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Breastfeeding Continues To Increase Into The New Millennium


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Breastfeeding Continues To Increase Into The New Millennium

  1. 1. Breastfeeding Continues to Increase Into the New Millennium Alan S. Ryan, Zhou Wenjun and Andrew Acosta Pediatrics 2002;110;1103-1109 DOI: 10.1542/peds.110.6.1103 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2002 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from by on June 2, 2009
  2. 2. Breastfeeding Continues to Increase Into the New Millennium Alan S. Ryan, PhD; Zhou Wenjun, MS; and Andrew Acosta, MBA ABSTRACT. Objective. To update reported rates of ABBREVIATIONS. WIC, Supplemental Nutrition Program for breastfeeding and exclusive breastfeeding through 2001 Women, Infants, and Children; RLMS, Ross Laboratories Mothers and to compare rates in 2001 to those from 1996. Survey. Methods. The Ross Laboratories Mothers Survey (RLMS) is a large, national survey designed to determine O patterns of milk feeding during infancy. Questionnaires ngoing surveys by the Ross Products Divi- were mailed each month to a representative sample of sion of Abbott Laboratories have docu- mothers when their infant was 1 month of age, 2 months mented trends in breastfeeding in the United of age, 3 months or age, and so forth. In 1996, approxi- States since 1954.1– 8 Ryan8 described the resurgence mately 744 000 questionnaires were mailed, and in 2001, in both the initiation of breastfeeding and continued 1.4 million questionnaires were mailed. Mothers were breastfeeding at 6 months of age between 1989 and asked to recall the type of milk fed to their infant in the 1995, following a sharp decline in breastfeeding from hospital, and during each month of age. Two categories of breastfeeding were considered: breastfeeding (human 1984 –1989. The increases in breastfeeding were ob- milk or a combination of human milk and formula or served across all sociodemographic groups but were cow’s milk) and exclusive breastfeeding (only human greater among groups that have been historically less milk). Rates of breastfeeding and exclusive breastfeeding likely to practice breastfeeding: mothers who were in the hospital and at 6 months of age were evaluated. enrolled in the Supplemental Nutrition Program for Results. In 2001, the prevalence of the initiation of Women, Infants, and Children (WIC), younger in breastfeeding and breastfeeding to 6 months of age in the age, poorer, black, no more than grade school-edu- United States reached their highest levels recorded to cated, primiparous, employed full-time, and who date, 69.5% and 32.5%, respectively. Comparing rates in were not living in the western region of the United 2001 and 1996, increases in the initiation of breastfeeding States. and continued breastfeeding to 6 months of age were observed across all sociodemographic groups but were The present study updates rates of breastfeeding greater among groups that have been historically less through 2001 and compares rates in 2001 to those in likely to breastfeed: women who were black, younger 1996. We also describe rates for breastfeeding and (<20 years of age), no more than high school-educated, exclusive breastfeeding in the hospital and at 6 primiparous, employed at the time they received the months according to several sociodemographic fac- survey, and who participated in the Supplemental Nutri- tors. tion Program for Women, Infants, and Children (WIC). Breastfeeding in the hospital and at 6 months of age was METHODS most common in the Mountain and Pacific states and The Ross Laboratories Mothers Survey (RLMS) is a large, na- among women who were white or Hispanic, older, col- tional survey designed to determine patterns of milk feeding lege-educated, and were not enrolled in WIC. Mothers during infancy. The method of the survey has been described in most likely to practice exclusive breastfeeding in the detail elsewhere.1– 8 The survey was developed in 1954 and has hospital (46.2%) and at 6 months of age (17.2%) had a been periodically (in 1982, 1985, 1991, and 1997) expanded to similar sociodemographic profile as mothers who breast- include many more infants. Before 1991, the survey was con- fed their