Breastfeeding Report Card—United States, 2010

Background

Improving the health of mothers and their children is a primary goal of the Centers for Disease Control and Prevention (CDC). Protecting, promoting, and supporting breastfeeding, with its many known benefits for infants, children, and mothers, is a key strategy toward this goal.

There are many different ways that communities support mothers and babies to breastfeed, and everyone plays a role. The CDC Breastfeeding Report Card provides state-by-state data so that health professionals, legislators, employers, business owners, community advocates and family members can work together to protect, promote, and support breastfeeding. The Report Card indicators measure types of support in key community settings as well as the most current data on the breastfeeding goals outlined in Healthy People 2010.

The Report Card brings together all of this information to help tell the story of breastfeeding practices in your state. It condenses many types of data so that community partners can monitor progress, celebrate state successes, and identify opportunities for growth and improvement.

What's new this year?

The most recent CDC data show that 3 out of every 4 new mothers in the United States now starts out breastfeeding. The United States has now met the Healthy People 2010 national objective for breastfeeding initiation. However, rates of breastfeeding at 6 and 12 months as well as rates of exclusive breastfeeding at 3 and 6 months remain stagnant and low.

More babies in the United States are now born at Baby-Friendly^TM facilities than ever before. However, these births still represent less than 4% of all U.S. births. Further, the CDC mPINC survey of all birth facilities in the U.S. shows that the average score for facilities nationwide is only 65 out of 100, and only 2 states' facilities scored 80 or more points.

A greater number of people are now working on improving how states support mothers and babies to breastfeed.  Nationwide, health departments now dedicate nearly 97 full-time equivalents (FTEs) to supporting breastfeeding mothers and babies in their states. However, this still represents less than 2 FTEs per state dedicated to a health issue that is clearly recognized as a national priority.

What do the numbers tell us?

High breastfeeding initiation rates show that most mothers in the United States want to breastfeed and are trying to do so. However, even from the very start, mothers may not be getting the breastfeeding support they need.  Low breastfeeding rates at 3, 6, and 12 months illustrate that mothers continue to face multiple barriers to breastfeeding.

Across the United States, the average level of support that birth facilities provide to mothers and babies as they get started with breastfeeding is inadequate, and hospital practices and policies that interfere with breastfeeding remain common. In the United States, too few hospitals participate in the global program to recognize best practices in supporting breastfeeding mothers and babies, known as the Baby-Friendly Hospital Initiative.

What can states do to improve breastfeeding rates?

Use the Breastfeeding Report Card to identify your state's needs, develop solutions, and work together within your community to better protect, promote, and support breastfeeding statewide.

Breastfeeding Report Card Indicators – 2010

Each indicator is measured in every state, allowing easy state-by-state comparisons.

Outcome Indicators

Five indicators profile the extent to which infants in a state are breastfed.  These are derived from the breastfeeding goals outlined in Healthy People 2010, a description of the nation's health priorities.

For more, see Breastfeeding Report Card, United States: Outcome Indicators.

Process Indicators

Elements of breastfeeding-friendly communities are measured in nine more indicators, measuring support from birth facilities, health professionals, state legislation, and public infrastructure (public facilities and services).

For more, see Breastfeeding Report Card, United States: Process Indicators.

Healthy People 2010 Targets
Objective 16-19 – Increase the proportion of mothers who breastfeed their babies:

• In early postpartum to 75%.
• At 6 months to 50%.
• At 12 months to 25%.
• Exclusively through 3 months to 40%.
• Exclusively through 6 months to 17%.

Birth Facility Support

• State Maternity Practices in Infant Nutrition and Care (mPINC) score.
• Percentage of live births occurring at facilities identified as part of the Baby-Friendly Hospital Initiative.
• Percentage of breastfed infants receiving formula before 2 days of age.

Birth facility policies and practices significantly impact whether a woman chooses to start breastfeeding and how long she continues to breastfeed. Several specific policies and practices, in combination, determine how much overall support for breastfeeding a woman birthing in a given facility is likely to receive and how likely her baby is to receive formula in the first 2 days.

Two initiatives, one national and one global, provide informative measures of birth facility support. The mPINC Survey initiated by CDC, in collaboration with the Battelle Centers for Public Health Research and Evaluation in 2007, measures breastfeeding-related maternity care practices at intrapartum care facilities across the U.S. and compares the extent to which these practices vary by state. Thus, the state mPINC score represents the extent to which each state's birth facilities provide maternity care that supports breastfeeding.

The Baby-Friendly Hospital Initiative (BFHI) is a global program sponsored by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for lactation based on the WHO/UNICEF Ten Steps to Successful Breastfeeding for Hospitals.

To be designated as "Baby-Friendly," facilities undergo external evaluation to demonstrate that the facility meets all of the Ten Steps requirements. All types and sizes of birth facilities can seek the Baby-Friendly designation. Some states have several small Baby-Friendly facilities, others have only one or two large ones, and still others have none at all. Because facilities vary in size and the number of births, measuring their impact on public health requires more than just counting the number of Baby-Friendly facilities per state. The best way to measure their impact is to look at the proportion of births in a given state occurring at facilities that have earned the Baby-Friendly distinction.

Professional Support

• Number of International Board Certified Lactation Consultants (IBCLCs) per 1,000 live births.

