 times more likely to achieve their exclusive breastfeeding intention compared to those at hospitals implementing 0-
American College of physicians ACP high value care recommendations in rheumat...
Hospital Practices And Womens Likelihood Of Fulfilling Their Intention To Exclusively Breastfeed
1. RESEARCH AND PRACTICE
Hospital Practices and Women's Likelihood of Fulfilling Their
Intention to Exclusively Breastfeed
Eugene Declercq, PhD, Miriam H. Labbok, MD, MPH, Carol Sakata, PhD, MPH, and MaryAnn O'Hara. MD, MPH
Exclusive breastfeeding through at least the
Objectives. We sought to assess whether breastfeeding-related bospital prac-
first 6 months is the physiologically appropriate
tices reported by mothers were associated with achievement of tbeir intentions
approach to infant feeding,' Mixed or formula
to exclusively breastfeed.
feeding canics with it increased lisks of inleclion,
Methods. We used data from Listening to Mothers II, a nationally represen-
developmental probkims, mortality, and long-
tative survey of 1573 mothers wbo bad given birtb in a hospital to a singleton in
ailments such as diabetes and cancers For 2005, Mothers were asked retrospectively about their breastfeeding intention,
child." "'^ In support of the infant feeding at 1 week, and 7 bospital practices.
evidence, the American Academy of Pediatrics,'^ Results. Primíparas reported a substantial difference between tbeir intention
American College of Obstetrics and Gynecol- to exclusively breastfeed (70%) and tbis practice at 1 week (50%). They also
i.)gy,^ the American Public Health Association" reported bospitat practices that conflicted witb the Baby-Friendly Ten Steps,
the World Heidth Organization," iuid many including supplementation (49%) and pacifier use (45%|. Primíparas wbo deliv-
other medical and heallli pfofes,sioiial organiza- ered in hospitals that practiced 6 or 7 of tbe steps were 6 times more likely for
tions'"""'" recommend that infants consume only acbieve their intention to exclusively breastfeed than were tbose in hospitals that
mother's milk (exdusive breastfeeding) for at practiced none or 1 of the steps. Mothers wbo reported supplemental feedings for
tbeir infant were less likely to acbieve tbeir intention to exclusively breastfeed.
least the first 6 months of life, followed by
primíparas (adjusted odds ratio [A0R]=4.4; 95% confidence interval |CI1 = 2.1,
continued breastfeeding with age-^propriate
9.3); multiparas (AOR = 8.8; 95% CU4.4, 17.6).
nutrient ridi complementaiy foods. The
Conclusions. Hospitals should implement policies that support breastfeedrtig
irvised US Healthy P{!ople 2010 national objec-
witb particular attention to eliminating supplementation of heallby newborns.
tives call for 17"/(i of new mothers to be {Atn J Public Health. 2009;99:929-936. doi:10.2105/AJPH.2008.135236)
exclusively breastfeeding at 6 montlis.''