infants. ducted on a quarterly basis, and approximately 40 000 to 50 000 Conclusions. If increases in breastfeeding continue at questionnaires were mailed each quarter. Beginning in 1991, the the current rate (approximately 2% per year), in-hospital survey was conducted monthly. Approximately 60 000 question- naires were mailed each month to mothers at the time their infant breastfeeding in the United States should meet or exceed was 6 or 12 months of age. In 1997, the sample size was greatly the Healthy People 2010 goal of 75% for the early post- expanded: 1.4 million questionnaires were mailed, 117 000 each partum period. However, the Healthy People 2010 goal month. Also beginning in 1997, to eliminate potential problems of for continued breastfeeding to 5 to 6 months of age (50%) recall over a 6-month period, questionnaires were mailed each may not be reached in every subgroup. To ensure that month to mothers with infants 1 month of age, 2 months of age, 3 these goals are achieved, educational and promotional months of age and so forth until 12 months of age. Because of the strategies for breastfeeding must be continued to support sensitive nature of asking mothers their total family income, the mothers who are young, less educated, and participating question was eliminated. in WIC. Pediatrics 2002;110:1103–1109; breastfeeding, in- Questionnaires were mailed to a probability sample of new mothers selected from a database of names supplied by Experian fant feeding, trends in breastfeeding. (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 From the Ross Products Division of Abbott Laboratories, Columbus, Ohio. United States for 2001). The database is designed to include moth- Received for publication Jul 8, 2002; accepted Sep 11, 2002. ers across all socioeconomic levels. The list is compiled from Reprint requests to (A.S.R.) Ross Products Division of Abbott Laboratories, approximately 2500 sources including hospital package programs 625 Cleveland Ave, Columbus, OH 43215. E-mail: and self-reported information from survey cards, magazine sub- PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- scriptions, maternity shops, etc. Mothers cannot participate in the emy of Pediatrics. survey for a second time for at least 4 months. PEDIATRICS Vol. 110 No. 6 December 2002 1103 Downloaded from by on June 2, 2009
  3. 3. Since 1997, the RLMS averaged 33 000 completed question- naires each month (28% response rate). To ensure that all geo- graphical areas are represented and to adjust for difference re- sponse 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 socio- demographic 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. Fig 1. In-hospital breastfeeding and exclusive breastfeeding We chose 1996 as the starting point, because our previous pub- rates: 1965–2001 (see Appendix for data by year). lished data described breastfeeding trends up to 1995.8 In 1996, approximately 744 000 questionnaires were mailed. In 2001, 1.4 million questionnaires were mailed. ing, however, increased slightly from 43.5% in 1990 Two categories of breastfeeding practices were considered: to 46.3% in 2001. From 1997–2001, exclusive breast- breastfeeding and exclusive breastfeeding. The breastfeeding cat- feeding in the hospital held steady at around 46% to egory included all infants fed human milk or a combination of human milk and formula or cow’s milk (ie, any breastfeeding) in 47%. the hospital or at 6 months of age. This category was used in our Trends in breastfeeding and exclusive breastfeed- previous publications. Exclusive breastfeeding included the sub- ing at 6 months of age were similar to those seen in set of infants who were fed only human milk in the hospital or at the hospital. As shown in Fig. 2, breastfeeding and 6 months of age; no supplemental formula and/or cow’s milk were used. Information about the introduction and types of solid exclusive breastfeeding at 6 months of age increased foods fed to infants was not collected. from 1971 to a high point in 1982 (27.1% and 19.8%, The employment variable considered in this study represented respectively). The prevalence of continued breast- postpartum employment outside the home at the time mothers feeding and exclusive breastfeeding to 6 months of received the