PEDIATRICS Vol. 110 No. 6 December 2002, pp. 1103-1109
Breastfeeding Continues to Increase Into the New Millennium
From the Ross Products Division of Abbott Laboratories, Columbus, Ohio
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Objective. To update reported rates of breastfeeding and exclusive breastfeeding through 2001 and to compare rates in 2001 to those from 1996.
Methods. The Ross Laboratories Mothers Survey (RLMS) is a large, national survey designed to determine patterns of milk feeding during infancy. Questionnaires were mailed each month to a representative sample of mothers when their infant was 1 month of age, 2 months of age, 3 months or age, and so forth. In 1996, approximately 744 000 questionnaires were mailed, and in 2001, 1.4 million questionnaires were mailed. Mothers were asked to recall the type of milk fed to their infant in the hospital, and during each month of age. Two categories of breastfeeding were considered: breastfeeding (human milk or a combination of human milk and formula or cow’s milk) and exclusive breastfeeding (only human milk). Rates of breastfeeding and exclusive breastfeeding in the hospital and at 6 months of age were evaluated.
Results. In 2001, the prevalence of the initiation of breastfeeding and breastfeeding to 6 months of age in the United States reached their highest levels recorded to date, 69.5% and 32.5%, respectively. Comparing rates in 2001 and 1996, increases in the initiation of breastfeeding and continued breastfeeding to 6 months of age were observed across all sociodemographic groups but were greater among groups that have been historically less likely to breastfeed: women who were black, younger (<20 years of age), no more than high school-educated, primiparous, employed at the time they received the survey, and who participated in the Supplemental Nutrition Program for Women, Infants, and Children (WIC). Breastfeeding in the hospital and at 6 months of age was most common in the Mountain and Pacific states and among women who were white or Hispanic, older, college-educated, and were not enrolled in WIC. Mothers most likely to practice exclusive breastfeeding in the hospital (46.2%) and at 6 months of age (17.2%) had a similar sociodemographic profile as mothers who breastfed their infants.
Conclusions. If increases in breastfeeding continue at the current rate (approximately 2% per year), in-hospital breastfeeding in the United States should meet or exceed the Healthy People 2010 goal of 75% for the early postpartum period. However, the Healthy People 2010 goal for continued breastfeeding to 5 to 6 months of age (50%) may not be reached in every subgroup. To ensure that these goals are achieved, educational and promotional strategies for breastfeeding must be continued to support mothers who are young, less educated, and participating in WIC.
Key Words: breastfeeding • infant feeding • trends in breastfeeding
Abbreviations: WIC, Supplemental Nutrition Program for Women, Infants, and Children • RLMS, Ross Laboratories Mothers Survey
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INTRODUCTION |
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Ongoing surveys by the Ross Products Division of Abbott Laboratories have documented trends in breastfeeding in the United States since 1954.1–8 Ryan8 described the resurgence in both the initiation of breastfeeding and continued breastfeeding at 6 months of age between 1989 and 1995, following a sharp decline in breastfeeding from 1984–1989. The increases in breastfeeding were observed across all sociodemographic groups but were greater among groups that have been historically less likely to practice breastfeeding: mothers who were enrolled in the Supplemental Nutrition Program for Women, Infants, and Children (WIC), younger in age, poorer, black, no more than grade school-educated, primiparous, employed full-time, and who were not living in the western region of the United States.
The present study updates rates of breastfeeding through 2001 and compares rates in 2001 to those in 1996. We also describe rates for breastfeeding and exclusive breastfeeding in the hospital and at 6 months according to several sociodemographic factors.
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METHODS |
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The Ross Laboratories Mothers Survey (RLMS) is a large, national survey designed to determine patterns of milk feeding during infancy. The method of the survey has been described in detail elsewhere.1–8 The survey was developed in 1954 and has been periodically (in 1982, 1985, 1991, and 1997) expanded to include many more infants. Before 1991, the survey was conducted on a quarterly basis, and approximately 40 000 to 50 000 questionnaires were mailed each quarter. Beginning in 1991, the survey was conducted monthly. Approximately 60 000 questionnaires were mailed each month to mothers at the time their infant was 6 or 12 months of age. In 1997, the sample size was greatly expanded: 1.4 million questionnaires were mailed, 117 000 each month. Also beginning in 1997, to eliminate potential problems of recall over a 6-month period, questionnaires were mailed each month to mothers with infants 1 month of age, 2 months of age, 3 months of age and so forth until 12 months of age. Because of the sensitive nature of asking mothers their total family income, the question was eliminated.
