Post on 26-May-2015
transcript
RESEARCH AND PRACTICE
Hospital Practices and Women's Likelihood of Fulfilling TheirIntention to Exclusively BreastfeedEugene Declercq, PhD, Miriam H. Labbok, MD, MPH, Carol Sakata, PhD, MPH, and MaryAnn O'Hara. MD, MPH
Exclusive breastfeeding through at least the
first 6 months is the physiologically appropriate
approach to infant feeding,' Mixed or formula
feeding canics with it increased lisks of inleclion,
developmental probkims, mortality, and long-
ailments such as diabetes and cancers For
child." "' In support of the
evidence, the American Academy of Pediatrics,'^
American College of Obstetrics and Gynecol-
i.)gy, the American Public Health Association"
the World Heidth Organization," iuid many
other medical and heallli pfofes,sioiial organiza-
tions'"""'" recommend that infants consume only
mother's milk (exdusive breastfeeding) for at
least the first 6 months of life, followed by
continued breastfeeding with age-^propriate
nutrient ridi complementaiy foods. The
irvised US Healthy P{!ople 2010 national objec-
tives call for 17"/(i of new mothers to be
exclusively breastfeeding at 6 montlis.''
Nonetlieless. national statistics indicate that less
tlian 12'yu of mottier-baby pairs achieve this
goal."*
The "Ten Steps for the FYotection, Promo-
tion and Support of Breastfeeding"'" are the
centr-al part of the Baby-Friendly Hospital
initiative, along with adherence to the hitema-
tional Code of Marltelitig of Breast-Milk Substitule.'i
and subsequent World I leatth Orgaiiiy^Eion
resolutions."' 'Ihi'se pracücts have been
reported to support breastfeeding behaviors
iuid influence outc»mes,''''" t h o u ^ in some
cases ihcy have been subjecis of political dis-
[jutca,'' However, with the exception of a
I ecent Centere for Disease Control and
ñ-evendon stiidy*^" and sum«! data fi-orn
hos|jitals that have achieved "Baby-Friendly"
status, little is known about the prevalenœ of
these practices in haspitals acrass the United
States.
Grizzard et al.^' assessed Massachusetts hos-
pitals and noted tliat hos¡iil;ils witli high or
moderately liigb levels of implementation signif-
icantly differed fi'om hospitals with paitial
implementation vnth respect to pacifier usage
(F=.i)()2) and postpattiim breastfeeding
Objectives. We sought to assess whether breastfeeding-related bospital prac-tices reported by mothers were associated with achievement of tbeir intentionsto exclusively breastfeed.
Methods. We used data from Listening to Mothers II, a nationally represen-tative survey of 1573 mothers wbo bad given birtb in a hospital to a singleton in2005, Mothers were asked retrospectively about their breastfeeding intention,infant feeding at 1 week, and 7 bospital practices.
Results. Primíparas reported a substantial difference between tbeir intentionto exclusively breastfeed (70%) and tbis practice at 1 week (50%). They alsoreported bospitat practices that conflicted witb the Baby-Friendly Ten Steps,including supplementation (49%) and pacifier use (45%|. Primíparas wbo deliv-ered in hospitals that practiced 6 or 7 of tbe steps were 6 times more likely foracbieve their intention to exclusively breastfeed than were tbose in hospitals thatpracticed none or 1 of the steps. Mothers wbo reported supplemental feedings fortbeir infant were less likely to acbieve tbeir intention to exclusively breastfeed.primíparas (adjusted odds ratio [A0R]=4.4; 95% confidence interval |CI1 = 2.1,9.3); multiparas (AOR = 8.8; 95% CU4.4, 17.6).
Conclusions. Hospitals should implement policies that support breastfeedrtigwitb particular attention to eliminating supplementation of heallby newborns.{Atn J Public Health. 2009;99:929-936. doi:10.2105/AJPH.2008.135236)
instRiction (/'< .001 ). Acceptance of fi-ee fomiula
was significantly assodatfîd (7^.03) with overall
Ten Steps implementation. Althougti several in-
ternational studies iiave eoneluded that even
some progress toward "Baby-Friendly Hospil^"
status is assodated with ino-eases in breastfeed-
ing, availaliie US data"" on the achievement of
exdusive breastfeeding in relation to the nuniber
of steps in place are limited.
The goal of our study was to provide dinica!
and hospital administi'ative dedsion-makers
with the infonnation they need to institute
policies and practices that enhance a woman's
ability to achieve her intended duration of
exclusive breastfeeding. We examined tbe re-
sults of a national survey tliat asked mothers
about their feeding intentions "as [they] came
to tbe end t)f ftheirl pregnancy" «md their actual
feeding patterns 1 week after tbe birth. We also
asked motliers to report on their experiences
with hospital practices kiiown to influence
breastfeeding success. Based on past research,
we expected that hospital pracUcc-s would be
related to tlie fulfillment of a plan to exclusively
breastfeed.
METHODS
We present rt"suft.s from a 2006 national
sui-vey of 1573 women aged 18 to 45 yeai-s
who had given birth in 2005 in a hospital to a
singleton, sdll-living infant. The survey, entitled
Listening to Mothers II,"" was devclo|.xd
thiougli a collalioration between Childbirtli
Connection iuid tlie Boston Univci'sity School of
I'ublic Heaitii and was conducted by Hanis
Interactive. The standard tclcpbone sam|)ling
approadi of random-digit dialing, though ad-
vaiitageous for reaching a divei-se population, is
not feasible for a national sui'vey of new motliers
becaii.se tlic number of US birtlis (4 million
annually) Ls small in proptJiüon to the number of
boiiseholcfs (IU million); tlierefore, respondents
were drawn fi om 2 oth(?i' sourcts.