Nonetlieless. national statistics indicate that less
tlian 12'yu of mottier-baby pairs achieve this instRiction (/'< .001 ). Acceptance of fi-ee fomiula METHODS
goal."* was significantly assodatfîd (7^.03) with overall
The "Ten Steps for the FYotection, Promo- Ten Steps implementation. Althougti several in- We present rt"suft.s from a 2 0 0 6 national
tion and Support of Breastfeeding"'" are the ternational studies iiave eoneluded that even sui-vey of 1573 women aged 18 to 4 5 yeai-s
centr-al part of the Baby-Friendly Hospital some progress toward "Baby-Friendly Hospil^" who had given birth in 2 0 0 5 in a hospital to a
initiative, along with adherence to the hitema- status is assodated with ino-eases in breastfeed- singleton, sdll-living infant. The survey, entitled
tional Code of Marltelitig of Breast-Milk Substitule.'i ing, availaliie US data"" on the achievement of Listening to Mothers II,"" was devclo|.xd
and subsequent World I leatth Orgaiiiy^Eion exdusive breastfeeding in relation to the nuniber thiougli a collalioration between Childbirtli
resolutions."' 'Ihi'se pracücts have been of steps in place are limited. Connection iuid tlie Boston Univci'sity School of
reported to support breastfeeding behaviors The goal of our study was to provide dinica! I'ublic Heaitii and was conducted by Hanis
iuid influence outc»mes,''''" t h o u ^ in some and hospital administi'ative dedsion-makers Interactive. The standard tclcpbone sam|)ling
cases ihcy have been subjecis of political dis- with the infonnation they need to institute approadi of random-digit dialing, though ad-
[jutca,'' However, with the exception of a policies and practices that enhance a woman's vaiitageous for reaching a divei-se population, is
I ecent Centere for Disease Control and ability to achieve her intended duration of not feasible for a national sui'vey of new motliers
ñ-evendon stiidy*^" and sum«! data fi-orn exclusive breastfeeding. We examined tbe re- becaii.se tlic number of US birtlis (4 million
hos|jitals that have achieved "Baby-Friendly" sults of a national survey tliat asked mothers annually) Ls small in proptJiüon to the number of
status, little is known about the prevalenœ of about their feeding intentions "as [they] came boiiseholcfs (IU million); tlierefore, respondents
these practices in haspitals acrass the United to tbe end t)f ftheirl pregnancy" «md their actual were drawn fi^om 2 oth(?i' sourcts.
States. feeding patterns 1 week after tbe birth. We also Tbe Internet portion of tlie sample was
Grizzard et al.^' assessed Massachusetts hos- asked motliers to report on their experiences drawn from Hanis Interactive's ongoing Inter-
pitals and noted tliat hos¡iil;ils witli high or with hospital practices kiiown to influence net panel of more tlian 5 million individuals
moderately liigb levels of implementation signif- breastfeeding success. Based on past research, who agree to periodically pajtidpate in tlieir
icantly differed fi'om hospitals with paitial we expected that hospital pracUcc-s would be surveys. To ensure a more representative
implementation vnth respect to pacifier usage related to tlie fulfillment of a plan to exclusively overall sample, a telephone sample was also
(F=.i)()2) and postpattiim breastfeeding breastfeed. drawn. Respondents in tliis sample were
May 2009, Vol 99, No. 5 , American Joumal of Public Health Declercq et al. Peer Reviewed Research and Practice 929
2. RESEARCH AND PRACTICE
limited to non-White mothei-s and were iden- all 50 states and the Distiid of Columbia In community breastfeeding rtisoui'ces, supple-
Liiied through tlie useofapropnetaiy list"^ tliat tenus of age. nZ'^'ii of the study ¡xipulation and menting breastfeeding with fonnula or water,
contained telephone numbers and zip eodes of 52% of the comparable birthing population were giving tbe baby a pacifier, providing free for-
motliers who had given hirth in 2005. House- aged between 25 and 34 years. Non-Hispanic mula samples to mothers), and a global ques-
holds in ziji codfis willi lai^ge non-White popu- Black mothers made up 12'I'd and I iisparuc tion about tiw. hrt^astfeeding support they re-
lations were called and respondents were mothers 21% of the study sample, compaied with ceived from hospital staff. Where possible,
screened to eiisuR' nol only thai they met llie 14'Vi) and 23"''i). respectively, in the birthing these items were taken directly from the Raby-
original inclusion aiteria hut also that they were population. Finally, tlie breastfeeding ratis we Friendly Hospital Initiative Ten Steps,''^ with
non-Hispanic Black or Hispanie. The combined report are generally comparable to 2 0 0 5 rates spedfic Baby-Friendly Hospital Initiative steps
survey resulLs wen' weighttid by 1 lanis with tlieir repoited by the Centers ft)i" Disease Contnil conesponding to survey questions nottxl in 1 a-
validated "propensity sa)re" metliodology {G. and IVeverition hasi-d on the National Immuni- hte 2. Mothers were given 3 [ios.sible ways to
Terhanian et al., unpublished data, 2000; avail- zation Survey. Althou^ the spedfic questions dfscribe the pattern of feeding intended during
ahle from authors on request) to adjust for were not the same, the overall rate of any late pn'gnancy and practiced at 1 week: (1)
|X)tentiiiJ biases associated witli online res|N)n- bi^eastfeetling at ;ill at 1 week iu oui" sample exclusive breasUetniing, (2) exclusive formula
dents. We applied population wei^ts to statisti- {73"/()) matches tlie 73.1<^/(i reported as any feeding, or (3) mixed feeding. In a separate pml
cal analyses by using ciurently available options breastfeeding at 7 days in the 2 0 0 5 National of the questionnairi', we also asked the mother's if
m S I ^ version 15.0 (Sf'SS Inc, Chicago, IL). biununization Sur'ey."^^ tliey experienced "rooming in" and induded thai
vaiiable in the muitivariate analysis.