Questionnaires were mailed to a probability sample of new mothers selected from a database of names supplied by Experian (Costa Mesa, CA). The database covers >1 300 000 expectant mothers and >3 000 000 families with newborns from the US population of about 4 000 000 births (ie, number of birth in the United States for 2001). The database is designed to include mothers across all socioeconomic levels. The list is compiled from approximately 2500 sources including hospital package programs and self-reported information from survey cards, magazine subscriptions, maternity shops, etc. Mothers cannot participate in the survey for a second time for at least 4 months.
Since 1997, the RLMS averaged >33 000 completed questionnaires each month (28% response rate). To ensure that all geographical areas are represented and to adjust for difference response rates, regions of the country where the response rates were low were oversampled.
To maintain consistency, the question included in the RLMS, with respect to milk feeding, has not changed markedly over time. From a list of all commercial infant formulas, human milk, and cow’s milk (whole, 2%, etc) mothers were asked to indicate the type of milk fed to their infant "in the hospital," "at 1 week of age," "in the last 30 days." and "most often in the last week." The "in the hospital" category was used to determine infant feeding practices initiated at birth. The "most often in the last week" category was used to determine the types(s) of milk fed to a 6-month-old infant. The list of infant formulas is updated as new formulas are introduced or removed from the marketplace. Each mother was also asked to answer questions describing her sociodemographic status.
Following the approach taken in previous publications,1–8 the rates of breastfeeding in the hospital and at 6 months of age were evaluated. The present study provides breastfeeding data for 1996 and 2001, with some additional information on trends since 1965. We chose 1996 as the starting point, because our previous published data described breastfeeding trends up to 1995.8 In 1996, approximately 744 000 questionnaires were mailed. In 2001, 1.4 million questionnaires were mailed.
Two categories of breastfeeding practices were considered: breastfeeding and exclusive breastfeeding. The breastfeeding category included all infants fed human milk or a combination of human milk and formula or cow’s milk (ie, any breastfeeding) in the hospital or at 6 months of age. This category was used in our previous publications. Exclusive breastfeeding included the subset of infants who were fed only human milk in the hospital or at 6 months of age; no supplemental formula and/or cow’s milk were used. Information about the introduction and types of solid foods fed to infants was not collected.
The employment variable considered in this study represented postpartum employment outside the home at the time mothers received the questionnaire. To evaluate WIC participation status, mothers were asked, "Since the birth of your youngest infant, have you or your youngest infant participated in the government Supplemental Nutrition Program for Women, Infants, and Children (WIC)?" The WIC variable, therefore, represented whether the mother and/or her child received WIC benefits.
The responses to the survey were weighted to account for the varying geographical coverage and response rates and to more precisely reflect the sociodemographic profile of births in the United States. The weights were based on proportions of mothers within specific sociodemographic subgroups in the United States: maternal region of residence (within 9 census regions), ethnic background (either black or non-black), maternal age (<24, 25–29, 30–34, and 35+ years of age), and education (either college or no college). The weights that were used corresponded to the sociodemographic variables that have historically been associated with breastfeeding. The weights for these variables were derived from the National Center for Health Statistics.9,10
A z statistic was produced to test for significant increases in rates of breastfeeding between 1996 and 2001 in each sociodemographic subgroup. An absolute value of z >1.65 for a 1-tailed test (P < .05) was considered to be unlikely to have occurred by chance.11
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RESULTS |
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Trends in Breastfeeding and Exclusive Breastfeeding From 1965–2001
As shown in Fig. 1, initiation of breastfeeding and exclusive breastfeeding increased from 1971 to a high point in 1982 (61.9% and 55.0%, respectively). The prevalence of the initiation of breastfeeding and exclusive breastfeeding declined from 1983 to 1989. Since 1990, the prevalence of the initiation of breastfeeding dramatically increased 35%, from 51.5% in 1990 to 69.5% in 2001, reaching the highest level recorded to date. Initiation of exclusive breastfeeding, however, increased slightly from 43.5% in 1990 to 46.3% in 2001. From 1997–2001, exclusive breastfeeding in the hospital held steady at around 46% to 47%.
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Trends in breastfeeding and exclusive breastfeeding at 6 months of age were similar to those seen in the hospital. As shown in Fig. 2, breastfeeding and exclusive breastfeeding at 6 months of age increased from 1971 to a high point in 1982 (27.1% and 19.8%, respectively). The prevalence of continued breastfeeding and exclusive breastfeeding to 6 months of age declined from 1984–1989. Since 1990, the prevalence of breastfeeding at 6 months of age nearly doubled from 17.6% in 1990 to 32.5% in 2001, surpassing its previous high level in 1982. Since 1990, exclusive breastfeeding at 6 months of age increased steadily from 10.4% 1990 to 17.2% in 2001.