questionnaire. To evaluate WIC participation status, age declined from 1984 –1989. Since 1990, the preva- mothers were asked, “Since the birth of your youngest infant, have you or your youngest infant participated in the government Sup- lence of breastfeeding at 6 months of age nearly plemental Nutrition Program for Women, Infants, and Children doubled from 17.6% in 1990 to 32.5% in 2001, sur- (WIC)?” The WIC variable, therefore, represented whether the passing its previous high level in 1982. Since 1990, mother and/or her child received WIC benefits. exclusive breastfeeding at 6 months of age increased The responses to the survey were weighted to account for the varying geographical coverage and response rates and to more steadily from 10.4% 1990 to 17.2% in 2001. precisely reflect the sociodemographic profile of births in the United States. The weights were based on proportions of mothers Prevalence of Breastfeeding by Sociodemographic within specific sociodemographic subgroups in the United States: Characteristics: 1996 Versus 2001 maternal region of residence (within 9 census regions), ethnic Increases in the rates of initiation of breastfeeding background (either black or non-black), maternal age ( 24, 25–29, 30 –34, and 35 years of age), and education (either college or no between 1996 and 2001 were statistically significant college). The weights that were used corresponded to the socio- demographic 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 sociodemo- graphic 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 RESULTS 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 ex- clusive breastfeeding declined from 1983 to 1989. Since 1990, the prevalence of the initiation of breast- feeding dramatically increased 35%, from 51.5% in 1990 to 69.5% in 2001, reaching the highest level Fig 2. Breastfeeding and exclusive breastfeeding rates at 6 recorded to date. Initiation of exclusive breastfeed- months of age: 1971–2001 (see Appendix for data by year). 1104 BREASTFEEDING CONTINUES TO INCREASE INTO THE NEW MILLENNIUM Downloaded from by on June 2, 2009
  4. 4. (P .05) across each demographic subgroup (Table groups increases in breastfeeding at 6 months of age 1). The largest increases in the initiation of breast- between 1996 and 2001 were statistically significant feeding between 1996 and 2001 occurred among (P .05). There was approximately a twofold in- women who were black, younger ( 20 years of age), crease in the prevalence of breastfeeding at 6 months no more than high school-educated, primiparous, of age among women who were black, younger ( 20 living in the West South Central region of the United years of age), employed full-time, and women with States; women who were not employed at the time low birth weight infants. Continued breastfeeding at they received the survey; and women who partici- 6 months of age was most common in the Western pated in the WIC program (Table 1). It is noteworthy states and among women who were white or His- that, in 2001 for the first time, Hispanic women had panic, college-educated, older and multiparous, and a higher rate of in-hospital breastfeeding than did did not participate in WIC. Breastfeeding at 6 months white women (73% vs 69.5%). The increase in the rate of age was also more common among women who for initiation of breastfeeding of low birth weight were employed part-time or not working outside infants was 30.6%. their home than among women employed full-time. Not surprising, the smallest increases occurred among women who have been traditionally more Prevalence of Exclusive Breastfeeding by likely to initiate breastfeeding: women who were Sociodemographic Characteristics: 2001 white, older ( 25 years of age), college-educated, Table 2 provides the rates for initiation of exclusive multiparous, not in WIC, and living in the Mountain breastfeeding and continued exclusive breastfeeding and Pacific regions of the United States. The rates of to 6 months of age in 2001. As in the initiation of in-hospital breastfeeding in these groups were al- breastfeeding, exclusive breastfeeding initiated in ready at relatively high levels. the hospital was most common among mothers who Increases in rates of breastfeeding at 6 months of were white, older in age, employed part-time, pri- age