Survey Measurements We tabulated these results with a particufar
Details on the survey metliodology are We retrospectively asked motlitirs about foais on wheUier women who intended to
available elsewhere.^"^ The survey sample se- their infant feeding intention at the end of their exdusively breastfeed at the end of pregnancy
lection and consent process complied with the pregnancy, their feeding practices at 1 week had in fact established exdusive breastfeeding
codes and standards ol' the Council ol' American (summarized in Table I), their experience with 1 week postpartum. We recognize tbat many
Survey Reso^eh Oi^anizations and the code of hospital stafî related to 7 specific practices women make mfaiit feeding dedsions at an
the National Council of Public Polls, Data were associated with exclusive breastfeeding (help- earlier point in time and that many women who
(Xitiectpd and housed secur<!ly hy Harris Intnr- ing mother get stalled breastfeeding, showing establish breastfeeding continue beyond
active and the authors had acass only to a mothers how to position baby, encouraging 1 week. We selected these time points to
deidentified file provided by Harris Interactive. feeding on demand, infomiing mothers about examine the assodation between hospital
Questions related to hi'eastfeeding were a
brief part oí the 3(>minute survey that also
ineluded questions on prenatal, intrapartiim,
and postpartum experiences: maternal atti- TABLE 1-lnfant Feeding Intentions Compared With Actual Practice at 1 Week Postpartum
tudes related to bittli; and demogi'aphic ehar- Among US Mothers Who Gave Birth in 2005, hy Parity: Listening to Mothers II Survey
aeteristies.^' AU phone and Internet interviews
Feeding Intention
were conducted between January 20 and Feb-
Exclusive Mixed (Breastfeeding Exclusive
niaiy 21, 2006; no niotlier was askefl to recdl
Feeding Practice'' at 1 Week Postpartum Breastfeeding, % and Formula), % Formula, % Total,' %
experiences from morí* than 13 months earlier,
and for most mothers the recall time period was Primiparas
much sootiei'. The average i-eK[>oiident had given Exclusive breastfeeding 44 4 1 50
birtb 7.3 months before completing the survey Mixed (breastfeeding and formula) 20 8 0 28
(online, 7.4 months; telephone, fi.4 montlis). Past Exclusive formula 6 4 13 22
researdi has found tliat mothei-s are able to Total 70 16 14 100
validly recall estimates of breastfeeding initiation Multiparâs
and duration up to 3 years.""* Exclusive breastfeeding 17 5 1 53
The resulting sample of mothers who had Mixed (breastfeeding aid formula) 7 U 1 18
given birth in 2 0 0 5 was generally representa- Exclusive fomiiiia 3 5 21 29
tive (within 1 to 3 percentajie points) of the Total 57 21 22 100
comparable national population of hiilhing Note. For primiparas, n'519. For multíparas, n-1052.
mothers—aged 18 to 4 5 years; singleton, hos- *Women were asked, "As you came to tfie end of your pregnancy, bow liad you fioped to feed your baby? Options:
pital births—based on the most recent US breastfeeding alone, formula only, a combination of breastfeeding and formula."
