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Breastfeeding Report Card—United States, 2011

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 ways that communities support mothers and babies to breastfeed, and everyone plays a role. The CDC Breastfeeding Report Card brings together state-by-state information to help tell the story of breastfeeding practices in states. It compiles many types of data so states can monitor progress, celebrate state successes, and identify opportunities to work with health professionals, legislators, employers, business owners, community advocates and family members to protect, promote, and support breastfeeding.

What's new this year?

The Breastfeeding Report Card, now in its 5th year, provides perspectives on state and national trends in breastfeeding data. Since the release of the first Report Card in 2007, there have been steady improvements in several indicators, especially in 3 month and 6 month exclusive breastfeeding rates, which increased more than 5 and 4 percentage points, respectively. Changes in state and national rates are not attributable to any one factor. A woman's ability to reach her breastfeeding goals is affected by a host of factors including support from her family, community, employer and health system.

In the U.S., more babies are being born in facilities that have made special efforts to support breastfeeding than ever before. However, less than 5% of U.S. infants are born in Baby-Friendly hospitals, a global designation that indicates best practices in maternity care to support breastfeeding mothers. The hospital period is critical for mothers and babies to learn to breastfeed, and hospitals need to do more to support them. Hospitals can participate in the Maternity Practices in Infant Nutrition and Care (mPINC) survey, and use their results to improve maternity care practices. Hospitals can also work together to share information and experiences on how to achieve the Baby-Friendly designation. State health departments are a valuable resource that can provide technical assistance to hospitals seeking the Baby-Friendly designation.

Child care providers play an important role in supporting employed, breastfeeding mothers. As an indicator of support for breastfeeding mothers, child care regulations first appeared on the report card in 2010. This year, state child care regulations related to breastfeeding have been classified to reflect the range of support in states based on the National Resource Center for Health and Safety in Child Care and Early Education best care standards. States that received optimal scores were those whose regulations fully comply with national standards regarding breastfeeding, including making arrangements for a mother to be able to feed her child on-site.

Through funding from the Communities Putting Prevention to Work initiative, several states and communities have expanded their activities, hired additional staff (FTEs) and engaged new partners. For example, funded states and communities have worked with hospitals to improve maternity care practices and have provided guidance to hospitals seeking Baby-Friendly designation. They have also worked with employers and child care providers to help employed women continue to breastfeed.

How can states use the Report Card to improve breastfeeding rates?

Mothers need support from the people and organizations they interact with to meet their breastfeeding goals. States can use this Report Card and previous year's Report Cards to track progress, identify the areas where mothers need more support, and work within their communities to better protect, promote and support breastfeeding mothers.

Healthy People 2020 Objective
MICH-21: Increase the proportion of infants who are breastfed
MICH-21.1Ever81.9%
MICH-21.2At 6 months60.6%
MICH-21.3At 1 year34.1%
MICH-21.4Exclusively through 3 months46.2%
MICH-21.5Exclusively through 6 months25.5%
MICH-22: Increase the proportion of employers that have worksite lactation support programs.38%
MICH-23: Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.14.2%
MICH-24: Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.8.1%

Percent of births at Baby-Friendly facilities in 2011, by state
Percent of Births at Baby-Friendly Hospitals, by State. For data, see Process Indicators below.
Data Sources: Baby-Friendly facilities : http://www.babyfriendlyusa.org/
Live Births: CDC NCHS 2009 Live Births by State

Breastfeeding rates from the U.S. National Immunization Survey

  • Ever Breastfed
  • Breastfeeding at 6 months
  • Breastfeeding at 12 months
  • Exclusive breastfeeding at 3 months
  • Exclusive breastfeeding at 6 months

This nationwide survey provides current national, state, and selected urban-area estimates of vaccination coverage rates for U.S. children ages 19 to 35 months. Since July 2001, breastfeeding questions have been asked on the NIS to assess the population's breastfeeding practices.

Breastfeeding Report Card Indicators – 2011

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 2020, 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 seven more indicators, measuring support from birth facilities, health professionals, public infrastructure (public facilities and services) and child care settings.
For more, see Breastfeeding Report Card, United States: Process Indicators.

Birth Facility Support

  • State Maternity Practices in Infant Nutrition and Care (mPINC) score
  • Percent of live births occurring at facilities designated as Baby-Friendly
  • 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.

Mother-to-Mother Support

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

La Leche League (LLLI) is an organization of trained and accredited volunteer mothers who provide support and help to pregnant and breastfeeding mothers through group meetings, online, via telephone and partnership efforts throughout their communities to help ensure support for breastfeeding mothers and babies. This kind of assistance is an important element of comprehensive breastfeeding support. The number of La Leche League Leaders per 1,000 live births provides a broad estimate of the availability of breastfeeding assistance in a given community.

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. Availability is measured by the ratio of IBCLCs to the number of live births.

Infrastructure

  • Number of state health department full-time equivalents (FTEs) responsible for breastfeeding

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.

Support in Child Care Settings

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

In the U.S., 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. State scores were obtained by using the average appropriate fluids rating (1A1) as determined by the National Resource Center for Health and Safety in Child Care and Early Education. Cut-off points (1- inappropriate; 2- not optimal; 3- less optimal; 4- optimal) were set. States whose regulations are less than optimal can improve breastfeeding support at child care facilities by meeting best-practice standards as set by the 3rd edition of 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
  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 2009. National vital statistics reports, Web release; vol 59 no 3. Hyattsville, MD: National Center for Health Statistics. Released Dsec 21, 2011. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_03.pdf [PDF-306k]. Accessed 6/1/2011.
      • Percentage of live births at facilities designated as Baby Friendly (BFHI)
        Source: Baby Friendly USA. Baby-Friendly Hospitals and Birth Centers as of June 2011. Available at http://www.babyfriendlyusa.org/
        • Hospital annual birth census information: American Hospital Association Annual Survey Database for Fiscal Year 2009.
        • Birth center annual birth census information: 2009 CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey and personal communication.
      • Number of La Leche League Leaders per 1,000 live births, June 2011.
        Source: Personal communication with State WIC Breastfeeding Coordinators and other state employees in each state.
      • State child care center regulation supports lactation.
        Source: National Resource Center for Health and Safety in Child Care and Early Education, University of Colorado Denver. 2011. National Resource Center for Health and Safety in Child Care and Early Education: Achieving a State of Healthy Weight: A National Assessment of Obesity Prevention Terminology in Child Care Regulations 2010. Aurora, CO.

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