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Prevalence of Breastfeeding by Sociodemographic Characteristics: 1996 Versus 2001
Increases in the rates of initiation of breastfeeding between 1996 and 2001 were statistically significant (P < .05) across each demographic subgroup (Table 1). The largest increases in the initiation of breastfeeding between 1996 and 2001 occurred among women who were black, younger (<20 years of age), no more than high school-educated, primiparous, living in the West South Central region of the United States; women who were not employed at the time they received the survey; and women who participated in the WIC program (Table 1). It is noteworthy that, in 2001 for the first time, Hispanic women had a higher rate of in-hospital breastfeeding than did white women (73% vs 69.5%). The increase in the rate for initiation of breastfeeding of low birth weight infants was 30.6%.
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Not surprising, the smallest increases occurred among women who have been traditionally more likely to initiate breastfeeding: women who were white, older (
25 years of age), college-educated, multiparous, not in WIC, and living in the Mountain and Pacific regions of the United States. The rates of in-hospital breastfeeding in these groups were already at relatively high levels. Increases in rates of breastfeeding at 6 months of age were much larger than those for the initiation of breastfeeding (Table 1). Except for mothers in the grade and high school subgroups, for the other subgroups increases in breastfeeding at 6 months of age between 1996 and 2001 were statistically significant (P < .05). There was approximately a twofold increase in the prevalence of breastfeeding at 6 months of age among women who were black, younger (<20 years of age), employed full-time, and women with low birth weight infants. Continued breastfeeding at 6 months of age was most common in the Western states and among women who were white or Hispanic, college-educated, older and multiparous, and did not participate in WIC. Breastfeeding at 6 months of age was also more common among women who were employed part-time or not working outside their home than among women employed full-time.
Prevalence of Exclusive Breastfeeding by Sociodemographic Characteristics: 2001
Table 2 provides the rates for initiation of exclusive breastfeeding and continued exclusive breastfeeding to 6 months of age in 2001. As in the initiation of breastfeeding, exclusive breastfeeding initiated in the hospital was most common among mothers who were white, older in age, employed part-time, primiparous, did not participate in the WIC program, and living in the Mountain and Pacific states. In contrast to in-hospital breastfeeding, the rate for exclusive in-hospital breastfeeding was higher among white women than Hispanic women.
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In 2001, at 6 months of age, as in the hospital, exclusive breastfeeding was most common among women who were white, older, college-educated, did not participate in WIC, and living in the Western regions of the country. Exclusive breastfeeding at 6 months of age was also more common among women who were more experienced (multiparous), or were not working outside their home than among first-time mothers, and mothers who were working part-time or full-time.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Since the RLMS began tracking breastfeeding in the United States in 1954, the percentage of mothers who nursed their infants has fluctuated widely. After dropping steadily throughout the late 1950s and 1960s, initiation of breastfeeding reached its lowest level in 1971, with only 24.7% of mothers breastfeeding. By 1982, initiation of breastfeeding had increased dramatically, to 61.9%, but by 1990 it had dropped again, to 51.5%. Now, the RLMS indicates that breastfeeding is more popular than ever. In 2001, 69.5% of mothers breastfed their infants in the hospital; 46.3% of mothers exclusively breastfed their infants. In 2001, 32.5% of mothers were still breastfeeding their infants at 6 months of age; 17.2% were exclusively breastfeeding.
Some studies have considered the strengths and weaknesses of the RLMS.12,13 The RLMS breastfeeding rates have been compared with those from other national surveys including the 1988 National Surveys of Family Growth,6 the 1988 National Maternal and Infant Health Survey,12 and the third National Health and Nutrition Examination Survey, 1988–1994.14 Rates for exclusive breastfeeding from Phase II (1991–1994) of the third National Health and Nutrition Examination Survey were also compared with those from the RLMS.15 Results of all these comparisons demonstrate that despite differences in survey methods and design, these surveys report similar trends and rates of breastfeeding across several sociodemographic characteristics. The advantage of the RLMS is its ability to provide breastfeeding trends on a continuous basis over a long period of time.12 The RLMS will be the main instrument used to monitor progress toward meeting the Healthy People 2010 goals.13
Between 1996 and 2001, the largest increases in the initiation of breastfeeding and continued breastfeeding to at least 6 months occurred among groups of women who have been historically less likely to breastfeed: women who were black, younger in age, less educated, receiving WIC benefits, and living in regions of the country where mothers are less inclined to breastfeed. Increases in the prevalence of breastfeeding at 6 months among mothers in these groups were particularly large.
