Breastfeeding Report Card

United States, 2020

The Breastfeeding Report Card is released every two years; however, breastfeeding data continue to be released annually on the DNPAO National Immunization Survey Breastfeeding Rates web page and on the interactive Data, Trends, and Maps website.

Overview

Breastfeeding has many known health benefits for infants, children, and mothers and is a key strategy to improve public health. The American Academy of Pediatrics recommends infants are exclusively breastfed for about the first 6 months with continued breastfeeding while introducing complementary foods for at least 1 year. CDC’s Breastfeeding Report Card, 2020, provides data on breastfeeding practices and supports in all states, the District of Columbia (DC), Puerto Rico, Guam, and the US Virgin Islands. This year’s report highlights data from CDC’s 2018 national survey of Maternity Practices in Infant Nutrition and Care (mPINC) that assesses practices and policies affecting newborn feeding, feeding education and support, staff skills, and discharge support.

The 2020 Breastfeeding Report Card presents data that were collected before the start of the COVID-19 pandemic. Maternity care practices that support breastfeeding may have changed in some hospitals because of the COVID-19 pandemic. CDC is working to learn more about potential changes in hospital practices that could affect breastfeeding through a supplemental survey sent to hospitals that participated in the 2018 mPINC survey.

What Do the Numbers Tell Us?

Evidence-based hospital practices are important for establishing breastfeeding. Individualized support in the first few hours and days is critical to help mothers meet their breastfeeding goals. Although most infants born in 2017 started breastfeeding (84.1%), only 58.3% of infants were breastfeeding at 6 months (Table 1). The percentage of breastfed infants supplemented with infant formula before 2 days of age was 19.2% among infants born in 2017, an increase from 16.9% among infants born in 2016. Comprehensive hospital practices and policies that support breastfeeding have been shown to reduce medically unnecessary formula supplementation, reduce disparities in breastfeeding, and help give infants the best start in life.

CDC’s national mPINC survey assesses maternity care practices that affect how babies are fed. About every 2 years, all maternity care hospitals in the United States and US territories are invited to participate. In 2018, 2,045 hospitals participated and were asked about early postpartum care practices, feeding practices, education and support of mothers and caregivers, staff and provider responsibilities and training, and hospital policies and procedures. These policies and practices are organized into six main areas of care called subdomains that are scored and comprise each state’s total mPINC score (Table 2). Data can be used to monitor and improve evidence-based maternity care practices and policies. The national total mPINC score was 79 out of 100 and state total mPINC scores ranged from 68 to 96.

Figure 1 represents the range of scores from the highest state score to the lowest state score for each of the 6 mPINC subdomains across 50 states and Puerto Rico. The horizontal bar represents the national average score for each subdomain. States are performing well in the area of Feeding Education and Support with state scores ranging from 83 to 99 and a national score of 92. This domain includes teaching mothers to position and latch their newborn, assessing effective breastfeeding, hand expressing milk, recognizing and responding to feeding cues, breastfeeding on demand, and understanding the risks of using artificial nipples and pacifiers. This subdomain also assesses whether mothers whose newborns are fed any formula are taught feeding techniques and how to safely prepare and feed a baby formula. There is a wide range of scores for the other 5 subdomains, indicating room for improvement.

Figure 1. National score and state score ranges for Maternity Practices in Infant Nutrition and Care (mPINC) subdomains, 2018.

Figure 1. National score and state score ranges for Maternity Practices in Infant Nutrition and Care (mPINC) subdomains, 2018.

National score and state score ranges for Maternity Practices in Infant nutrition and Care (mPINC) subdomains, 2018.
Immediate Postpartum Care Rooming-In Feeding Practices Feeding Education & Support Discharge Support Institutional Management
Highest State Score 93 96 96 99 100 95
National Average Score 81 71 82 92 78 70
Lowest State Score 57 56 64 83 61 47

One area for improvement is institutional management. State scores for Institutional Management ranged from 47 to 95 with a national score of 70. Institutional Management demonstrates the commitment of hospitals’ administrations to policies and practices that support optimal infant nutrition and care. The Institutional Management subdomain score includes the elements listed in Box 1. Institutional Management score for each state or territory is presented in Figure 2. Only 6 states scored an 80 or higher for this subdomain. Although most hospital accreditation programs require hospitals to track exclusive breastfeeding (Box 1, element 3), quality improvement efforts that focus on the other elements within Institutional Management will improve this subdomain score.