were much larger than those for the initiation of miparous, did not participate in the WIC program, breastfeeding (Table 1). Except for mothers in the and living in the Mountain and Pacific states. In grade and high school subgroups, for the other sub- contrast to in-hospital breastfeeding, the rate for ex- TABLE 1. Breastfeeding in the Hospital and at 6 Months of Age by Selected Demographic Characteristics, 1996 and 2001 Characteristic In-Hospital At 6 Months 1996, % 2001, % Change, %* 1996, % 2001, % Change, %* All infants 59.2 69.5 17.4 21.7 32.5 49.8 White 63.8 72.2 13.2 24.3 34.2 40.7 Black 37.1 52.9 42.6 11.3 21.9 93.8 Hispanic 60.5 73.0 20.7 19.5 32.8 68.2 Maternal age, y 20 43.3 57.2 32.1 9.6 19.5 103.1 20–24 52.7 65.6 24.5 15.0 25.5 70.0 25–29 62.2 72.8 17.0 23.1 35.1 51.9 30–34 67.5 75.8 12.3 28.5 41.8 46.7 35 69.3 76.1 9.8 33.9 43.7 28.9 Maternal education Grade school 46.8 55.1 17.7 17.6 18.9† 7.4 High school 49.2 61.1 24.2 15.1 23.9† 58.3 College 73.8 82.1 11.2 31.1 45.8 47.3 Maternal employment Employed full-time 60.2 67.6 12.3 14.8 25.1 69.6 Employed part-time 63.3 71.5 13.0 23.4 34.0 45.3 Not employed 57.5 69.0 20.0 24.9 35.8 43.8 Birth weight Low ( 2500 g) 48.0 62.7 30.6 13.1 22.1 68.7 Parity Primiparous 61.0 72.0 18.0 19.7 31.9 61.9 Multiparous 57.4 66.5 15.9 23.6 33.3 41.1 WIC participant Participant 46.6 58.2 24.9 12.9 20.8 61.2 Nonparticipant 70.8 78.9 11.4 29.5 43.2 46.4 US census region New England 60.9 70.8 16.3 23.1 37.1 60.6 Middle Atlantic 53.5 64.0 19.6 19.8 30.3 53.0 East North Central 54.3 64.6 19.0 19.0 27.7 45.8 West North Central 60.8 72.0 18.4 20.8 31.7 52.4 South Atlantic 54.7 65.7 20.1 18.5 29.3 58.4 East South Central 45.1 54.4 20.6 14.0 20.3 45.0 West South Central 53.8 65.9 22.5 16.6 26.8 61.4 Mountain 73.8 82.8 12.2 30.9 44.3 43.4 Pacific 73.9 82.9 12.2 30.7 44.2 44.0 * The percent change % breastfed in 2001 % breastfed in 1996/% breastfed in 1996. † No significant difference between 1996 and 2001. ARTICLES 1105 Downloaded from by on June 2, 2009
  5. 5. TABLE 2. Exclusive Breastfeeding in the Hospital and at 6 feeding their infants at 6 months of age; 17.2% were Months of Age by Selected Demographic Characteristics, 2001 exclusively breastfeeding. Characteristic In-Hospital At 6 Months Some studies have considered the strengths and % % weaknesses of the RLMS.12,13 The RLMS breast- All infants 46.3 17.2 feeding rates have been compared with those from White 52.8 18.7 other national surveys including the 1988 National Black 26.6 10.7 Surveys of Family Growth,6 the 1988 National Hispanic 36.2 16.2 Maternal age, y Maternal and Infant Health Survey,12 and the third 20 34.4 10.3 National Health and Nutrition Examination Survey, 20–24 43.3 13.9 1988 –1994.14 Rates for exclusive breastfeeding from 25–29 49.9 19.1 Phase II (1991–1994) of the third National Health and 30–34 51.9 21.3 35 50.4 21.8 Nutrition Examination Survey were also compared Maternal education with those from the RLMS.15 Results of all these Grade school 29.9 13.3 comparisons demonstrate that despite differences in High school 39.0 12.7 survey methods and design, these surveys report College 57.3 24.0 Maternal employment similar trends and rates of breastfeeding across sev- Employed full-time 44.7 10.4 eral sociodemographic characteristics. The advan- Employed part-time 50.2 16.5 tage of the RLMS is its ability to provide breastfeed- Not employed 46.1 21.2 ing trends on a continuous basis over a long period Birth weight of time.12 The RLMS will be the main instrument Low ( 2500 g) 27.1 8.4 Parity used to monitor progress toward meeting the Healthy Primiparous 47.3 17.0 People 2010 goals.13 Multiparous 45.1 17.3 Between 1996 and 2001, the largest increases in the WIC participant initiation of breastfeeding and continued breastfeed- Participant 33.9 10.0 Nonparticipant 56.5 23.5 ing to at least 6 months occurred among groups of Census region women who have been historically less likely to New England 53.6 20.6 breastfeed: women who were black, younger in age, Middle Atlantic 38.2 15.7 less educated, receiving WIC benefits, and living in East North Central 44.6 14.0 West North Central 56.0 15.8 regions of the country where mothers are less in- South Atlantic 42.8 15.6 clined to breastfeed. Increases in the prevalence