Tbe Internet portion of tlie sample was
drawn from Hanis Interactive's ongoing Inter-
net panel of more tlian 5 million individuals
who agree to periodically pajtidpate in tlieir
surveys. To ensure a more representative
overall sample, a telephone sample was also
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
RESEARCH AND PRACTICE
limited to non-White mothei-s and were iden-
Liiied through tlie useofapropnetaiy list" tliat
contained telephone numbers and zip eodes of
motliers who had given hirth in 2005. House-
holds in ziji codfis willi lai ge non-White popu-
lations were called and respondents were
screened to eiisuR' nol only thai they met llie
original inclusion aiteria hut also that they were
non-Hispanic Black or Hispanie. The combined
survey resulLs wen' weighttid by 1 lanis with tlieir
validated "propensity sa)re" metliodology {G.
Terhanian et al., unpublished data, 2000; avail-
ahle from authors on request) to adjust for
|X)tentiiiJ biases associated witli online res|N)n-
dents. We applied population wei^ts to statisti-
cal analyses by using ciurently available options
m S I ^ version 15.0 (Sf'SS Inc, Chicago, IL).
Survey
Details on the survey metliodology are
available elsewhere.^"^ The survey sample se-
lection and consent process complied with the
codes and standards ol' the Council ol' American
Survey Reso^eh Oi^anizations and the code of
the National Council of Public Polls, Data were
(Xitiectpd and housed secur<!ly hy Harris Intnr-
active and the authors had acass only to a
deidentified file provided by Harris Interactive.
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-
tudes related to bittli; and demogi'aphic ehar-
aeteristies.^' AU phone and Internet interviews
were conducted between January 20 and Feb-
niaiy 21, 2006; no niotlier was askefl to recdl
experiences from morí* than 13 months earlier,
and for most mothers the recall time period was
much sootiei'. The average i-eK[>oiident had given
birtb 7.3 months before completing the survey
(online, 7.4 months; telephone, fi.4 montlis). Past
researdi has found tliat mothei-s are able to
validly recall estimates of breastfeeding initiation
and duration up to 3 years.""*
The resulting sample of mothers who had
given birth in 2005 was generally representa-
tive (within 1 to 3 percentajie points) of the
comparable national population of hiilhing
mothers—aged 18 to 45 years; singleton, hos-
pital births—based on the most recent US
tinta" ' available for comparison. A table sum-
marizing the compajTson was published in a
related article.^'' Survey respondents {»me from
all 50 states and the Distiid of Columbia In
tenus of age. nZ' 'ii of the study ¡xipulation and
52% of the comparable birthing population were
aged between 25 and 34 years. Non-Hispanic
Black mothers made up 12'I'd and I iisparuc
mothers 21% of the study sample, compaied with
14'Vi) and 23"''i). respectively, in the birthing
population. Finally, tlie breastfeeding ratis we
report are generally comparable to 2005 rates
repoited by the Centers ft)i" Disease Contnil
and IVeverition hasi-d on the National Immuni-
zation Survey. Althou^ the spedfic questions
were not the same, the overall rate of any
bi^eastfeetling at ;ill at 1 week iu oui" sample
{73"/()) matches tlie 73.1< /(i reported as any
breastfeeding at 7 days in the 2005 National
biununization Sur\'ey."^^
MeasurementsWe retrospectively asked motlitirs about
their infant feeding intention at the end of their
pregnancy, their feeding practices at 1 week
(summarized in Table I), their experience with
hospital stafî related to 7 specific practices
associated with exclusive breastfeeding (help-
ing mother get stalled breastfeeding, showing
mothers how to position baby, encouraging
feeding on demand, infomiing mothers about
community breastfeeding rtisoui'ces, supple-
menting breastfeeding with fonnula or water,
giving tbe baby a pacifier, providing free for-
mula samples to mothers), and a global ques-
tion about tiw. hrt^astfeeding support they re-
ceived from hospital staff. Where possible,
these items were taken directly from the Raby-
Friendly Hospital Initiative Ten Steps,''^ with
spedfic Baby-Friendly Hospital Initiative steps
conesponding to survey questions nottxl in 1 a-
hte 2. Mothers were given 3 [ios.sible ways to
dfscribe the pattern of feeding intended during
late pn'gnancy and practiced at 1 week: (1)
exclusive breasUetniing, (2) exclusive formula
feeding, or (3) mixed feeding. In a separate pml
of the questionnairi', we also asked the mother's if
tliey experienced "rooming in" and induded thai
vaiiable in the muitivariate analysis.
