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Breastfeeding Report Card—United States, 2009

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.

Throughout your community, everyone plays a role in fostering breastfeeding. When health care professionals, legislators, employers, business owners, and community and family members work together, their efforts can increase the number of women who are able to start breastfeeding and the length of time they continue to breastfeed.

The 2009 Breastfeeding Report Card shows how breastfeeding is being protected, promoted, and supported in each state using five "outcome" and nine "process" indicators. This allows you to make comparisons across states and indicators and work to increase breastfeeding nationwide.

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

The nine process indicators measure elements of breastfeeding-friendly communities. Each indicator is measured in every state, allowing easy state-by-state comparisons. As measures of a state's ability to protect, promote, and support breastfeeding, the report card indicators show where a state has been successful and where more work is needed.

The Breastfeeding Report Card can help you:

  • Tell the story of breastfeeding practices in your state.
  • Monitor progress and celebrate state successes.
  • Identify opportunities for growth and improvement in breastfeeding protection, promotion, and support within your state.

Breastfeeding Report Card Indicators – 2009

Outcome Indicators

The five outcome indicators directly track the Healthy People 2010 breastfeeding objectives. Outcomes are estimated using data from the annual CDC National Immunization Survey (NIS).

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

Process Indicators

The nine process indicators measure five different types of breastfeeding support: birth facility support; professional support; mother-to-mother support; state legislation; and public infrastructure (public facilities and services).

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

Birth Facility Support

  • State mPINC score
  • Percent of live births occurring at facilities identified as part of the Baby-Friendly Hospital Initiative
  • Percent 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 Maternity Practices in Infant Nutrition and Care (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 United States 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

International Board Certified Lactation Consultants (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.

Mother-to-Mother Support

  • Number of La Leche League Groups per 1,000 live births

La Leche League is an organization of trained and accredited volunteer mothers who provide mother-to-mother support and help to pregnant women considering breastfeeding and mothers who are breastfeeding in group meetings, as well as online and via telephone. This kind of assistance is an important element of comprehensive breastfeeding support. The number of La Leche League groups per 1,000 live births provides a broad estimate of the availability of breastfeeding assistance in a given community.

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 websites

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 websites 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.

Distribution of Breastfeeding Legislation, by State and Legislation Type – 2009

Distribution of Breastfeeding Legislation, by State and Legislation Type – 2009. For data, see below.
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States with mandates for both employer lactation support and support for breastfeeding in public are: Arkansas, California, Colorado, Connecticut, District of Columbia, Illinois, Indiana, Maine, Minnesota, Montana, New Mexico, New York, Oregon, Tennessee, and Vermont.

States with mandates for support for breastfeeding in public are: Alabama, Alaska, Arizona, Delaware, Florida, Georgia, Hawaii, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Nevada, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

States that have mandates for neither employer lactation support nor support for breastfeeding in public are Idaho and Nebraska.

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
  2. Breastfeeding process indicators
    • Average mPINC Score
      Source: DiGirolamo AM, Manninen DL, Cohen JH, Shealy KR, Murphy PE, MacGowan CA, Sharma AJ, Scanlon KS, Grummer-Strawn LM, Dee DL. Breastfeeding-Related Maternity Practices at Hospitals and Birth Centers --- United States, 2007. MMWR Morbid Mortal Wkly Rep:7(23);621-625. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5723a1.htm
    • 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 57 no 12. Hyattsville, MD: National Center for Health Statistics. Released March 18, 2009. http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf [PDF-647k] Accessed 6/29/2009.
    • Percent of live births at facilities designated as Baby Friendly (BFHI)
      Source: Baby Friendly USA. Baby-Friendly Hospitals and Birth Centers as of May 2009. http://www.babyfriendlyusa.org/
      • Hospital annual birth census information: American Hospital Association Annual Survey Database for Fiscal Year 2007
      • Birth center annual birth census information: 2007 CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey
    • Number of IBCLCs per 1,000 live births
      Source: International Board of Lactation Consultant Examiners. IBCLC Facts and Figures as of June 2009 http://americas.iblce.org/factsandfigures.php#USstate
    • Number of La Leche League Groups per 1,000 live births
      Source: La Leche League in the USA list of groups by state as of July 2008. http://www.lllusa.org/groups.php
    • Number of state health dept FTEs dedicated to breastfeeding
      Source: Personal communications with state WIC Breastfeeding Coordinators and other state employees in each state.
    • State legislation about breastfeeding
    • State breastfeeding coalitions

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