of East South Central 36.9 10.8 breastfeeding at 6 months among mothers in these West South Central 41.4 13.9 groups were particularly large. Mountain 56.4 23.4 Pacific 54.2 24.1 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 clusive in-hospital breastfeeding was higher among breastfeeding were less dramatic in these subgroups white women than Hispanic women. because rates of breastfeeding were initially very In 2001, at 6 months of age, as in the hospital, high. exclusive breastfeeding was most common among The gap between breastfeeding and exclusive women who were white, older, college-educated, did breastfeeding in the hospital and at 6 months of age not participate in WIC, and living in the Western has increased through time. In 1971, the gap between regions of the country. Exclusive breastfeeding at 6 breastfeeding and exclusive breastfeeding in the hos- months of age was also more common among pital was only 3%. By 2001, the gap widened to 23%. women who were more experienced (multiparous), At 6 months of age, the gap between breastfeeding or were not working outside their home than among and exclusive breastfeeding increased from 2% in first-time mothers, and mothers who were working 1971 to 15% in 2001. Considering that rates of exclu- part-time or full-time. sive breastfeeding initiation have not increased as rapidly as those for breastfeeding, it is clear that DISCUSSION many more mothers than ever before used supple- Since the RLMS began tracking breastfeeding in mental feedings in the hospital and at 6 months of the United States in 1954, the percentage of mothers age. who nursed their infants has fluctuated widely. After The effect that early introduction of formula has dropping steadily throughout the late 1950s and on breastfeeding initiation and duration is equivocal. 1960s, initiation of breastfeeding reached its lowest A recent meta-analysis of 9 randomized, controlled level in 1971, with only 24.7% of mothers breastfeed- trials involving 3730 women found that when hospi- ing. By 1982, initiation of breastfeeding had in- tal discharge packages (with or without formula) creased dramatically, to 61.9%, but by 1990 it had were distributed to new mothers, the number of dropped again, to 51.5%. Now, the RLMS indicates women exclusively breastfeeding was slightly re- that breastfeeding is more popular than ever. In 2001, duced, but there was no effect on early termination 69.5% of mothers breastfed their infants in the hos- of any breastfeeding (women who were using sup- pital; 46.3% of mothers exclusively breastfed their plements).16 Howard et al17 compared the effect that infants. In 2001, 32.5% of mothers were still breast- prenatal distribution of formula company materials, 1106 BREASTFEEDING CONTINUES TO INCREASE INTO THE NEW MILLENNIUM Downloaded from by on June 2, 2009
  6. 6. advertising, and samples had on breastfeeding pat- ployed women began breastfeeding, but at 6 months terns. They found that these materials did not signif- postpartum, only 10% of full-time working mothers icantly effect breastfeeding initiation and duration, were still breastfeeding, compared with 24% of those but women who received formula promotion mate- not employed.5 In 2001, maternal employment still rials were more likely to cease breastfeeding before had little effect on the initiation of breastfeeding or hospital discharge or before 2 weeks postpartum. exclusive breastfeeding. However, full-time employ- Using data from the RLMS, Ryan18 considered the ment was associated with early weaning, but to a effects that infant formula discharge packages, socio- much smaller degree than seen in the 1980s.5,23,24 demographic characteristics, and breastfeeding in- In 2001, mothers working part-time were more structions had on exclusive and any breastfeeding at likely to initiate and continue breastfeeding or exclu- 1 and 4 months of age. Stepwise regression analysis sive breastfeeding relative to those working full- indicated that discharge kits did not exert as large an time; rates for breastfeeding among part-time work- effect on breastfeeding as other factors such as ma- ing mothers exceeded those observed at the national ternal employment, family income, maternal educa- level. At 6 months of age, part-time working