We tabulated these results with a particufar
foais on wheUier women who intended to
exdusively breastfeed at the end of pregnancy
had in fact established exdusive breastfeeding
1 week postpartum. We recognize tbat many
women make mfaiit feeding dedsions at an
earlier point in time and that many women who
establish breastfeeding continue beyond
1 week. We selected these time points to
examine the assodation between hospital
TABLE 1-lnfant Feeding Intentions Compared With Actual Practice at 1 Week Postpartum
Among US Mothers Who Gave Birth in 2005, hy Parity: Listening to Mothers II Survey
Feeding Practice'' at 1 Week Postpartum
Primiparas
Exclusive breastfeeding
Mixed (breastfeeding and formula)
Exclusive formula
Total
Multiparâs
Exclusive breastfeeding
Mixed (breastfeeding aid formula)
Exclusive fomiiiia
Total
Exclusive
Breastfeeding, %
4420
6
70
17
7
3
57
Feeding Intention
Mixed (Breastfeeding
and Formula), %
48
416
5
U5
21
Exclusive
Formula, %
1
01314
1
12122
Total,' %
50
28
22
100
53
18
29100
Note. For primiparas, n '519. For multíparas, n-1052.
*Women were asked, "As you came to tfie end of your pregnancy, bow liad you fioped to feed your baby? Options:
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
only, a combination of breastfeeding and formula,"
" Totals are rounded.
930 I Research and Practice | Peer Reviewed | Declercq et al. American Joumal of Public Health 1 fulay 2009, Vol 99 , No, 5
RESEARCH AND PRACTICE
TABLE 2-Hospital Practices Reported by US Mothers Who Gave Birth in 2005 and Who
intended to Exclusiveiy Breastfeed, by Parity: Listening to Mothers II Survey
Hospital Practice (6FHI Step' Primiparas, % Multipafas, % All, %
On ttie whole would you say Ihe staff, (BFHI 3)
Encouraged breastfeeding
Encouraged formula feeding
Expressed no preference
Other hospital practices
Helped you get started breastfeeding when you and your
baby were ready (BFH! 4) '
Gave you free formula samples or offers"
Showed you how to position your baby to limit nipple soreness (BRil
Encouraged you to feed "on demand" (BFHI 8) '
Told you about community breastfeeding support resoun:es for
ongoing help (BFHI 10)'
Provided formula or water to supplement your breastmilk (BFHI 6)"
Gave your baby a pacifier (BFHI 9 f
815
15
731
26
762
22
89 70 77
7478
80
69
49
45
6159
75
64
29
40
6566
77
65
37
42
Note. BFHI-Baby-Friendly Hospital Initiative. Data excludes mothers with babies ir the neonatal intensive care unit. Forprimíparas, n-338. For multíparas, n' '577. For the total sample, N = 915.^Most closely related BFHI step noted in parentheses. The 10 steps are available at: http://www.ünicef,org/nutntion/index_24806,html.'Violates Ititernational Cotie of Marketing Breast-Milk Substitutes.^
practices and initial fulfillment of intention toexclusively breastfeed. Past research has foundwide variations in exclusive breastfeeding byparity.^^'^^ so we stratified all analyses to dis-tinguish primiparas from multíparas. Because ourintention was to examine the typical pos^artumhospital experienœ for mothers, we limitedanalyses to those cases where the infant was notin the intensive care unit, resulting in the toss of6% (100) ofthe respondents (Table 2, Table 3,and Figure 1).
Analyses
We conducted data analyses with SPSS ver-sion 15.0 (SPSS Inc, Chicago, IL). We per-formed multiple logistic regression methods toexamine the association between ñüfillment ofintention to exclusively breastfeed, varioushospital practices, and related demographicvariables for each parity stratum.
RESULTS
Table 1 compares intended and 1-week ratesof feeding types, by parity. Mothers' repoi-ts offulfilling their feeding intention (exclusivebreastfeeding, exclusive formula, or mixed)
differed by parity, with 65% of primiparas and79''/ii of multiparas feeding the baby at 1 weekin the way they had intended at the end ofpregnancy. The largest group were thosemothers who intended to, and at 1 week were.exclusively breastfeeding their babies. Mostwho did not achieve their intention to exclu-sively breastfeed (2O"/o of piimipaious women;7% of multiparous women) practiced mixedfeeding. There were some respondents (4' /i) ofprimiparas and 5"/o of multiparas) who hadintended to use mixed feeding but were ex-clusively breastfeeding at 1 week.
Overall, 61"/(! of respondents indicated thatthey had intended to exclusively breastfeed,and about half of the mothei-s (51%) wereexclusively breastfeeding at 1 week. Whenthese findings were stratified by parity anddemographic characteiistics of mothers, wefound substantial variance across groups(data not shown). TTiose most likely to intendto and aclually exclusively breastfeed at I weekwere mothers who were non-Hispanic White,better educated, had higher incomes, had pri-vate insurance, or were employed pmt-time.When we stratified the results by parity, wefound that first-time mothei-s with the largest
discrepancy between intent and exclusivebreastfeeding to be those mothers with areported income of $25000 to $49999 (78%intention vs 49"/o actual exclusive breastfeed-ing at 1 week), Hispanic mothers (59% vs 32"Vo,respectively), non-Hispanic Black mothers(59% vs 33'y(i, respectively), or mothersemployed part-time (78'Vo vs 51'ya, respec-tively). Among multiparas the same generalpatterns emerged, though the difîei-ence be-tween intent and actual exclusive breastfeedingwas mudi smaller.