See Maternity Practices in Infant Nutrition and Care (mPINC) Survey for more information about mPINC and to view individual state and territory reports .

Box 1: Institutional Management Elements
  1. Nurses are required to demonstrate competency in assessing breastfeeding (milk transfer and maternal pain), assisting with breastfeeding (positioning and latch), teaching hand expression, safe formula preparation and feeding, and demonstrating safe skin-to-skin practices.
  2. Hospital requires nurses to be formally assessed for clinical competency in breastfeeding support and lactation management.
  3. Hospital records and tracks exclusive breastfeeding throughout the entire hospitalization.
  4. Hospital pays a fair market price for infant formula.
  5. Hospital has 100% of all written policy elements that support breastfeeding in place.

Figure 2. Institutional Management subdomain scores for Maternity Practices in Infant Nutrition and Care (mPINC) by state, mPINC 2018.

Figure 2. Institutional Management subdomain scores for Maternity Practices in Infant Nutrition and Care (mPINC) by state, mPINC 2018.

Note: Data are not reported for District of Columbia, Guam, or the US Virgin Islands because of a small sample.

Institutional Management subdomain scores for Maternity Practices in Infant Nutrition and Care (mPINC) by state, mPINC 2018.
State/Territory Inst. Score
Alabama 74
Alaska 69
Arizona 64
Arkansas 62
California 81
Colorado 76
Connecticut 84
Delaware 86
District of Columbia .
Florida 77
Georgia 66
Guam .
Hawaii 49
Idaho 64
Illinois 71
Indiana 72
Iowa 55
Kansas 61
Kentucky 56
Louisiana 73
Maine 73
Maryland 74
Massachusetts 85
Michigan 65
Minnesota 64
Mississippi 71
Missouri 63
Montana 71
Nebraska 47
Nevada 66
New Hampshire 80
New Jersey 77
New Mexico 79
New York 79
North Carolina 73
North Dakota 60
Ohio 68
Oklahoma 63
Oregon 68
Pennsylvania 71
Puerto Rico 70
Rhode Island 95
South Carolina 70
South Dakota 52
Tennessee 66
Texas 70
US Virgin Islands .
Utah 60
Vermont 70
Virginia 74
Washington 70
West Virginia 72
Wisconsin 68
Wyoming 50
Table 1. Breastfeeding Rates among Infants Born in 2017
State/Territory Ever breastfed Breastfeeding at 6 months Breastfeeding at 12 months Exclusive breastfeeding through 3 months Exclusive breastfeeding through 6 months Breastfed infants receiving formula before 2 days of age
US Nationalb 84.1 58.3 35.3 46.9 25.6 19.2
Alabama 69.0 38.5 21.6 37.8 20.4 16.4
Alaska 91.9 67.4 43.9 58.6 35.3 12.4
Arizona 89.9 64.9 39.3 48.8 24.6 24.9
Arkansas 70.1 43.1 23.8 39.4 19.4 14.1
California 90.3 67.1 43.3 50.1 28.2 23.4
Colorado 92.2 69.2 47.0 54.5 34.1 17.8
Connecticut 85.4 62.4 43.2 48.4 25.7 23.5
Delaware 79.7 55.2 31.2 42.7 23.6 15.8
District of Columbia 88.0 64.7 39.3 47.3 24.0 24.3
Florida 75.6 52.4 30.7 41.1 19.9 21.6
Georgia 83.5 56.7 33.5 43.9 22.1 19.6
Guam 76.0 47.5 29.9 35.4 22.4 21.7
Hawaii 89.1 74.5 55.0 57.4 30.6 13.7
Idaho 94.6 63.4 38.3 52.4 24.6 19.3
Illinois 84.2 52.9 30.3 42.1 23.9 26.2
Indiana 78.4 47.0 27.4 42.6 21.1 10.8
Iowa 80.2 54.1 32.5 41.8 24.8 16.8
Kansas 84.6 58.7 37.2 51.6 31.6 13.6
Kentucky 72.6 44.5 23.2 37.5 23.0 19.9
Louisiana 66.2 41.0 21.8 39.0 21.8 13.4
Maine 88.1 62.2 39.6 52.7 28.1 12.3
Maryland 88.6 65.7 41.2 51.9 29.4 20.1
Massachusetts 80.7 58.1 37.9 44.5 23.9 18.7
Michigan 85.3 58.0 34.4 48.1 25.8 15.6
Minnesota 95.3 79.1 49.8 61.9 38.7 13.1
Mississippi 70.0 38.6 20.3 34.8 18.1 17.5
Missouri 77.5 50.2 27.2 42.3 23.4 15.0
Montana 84.6 62.1 36.8 55.1 31.1 12.4
Nebraska 85.3 63.0 41.4 53.9 32.6 13.8