'^omen were asked, "One week after you gave birth, how were you feeding your baby? Options: breastfeeding alone, formula
tinta" ' available for comparison. A table sum- only, a combination of breastfeeding and formula,"
marizing the compajTson was published in a "^Totals are rounded.
related article.^'' Survey respondents {»me from
9 3 0 I Research and Practice | Peer Reviewed | Declercq et al. American Joumal of Public Health 1 fulay 2 0 0 9 , Vol 9 9 , No, 5
3. RESEARCH AND PRACTICE
discrepancy between intent and exclusive
TABLE 2-Hospital Practices Reported by US Mothers Who Gave Birth in 2005 and Who breastfeeding to be those mothers with a
intended to Exclusiveiy Breastfeed, by Parity: Listening to Mothers II Survey reported income of $25000 to $49999 (78%
Hospital Practice (6FHI Step' Primiparas, % Multipafas, % All, %
intention vs 49"/o actual exclusive breastfeed-
ing at 1 week), Hispanic mothers (59% vs 32"Vo,
On ttie whole would you say Ihe staff, (BFHI 3) respectively), non-Hispanic Black mothers
Encouraged breastfeeding 81 73 76 (59% vs 33'y(i, respectively), or mothers
Encouraged formula feeding 5 1 2 employed part-time (78'Vo vs 51'ya, respec-
Expressed no preference 15 26 22 tively). Among multiparas the same general
Other hospital practices patterns emerged, though the difîei-ence be-
Helped you get started breastfeeding when you and your 89 70 77 tween intent and actual exclusive breastfeeding
baby were ready (BFH! 4)' was mudi smaller.
Gave you free formula samples or offers" 74 61 65 We also examined the bivariatc relationship
Showed you how to position your baby to limit nipple soreness (BRil 78 59 66 between intrapartuni experiences and fulfill-
Encouraged you to feed "on demand" (BFHI 8)' 80 75 77 ment of intention to exclusively breastfeed
Told you about community breastfeeding support resoun:es for 69 64 65 (data not showi). Among primiparas, factors
ongoing help (BFHI 10)' that were related in bivaiiatc analysis to
Provided formula or water to supplement your breastmilk (BFHI 6)" 49 29 37 achievement of intent to exclusively breastfeed
Gave your baby a pacifier (BFHI 9 f 45 40 42 included having an obstetrician (rather than a
Note. BFHI-Baby-Friendly Hospital Initiative. Data excludes mothers with babies ir the neonatal intensive care unit. For
family doctor or midwife) as the ¡jrenaLal care
primíparas, n-338. For multíparas, n''577. For the total sample, N = 915. provider and not having a cesarean delivery.
^Most closely related BFHI step noted in parentheses. The 10 steps are available at: http://www.ünicef,org/nutntion/ Among multipaius. there were more factors
index_24806,html.
related to achievement of intention to exclu-
'Violates Ititernational Cotie of Marketing Breast-Milk Substitutes.^
sively breastfeed, including not having an epi-
dural or a cesarean delivery, having the baby in
contact witli the mother immediately after
practices and initial fulfillment of intention to differed by parity, with 65% of primiparas and birth, rooming in with the baby, and a post-
exclusively breastfeed. Past research has found 79''/ii of multiparas feeding the baby at 1 week partum length of stay of 2 days or less. TTiese
wide variations in exclusive breastfeeding by in the way they had intended at the end of variables were included in the multivariate
parity.^^'^^ so we stratified all analyses to dis- pregnancy. The largest group were those analysis.