We also examined the bivariatc relationshipbetween intrapartuni experiences and fulfill-ment of intention to exclusively breastfeed(data not showi). Among primiparas, factorsthat were related in bivaiiatc analysis toachievement of intent to exclusively breastfeedincluded having an obstetrician (rather than afamily doctor or midwife) as the ¡jrenaLal careprovider and not having a cesarean delivery.Among multipaius. there were more factorsrelated to achievement of intention to exclu-sively breastfeed, including not having an epi-dural or a cesarean delivery, having the baby incontact witli the mother immediately afterbirth, rooming in with the baby, and a post-partum length of stay of 2 days or less. TTiesevariables were included in the multivariateanalysis.
Table 2 presents responses concerning hos-pital practices related to breastfeeding frommothers who intended to exclusiveiy bi'east-feed and whose babies were not in tlic neonatalintensive care unit. Responses are sti atified byparity. More than four fifths of priniipai-as(81"/ü) who intended to exclusively breastfeedindicated that the staff encouraged breastfeed-ing. In terms of specific hospital practices,primiparas reported that in some cases staffwere highly supportive in providing help get-ting started (89%), encouraging breastfeedingon demand (8O'fo). and showing how to posi-tion the baby (78'Wi). However, almost half{49%) of those first-time mothers who intendedto exclusively breastfeed reported that theirbaby was given water or formula for supple-mentation, 45% reported that their baby hadbeen given a pacifier, and 74% of thoseintending to exclusively breastfeed reportt dbeing given free formula samples or ofTei-s. Onthe whole, the pattern for multiparas involvedless 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
RESEARCH AND PRACTICE
TABLE 3-Percentage of US Mothers Who Gave Birth in 2005 Who Intended to Exclusively
Breastfeed and Were Exclusively Breastfeeding at 1 Week, by Parity and Reported Hospital
Practices: Listening to Mothers il Survey
Primíparas Multíparas
Mother Mother Did
Experienced Not Experience
Practice, Practice,
% (No.) % (No.)
Mother Mother Did
Experienced Not Experience
Practice. Practice.
% (No.) % (No.)
Hospital practice
Helped yoL gel started hreastfeeding when
you and your baby were ready
Gave you free formula samples or offers
Showed yoj how to position your hshy to
limit nipple soreness
Encouraged you to feed "on demand"
Told you about community breastfeeding
support resources for ongoing help
Provided fomuia or water to supplement
your breastmilk
Gave your baby a pacifier
Hospital staff attitude
Hospital staff encouraged breastfeeding
Hospital staff encouraged formula
Hospital staff expressed no preference
69 (301) 33 (36) <.O01" 83 (403) 82 (173) ,691
61 (249)69 (263)
69 (271)
73 (231)
74 (90)49 (75)
50 (66)
48 (106)
.002
.002
.004
<.0Ol
7782
87
84
(349)(339)
(432)
(367)
92 (228)83 (238)
70 (144)
81 (210)
<.OO1.883
<,001
.334
49(166) 81(172) <,001 56(169) 94(407) <.O01
57 (152) 71 (186)
67
40
60
.009
,071
82 (228) 83 (349)
85
78
.640
.115
Note. Data eKcluöes motfiers witfi babies in the neonatai intensive care unit.
''P values reflect x^ test on comparisons of within parity group breastfeeding rate at 1 week across hospital practices.
clifîerent hospital practices. An analysis of tJicscpractices by racc/cthnicity (data not shown)loiind that non-Hi.spaiiic White primiparasintending lo exclusively breastfeed were muchless likely to report supplementation wilh wateror formula (40"'o) than were non-HispanicBlack (71%) or Hispanic (74"/ii) mothers withthis intention.
Table 3 presents data on Ehe percentages ofmothers who Ililhlled llieir intention to exclu-sively breastfeed. In this table, the columnsrepresent different levels of painty and whetherthe mother reported that the hospital engagedin a paiiiailar practice. For example, (i9'Vi) ofthe mothers who intended to exclusivelybi'eastfeed and repoited iliat hospital staffhelped them get stalled hreastCeeding wereexclusively breastfeeding at 1 week. This find-ing can be compai ed with 33"/o of piiniiparasfulfilling their intention to exclusively breast-feed at 1 week in hospitals where they reportedthat they did not get help in starting to
breastfeed. .-Vmong primiparas there was asignificant difference in the rate of achievingtheir intention by whether a hospital engagedin each ofthe practices, partiailariy supple-mentation, with slightly less than half (49"''o)achieving their intention to exclusively breast-feed compared with 81"/n in cases where therewas no supplementation.
The differences for multiparas were gener-ally less pronounced, with the exception ofsupplementation: 94% of the mothers who didnot report supplementation occuning achievedtheir intention to exclusively breastfeed, com-pared with 56%) where supplementation wasreported. The provision of formula samples orcoupons'"' was associated with a significantrcHiuction in achievement of intention to exclu-sively breastfeed for both primiparas and mul-tiparas.
We examined whether there was a dose-response relationship between the number ofsupportive practices mothers reported that
hospitals engaged in and the achievement ofexclusive breastfeeding, f-igure 1 displays astrong cumulative effect of these polides forboth parity groups. Primiparas who reportedexperiencing at least 6 of the 7 practices were 6times more likely (86% vs 14%) to fulfill theirintention to exclusively breastfeed thanmothers experiencing 1 or none of these prac-tices, Multiparous mothers in the same com-parison were more than twice as likely (93'Vi) vs45"/o),
Finally we examined what factors weremost strongly related to achievemeni of ex-clusive breastfeeding intention in a multi-variate analysis. Because of the substantialdifferences consistently noted for parity, weran separate models for primiparEis andmultiparas. Consistent with our focus on therelationship between hospital practices andachievement of intention to exclusivelybreastfeed, we included the 7 hospital prac-tices as well as key intrapartum variables(prenatal care provider, epidural use, methodof delivery, rooming in, where the habywas in the first hours after birth, and post-partum length of stay), and demographicvariables (age, education, income, race/eth-nicity, employment status, and third-partypayer source) associated with feedingchoices.