Breastfeeding and exclusive breastfeeding in the hospital and at 6 months of age were more common among privileged mothers and those living in the Mountain and Pacific states. Increases in the rates of breastfeeding were less dramatic in these subgroups because rates of breastfeeding were initially very high.
The gap between breastfeeding and exclusive breastfeeding in the hospital and at 6 months of age has increased through time. In 1971, the gap between breastfeeding and exclusive breastfeeding in the hospital was only 3%. By 2001, the gap widened to 23%. At 6 months of age, the gap between breastfeeding and exclusive breastfeeding increased from 2% in 1971 to 15% in 2001. Considering that rates of exclusive breastfeeding initiation have not increased as rapidly as those for breastfeeding, it is clear that many more mothers than ever before used supplemental feedings in the hospital and at 6 months of age.
The effect that early introduction of formula has on breastfeeding initiation and duration is equivocal. A recent meta-analysis of 9 randomized, controlled trials involving 3730 women found that when hospital discharge packages (with or without formula) were distributed to new mothers, the number of women exclusively breastfeeding was slightly reduced, but there was no effect on early termination of any breastfeeding (women who were using supplements).16 Howard et al17 compared the effect that prenatal distribution of formula company materials, advertising, and samples had on breastfeeding patterns. They found that these materials did not significantly effect breastfeeding initiation and duration, but women who received formula promotion materials were more likely to cease breastfeeding before hospital discharge or before 2 weeks postpartum. Using data from the RLMS, Ryan18 considered the effects that infant formula discharge packages, sociodemographic characteristics, and breastfeeding instructions had on exclusive and any breastfeeding at 1 and 4 months of age. Stepwise regression analysis indicated that discharge kits did not exert as large an effect on breastfeeding as other factors such as maternal employment, family income, maternal education, parity, and breastfeeding instructions. Women who received a formula discharge kit compared with those who did not had a slightly higher probability of initiating any breastfeeding in the first (10% vs 7%) and fourth month (27% vs. 25%.). In addition, relative to other sociodemographic factors that influence breastfeeding initiation and duration, 2 randomized clinical studies reported that the inclusion of formula in discharge packages did not decrease the duration of exclusive or any breastfeeding19 or had at best a very modest effect on breastfeeding feeding method and breastfeeding duration.20
The Healthy People 2010 goal for the initiation of breastfeeding was identical to that established for 2000: 75% breastfeeding in the early postpartum period.21,22 In 2001, this goal was exceeded by mothers who were older (>35 years of age), college-educated, not participating in WIC, and living in the Mountain and Pacific states. In the Mountain and Pacific regions of the United States, >8 of 10 infants were breastfed in the hospital.
The Healthy People 2000 and Healthy People 2010 goal for continued breastfeeding to 5 to 6 months postpartum was earmarked to be at least 50%.21,22 In 2001, this goal was not achieved by any sociodemographic subgroup and disparities still existed across many subgroups. Moreover, despite the relative high increases in the rates of in-hospital breastfeeding and continued breastfeeding to 6 months of age, rates for breastfeeding among low birth weight infants fell short of the national averages.
From 1996–2001, the RLMS rates of in-hospital breastfeeding increased approximately 2% per year nationally and >3% per year in some sociodemographic subgroups (eg, 3.2% per year among blacks). Assuming the 2% per year rate of increase, in-hospital breastfeeding rates at the national level and in every sociodemographic group of women should meet or exceed the Healthy People 2010 goal. Continued breastfeeding at 6 months of age also increased about 2% per year nationally and across many subgroups. At this rate, the Healthy People 2010 goal may not be reached by several subgroups including women who are black, less educated, and participating in WIC.
