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CDC Vital Signs: Hospital Practices to Support Breastfeeding – United States, 2007 and 2009

Tuesday, August 2, 2011 – 12:00pm ET

Operator: Welcome and thank you for standing by.  At this time, all participants are in a listen-only mode.  During the question-and-answer session today, you may press star 1 to ask a question.  Today's conference is being recorded, and tom skinner, you may begin, sir.

Tom Skinner: Thank you, Shirley, and thank you all for joining us today for this telebriefing on a Vital Signs report out from CDC today on hospital practices to support breastfeeding in the United States for the years 2007 and 2009.  Joining us today is the director of the CDC, Dr. Thomas Frieden, who will provide some opening remarks.  Then we'll move to Q&A, and we'd like to have Q&A involve one question and one follow-up. Also joining us for the Q&A is Dr. Cria Perrine, an epidemiologist in our division of nutrition, physical activity and obesity, and her name is spelled c-r-i-a p-e-r-r-i-n-e.  So with that, I’ll turn it over to Dr. Frieden.

Tom Frieden: Good afternoon, everybody. Welcome and thank you very much for joining us.  The information we're releasing today shows that although there has been some improvement in hospital practices to support mothers who want to breastfeed, we're still a very long way from where we need to be.  Hospitals need to greatly improve practices to support mothers who want to breastfeed.  If they don't, at current trends, it will take more than 100 years before every baby in this country is born in a hospital where the hospital fully supports a mother's desire to breastfeed. 

Breastfeeding is an important issue.  It has both health and economic benefits.  For the child, there is a lower risk of infections -- ear infections, lung infections, gastrointestinal infections.  There is a lower risk of sudden infant death syndrome, of diabetes and of obesity.  For the mother, there is a lower risk of breast cancer and ovarian cancer.  And for the health care system, the failure to ensure breastfeeding or promote breastfeeding costs us $2.2 billion every year in health care costs alone, not even including lost productivity and other costs.  We're a very long way from where we need to be.  Currently, only about one in six mothers, only 15% of mothers breastfeed exclusively for six months, and less than half of mothers, 44%, breastfeed at all for six months.  75% of women start breastfeeding in the hospital, but many barriers are presented that make it less likely that women who want to breastfeed will do so.  In fact, less than 1 out of 20 babies born in the U.S. in this year is born in a hospital that meets the baby-friendly guidelines of the world health organization and UNICEF.  Only about half of hospitals help mothers initiate breastfeeding within one hour of birth.  That's particularly important because it's associated with beginning and having a good experience and continuing with breastfeeding.  Only about one-third practice rooming in, where the baby and the mother stay together in the hospital.  And only about a quarter of hospitals in the U.S. work with groups in the community to support mothers to continue breastfeeding after hospital discharge.  In fact, an earlier study released a couple of years ago by CDC found that the more baby-friendly practices a hospital participated in, the more likely it is that women will continue to breastfeed.  In fact, women who were at hospitals which had most of the practices in place were more than ten times as likely to be breastfeeding at two months as hospitals which had none of the practices in place. 

So, these are very important steps that hospitals can take, and an increasing number of hospitals are taking these steps.  We've seen hospital systems and individual hospitals making very substantial progress.  The key steps for baby-friendly hospitals include helping mothers initiate breastfeeding within an hour of birth, giving newborn infants no food or drink other than breast milk unless medically indicated.  Unfortunately, only about 22% of hospitals do that.  Another is to practice rooming in, and as I mentioned, it's only about a third of hospitals that do that.  Another is to foster the establishment of breastfeeding support groups.  And again, only about a quarter, 27% do that.  And table 1 in the MMWR outlines where we were in 2009.  And you can see that although there was progress, the progress was really quite slow, and only 14% of U.S. hospitals have comprehensive policies that support breastfeeding.  Baby-friendly hospital practices work.  They greatly increase the likelihood that women who want to breastfeed will breastfeed, that they will be breastfeeding in the hospital, at discharge, and months later, and the benefits of doing so for both the mother and the child are quite substantial.

 So, an important issue for both health and medical costs.  If we don't accelerate the current slow improvement in practices, most of the next few generations of kids in this country will be born in hospitals that don't effectively support women who want to breastfeed.  We're encouraged by the many hospitals that have made progress, and we look forward to accelerating progress in the future, and we hope that this report and your coverage of this issue will encourage an acceleration of that trend.  So, thank you very much, and we can open for questions. 

Tom Skinner: Shirley, I believe we're ready for questions, please. 

Operator: Thank you.  We will now begin the question-and-answer session.  If you would like to ask a question, please press star 1 and record your name clearly.  Again, press star 1 to ask a question.  And one moment for our first question.  Our first question comes from David Beasley with Reuters News Service.  You may ask your question.

David Beasley: Yes, can you talk a little bit about what makes breast milk so healthy?  Is it the low fat content or just the built-in immunities that it provides, or all of the above? 