When we controlled for all the other noteddemographic and intrapartum variables,among pnmiparas. only 4 hospital practiceswere statistically significantly assocjated witlithe likelihood of achieving hreastfeeding in-tention; (1) helping mothers get started (ad-justed odd.s ratio [AORl—6.3; 95"/() confidenceinterval [a] = 1.8, 21,6). (2) hospital staff notsupplementing with formula or water(AOR = 4.4; 95% Cl = 2.1, 9.3). (3) tellingmothers about community resources forbreastfeeding support (AOR=2,3; 95%CI = 1.1, 4.9), and (4) staff not giving the baby apadñer(AOR = 2.3; 95"/.iCI = 1.2, 4.4). Amongmultiparas, 2 hospital practices significantlyimpacted fulfillment of intention; hospital staffnot supplementing (A0R=a.8; 95% CI=4,4,17.6) and hospital staff encouraging feeding ondemand (AOR=3.4; 95% CI=1.7, 6.8). Noneof the demographic or intrapartum eventsremained significantly related to iiilfillment ofintended exclusive breastfeeding duration inthese models.
932 [ Research ancf Practice | Peer Reviewed Declercq et al. American Joumal of Public Health I May 2009, Vol 99, No. 5
RESEARCH AND PRACTICE
2-3 fl-5 6-7
Number of the 7 Policies Mothers Reponed Hoîpiials Practicing
iVoíes. Hospital practices: (1) staff fielped mother get stafted breastfeeding, (3) staff showed mother how to position baby,{3) staff encouraged feeding on demand, (4) staff directed motbers to community breastfeeding resources, (5) staff did notencourage supplementing breastfeeding with formula or water, (6) staff did not encourage pacifier use. (7) staff did not giveout free formula or offers. Differences in fulfillment are statistically significant across numbers of policies (P<,01),
FIGURE 1-Hospital support and breastfeeding success among US mothers who gave birth in
2005: Listening to iVIothers ii Survey.
DISCUSSION
We itkîiitihed several hospital practices, asreported by mothers, that were strongiy relatedto rates of exclusive breastfeeding. We used aiarge. representative national sample to focuson a cridcai time in estabiishing exciusivebreastfeeding and examined how hospitalpractices were positiveiy and negativeiy asso-ciated with the likeiihood that a mother whointended to exclusively breastfeed her infantwas actuaiiy doing so 1 week after birth. Wealso doaimented hospitai practices from aunique pei'speilive—that of niothei-s—ratherthan stated policies or rcpoils nom hospitalstíüT. In this way, our study can serve as acomplement to a recent Centers for DiseaseConti'oi and Prevention survey of hospitaipractices and policies reiated to breastfeedingas reported by hospital staff at the fadiitylevei.^"
We found a substantiai difference betweenprimipai-as' intention to exclusively breastfeed(7O"/o) and their actual rate of exclusivebreastfeeding 1 weei< after birth (50"/ii). Theseshifts between intention and practice representa huge lost opportunity to encourage ajid
support breastfeeding in the United States.Applying these differences to national dataresults in a totai of more than 400000 infantsannually (10% of all US births) whose mothersintended lo exclusiveiy breastfeed as theycompleted their pregnancies but were not do-ing so 1 week after birth.
Experiencing hospital practices that inhibitexclusive breastfeeding (i.e., staff supplement-ing breastfeeding with formula or water, beinggiven free fomiula samjjies, babies given pac-ifiers) was significantly assodated with mothers'failure to fuifill their intendon to exdusivelybreastfeed, in cases where mothers reported acomprehensive pacicage of supportive prac-tices, primiparas were 6 times more iikely andmultiparas twice as iikely to achieve theirintention to exclusively breastfeed.
The practice of hospital staff providing for-mula or water to supplement breastfeeding wassigiiificantiy related to failure to achieve ex-dusive breastfeeding. Mothers whose babiesdid not experience supplementation were 4.4dmes {primíparas) or 8.8 dmes (muldparas)more iikely to achieve their intention to exclu-sively breastfeed. ITie Worid Health Organi-zadon 1998 compendium. Evidence for (he Ten
Steps to Successful Breastfeeding, confirms thatthere is substandal evidence beiiind Step 6,"Give newborn infants no food or drink otherthan breastmiik, unless medically indicated,"repoiting that the feiding of supplements dis-rupted breastfeeding,'" a condusion supportedby studies from Honduras and italy.'"' '
Comparison With Other StudiesFew studies have examined hospital prac-
tices as predictors of success at (exclusivebreastfeeding."" '" A recent shidy of Coloradomothers' descripdons of hijspitai pracdces andtheir inlant feeding exix'riences found a signifi-cant relation between hospital pracdces unsup-pordve of breastfeeding and discontinuation ofbreastfeeding at 8 weei«. The study also found,as we did, a aimuladve effect of hospital prac-dces, but did not .sti-atify mothers by ¡jaiity- orperform a muttivariate analysis on their resuits."'These studies, which invoived different method-ologies and were done in different settings,reinforce Hie need for hospital practices sup-porting inidadon ajid later suca^ssful continua-tion of exdusive breastfeeding.
