Hospitals Can Help Mothers Meet Breastfeeding Goals

by Heidi Green
June 14, 2012

Health experts across the U.S. and worldwide recommend that babies be breastfed exclusively for their first six months but few mothers in the U.S. achieve that goal. One in three mothers (35 percent) breastfeed exclusively for three months, and only 15 percent breastfeed exclusively for six months.

Why so few U.S. women breastfeed exclusively for six months is unclear. How does the “official” goal compare with that of U.S. women? What role might hospital practices play in helping women achieve their personal goals for exclusive breastfeeding? A recently published study sought to shed light on these issues.

Research
Perrine and colleagues analyzed data from the Infant Feeding Practices Study II (IFPS II), a national survey of infant feeding and care conducted from 2005–2007 by the Food and Drug Administration (FDA) in conjunction with the Centers for Disease Control and Prevention (CDC). Women were recruited for the study in their third trimester of pregnancy. Inclusion criteria were: age 18 years or older, mother and baby free of medical conditions that would affect feeding, and baby born after at least 35 weeks of gestation with a birthweight of at least 5 pounds. Participants completed one survey before their baby’s birth; afterwards, they received 10 more surveys, roughly one each month.

Women’s intention to breastfeed was determined by their response to a question on the prenatal survey: “What method do you plan to use to feed your baby in the first few weeks?” The researchers classified participants as intending to exclusively breastfeed if they answered “breastfeed only” to this question. Other options were: “formula-feed only,” “both breast and formula feed,” or “don’t know yet.”

A follow-up question for women who intended to breastfeed exclusively asked, “How old do you think your baby will be when you first feed him or her formula or any other food besides breast milk?” The researchers classified responses as “less than 1 month,” “1–2 months,” “3–4 months,” “5–6 months,” or “7 months or longer.”

The initial post-birth questionnaire evaluated the mother’s hospital stay. Mothers were asked questions about six of the Ten Steps to Successful Breastfeeding developed by the World Health Organization (WHO):

• breastfeeding initiation within one hour of their babies’ birth
• no food/drink other than breast milk in the hospital
• babies rooming in with their mothers
• breastfeeding on demand
• not giving pacifiers to babies
• information on breastfeeding support

The questionnaire also assessed how the mother was feeding her baby when she left the hospital. If the mother was breastfeeding her baby at hospital discharge, she was classified as “exclusively breastfeeding” for purposes of data analysis, even if the hospital had given the baby formula, water, or glucose water during the hospital stay.

Exclusive breastfeeding was assessed on each monthly survey as the mother indicated what food her baby had received during the preceding seven days. This feeding data was used to calculate exclusive breastfeeding duration, then compared with each mother’s personal goal.

Results
More than 85 percent of study participants said they intended to exclusively breastfeed for at least three months, and over half (57.8 percent) intended to exclusively breastfeed for at least five months. In spite of this, only 45.3 percent of mothers actually exclusively breastfed their babies for three months, and just 24.9 percent exclusively breastfed for five months or more. In fact, a whopping 41.6 percent of mothers introduced formula supplements before their babies were even a month old.

Less than one-third (32.4 percent) of study participants met their personal breastfeeding goals for exclusive breastfeeding.

In this study, mothers who were married or who had given birth to babies before were more likely to meet their goals. Those who were obese, who smoked, or whose goals were longer in duration were less likely to meet their goals.

Looking at the hospital practices assessed in this study, the researchers determined that only giving babies no food or drink other than breast milk had a statistically significant impact on mothers reaching their breastfeeding goals. While 84.6 percent of mothers reported that they were exclusively breastfeeding when they left the hospital, 41.1 percent of those babies had received formula, water, or glucose in the hospital. Given that breastfeeding is a supply-and-demand function, and the days after birth are a crucial period for the mother to establish a full and adequate milk supply to meet her baby’s needs, this figure is troubling.

The Academy for Breastfeeding Medicine (ABM), an international multi-disciplinary group of physicians, identifies very limited circumstances for supplementary feeding in the hospital. Since this study did not involve analysis of medical records, we cannot know how many participants met the ABM’s criteria.

Limitations
The study has some limitations. First, although the survey enrolled women nationwide, 84 percent of participants were white. It is unclear how the study findings may have been different if the study population included more mothers who were black, Hispanic, and/or Asian/Pacific Islanders, or whether these findings can be generalized to those populations.

Second, the study gives an incomplete picture of hospitals’ role in supporting breastfeeding, as described in the WHO’s Ten Steps to Successful Breastfeeding. Mothers may be unaware of some steps (specifically #1, “Have a written breastfeeding policy that is routinely communicated to all health care staff,” and #2 “Train all health care staff in skills necessary to implement this policy”). However, it seems it would have been very helpful for researchers to include step #5 in this study: “Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.” Perhaps it is not enough that 62.6 percent of mothers were able to initiate breastfeeding within the first hour (step #4); very likely many mothers needed breastfeeding help after that first experience, and this study leaves us wondering whether or not those mothers got any help at all.

Similarly, it would be helpful to know whether mothers felt their health care staff had completed step #3: “Inform all pregnant women about the benefits and management of breastfeeding.” More than half of women intended to exclusively breastfeed less than five months, in spite of expert recommendations of six months. What information regarding the benefits of breastfeeding did the women have when they set their personal goals?

Recommendations
The smoking gun here seems to be the high rate of in-hospital supplementation of infants whose mothers intended to breastfeed exclusively. With only 143 hospitals or birthing centers in the U.S. certified as baby-friendly to date, expectant mothers can’t assume their hospital will provide best-practices breastfeeding care. Some tips:

• Be prepared. The Ten Steps calls for women to be informed about “the benefits and management of breastfeeding” during pregnancy. Breastfeeding isn’t always easy, and mothers who know what to expect are less likely to fall into “booby traps” such as early supplementation. (For example, a mother’s post-colostrum milk often doesn’t arrive until 3–5 days postpartum, well after the typical 48-hour hospital stay. Putting the baby to breast often during the first days, when the baby doesn’t yet need a lot of milk, helps ensure a good milk supply.)
• Arm yourself with the facts. Know when formula supplementation might be called for, so you can opt out when formula clearly isn’t necessary. Some hospitals offer breastfeeding classes to expectant parents.
• Bring your own support. It’s no surprise that married women were more likely to reach their breastfeeding goals; it helps to have someone in your corner. Discuss your breastfeeding intentions with a supportive partner, and consider enlisting the help of a doula during your labor and postpartum recovery. If the postpartum nurse seems unable to provide the breastfeeding support you need, consider a lactation consultant. Some hospitals have lactation consultants on staff who are available to provide help during your hospital stay or after you return home; ask your health care provider if these services are available to you.
• Keep your baby close. Keeping your baby in the room with you (e.g., “rooming in”) helps you to learn, and respond to, your baby’s hunger cues. And skin-to-skin contact during the first hour after birth and throughout your hospital stay encourages your baby to breastfeed early and often, a critical part of establishing a good milk supply.