tinguish primiparas from multíparas. Because our mothers who intended to, and at 1 week were. Table 2 presents responses concerning hos-
intention was to examine the typical pos^artum exclusively breastfeeding their babies. Most pital practices related to breastfeeding from
hospital experienœ for mothers, we limited who did not achieve their intention to exclu- mothers who intended to exclusiveiy bi'east-
analyses to those cases where the infant was not sively breastfeed (2O"/o of piimipaious women; feed and whose babies were not in tlic neonatal
in the intensive care unit, resulting in the toss of 7% of multiparous women) practiced mixed intensive care unit. Responses are sti atified by
6% (100) ofthe respondents (Table 2, Table 3, feeding. There were some respondents (4'^/i) of parity. More than four fifths of priniipai-as
and Figure 1). primiparas and 5"/o of multiparas) who had (81"/ü) who intended to exclusively breastfeed
intended to use mixed feeding but were ex- indicated that the staff encouraged breastfeed-
Analyses clusively breastfeeding at 1 week. ing. In terms of specific hospital practices,
We conducted data analyses with SPSS ver- Overall, 61"/(! of respondents indicated that primiparas reported that in some cases staff
sion 15.0 (SPSS Inc, Chicago, IL). We per- they had intended to exclusively breastfeed, were highly supportive in providing help get-
formed multiple logistic regression methods to and about half of the mothei-s (51%) were ting started (89%), encouraging breastfeeding
examine the association between ñüfillment of exclusively breastfeeding at 1 week. When on demand (8O'fo). and showing how to posi-
intention to exclusively breastfeed, various these findings were stratified by parity and tion the baby (78'Wi). However, almost half
hospital practices, and related demographic demographic characteiistics of mothers, we {49%) of those first-time mothers who intended
variables for each parity stratum. found substantial variance across groups to exclusively breastfeed reported that their
(data not shown). TTiose most likely to intend baby was given water or formula for supple-
RESULTS to and aclually exclusively breastfeed at I week mentation, 45% reported that their baby had
were mothers who were non-Hispanic White, been given a pacifier, and 74% of those
Table 1 compares intended and 1-week rates better educated, had higher incomes, had pri- intending to exclusively breastfeed reportt^d
of feeding types, by parity. Mothers' repoi-ts of vate insurance, or were employed pmt-time. being given free formula samples or ofTei-s. On
fulfilling their feeding intention (exclusive When we stratified the results by parity, we the whole, the pattern for multiparas involved
breastfeeding, exclusive formula, or mixed) found that first-time mothei-s with the largest less vaiiation tban primiparas across the
May 2009. Vol 99. No. 5 American Journal of Public Health Declercq et al. Peer Reviewed Research and Practice i 931
4. RESEARCH AND PRACTICE
hospitals engaged in and the achievement of
TABLE 3-Percentage of US Mothers Who Gave Birth in 2005 Who Intended to Exclusively
exclusive breastfeeding, f-igure 1 displays a
Breastfeed and Were Exclusively Breastfeeding at 1 Week, by Parity and Reported Hospital strong cumulative effect of these polides for
Practices: Listening to Mothers il Survey both parity groups. Primiparas who reported
experiencing at least 6 of the 7 practices were 6
Primíparas Multíparas
times more likely (86% vs 14%) to fulfill their
Mother Mother Did Mother Mother Did
intention to exclusively breastfeed than
Experienced Not Experience Experienced Not Experience
Practice, Practice, Practice. Practice.
mothers experiencing 1 or none of these prac-
% (No.) % (No.) % (No.) % (No.) tices, Multiparous mothers in the same com-
parison were more than twice as likely (93'Vi) vs
Hospital practice
45"/o),
Helped yoL gel started hreastfeeding when 69 (301) 33 (36) <.O01" 83 (403) 82 (173) ,691
you and your baby were ready
Finally we examined what factors were
Gave you free formula samples or offers
most strongly related to achievemeni of ex-
61 (249) 74 (90) .002 7 (349)
7 92 (228) <.OO1
clusive breastfeeding intention in a multi-
Showed yoj how to position your hshy to 69 (263) 49 (75) .002 82 (339) 83 (238) .883
variate analysis. Because of the substantial
limit nipple soreness
differences consistently noted for parity, we
Encouraged you to feed "on demand" 69 (271) 50 (66) .004 87 (432) 70 (144) <,001
ran separate models for primiparEis and
Told you about community breastfeeding 73 (231) 48 (106) <.0Ol 84 (367) 81 (210) .334
multiparas. Consistent with our focus on the
support resources for ongoing help
relationship between hospital practices and
Provided fomuia or water to supplement 49(166) 81(172) <,001 56(169) 94(407) <.O01
achievement of intention to exclusively
your breastmilk
breastfeed, we included the 7 hospital prac-
Gave your baby a pacifier 57 (152) 71 (186) .009 82 (228) 83 (349) .640 tices as well as key intrapartum variables
Hospital staff attitude ,071 .115 (prenatal care provider, epidural use, method
Hospital staff encouraged breastfeeding 67 85 of delivery, rooming in, where the haby
Hospital staff encouraged formula 40 was in the first hours after birth, and post-
Hospital staff expressed no preference 60 78 partum length of stay), and demographic
Note. Data eKcluöes motfiers witfi babies in the neonatai intensive care unit. variables (age, education, income, race/eth-
''P values reflect x^ test on comparisons of within parity group breastfeeding rate at 1 week across hospital practices. nicity, employment status, and third-party
payer source) associated with feeding
choices.