LimitationsOur study was based on a US nadonal
sample drawn from a combinadon of internetand teiephone respondents. Internet-basedsamples ai-e increasingly being used in publicopinion research,'' and our data weœ .supple-mented with a telephone survey of non-White,English-speaking mothers. The aimbined samplewas weighted to adjust for the nadonal úv.ma-graphic dLstribudon of tlie childbeamig ¡jopiila-don and the propensity to be online. The result isa sample that is generally representadve of theUS birthing populadon and US breastfeiKlingrates. Althou^ the resiiits mirror the demo-graphic chai acterisdcs of tlie US birthing popu-ladon, we cannot be ceiiain that our respondentswere representadve of ali hospital and breast-feeding experiences of birtliing women in theUnited States. However, there were no indica-tions suggesdJig a likelihood of bias in the results.
Our study relied on mothers' recall and wasnot validated by recoids review. Past researdihas shown that mothers are generally accuratein their reports of their own birth experi-ences.''^ Nonetheie.ss, it is possible that somerespondents could have based their rétrospectiveresponse 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
RESEARCH AND PRACTICE
bit'astfcetiing experience. To pR)tec1 againstUlis possibility, tlie survey was stnictui-ed to beneutral and nonjudgmental about feetling choice.It is also fx)ssib!e that motliei-s who stoppedbreastfeeding chose to "blanu!" hospital practicesfor theii- decision. To minimize this possibleefFect, we asked the question on breastfeeding at1 wec'k after the questions on haspital practice.Also the comparable national data most oftenusetl in reporting breastfeeding trends, the Na-tional Immunization Survey, as well as data fromRoss Laboratories Mothers Surveys'''"' relied onmatemal recall."*" and a study of maternal recallof bi'eastfeeding experiences Ibiuid motheiï' i"e-sponses both valid and reliable.'"''
ConclusionsBreastfeeding protection, promotion, and
suppoil may rely on identifying and using"teachable moments"' to increase motheiV in-tention to achieve exclusive breastfeeding, andthese findings present opportunities and raisequestions in 2 ai eas. First, should we bepleased or disappointed that 7O"/o of first-timeand 57''^ of experienced mothers had theintention late in their pregnancy to exdusivelybreastfeed? We need to consider why almosthalf of thf nuiltiparoiis mothofs in 2005ix'poited no intention to exdusively breast-feed their baby. Clearly some efïbris areneeded to promote a gi"eater interest in exclu-sive breastfeeding among all mothers, particu-larly among those who have given birth beforeand may have had adverse experiences. Im-proving in-hospital breastfeeding support forfirst-time mothers may have the added benefitof promoting exdusive breastfeeding in subse-quent diildren.
Second, why are those hospital practices thathave been repeatedly shown to increasebreastfeeding among new mothers not moreconsistently instituted in Uniled States hospi-tals? A large proportion of mothers stop ex-dusive breastfeeding within the first week, andthat action was strongly related to hospitalpractices. As policy statements from theAmerican Public Health Assodation and otherleading oi ganizations declare, these practicesmust be changed at the hospital and profes-sional levels to ensure that the hospitaJ expe-rience more consistently contributes to tliehealth and welfare of mothers and babies.implementatioÈi of the updated Baby-Friendly
Hospital Initiative will contribute to increasingthe proportion of mothers who are given tliesupport tliey need to fulfill their intention toexclusively breastfeed. •
About the Authors.-^t the time oftkestudi/. Eugene Declercq tvas With School ofPublic Health, Boston Uniivi'siti/. \fA. Miriam H. Lohhcikwas with the School of Public Hetillh, Universitif of NorthCarolina. Chapel Hill. Carol Sakala was with ChildbirthCannectinns, .Veit' York. iVV. Mary.Ann O'Hara wtii with theUniversittf of Washington. Seattle.
Requests for reprints can be sent to Eugene Declercq.Department of Matermd ami Child Health. Boston Uni-verstty School of Puhlic Heohh. 71 ñ .Mhany St, TalhotW5-40. ihston. .MA 021 IS (e-mail: declercq@bu.edu).
Tliis article was accepted October 7. 2008.
ContributorsE. Dedercq designed the sttidy, wrote the first draft of(he "Methotis" mid "Rcsulls" sections, and did the dataanalysis. M. H. I.abbok, M. O'Hara. and C. Sakala did Üicliterature review and wrote the first draft of the Intro-duction and "Discussion" sections. C. Sakala and E.Declercq were iTivolved in the design of the tinestion-nairc thai wai Ihc basis tor the siin'cy. All autliors wereinvolved in writing subsequent drafts.
AcknowledgmentsThis research was .suppoited by the Roheit WoodJohnson I'oiiiidation and Childhirth Connection.
KobJn Young assisted witJi tlie data analysis.
Human Participant ProtectionThis study was ruled exempt by the institutional reviewboard office of the Bost[>n University School of Medidjiebecaii.se autliors only had access to a rieidentified file.Original data are securely stored al Harris Interactive.
References1. Kraniei" M.S. Kakiinia R. Tlie ojitinial duiation ofexclusive breastfeeding: a systematic review. Adv HxjiMei/flio/.2O04;554:63-77.