Nevada 81.8 57.4 36.0 40.9 21.7 22.7
New Hampshire 88.3 65.4 39.5 63.0 36.7 8.7
New Jersey 88.7 63.5 38.6 46.9 27.7 23.3
New Mexico 83.4 57.9 40.0 49.1 26.6 14.1
New York 87.4 59.8 37.8 45.2 25.8 24.9
North Carolina 80.3 50.3 29.2 42.5 23.3 18.4
North Dakota 84.0 56.8 32.4 50.7 29.1 11.4
Ohio 80.1 51.1 31.1 41.3 21.6 16.3
Oklahoma 77.7 53.6 31.0 44.7 23.7 15.5
Oregon 93.2 73.4 48.4 65.8 35.6 7.9
Pennsylvania 82.9 58.0 34.6 47.9 25.9 14.5
Puerto Ricoc
Rhode Island 82.8 53.9 35.4 45.0 22.7 22.1
South Carolina 80.5 55.6 30.9 45.0 25.6 16.7
South Dakota 88.5 70.1 41.2 53.1 32.1 15.2
Tennessee 75.8 48.7 24.0 49.9 27.2 8.9
Texas 85.9 55.1 31.3 45.8 23.9 22.5
US Virgin Islandsc
Utah 91.8 64.1 42.4 48.2 26.3 19.8
Vermont 90.2 70.4 51.3 58.6 36.8 13.0
Virginia 91.7 74.0 42.3 56.8 30.4 16.2
Washington 92.5 74.6 49.6 58.0 28.9 14.9
West Virginia 69.9 42.6 25.3 37.5 20.9 15.4
Wisconsin 82.8 59.2 34.0 51.0 28.1 13.2
Wyoming 90.0 64.8 38.0 51.7 31.8 16.9
aSource: CDC National Immunization Survey (NIS) 2018–2019, among 2017 births. Breastfeeding rate indicators are the percentage of infants breastfeeding at the specified time points, calculated among all infants. The rate for infants receiving formula before 2 days of age is calculated among breastfed infants.
bData from Guam, Puerto Rico, and the US Virgin Islands are not included in the national average for any breastfeeding rate.
cData not reported for Puerto Rico or the US Virgin Islands.
Table 2. mPINC State Scores by Total and Subdomain, 2018
State/Territory mPINC
Total Score Immediate Postpartum Care Rooming-In Feeding Practices Feeding Education and Support Discharge Support Institutional Management
US National 79 81 71 82 92 78 70
Alabama 78 78 66 82 95 74 74
Alaska 83 90 70 83 98 86 69
Arizona 77 73 82 79 90 77 64
Arkansas 69 61 61 64 91 75 62
California 86 88 82 87 93 85 81
Colorado 85 82 82 90 94 87 76
Connecticut 85 92 73 80 95 86 84
Delaware 83 77 69 81 89 95 86
District of Columbiaa
Florida 81 80 81 81 92 77 77
Georgia 73 74 61 76 90 74 66
Guama
Hawaii 68 73 60 72 83 71 49
Idaho 75 81 65 81 84 74 64
Illinois 80 84 74 85 91 77 71
Indiana 78 79 67 84 91 73 72
Iowa 72 79 56 79 90 73 55
Kansas 79 85 70 85 90 79 61
Kentucky 68 72 57 71 91 63 56
Louisiana 75 74 66 76 91 71 73
Maine 85 88 68 93 98 88 73
Maryland 79 79 72 82 87 81 74
Massachusetts 86 88 80 83 93 89 85
Michigan 77 83 73 81 91 73 65
Minnesota 82 87 75 90 92 84 64
Mississippi 73 77 66 68 86 72 71
Missouri 75 75 65 81 92 75 63
Montana 86 87 85 93 97 86 71
Nebraska 71 83 63 73 87 73 47
Nevada 77 79 73 91 94 61 66
New Hampshire 90 93 80 96 97 91 80
New Jersey 80 80 68 79 96 82 77
New Mexico 82 82 80 85 86 81 79
New York 82 80 68 83 94 86 79
North Carolina 77 73 70 78 90 78 73
North Dakota 73 80 66 76 86 68 60
Ohio 78 84 64 82 92 77 68
Oklahoma 75 84 71 75 87 69 63
Oregon 85 86 80 91 94 92 68
Pennsylvania 78 82 70 82 91 70 71
Puerto Rico 72 57 61 65 94 86 70
Rhode Island 96 93 96 92 99 100 95
South Carolina 77 74 64 83 92 76 70
South Dakota 73 82 60 81 92 73 52
Tennessee 72 70 60 73 92 70 66
Texas 77 78 70 77 92 76 70
US Virgin Islandsa
Utah 73 80 62 80 90 68 60
Vermont 82 81 65 94 94 91 70
Virginia 81 83 70 84 94 81 74
Washington 85 86 86 90 93 86 70
West Virginia 76 73 64 80 87 80 72
Wisconsin 80 84 67 86 93 80 68
Wyoming 76 79 80 84 90 73 50
amPINC scores are not reported for District of Columbia (DC), Guam, or the US Virgin Islands because of low sample sizes but are included in the US National Total mPINC Score and US mPINC Subdomain scores.