When we controlled for all the other noted
clifîerent hospital practices. An analysis of tJicsc breastfeed. .-Vmong primiparas there was a demographic and intrapartum variables,
practices by racc/cthnicity (data not shown) significant difference in the rate of achieving among pnmiparas. only 4 hospital practices
loiind that non-Hi.spaiiic White primiparas their intention by whether a hospital engaged were statistically significantly assocjated witli
intending lo exclusively breastfeed were much in each ofthe practices, partiailariy supple- the likelihood of achieving hreastfeeding in-
less likely to report supplementation wilh water mentation, with slightly less than half (49"''o) tention; (1) helping mothers get started (ad-
or formula (40"'o) than were non-Hispanic achieving their intention to exclusively breast- justed odd.s ratio [AORl—6.3; 95"/() confidence
Black (71%) or Hispanic (74"/ii) mothers with feed compared with 81"/n in cases where there interval [a] = 1.8, 21,6). (2) hospital staff not
this intention. was no supplementation. supplementing with formula or water
Table 3 presents data on Ehe percentages of The differences for multiparas were gener- (AOR = 4.4; 95% Cl = 2.1, 9.3). (3) telling
mothers who Ililhlled llieir intention to exclu- ally less pronounced, with the exception of mothers about community resources for
sively breastfeed. In this table, the columns supplementation: 94% of the mothers who did breastfeeding support (AOR=2,3; 95%
represent different levels of painty and whether not report supplementation occuning achieved CI = 1.1, 4.9), and (4) staff not giving the baby a
the mother reported that the hospital engaged their intention to exclusively breastfeed, com- padñer(AOR = 2.3; 95"/.iCI = 1.2, 4.4). Among
in a paiiiailar practice. For example, (i9'Vi) of pared with 56%) where supplementation was multiparas, 2 hospital practices significantly
the mothers who intended to exclusively reported. The provision of formula samples or impacted fulfillment of intention; hospital staff
bi'eastfeed and repoited iliat hospital staff coupons'"' was associated with a significant not supplementing (A0R=a.8; 95% CI=4,4,
helped them get stalled hreastCeeding were rcHiuction in achievement of intention to exclu- 17.6) and hospital staff encouraging feeding on
exclusively breastfeeding at 1 week. This find- sively breastfeed for both primiparas and mul- demand (AOR=3.4; 95% CI=1.7, 6.8). None
ing can be compai^ed with 33"/o of piiniiparas tiparas. of the demographic or intrapartum events
fulfilling their intention to exclusively breast- remained significantly related to iiilfillment of
We examined whether there was a dose-
feed at 1 week in hospitals where they reported intended exclusive breastfeeding duration in
response relationship between the number of
that they did not get help in starting to these models.
supportive practices mothers reported that
932 [ Research ancf Practice | Peer Reviewed Declercq et al. American Joumal of Public Health I May 2009, Vol 99, No. 5
5. RESEARCH AND PRACTICE
Steps to Successful Breastfeeding, confirms that
there is substandal evidence beiiind Step 6,
"Give newborn infants no food or drink other
than breastmiik, unless medically indicated,"
repoiting that the feiding of supplements dis-
rupted breastfeeding,'" a condusion supported
by studies from Honduras and italy.'"' '^
Comparison With Other Studies
Few studies have examined hospital prac-
tices as predictors of success at (exclusive
breastfeeding."" '"^ A recent shidy of Colorado
mothers' descripdons of hijspitai pracdces and
their inlant feeding exix'riences found a signifi-
2-3 fl-5 6-7
cant relation between hospital pracdces unsup-
pordve of breastfeeding and discontinuation of
Number of the 7 Policies Mothers Reponed Hoîpiials Practicing
breastfeeding at 8 weei«. The study also found,
iVoíes. Hospital practices: (1) staff fielped mother get stafted breastfeeding, (3) staff showed mother how to position baby, as we did, a aimuladve effect of hospital prac-
{3) staff encouraged feeding on demand, (4) staff directed motbers to community breastfeeding resources, (5) staff did not dces, but did not .sti-atify mothers by ¡jaiity- or
encourage supplementing breastfeeding with formula or water, (6) staff did not encourage pacifier use. (7) staff did not give
perform a muttivariate analysis on their resuits."'
