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Breastfeeding Status On Us Birth Certificates Where Do We Go From Here

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Breastfeeding Status On Us Birth Certificates Where Do We Go From Here

  1. 1. Breastfeeding Status on US Birth Certificates: Where Do We Go From Here? Donna J. Chapman, Anne Merewood, Robert Ackatia Armah and Rafael Pérez-Escamilla Pediatrics 2008;122;e1159-e1163 DOI: 10.1542/peds.2008-1662 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/122/6/e1159 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 © 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on June 2, 2009
  2. 2. ARTICLE Breastfeeding Status on US Birth Certificates: Where Do We Go From Here? Donna J. Chapman, PhD, RDa, Anne Merewood, MPH, IBCLCb, Robert Ackatia Armah, BSc, MPhilb, Rafael Perez-Escamilla, PhDa ´ aDepartment of Nutritional Sciences, Center for Eliminating Health Disparities Among Latinos, University of Connecticut, Storrs, Connecticut; bDivision of General Pediatrics, Boston Medical Center, Boston, Massachusetts The authors have indicated they have no financial relationships relevant to this article to disclose. What’s Known on This Subject What This Study Adds In 2003, the US SCLB was revised and for the first time included a question on breast- In May 2008, 79% of US states reported that breastfeeding data were currently collected feeding; however, states are required neither to use the SCLB nor to adopt the exact on the birth certificate or would be collected within the next 2 years. The wording of the wording of SCLB questions. breastfeeding question is not standardized. Suggestions are provided for revision. ABSTRACT OBJECTIVES. The objectives of this study were to assess the extent to which states collected breastfeeding data on the birth certificate, to verify the wording of the breastfeeding questions used, and to develop recommendations for future revisions www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1662 of the breastfeeding question asked on the US Standard Certificate of Live Birth. doi:10.1542/peds.2008-1662 METHODS. Registrars of vital statistics in US states and territories were contacted via Key Words telephone with e-mail follow-up between April 2006 and May 2008 to determine breastfeeding, Standard Certificate of Live whether their state/territory collected breastfeeding data on its birth certificate. Birth, birth certificate, US birth certificate, exclusive breastfeeding Responses were categorized as follows: (1) breastfeeding data currently collected; (2) Abbreviations breastfeeding data not currently collected but implementation date set; or (3) breast- SCLB—Standard Certificate of Live Birth feeding data not currently collected and no implementation plans. PRAMS—Pregnancy Risk Assessment Monitoring System RESULTS. In May 2008, 56.6% (30 of 53) of US states and territories were collecting data Accepted for publication Aug 15, 2008 on breastfeeding status at hospital discharge on their birth certificate. The questions Address correspondence to Donna used to collect breastfeeding data, however, had not been standardized. Approxi- J. Chapman, PhD, RD, University of mately one quarter (12 of 53) reported that they were not yet collecting breastfeed- Connecticut, Department of Nutritional Sciences, 3624 Horsebarn Rd Extension, Storrs, ing data on their birth certificate but that an implementation date had been set. CT 06269-4017. E-mail: donna.chapman@ Approximately one fifth (11 of 53) indicated that their state birth certificate did not uconn.edu plan to collect breastfeeding data by January 2010. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2008 by the CONCLUSIONS. A total of 79% of the registrars reported that breastfeeding data were American Academy of Pediatrics collected on the birth certificate or that the process would begin within the next 2 years. Future revisions to the Standard Certificate of Live Birth breastfeeding question should assess breast- feeding exclusivity. The revision process should include feedback from health professionals who collect these data, pretesting of the revised question for feasibility, and extensive training before data collection. Pediatrics 2008;122:e1159–e1163 E LEVEN FEDERALLY FUNDED US surveys/data sets collect data on breastfeeding practices; however, issues such as sampling procedures, recall bias, inconsistent wording of the breastfeeding questions, and limited racial/ethnic category choices constrain the extent to which these data can be generalized.1 In 2003, the US Standard Certificate of Live Birth (SCLB) was revised and for the first time included a question on breastfeeding. The SCLB is a model or template birth certificate that can be adopted or modified by individual states. In the “newborn” section of this document, breastfeeding status is assessed by using the question, “Is the infant breastfed at discharge?” with the responses listed as “yes” and “no.”2 This question is designed to capture breastfeeding status at hospital discharge, and because SCLB breastfeeding data should be collected for all newborns in