mothers tion, parity, and breastfeeding instructions. Women were also more likely to use supplemental feedings who received a formula discharge kit compared with than mothers who worked full-time or were not em- those who did not had a slightly higher probability ployed. Fein and Roe25 found that part-time work of initiating any breastfeeding in the first (10% vs 7%) was an effective strategy to help new mothers com- and fourth month (27% vs. 25%.). In addition, rela- bine breastfeeding and employment by providing tive to other sociodemographic factors that influence mothers more access to their infant. The likelihood breastfeeding initiation and duration, 2 randomized that mothers will continue to breastfeed after return- clinical studies reported that the inclusion of formula ing to work may also depend on the mother’s occu- in discharge packages did not decrease the duration pation. Women employed as professionals may have of exclusive or any breastfeeding19 or had at best a more control over their environment and may have very modest effect on breastfeeding feeding method more flexibility to met both the needs of their job and and breastfeeding duration.20 their infant.23 The Healthy People 2010 goal for the initiation of The recent increase in breastfeeding among low- breastfeeding was identical to that established for income women may be attributable to program 2000: 75% breastfeeding in the early postpartum pe- changes within WIC and the targeting of breastfeed- riod.21,22 In 2001, this goal was exceeded by mothers ing promotion materials to meet the specific needs of who were older ( 35 years of age), college-educated, these women,26,27 Programs such as peer counseling not participating in WIC, and living in the Mountain (provided by those who have previously breastfed and Pacific states. In the Mountain and Pacific re- and have been on WIC),28 intensive breastfeeding gions of the United States, 8 of 10 infants were informational and support campaigns for inner-city breastfed in the hospital. mothers,29 the development of the Best Start Pro- The Healthy People 2000 and Healthy People 2010 gram30 and the Baby-Friendly Hospital Initia- goal for continued breastfeeding to 5 to 6 months tive,31,32,33 have had a positive, significant impact on postpartum was earmarked to be at least 50%.21,22 In breastfeeding rates even in high-risk populations. 2001, this goal was not achieved by any sociodemo- Recently, the Department of Health and Human graphic subgroup and disparities still existed across Services (DHHS) Blueprint for Action on Breastfeeding many subgroups. Moreover, despite the relative high introduced a plan for breastfeeding that involves increases in the rates of in-hospital breastfeeding and education, training, awareness, support and re- continued breastfeeding to 6 months of age, rates for search.34 This plan provides detailed recommenda- breastfeeding among low birth weight infants fell tions for the promotion of breastfeeding. Certain short of the national averages. populations such as adolescents and ethnic minori- From 1996 –2001, the RLMS rates of in-hospital ties need to be targeted. Black adolescents are typi- breastfeeding increased approximately 2% per year cally less likely to be encouraged to breastfeed by nationally and 3% per year in some sociodemo- their health care providers, mothers, partner, or graphic subgroups (eg, 3.2% per year among blacks). peers.35 The primary reason given by black women Assuming the 2% per year rate of increase, in-hospi- for not breastfeeding was that they preferred bottle- tal breastfeeding rates at the national level and in feeding.36 This suggests that black women bottle- every sociodemographic group of women should feed their infants not because of employment or meet or exceed the Healthy People 2010 goal. Contin- physical difficulties but because of preference.36,37 ued breastfeeding at 6 months of age also increased Although black and Latino adolescents recognized about 2% per year nationally and across many sub- that breastfeeding offers many health benefits to groups. At this rate, the Healthy People 2010 goal may both the mother and infant, fear or pain, embarrass- not be reached by several subgroups including ment with public exposure and unease with the act women who are black, less educated, and participat- of breastfeeding acted as significant barriers.38 ing in WIC. Among low-income mothers, barriers to breastfeed- In the 1980s, full-time work had no effect on the ing were also associated with their perceptions of initiation of breastfeeding but had a profound effect social disapproval of breastfeeding in public, reports on the duration of breastfeeding.5,23 For example, in of ridicule by friends, lack of support from some 1988, an equal number of employed and nonem- health providers, and difficulties associated with em- ARTICLES 1107 Downloaded from by on June 2, 2009