Call to Action

A mother breastfeeding her child.

Use your state’s data to:

  • Celebrate state achievements in breastfeeding and breastfeeding supportive maternity care practices.
  • Identify gaps and opportunities for improvement in maternity care practices.
  • Bring together partners to promote and support breastfeeding.
  • Prioritize the next steps to put into action best practices and policies in maternity care.
Key Breastfeeding Indicators
Key Breastfeeding Indicators Current Rates
Percentage of infants who are breastfed: Ever.a 84.1
Percentage of infants who are breastfed: At 6 months.a 58.3
Percentage of infants who are breastfed: At 1 year.a 35.3
Percentage of infants who are breastfed: Exclusively through 3 months.a 46.9
Percentage of infants who are breastfed: Exclusively through 6 months.a 25.6
Percentage of employers that have worksite lactation support programs.b 51.0
Percentage of breastfed newborns who receive formula supplementation within the first 2 days of life.a 19.2
aCurrent rates represent infants born in 2017, National Immunization Survey 2018–2019.

bCurrent rates represent employers providing an on-site lactation room, Society for Human Resource Management, 2019 surveyexternal icon.

Data Sources for the Breastfeeding Report Card Indicators—2020
Indicators Data Source Background
Ever breastfed National Immunization Survey (NIS) Breastfeeding rates for infants born in 2017 come from the US National Immunization Surveys (NIS) 2018 and 2019. The NIS provides current national, state, and selected urban-area estimates of vaccination coverage rates for US children.

Because breastfeeding data are obtained by maternal recall when children are between 19 and 35 months of age, breastfeeding rates are analyzed by birth cohort rather than survey year.

Available at http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm.

Breastfeeding at 6 months
Breastfeeding at 12 months
Exclusive breastfeeding through 3 months
Exclusive breastfeeding through 6 months
Breastfed infants receiving formula before 2 days of age
mPINC Scores
(Total, Immediate Postpartum Care, Rooming-In, Feeding Practices, Feeding Education and Support, Discharge Support, Institutional Management)
mPINC CDC’s national survey of Maternity Practices in Infant Nutrition and Care (mPINC) assesses maternity care practices and provides feedback to encourage hospitals to make improvements that better support breastfeeding. Data for this report come from the 2018 mPINC survey. From 2007 to 2015, CDC administered the mPINC survey every 2 years. mPINC was revised in 2018 and these data should NOT be compared to previous mPINC survey years.

Available at https://www.cdc.gov/breastfeeding/data/mpinc/index.htm.