participating states, these data should be representative at the state level. It has limitations, however, because it does not directly assess breastfeeding initiation and does not measure breastfeeding exclusivity. Given the limitations of the federally funded surveys in assessing US breastfeeding outcomes, the inclusion of a carefully constructed breastfeeding question on the SCLB has the potential to make a valuable contribution to our knowledge on breastfeeding practices during the early postpartum period. The SCLB contains a wealth of information on relevant confounders that may affect breastfeeding rates, including maternal and paternal variables (age, education, birthplace, and race/ethnicity), maternal variables (height; prepregnancy weight; marital status; smoking status; participation in Special Supplemental Nutrition Program for Women, Infants, and PEDIATRICS Volume 122, Number 6, December 2008 e1159 Downloaded from www.pediatrics.org by on June 2, 2009
  3. 3. FIGURE 1 US map indicating status of breastfeeding data collection on birth certificates. Children; parity; pregnancy risk factors; delivery method; text of their question to the research assistant. New York and insurance status), and infant variables (birth weight, City was included as a separate entity from the state of Apgar scores, and gestational age). Thus, the SCLB data New York in our analyses. This was done because, as could be analyzed for determinants of breastfeeding out- reported in other analyses of birth certificate data,8,9 New comes. York City and New York State use different birth certif- Breastfeeding data derived from birth certificates icates. have been used to evaluate factors that affect breastfeed- Follow-up e-mail surveys were sent approximately ing initiation3–7; however, states are required neither to every 4 months to recontact registrars who had not use the SCLB nor to adopt the exact wording of SCLB responded. Registrars who did not respond by July 1, questions. The objectives of this study were to assess the 2007, were recontacted by telephone to verify their in- extent to which US states and territories collected breast- formation. States that were categorized as not collecting feeding data on the birth certificates, to verify the word- breastfeeding data (with or without implementation ing of the breastfeeding questions used, and to develop dates) were recontacted by telephone and e-mail every 3 recommendations for future revisions of the SCLB months between December 2007 and May 2008 to de- breastfeeding question. termine whether their status had changed. Data were tabulated in Microsoft Excel (Redmond, WA). This study METHODS was not subject to institutional review board approval To assess the extent to which breastfeeding data were because no private, identifiable information was ob- collected on birth certificates, the registrar of vital statis- tained. tics in each of the 50 states plus New York City, Wash- ington, DC, and 4 US territories (Puerto Rico, Guam, US RESULTS Virgin Islands, and American Samoa) were contacted via Responses were received from 100% of the state vital telephone by a research assistant in Spring 2006, with statistics registrars (including Washington, DC, and New e-mail follow-up beginning in August 2006. During York City) and from 1 of the 4 registrars in a US territory these contacts, registrars were asked whether their state (Puerto Rico). Among those who responded, 56.6% (30 was collecting breastfeeding data on their birth certifi- of 53) were collecting data on breastfeeding status on cate. Responses were recorded as follows: (1) breastfeed- their state birth certificate (Fig 1). Approximately one ing data currently collected; (2) breastfeeding data not quarter of the registrars (12 of 53) reported that they currently collected but a planned implementation date were not yet collecting breastfeeding data on their birth set; or (3) breastfeeding data not currently collected and certificate but that they had a scheduled date to begin no planned implementation date. Registrars who re- implementation of a revised birth certificate that would sponded that breastfeeding data were collected were collect breastfeeding data. Approximately one fifth (11 requested to verify the wording of their breastfeeding of 53) indicated that their state birth certificate did not question, either by sending an electronic template of the plan to collect breastfeeding data by January 2010. In birth certificate worksheet or by providing the verbatim total, 79% (42 of 53) of the registrars reported that their e1160 CHAPMAN et al Downloaded from www.pediatrics.org by on June 2, 2009