out free formula or offers. Differences in fulfillment are statistically significant across numbers of policies (P<,01),
These studies, which invoived different method-
FIGURE 1-Hospital support and breastfeeding success among US mothers who gave birth in ologies and were done in different settings,
2005: Listening to iVIothers ii Survey. reinforce Hie need for hospital practices sup-
porting inidadon ajid later suca^ssful continua-
tion of exdusive breastfeeding.
DISCUSSION support breastfeeding in the United States. Limitations
Applying these differences to national data Our study was based on a US nadonal
We itkîiitihed several hospital practices, as results in a totai of more than 400000 infants sample drawn from a combinadon of internet
reported by mothers, that were strongiy related annually (10% of all US births) whose mothers and teiephone respondents. Internet-based
to rates of exclusive breastfeeding. We used a intended lo exclusiveiy breastfeed as they samples ai-e increasingly being used in public
iarge. representative national sample to focus completed their pregnancies but were not do- opinion research,'' and our data weœ .supple-
on a cridcai time in estabiishing exciusive ing so 1 week after birth. mented with a telephone survey of non-White,
breastfeeding and examined how hospital Experiencing hospital practices that inhibit English-speaking mothers. The aimbined sample
practices were positiveiy and negativeiy asso- exclusive breastfeeding (i.e., staff supplement- was weighted to adjust for the nadonal úv.ma-
ciated with the likeiihood that a mother who ing breastfeeding with formula or water, being graphic dLstribudon of tlie childbeamig ¡jopiila-
intended to exclusively breastfeed her infant given free fomiula samjjies, babies given pac- don and the propensity to be online. The result is
was actuaiiy doing so 1 week after birth. We ifiers) was significantly assodated with mothers' a sample that is generally representadve of the
also doaimented hospitai practices from a failure to fuifill their intendon to exdusively US birthing populadon and US breastfeiKling
unique pei'speilive—that of niothei-s—rather breastfeed, in cases where mothers reported a rates. Althou^ the resiiits mirror the demo-
than stated policies or rcpoils nom hospital comprehensive pacicage of supportive prac- graphic chai acterisdcs of tlie US birthing popu-
stíüT. In this way, our study can serve as a tices, primiparas were 6 times more iikely and ladon, we cannot be ceiiain that our respondents
complement to a recent Centers for Disease multiparas twice as iikely to achieve their were representadve of ali hospital and breast-
Conti'oi and Prevention survey of hospitai intention to exclusively breastfeed. feeding experiences of birtliing women in the
practices and policies reiated to breastfeeding The practice of hospital staff providing for- United States. However, there were no indica-
as reported by hospital staff at the fadiity mula or water to supplement breastfeeding was tions suggesdJig a likelihood of bias in the results.