  7. 7. ployment.39 Thus, mothers must be equipped with APPENDIX. Breastfeeding and Exclusive Breastfeeding in the strategies designed to deal with perceptions of dis- Hospital and at 6 Months of Age by Year, 1965–2001 approval.39 A culturally sensitive approach that re- Year In-Hospital At 6 Months flects the woman’s familial social network, including % % encouragement from the infant’s father or the wom- Breastfeeding Exclusive Breastfeeding Exclusive an’s mother40,41,42 is also needed. Because decisions Breastfeeding Breastfeeding on whether to breastfeed are made early, positive 1965 28.2 24.5 attitudes and education concerning breastfeeding 1966 27.6 22.9 need to be developed before pregnancy and must be 1967 27.6 24.1 1968 28.7 25.3 provided throughout the pregnancy, perinatal, and 1969 28.4 25.3 postpartum period.43,44 1970 26.5 23.2 The workplace can be a barrier for the mother who 1971 24.7 21.7 5.4 3.2 decides to breastfeed. Legislative efforts have been 1972 28.1 24.8 5.0 3.1 1973 28.9 25.2 7.5 4.7 put into place to protect women’s rights to breastfeed 1974 32.2 27.8 6.5 5.2 after returning to work and to encourage employees 1975 35.5 31.1 14.1 10.3 to provide a safe, private environment for women to 1976 41.6 36.2 17.0 12.7 express (or pump) breast milk.45 Continued efforts in 1977 44.7 39.4 19.6 14.1 1978 46.6 41.7 18.9 13.7 the areas of improving attitudes, workplace policies, 1979 51.0 45.8 21.3 16.1 and a positive media portrayal of breastfeeding as 1980 55.3 49.5 23.2 17.0 the normal and preferred method of feeding infants 1981 57.6 51.5 25.1 17.8 will help promote and support breastfeeding in the 1982 61.9 55.0 27.1 19.8 1983 58.4 51.2 23.3 16.5 workplace. 1984 59.7 52.1 23.8 16.7 The health care system has an important role to 1985 58.0 50.6 22.1 14.5 play in the promotion and support of breastfeeding. 1986 56.9 49.3 21.6 14.0 Lu et al46 indicated that in populations less likely to 1987 55.5 47.6 20.2 13.1 1988 54.3 46.1 19.5 12.5 breastfeed, encouragement by nurses and physicians 1989 52.2 44.3 18.1 11.0 significantly increased breastfeeding initiation. 1990 51.5 43.5 17.6 10.4 Women who were encouraged by their physicians 1991 53.3 44.2 18.2 10.9 1992 54.2 44.5 18.9 11.1 and nurses to breastfeed were 4 times as likely to 1993 55.9 45.2 19.0 10.7 initiate breastfeeding than women who did not re- 1994 57.4 46.8 19.7 11.2 ceive such encouragement.46 1995 58.9 47.6 20.8 11.9 In a national survey of pediatric residents and 1996 59.2 47.3 21.7 12.2 1997 62.4 46.1 26.0 12.7 practicing physicians, 70% of practitioners indi- 1998 64.3 46.2 28.6 13.8 cated that more time needs to be devoted to direct 1999 67.2 46.3 30.7 15.8 patient interaction and practice of counseling and 2000 68.4 46.0 31.4 16.0 problems solving skills related to assist breastfeeding 2001 69.5 46.3 32.5 17.2 mothers.47 Breastfeeding knowledge, attitudes, train- ing, and experience among residents and practicing physicians in family medicine, obstetrics/gynecol- REFERENCES ogy, and pediatrics also demonstrate that more 1. 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  9. 9. Breastfeeding Continues to Increase Into the New Millennium Alan S. Ryan, Zhou Wenjun and Andrew Acosta Pediatrics 2002;110;1103-1109 DOI: 10.1542/peds.110.6.1103 Updated Information including high-resolution figures, can be found at: & Services References This article cites 37 articles, 21 of which you can access for free at: Citations This article has been cited by 66 HighWire-hosted articles: les Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition & Metabolism m Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on June 2, 2009