  4. 4. TABLE 1 Summary of the Questions Used to Assess Breastfeeding Status on State Birth Certificates Wording of Questiona No. of Specific States States 1. Is the infant being breastfed at discharge? (Yes/no) 5 Delaware, Iowa, Montana, Vermont, Wyoming (Yes/no/unknown) 6 Indiana, Kansas, New Hampshire, New Mexico, Ohio, Oregon (Yes/no/infant transferred, status unknown) 1 Texas 2. Is infant being breastfed at time of discharge? (Yes/no) 1 South Dakota (Yes/no/unknown) 1 North Dakota 3. Is infant being breastfed? (Yes/no) 8 Florida, Idaho, Kentucky, Nebraska, Pennsylvania, South Carolina, Tennessee, Washington 4. Is infant being breastfed, even partially? (no, unknown, yes) 1 Georgia 5. Is the infant receiving breast milk at discharge? (yes/no) 1 Colorado 6. Are you breastfeeding or do you intend to breastfeed? 1 Massachusetts (yes/no) 7. Breast feeding initiated, planned or not planned? (Initiated, planned, not planned, unknown) 1 Michigan 8. Feeding at discharge (check one) (Breast feeding, formula, combination, other) 1 New Jersey 9. How is infant being fed at discharge? (select one) Breast milk only, formula only, both breast milk and 1 New York State formula, other, do not know 10. How is infant being fed (check one): breast milk only, 1 New York City formula only, both, neither (ie, infant may be on intravenous fluids) 11. Method of feeding: (bottle, breast, or both) 1 Washington, DC a Slight variations in wording are grouped together. state was already collecting breastfeeding data on the are being used to collect breastfeeding data are not birth certificate or had a planned implementation date to standardized. Only 5 states use the exact wording of do so. the breastfeeding question and responses specified by The questions that were used to assess early breast- the SCLB. Six states plus New York City and Wash- feeding practices varied by state (Table 1). Among the 30 ington, DC, have developed their own questions. The localities (29 states and New York City) that collected wide variation in the wording of the breastfeeding breastfeeding data, 40% (12 of 30) used the wording of question adopted for use on individual state birth the breastfeeding question on the SCLB (“Is the infant certificates suggests dissatisfaction with the breast- being breastfed at discharge?”). Five of these states used feeding question originally specified in the US SCLB. the responses specified on the SCLB (“yes/no”), whereas Because the SCLB is periodically revised, we offer 7 added the option to respond “unknown.” Two addi- some suggestions for the future modifications of the tional states used a nearly identical question (“Is the breastfeeding question. infant being breastfed at time of discharge?”), each with We strongly recommend that future revisions of the a different set of potential responses. Eight states used a SCLB breastfeeding question assess breastfeeding exclu- slightly abbreviated form of the SCLB breastfeeding sivity during hospitalization. Increasing exclusive breast- question and asked “Is infant being breastfed? (yes/no).” feeding is a national public health priority,10 but, unfor- Eight states or municipalities developed their own tunately, a high percentage of breastfed infants start unique question. Half of these birth certificates (New receiving formula during their hospitalization.11 Data on Jersey, New York State, New York City, and Washing- in-hospital rates of exclusive breastfeeding would be ton, DC) included language that permitted analysis of useful at the state, county, and hospital levels to assess the exclusivity of breastfeeding. Some of the states that the adequacy of breastfeeding promotion efforts and reported not collecting breastfeeding data on their birth monitor progress toward improvement in breastfeeding certificate indicated that these data were being collected practices. It should be recognized that these exclusive by using other systems, such as a Newborn Screening breastfeeding data are likely to overestimate the true Test form or via the Pregnancy Risk Assessment Moni- incidence of exclusive breastfeeding. Because of time toring System (PRAMS) survey. constraints, the review of feeding practices may be lim- ited to the last 24 hours of the hospital stay, as done in DISCUSSION New Jersey.3 Thus, infants who were supplemented with In the majority of states, breastfeeding data are col- non– breast milk substances early during their hospital lected on the birth certificate, or this process will begin stay and then received only breast milk for the remain- within the next 2 years; however, the questions that der of their hospitalization would be misclassified as PEDIATRICS Volume 122, Number 6, December 2008 e1161 Downloaded from www.pediatrics.org by on June 2, 2009
  5. 5. exclusively breastfed. Despite this limitation, these data have resulted from analysis of birth certificate– derived are extremely useful, because they provide valuable in- breastfeeding data.3–7,12 sights regarding the adequacy of in-hospital lactation Ten states and Puerto Rico indicated that they do not support and allow benchmarking comparisons among have plans to collect breastfeeding data on their birth hospitals, counties, and states. certificates. Some of these states are collecting breast- The exact wording of this question should be devel- feeding data through alternative sources, such as the oped with guidance from experts in the areas of lactation newborn screening programs. Other states reported col- and public health and those currently involved in data lecting these data with PRAMS; however, given the collection. It would be essential