2. l|» S, CliiLiig M. Raman G, ct al., for Agenc>' forHealthcare Research and Quality. Evidence Report/Tech-nologii A.'isessment Number 153: Brea^feeding and Ma-tenial and Infant Health Otilcomes in Developed Countnes.Hockville. MD; Agency for Healthcare Research anciQuality; 2007.
3. Jones G, Sleketee RW. Black RE, Bhutta ZA.Morris SS; Bellagio Child Survival Study Croup Howmany child deaths can we prevent this year? Lancet.2003;362:fi5-71.
4. Horta B, Bahl R. Martines J. Victora C. Evidence onthe Long-Term Effects of Breastfeeding: Sptematic Reviewsund Meta-Analyses. Geneva. Switzerland; World HealthOrganization; 20t)7.
5. Labbok MH. Hffects oi' breastfeeding on the mothei\Pediatr Clin North Am.
ti. Gartner LM. Morton J. LawTence R.'\, et al Breast-fording and the use of human milk. Pediatrics. 2005;
7. ACQG Committee for Healthcare of underservedWomen and Committee on Ohsletriral huctices. Spedalreport from ACOG. Breastfeedingniatenial and infantaspects. Clin Rev. 2OO7;I2(1 suppi):lS-16S.
8. .-M'HA Potic>- Statement 200114. APHA Supportsthe Health ancl Human Services BliiepnnI for Action onBreastfeeding, Washington, IX; American l*ublic liedtti/XssocJation; 200! . Available at: http://www.apha.org/ad vocacy / pol i cj' /pol icy seareh /default.htin?id=253.Accessed Tebruary 20, 2009.
9. WHO-VNICEF Global Strategy for Infant and YoungChild Feeding. Geneva, Switzerland: Worid HeaitiiOrganization; 2003.
10. Moreland J, Coombs J. Promoting and .supportingbreast feeiling. .Am Fam Ptn/sidan. 20i)0;(il :2093-2100.2103-2104.
11. Mission statement. New Rochelle, fY; Academy ofBreastfeeding Medieinc; 2006. Available at; http;//ww\\:bfmed.oi-g, Accessed November 7. 2006,
12 Hasition statement; breastfeeding. Silver Spring. MD.American College of Nurse Midwives; 2004. Availableat: http://www.anim.org/siU;I''iles/p<)sition/Brf-astfeeding_05,|Kff. Accessed Decembei- 29. 2008.
Î 3, Centers for I)isea.se Control aiid tYevention,DATA2010 riTie Heal% People 2010 databa.se May2008 etlition foais area: 16-mateiTial infant and chikihealth]. Available at: http;//wonder,cdcgov/data20IO/objhtm. Accessed June 17. 2008.
14. Centers for Disease Control and Prevention.Breastfeeding among US children horn 1999-200S,CDC National InimunizatiiJii Survey. Available at; http;//www. ccic.gov/l)rea<itieeding/data/NlS_ciata/index.litm.Acct^sed October 2, 2008.
1 5. World Heaith Organization. Linited NationsChildren's Fund. Protecting. Promoting and SupporungBreastfeeding: The Special Hole of Materniti/ ServiceyGeneva, Switzerland: World Health Organisation;1990.
16. International Code of Marketing of Hrvast-Milk Sub-stitutes. Geneva, Switzerland: World Health Organiza-tion; 1981. Available at; http://www.who.iiit/nutiition/pubiicat ions/code_english.pdf Acees.se(i June 17, 2008.
17. Work! 1 lííalth Organization, Uniled Nations Chil-dren's Tumi. BFHl; RevLsecl and ujxiated materials,2006. .Available at: http;//www.unicef.org/nutrition/inde,\_2 48 5tl.html. Accessed June 17, 2008.
18. Kramer MS, Chalmers B. llotinen HD, et al. IVo-niotion of Breastfeeding Intervention Trial (PRQBIT): arandomized trial in the Repuhlic of Btrianis. JAMA.2001;285:413-420,
!9. Smith S. Romney ousts ') at health aiunril: goneare backers of a ban on infant formula giveaways.Boston Clobe. May 20, 2006. Available at; http;//w ww.boston .com/yourlife/health/other/a!iicl«/200(i/OS/20/roniney_oiisLs_3_at_heallli_,(;ounciL AccessedJune 17.2008.
20. Centers for Disease Control and hevcntion.Breastfeed ing-relateci maternity jiractices at hospitals aiuibiilh centers-United States, 2007. MMWR Morb MortaliniyRep. 2008;57;62I-625.
21. Grizzai-d TA. Bartick M, Nikolov M. Griffin BA, l.e<'KG. Policies and practices related to breastfeeding inMassachusetts; hospital implementation of the ten stepsto successful hi-eastfeeding. Mtueni Child Health J.200(i;10;247-2(i3.
934 Research and Practice Peer Reviewed ' Declercq et al. American Journai of Public Health | May 2009, Vol 99, No. 5
RESEARCH AND PRACTICE
1Í2. IJcdenT[ l-.R. Sakala C, Corry ME', Applcbauni S.Listening to Mothers 11: lîpporl of Iho Secoiid NationalU.S. Survey of Women's Childbcaring Kxpe rien ces. NewVnrk, NY: Childbirth Connection; 2006.