IBCLCs are health professionals who specialize in the clinical management of breastfeeding.  IBCLCs work in many health care settings, such as hospitals, birth centers, physicians' offices, public health clinics, and their own offices. A strong statewide group of professional breastfeeding experts (IBCLCs) is needed to assist the mother-infant pair, create and administer lactation programs, and educate other health professionals about breastfeeding. Much of an IBCLC's work is done one-on-one; therefore, only a rough estimate can be made of their availability to provide professional support within a state. The best measure is the ratio of IBCLCs to the number of live births.

Legislation

• Laws protecting breastfeeding in public.
• Laws mandating support for breastfeeding mothers who return to work.

Most states now have some form of legislation (laws) protecting the basic human right to breastfeed. Unfortunately, despite protective laws, mothers and babies who breastfeed in public still face obstacles and negative reactions.  Legislation reflects social acceptance of breastfeeding as a normal activity, concern for the health and well-being of children, and the importance of breastfeeding as a public health issue.

Laws mandating support for breastfeeding mothers who return to work encourage mothers to continue breastfeeding after returning to work by requiring a minimum level of breastfeeding support from the employer. Such laws support the economic goals of employers and employees as well as the well-being of mothers and children.

Infrastructure

• Number of state health department full-time equivalents (FTEs) responsible for breastfeeding.
• Statewide breastfeeding coalitions with public Web sites.

State health departments are the central state agencies responsible for the public health and welfare of women and children. Among their many responsibilities, employees in these agencies help ensure appropriate consideration of breastfeeding in public programs and services. FTEs dedicated to the protection, promotion, and support of breastfeeding are needed to develop, implement, monitor, and maintain breastfeeding interventions.

A statewide coalition dedicated to breastfeeding represents a basic level of community support for breastfeeding.  Though these coalitions differ in terms of what they do and how they do it, they share a commitment to empower community members to be local change agents. Coalition members make the case to their community for the importance of breastfeeding.

State coalitions with publicly available Web sites have an effective way to communicate. On their Web site, coalition members can share information with existing members and also recruit new members interested in breastfeeding issues. Coalition Web sites are also an excellent way to reach community members who want quality breastfeeding information and online support.

Support in Child Care Settings

• Number of states with child care center regulations that support breastfeeding.

In the United States, nearly two thirds of infants are routinely cared for by someone other than a parent. About half of these infants attend child care centers; the other half spend time in a variety of home-based settings including licensed family child care homes or the home of a family member, friend, or neighbor. Thus, child care facilities – both family child care homes and child care centers – play an important role in promoting breastfeeding among mothers whose infants are cared for in these facilities. States that lack regulations that support breastfeeding at child care facilities are encouraged to meet best-practice national standards set by Caring for Our Children.

Data Sources

1. Breastfeeding outcome indicators – Ever Breastfed, Breastfeeding at 6 months, Breastfeeding at 12 months, Exclusive breastfeeding at 3 months, Exclusive breastfeeding at 6 months
   • CDC National Immunization Survey, Provisional Data, 2007 births. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
2. Breastfeeding process indicators
   • Average mPINC Score
     Source:  2009 CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey.
   • Modes of support per live births by state
     Source:  Total live birth information:  Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2007. National vital statistics reports, Web release; vol 58 no 16. Hyattsville, MD: National Center for Health Statistics. Released April 6, 2010. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_16.pdf [PDF-312k]
     Accessed 7/20/2010.
     • Percentage of live births at facilities designated as Baby Friendly (BFHI)
       Source:  Baby Friendly USA. Baby-Friendly Hospitals and Birth Centers as of July 2010. Available at http://www.babyfriendlyusa.org/eng/03.html
       • Hospital annual birth census information:  American Hospital Association Annual Survey Database for Fiscal Year 2007.
       • Birth center annual birth census information:  2009 CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey and personal communication.
     • Number of IBCLCs per 1,000 live birth
       Source:  International Board of Lactation Consultant Examiners.  Facts and Figures about IBCLCs in the Americas and Israel. Available at http://www.americas.iblce.org/upload/Facts_Figures_AMS.pdf [PDF-93k]
       Accessed 7/10/2010.
     • Number of states with child care regulations that support breastfeeding
       Source:  Benjamin SE, Taveras EM, Cradock AL, Walker EM, Slining MM, Gillman MW. State and regional variation in regulations related to feeding infants in child care. Pediatrics. 2009;124:e104-e111. (following publication, authors updated data to Feb 2009 for use in the Breastfeeding Report Card). Available at http://pediatrics.aappublications.org/cgi/content/abstract/124/1/e104
       Accessed 7/20/2010.
   • Number of state health dept FTEs dedicated to breastfeeding
     Source:  Personal communication with State WIC Breastfeeding Coordinators and other state employees in each state
   • State legislation about breastfeeding
     • Breastfeeding in public places
     • Lactation and employment
       Sources:  National Conference of State Legislatures: Breastfeeding Laws, updated March 2010. Available at http://www.ncsl.org/programs/health/breast50
       Accessed 7/21/2010.
   • State breastfeeding coalitions
     • Presence of coalition Web site
       Source:  United States Breastfeeding Committee. State and Territory Breastfeeding Coalitions Directory. Available at www.usbreastfeeding.org/Coalitions/CoalitionsDirectory/tabid/74/Default.aspx
       Accessed 7/21/2010.

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