levei.^" sigiiificantiy related to failure to achieve ex- Our study relied on mothers' recall and was
We found a substantiai difference between dusive breastfeeding. Mothers whose babies not validated by recoids review. Past researdi
primipai-as' intention to exclusively breastfeed did not experience supplementation were 4.4 has shown that mothers are generally accurate
(7O"/o) and their actual rate of exclusive dmes {primíparas) or 8.8 dmes (muldparas) in their reports of their own birth experi-
breastfeeding 1 weei< after birth (50"/ii). These more iikely to achieve their intention to exclu- ences.''^ Nonetheie.ss, it is possible that some
shifts between intention and practice represent sively breastfeed. ITie Worid Health Organi- respondents could have based their rétrospective
a huge lost opportunity to encourage ajid zadon 1998 compendium. Evidence for (he Ten response regarding intention on their actuai
May 2009, Vol 99, No. 5 , American Journal of Public Health Declercq ei al. Peer Reviewed I Research and Practice | 933
6. RESEARCH AND PRACTICE
bit'astfcetiing experience. To pR)tec1 against Hospital Initiative will contribute to increasing 7. ACQG Committee for Healthcare of underserved
Women and Committee on Ohsletriral huctices. Spedal
Ulis possibility, tlie survey was stnictui-ed to be the proportion of mothers who are given tlie
report from ACOG. Breastfeedingniatenial and infant
neutral and nonjudgmental about feetling choice. support tliey need to fulfill their intention to aspects. Clin Rev. 2OO7;I2(1 suppi):lS-16S.
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efFect, we asked the question on breastfeeding at About the Authors ad vocacy / pol i cj' /pol icy seareh /default.htin?id=253.
1 wec'k after the questions on haspital practice. .-^t the time oftkestudi/. Eugene Declercq tvas With School of Accessed Tebruary 20, 2009.
Also the comparable national data most often Public Health, Boston Uniivi'siti/. fA. Miriam H. Lohhcik
9. WHO-VNICEF Global Strategy for Infant and Young
was with the School of Public Hetillh, Universitif of North
usetl in reporting breastfeeding trends, the Na- Carolina. Chapel Hill. Carol Sakala was with Childbirth
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Organization; 2003.
tional Immunization Survey, as well as data from Cannectinns, .Veit' York. iVV. Mary.Ann O'Hara wtii with the
Ross Laboratories Mothers Surveys'''"' relied on Universittf of Washington. Seattle. 10. Moreland J, Coombs J. Promoting and .supporting
Requests for reprints can be sent to Eugene Declercq. breast feeiling. .Am Fam Ptn/sidan. 20i)0;(il :2093-
matemal recall."*" and a study of maternal recall 2100.2103-2104.
Department of Matermd ami Child Health. Boston Uni-
of bi'eastfeeding experiences Ibiuid motheiï' i"e- verstty School of Puhlic Heohh. 71 ñ .Mhany St, Talhot 11. Mission statement. New Rochelle, ^fY; Academy of
sponses both valid and reliable.'"'' W5-40. ihston. .MA 021 IS (e-mail: declercq@bu.edu). Breastfeeding Medieinc; 2006. Available at; http;//
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Conclusions Contributors .American College of Nurse Midwives; 2004. Available
Breastfeeding protection, promotion, and E. Dedercq designed the sttidy, wrote the first draft of at: http://www.anim.org/siU;I''iles/p<)sition/
suppoil may rely on identifying and using (he "Methotis" mid "Rcsulls" sections, and did the data Brf-astfeeding_05,|Kff. Accessed Decembei- 29. 2008.
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duction and "Discussion" sections. C. Sakala and E.
2008 etlition foais area: 16-mateiTial infant and chiki
these findings present opportunities and raise Declercq were iTivolved in the design of the tinestion-
health]. Available at: http;//wonder,cdcgov/data20IO/
nairc thai wai Ihc basis tor the siin'cy. All autliors were
questions in 2 ai eas. First, should we be objhtm. Accessed June 17. 2008.
involved in writing subsequent drafts.
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and 57''^ of experienced mothers had the Breastfeeding among US children horn 1999-200S,
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approaches. l>ublic Opin Q. 2000;64:4fi4~494. ORDER TODAY! American Public Health Association
3y. Yawn BP. Suman VJ, Jarabsen S). Maternal recall of ISBN 0-87553-043-5 PUBLICATION SALES
di.'itaiit pregnancy events. / Clin Epidemiol 1 998; 590 pages, softcover, 2004 WEB: www.3pha,org E-MAIL: APHA@pbd,com
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May 2009, Vol 99, No. 5 | American Jojmal of Public Healtb Declercq et al. i Peer Reviewed | Research and Practice | 935