23. Survey Sampling Ititematíonat - SSI-I.ITP. Newbornbaby samples.
24. Li H, Sranlon KS, Serdiila MK. The validity aiirircliabilily of maternal recall of breastfeedtTig prartice..XiitrRev. 2005;63:103-110,
25. MaJ-tin JA, 1 Uiniillon BI', Sutn>n PD, ct al. Birtb.s; finaldala for 2(X)5. \'atl Vital Stat Rej). 2()()7;íiíi;l-103,
26. IXflLTc-q [-.. Cunniiigliam DK. Jobnson C, Sakala C.Motfifi-s' rp)M)rLs of postpartum pain aisociatctJ wiüivaginai and ci'sarran deliveries: resulls of a nationalsurvey, Birth. 2008;35:lfi-24.
27. Centers for Disease Control iunl Prevention.Breasl feeding practices—resulLs from Üie 20(15 NationalImmtinization Survey. Available at: bltp://ww\v.c(lc.gov/breastfceding/dala/NIS_(lala/iiidnx.hlm. Arrcsserl Oc-tober 2. 200B,
28. DiGirolamo AM, Tbompsnn N, Martorell R, Fein S.d n I m mer-Strain LM. Intentiun or ex{)erienee? fredic-iiirs (if coiiüniied bi-eastfeeding. Health Educ Behav.2 005 ;3 2:208-226.
29. Rosenberg KD, Eastbam CA. Kasebagen I.J.Sandnval Al'. Marketing infant funniila tlirougb hospitals:the impad of commercial hospital discharge packs onbrrastfeciiiilji. Am/ Public Hi-alth
30. Evidence for the Ten Stefjs to Siicces.'iful Brea.'itfeeding.
lVHn/CHIJ^98.9. Geneva. Swil/erlaml: World I k-allbOi-ganization; 1998.
,tl. Pèrez-Escamilla R, Segura-Millán S, Canabiiati J,Allen H. PnilacteaJ feeds are negatively associated withbreast-feeding oiitconics ii\ I lonciuras. / j'Viíír, 1 996;126:2765-2773.
32. Giíjvannini M. Riva K. Baiiderali G, el al. E.«Lclusiveverstrs pi'etiominant brea.stferoding in Italian maternitywards and feediTig ¡it aiticí-s ihrougii ibe first year of life.¡Hum ¡MCt. 2OO5;21:259-265.
33. Anderson AK. Damin G, Oiapman DJ. Peivz-HscamillaR, Differential resiKinse to an exclusive breastfeeding|N'w connsciing intei-ventiim: ihe role of clhnicity. / Hum¿flrt. 2007:23: lR-23.
34. Boimck KA, Trombley M, l-reem!in K, McKee D.Handomi/ed, controlled Irial oi a prenalal ¡aid postnatallaclation consiillan! incen^enlion (in duration and inten-sity of broastlceding up to 1 2 montlts. Pediatrics.2005;! l(i:1413-142fi.
35. Coiitinho SB. de Lira i'l, dc ('arvallio Lima M,Ashwortb A. Comparison of tfie effect ol' two systemsfor tile pnjmiiti(»n of t-xcUisive breastfeeding. Lancet.2005:366:1094-1100.
36. Murray KK, RirkettsS. DellaportJ. Hiwpi(a! practicesIhal increase breiLstfe€'ding duration: results h'om a pop-iilation-basiHl study. Hirth. 2007:34:202-21 1-
37. Couper M. W'eb surveys: a iTview of issues andapproaches. l>ublic Opin Q. 2000;64:4fi4~494.
3y. Yawn BP. Suman VJ, Jarabsen S). Maternal recall ofdi.'itaiit pregnancy events. / Clin Epidemiol 1 998;51:399-405.
39, Ryan .'\S. IVatl WT, WysongJL, I.ewaiidowski G,McNallyJW. Krieger FW. .\ companson of breasl-feedingilata from tJie National Surveys of Family Growtb and tbe
Ross Laixiratories Motbers Surveys, AmJ Public Heallh.199!;81;1O49-1O52.
40. Ryan M , Zliou W, Gaslon MH. Regional andsociodemograpbic variation oi'breastii-eciing in the Unit«)States, 2002. Clin PH/W/T fñiiH 2004,43:815-824,
Preventing OccupationalDisease and Injury,Edited by Barry S. Levy, Gregory R. Wagner, Kathleen M. Rest, lames L Weeks
"... unique in occupational health literature... an invaluable yethandy reference../' Medscapc nniay, Augt,st u. 2005
Most hazards can be anticipated, and prevented. However, each yearin the United States, 5,000 to 6,000 workers die from acute traumatic(Kcupational injuries.
This hook, thoroughly updated from its first edition puhlishedin 1991, provides information to assist in anticipating the potentialtor disea.se or injury, recognizing occupational diseases and in-juries, evaluating relevant data, and designing and implementingcontrol measures.
ORDER TODAY!ISBN 0-87553-043-5590 pages, softcover, 2004S25.00 APHA Members (plus s&h)S36.00 Nonfnembers (plus s&h)
American Public Health AssociationPUBLICATION SALESWEB: www.3pha,org E-MAIL: APHA@pbd,com
TEL: 888-320-APHA FAX: 888-361-APHA
May 2009, Vol 99, No. 5 | American Jojmal of Public Healtb Declercq et al. i Peer Reviewed | Research and Practice | 935