Tom Frieden: Breast milk does many things.  It is the perfect nutrition for an infant.  The initial breast milk has very important antibodies that are passed to the child.  The child can't make their own antibodies until they're about 6 months old, so breast milk is really the only way to give them the antibodies.  And even when we give vaccinations, it doesn't have the effect against all of the bacteria and viruses that we want to protect against.  I’ll ask Dr. Perrine to speak further on it.

Cria Perrine: All of those things are true.  Its antibodies.  It also has different hormones that we know are involved in appetite and energy balance, as well as varying protein content from formula.  And really, it's just the optimal nutrition for infants starting at birth. 

David Beasley: Is it also lower fat than formula?  I’m speaking about obesity in particular right there on that issue. 

Tom Frieden:  The issue of breastfeeding and obesity is complex, but two different studies of many studies have found that children who were breastfed had a lower likelihood of being obese at various ages compared to those who were formula-fed.  And children who were breastfed for nine months or more had a more than 30% reduced risk of becoming overweight compared to children who were never breastfed.  And the evidence suggests that the more months of breastfeeding, the lower the likelihood of obesity.  Whether that had to do with the exact content or the amount that's produced and fed is not entirely clear. 

Cria Perrine: The other hypothesis is that when an infant is breastfeeding, that they are able to control the amount that they are taking in, versus an infant that's being bottle-fed.  The amount consumed may be more based on external feeding cues, like how much is left in a bottle.  So, an infant feeding at the breast gets a better regulation of their energy intake. 

Tom Skinner: Okay, next question, Shirley? 

Operator: Thank you.  Next question comes from John Reichard with Congressional Quarterly, you may ask your question.

John Reichard: Yes, thank you.  I wondered what your thoughts were on why relatively few hospitals have adopted comprehensive policies, and what kind of policies are needed to increase the percentage of the hospitals? 

Tom Frieden:  it takes effort, and one of the things is cultural change within hospitals.  So, we've seen hospitals in various parts of the country which really have the, just routine of giving formula to every child.  I’m even aware of one set of hospitals that required the doctor to write a prescription before the mother could breastfeed, whereas it should probably be the other way around, that the doctor's prescription should probably be needed before formula is given.  There are also concerns on the part of hospitals that it will cost them money.  Formula companies provide free formula as long as the hospitals give a gift bag that includes formula to women on discharge.  And so, they are concerned that if they were to stop taking those services, it would end up costing more.  At least, some hospitals have found that going baby-friendly has not significantly increased their expenses, and of course, it will substantially reduce health care expenditures overall, as children are less likely to need to come back with respiratory infections and diarrhea and ear infections, and mothers are less likely to get ovarian and breast cancer. 

John Reichard: To the extent that there are concerns about, you know, it costing a hospital more money, what exactly would they have to -- or do they fear they'll have to spend more money on? 

Tom Frieden:  The formula companies will often provide free formula for the infants who are premature or otherwise needs special formulas, and they do that in exchange for the hospital promoting formula, basically, by giving formula to every mother who leaves the hospital, and that deal saves the hospital some cash in the purchase of the specialty formulas.

Cria Perrine:  We do have data that suggests that a baby-friendly hospital is no more than the cost of the birth in a non baby-friendly hospital, so while there may be costs associated with becoming baby-friendly, those depend on where they are and what improvements they need to make.  Regarding why it's so slow, we don't necessarily think that a lot of hospitals are doing this intentionally.  It's more that they may not know what they need to be doing to support breastfeeding.  Some practices have just been in existence for decades -- keeping infants in nurseries rather than putting them in the mother's room.  So, there are, as the doctor said, cultural changes we need to make in the hospital setting.  Here at CDC, we do do the maternity practices and infant and nutrition and care survey.  It's the data we use in the MMWR, but it's a census of all U.S. hospitals and birth centers.  And in addition to collecting the data and analyzing and aggregating it, we actually give a report back to every hospital that participates, which can be used as an education tool for them to help them prioritize areas where they can make improvements in improving their practices.

John Reichard: Okay, thank you.

Tom Skinner: Next question, Shirley? 

Operator:  This question comes from Lindsay Tanner with the Associated Press, you may ask your question. 

Lindsay Tanner: Hi.  I actually have a question about the salmonella outbreak.  Sorry to divert it, but I need to know why the government didn't think it was necessary to warn people before late last week and yesterday when, you know there was evidence that these cases were happening? 

Tom Skinner: Lindsey, we're going to spend our time talking about the breastfeeding article.  You can follow up with me after this call and we'll take care of that.  Do you have any questions about this?  If not, we'll move to the next question. 

Lindsay Tanner: Thank you, no. 

Tom Skinner: All right.  Shirley, next question? 

Operator: Thank you.  This question comes from Deborah Kotz with the Boston Globe, you may ask your question.