to obtain feedback from smaller sample size and the longer recall period involved Vital Records Registrars in New Jersey, New York State, with the PRAMS survey, this does not represent an New York City, and Washington, DC, where data on adequate substitute for collection of breastfeeding data breastfeeding exclusivity are currently collected on the on the birth certificate. birth certificate. Once developed, the breastfeeding question should be pilot tested for feasibility. Two states CONCLUSIONS (Michigan and Massachusetts) ask about both breast- Within the next 2 years, nearly 80% of US states are feeding intentions and initiation in a single question. expected to be collecting breastfeeding data on their This seems particularly confusing, because different re- birth certificate. This represents a significant contribu- sponses may be obtained, depending on the timing of tion to our national breastfeeding surveillance efforts, the question (prenatal versus postpartum). Given that because data should be collected for every newborn in feeding intentions are not always predictive of infant every participating state, thereby avoiding the potential feeding practices,12 we recommend that breastfeeding for sampling bias. Because birth certificates also collect intentions should not be documented on the birth cer- data on several relevant variables that are known to tificate. affect breastfeeding outcomes, the inclusion of a breast- In addition to standardized wording, the adminis- feeding question on birth certificates has a strong poten- tration of the birth certificate breastfeeding question tial to improve breastfeeding surveillance in the United should be standardized. The breastfeeding question States. Consistent with the Healthy People 2010 guide- typically appears on the Facility Worksheet, designed lines, we strongly encourage all states and US territories to be completed by health professionals. Process eval- to collect exclusive breastfeeding data on their birth uation should be conducted to determine exactly how certificates and to monitor this outcome closely. Standard- this question is currently answered and by whom. For ization of the breastfeeding question that is used on state example, is the mother interviewed, is the medical birth certificates should be a priority so that breastfeeding chart/infant feeding record reviewed, or are the data outcomes can be compared across states. The revision of entered from an electronic source? If mothers are this question should involve a process that includes feed- interviewed, then accurate translation of the stan- back from health professionals who collect these data, pre- dardized question should be developed in multiple testing of the revised question for feasibility, and training of languages. The timing of the data collection should be professionals who collect these data. consistent, to capture accurately the desired out- comes. If the phrase “at discharge” is included in ACKNOWLEDGMENTS future revisions, then it will be necessary to specify This research was supported by National Institutes of the meaning of “at discharge.” For example, does “at Health NCMHD EXPORT grant P20 MD001765. We discharge” refer to last 24 hours of hospitalization as is thank Lisa Phillips, Khara Leon and Ellen Meisterling for currently the case in New Jersey3? Alternatively, their assistance. should only the last 2 to 4 documented in-hospital feedings be assessed, to capture feeding practices clos- REFERENCES est to discharge? We do not recommend the use of the 1. Chapman D, Perez-Escamilla R. US national breastfeeding ´ last hospital feeding to answer this question, because monitoring and surveillance: current status and recommenda- tions. J Hum Lact. In press this would misclassify mixed feeders as either breast- 2. Kirby R, Salihu H. Back to the future? A critical commentary feeding or formula feeding. Thorough training of on the 2003 US national Standard Certificate of Life Birth. health professionals who collect birth certificate Birth. 2006;33(3):238 –244 breastfeeding data are essential, to maximize the use- 3. Kruse L, Denk C, Feldman-Winter L, Rotondo F. Comparing fulness of these data for breastfeeding surveillance sociodemographic and hospital influences on breastfeeding ini- purposes. tiation. 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  7. 7. Breastfeeding Status on US Birth Certificates: Where Do We Go From Here? Donna J. Chapman, Anne Merewood, Robert Ackatia Armah and Rafael Pérez-Escamilla Pediatrics 2008;122;e1159-e1163 DOI: 10.1542/peds.2008-1662 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/122/6/e1159 References This article cites 8 articles, 2 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/122/6/e1159#BIBL Citations This article has been cited by 1 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/122/6/e1159#otherarti cles Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition & Metabolism http://www.pediatrics.org/cgi/collection/nutrition_and_metabolis m Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org by on June 2, 2009

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