In the 1980s, full-time work had no effect on the initiation of breastfeeding but had a profound effect on the duration of breastfeeding.5,23 For example, in 1988, an equal number of employed and nonemployed women began breastfeeding, but at 6 months postpartum, only 10% of full-time working mothers were still breastfeeding, compared with 24% of those not employed.5 In 2001, maternal employment still had little effect on the initiation of breastfeeding or exclusive breastfeeding. However, full-time employment was associated with early weaning, but to a much smaller degree than seen in the 1980s.5,23,24
In 2001, mothers working part-time were more likely to initiate and continue breastfeeding or exclusive breastfeeding relative to those working full-time; rates for breastfeeding among part-time working mothers exceeded those observed at the national level. At 6 months of age, part-time working mothers were also more likely to use supplemental feedings than mothers who worked full-time or were not employed. Fein and Roe25 found that part-time work was an effective strategy to help new mothers combine breastfeeding and employment by providing mothers more access to their infant. The likelihood that mothers will continue to breastfeed after returning to work may also depend on the mother’s occupation. Women employed as professionals may have more control over their environment and may have more flexibility to met both the needs of their job and their infant.23
The recent increase in breastfeeding among low-income women may be attributable to program changes within WIC and the targeting of breastfeeding promotion materials to meet the specific needs of these women,26,27 Programs such as peer counseling (provided by those who have previously breastfed and have been on WIC),28 intensive breastfeeding informational and support campaigns for inner-city mothers,29 the development of the Best Start Program30 and the Baby-Friendly Hospital Initiative,31,32,33 have had a positive, significant impact on breastfeeding rates even in high-risk populations.
Recently, the Department of Health and Human Services (DHHS) Blueprint for Action on Breastfeeding introduced a plan for breastfeeding that involves education, training, awareness, support and research.34 This plan provides detailed recommendations for the promotion of breastfeeding. Certain populations such as adolescents and ethnic minorities need to be targeted. Black adolescents are typically less likely to be encouraged to breastfeed by their health care providers, mothers, partner, or peers.35 The primary reason given by black women for not breastfeeding was that they preferred bottle-feeding.36 This suggests that black women bottle-feed their infants not because of employment or physical difficulties but because of preference.36,37 Although black and Latino adolescents recognized that breastfeeding offers many health benefits to both the mother and infant, fear or pain, embarrassment with public exposure and unease with the act of breastfeeding acted as significant barriers.38 Among low-income mothers, barriers to breastfeeding were also associated with their perceptions of social disapproval of breastfeeding in public, reports of ridicule by friends, lack of support from some health providers, and difficulties associated with employment.39 Thus, mothers must be equipped with strategies designed to deal with perceptions of disapproval.39 A culturally sensitive approach that reflects the woman’s familial social network, including encouragement from the infant’s father or the woman’s mother40,41,42 is also needed. Because decisions on whether to breastfeed are made early, positive attitudes and education concerning breastfeeding need to be developed before pregnancy and must be provided throughout the pregnancy, perinatal, and postpartum period.43,44
The workplace can be a barrier for the mother who decides to breastfeed. Legislative efforts have been put into place to protect women’s rights to breastfeed after returning to work and to encourage employees to provide a safe, private environment for women to express (or pump) breast milk.45 Continued efforts in the areas of improving attitudes, workplace policies, and a positive media portrayal of breastfeeding as the normal and preferred method of feeding infants will help promote and support breastfeeding in the workplace.
The health care system has an important role to play in the promotion and support of breastfeeding. Lu et al46 indicated that in populations less likely to breastfeed, encouragement by nurses and physicians significantly increased breastfeeding initiation. Women who were encouraged by their physicians and nurses to breastfeed were >4 times as likely to initiate breastfeeding than women who did not receive such encouragement.46
In a national survey of pediatric residents and practicing physicians, >70% of practitioners indicated that more time needs to be devoted to direct patient interaction and practice of counseling and problems solving skills related to assist breastfeeding mothers.47 Breastfeeding knowledge, attitudes, training, and experience among residents and practicing physicians in family medicine, obstetrics/gynecology, and pediatrics also demonstrate that more knowledge regarding breastfeeding management is needed.48 The desire for breastfeeding education among pediatricians is strong.49 To address this issue, the American Academy of Pediatrics has published a policy statement concerning breastfeeding promotion and goals and offers suggestions to help pediatricians influence and improve breastfeeding rates.50
Increasing the rates of breastfeeding is a compelling public health goal, especially among groups who are less likely to initiate and sustain breastfeeding.21 Successful breastfeeding requires the support from family, friends, and health care professionals. Education and information are critical to continue the positive trends in breastfeeding seen over the last decade and into the new millennium.
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ACKNOWLEDGMENTS |
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This article is dedicated to the memory of Linda Goode, who helped supervise the day-to-day activities of the Ross Laboratories Mothers Survey for >30 years. Her attention to detail and appreciation for historical documentation will not be forgotten.
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FOOTNOTES |
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Received for publication Jul 8, 2002; Accepted Sep 11, 2002.
Reprint requests to (A.S.R.) Ross Products Division of Abbott Laboratories, 625 Cleveland Ave, Columbus, OH 43215. E-mail: alan.ryan{at}abbott.com
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[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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