Deborah Kotz: Yeah, hi.  I was just wondering, with regards to the formula that mothers are sent home with, does the CDC track whether hospitals -- I mean, have they started to move away from doing that, or is that still a problem?  And also, is there any weight in terms of which practice is most effective at getting mothers to continue breastfeeding, whether it's the rooming in or providing them support after they leave the hospital? 

Cria Perrine: We do -- in this survey specifically, we looked at hospitals that were supplementing versus specific -- we do have data on bags and distributions and formula.  It's not in this MMWR report.  I can get back to you with those data specifically, but we do track them.  Regarding the steps and what is the most important, we don't have a systemic answer to that, but we would definitely say that supplementation is one of the most important.  It consistently comes up in the literature as infants that breastfeeding infants that are supplemented in the hospital unnecessarily are much less likely to continue breastfeeding exclusively or continue for longer durations once they go home. 

Deborah Kotz: And is that because of nipple confusion?  Is that more on the part of the baby not wanting the breast or the mother thinking this is just easier? 

Cria Perrine:  The number one reason that women report that they stop breastfeeding is because of a perception of inadequate milk supply.  So, it's likely involved in affecting the mother's milk supply.  Whether that's the baby not latching or any other things, we're not sure specifically.

Tom Frieden: I think what we've found is that the steps are additive, and more is better. Ideally, all ten steps -- and they're really not that hard to get to if there's a commitment from the top level of the hospital or hospital system to do so, but we do know that things like breastfeeding within the first hour, given only breast milk, rooming in, supporting breastfeeding on demand are particularly important, and to continue long term, to link women with services in the community that provide breastfeeding support, such as a visit within the first week to encourage women.  All of these are important to get a good start on breastfeeding and a good start on nutrition for the child. 

Tom Skinner:  Next question, Shirley? 

Operator: This question comes from Althea Fung with National Journal, you may ask your question.

Althea Fung: The new HHS regulations include providing breastfeeding support and supplies for new mothers.  So, how would those regulations affect the way these hospitals are working? 

Cria Perrine: You're referring to the new HHD preventive services for women measures? 

Althea Fung: Yes. 

Cria Perrine:  I think it's a part of the continuation of care.  So, step ten here is that women need adequate post-discharge support.  And so, what that really gets into is that they need continued counseling in lactation and the rental of equipment, if they need it -- pumps to be able to express milk.  So, it really builds on what the hospitals are doing.  The hospitals are the place to start, but then they need a lot of continued care beyond that. 

Tom Frieden:  And in fact, in addition, the U.S. department of agriculture's WIC program has recently improved their practices to better support women who are breastfeeding and increase peer counseling support for breastfeeding.  So, these are encouraging developments.  We think there will be significant progress here.  Okay, next question? 

Operator: Our next question comes from Bridget Kuehn with JAMA Medical News, you may ask your question.

Bridget Kuehn: Hi.  Thanks for taking my question.  I appreciate it.  While the hospital care certainly seems to be an important component of this, in the U.S., we seem to see big fall-offs of breastfeeding around three or four months.  And so many women in the United States don't even have -- have very limited, if any, maternity leave.  Has there been any focus on what happens sort of when they get home and whether or not women have time to even really begin initiating feeding or getting feeding established in those first critical months? 

Tom Frieden:  Thank you.  You're absolutely right, that in addition to having good hospital policies, it's very important to have support for breastfeeding in communities.  And in fact, one of the aspects of the affordable care act was an amendment to the fair labor standards act to require employers with more than 50 employees to provide reasonable break time and a private location, other than a bathroom, for breastfeeding mothers to express milk.  So, supporting breastfeeding is something that needs to be done not just by hospitals, but also by doctors and nurses who encourage women, by the federal government, which is promoting policies, by state and local governments that can have quality standards for hospitals and encourage hospitals to become baby-friendly, and by mothers and their families.  So, it's not a simple thing to do, but it is possible, and we have seen progress, and I’m confident that we will continue to see progress in the future. 

Tom Skinner: Any more questions, Shirley? 

Operator: I’m showing no further questions.

Tom Skinner: Okay.  Let's have Dr. Frieden close, then.

Tom Frieden: Well, I want to thank you all for joining us.  Breastfeeding and the promotion of breastfeeding is a very important issue.  It has important health and economic benefits.  We have seen a little improvement in recent years, but much more is needed.  At the current rate of increase, several more generations of American children will be born primarily in hospitals that don't have effective support for women who want to breastfeed.  And at the current trends, it will be more than 100 years before every baby in this country is born in a baby-friendly hospital.  However, we are seeing an acceleration of progress, and I am confident that we will see more progress in the months and years to come.  Thank you all very much for joining us. 

Operator: Thank you, and that does conclude today's conference.  We thank you for your participation.  At this time, you may disconnect your line. 

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