Prenatal Breastfeeding Counseling — Pregnancy Risk Assessment Monitoring System, United States, 2010

Jennifer N. Lind, PharmD1,2,3

Indu B. Ahluwalia, PhD4

Cria G. Perrine, PhD2,3

Ruowei Li, MD, PhD2

Leslie Harrison, MPH4

Laurence M. Grummer-Strawn, PhD2,3

1Epidemic Intelligence Service, CDC

2Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC

3US Public Health Service Commissioned Corps

4Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Jennifer N. Lind, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 404-498-4339; E-mail: vox2@cdc.gov.

Introduction

Breastfeeding is a highly effective preventive measure a mother can take after birth to protect the health of her infant, as well as her own. Immunologic and antiinflammatory properties of breast milk protect against numerous illnesses and diseases in children (1). Benefits of breastfeeding for infants include a lower risk for ear infections (2), atopic dermatitis (3), lower respiratory tract infections (4), sudden infant death syndrome (SIDS) (2,5), necrotizing enterocolitis (NEC) in preterm infants (2), type 2 diabetes (6), asthma (7), and childhood obesity (8–10). For mothers, benefits of breastfeeding include a lower risk for breast cancer (11–13) and ovarian cancer (2). Increasing rates of breastfeeding and therefore its health benefits might lower health-care costs. A recent study found that if higher rates of mothers complied with medical recommendations for breastfeeding, an estimated $2.2 billion in additional direct medical costs would be saved annually in the United States (14).

The American Academy of Pediatrics (AAP) stated in its 2012 policy statement on breastfeeding that exclusive breastfeeding for the first 6 months of life is sufficient to support optimal growth and development and recommended that breastfeeding be continued for at least the first year of life and beyond (15). In 2010, the Joint Commission included exclusive breastfeeding during the newborn's entire hospitalization as part of a set of five nationally implemented measures that address perinatal care, endorsed by the National Quality Forum (NQF #0480) (16). Within the last decade, breastfeeding rates have been increasing; however, despite overall improvements, rates for breastfeeding duration remain relatively low, with only 49.4% of U.S. infants breastfed to any extent at age 6 months and only 18.8% of children exclusively breastfed through the recommended age of 6 months (17). Healthy People 2020 national breastfeeding objectives are to increase the proportion of infants who are ever breastfed to 81.9%, who are breastfed to any extent at 6 months to 60.6% and at 1 year to 34.1%, and who are exclusively breastfed through 3 months to 46.2% and through 6 months to 25.5% (objectives MICH-21.1, 21.2, 21.3, 21.4 and 21.5) (18).

AAP cites insufficient prenatal education about breastfeeding as an obstacle to initiation and continuation of breastfeeding (19). The U.S. Preventive Services Task Force (USPSTF) found adequate evidence indicating that interventions, such as formal breastfeeding education for mothers and families, increase the rates of initiation, duration, and exclusivity of breastfeeding. Therefore, the USPSTF guidelines recommend interventions during pregnancy and after birth to promote and support breastfeeding. This is a USPSTF Grade B recommendation, which means that there is moderate certainty that the interventions have a moderate net benefit (20). In addition, AAP, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists all recommend that pregnant women receive breastfeeding education and counseling throughout the perinatal period (19,21,22). Public health officials and clinicians play an important role in promoting and supporting breastfeeding and have the opportunity to not only increase mothers' breastfeeding knowledge and skills but also to influence attitudes toward breastfeeding by providing and encouraging the use of breastfeeding education and support during pregnancy and postpartum.

The reports in this supplement provide the public and stakeholders responsible for infant, child, and adolescent health (including public health practitioners, parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) with easily understood and transparent information about the use of selected clinical preventive services that can improve the health of infants, children, and adolescents. The topic in this report is one of 11 topics selected on the basis of existing evidence-based clinical practice recommendations or guidelines for the preventive services and availability of data system(s) for monitoring (23). This report analyzes 2010 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to estimate the proportion of women with recent live births who received breastfeeding counseling during prenatal care visits. Public health professionals and clinicians can use the data to identify specific subgroups of women and geographic areas in need of targeted interventions to increase prenatal breastfeeding counseling rates in the United States.

Methods

To estimate the proportion of women who received counseling on breastfeeding during the prenatal period, CDC analyzed 2010 data from PRAMS, a multistate, population-based surveillance system that collects data on a wide range of maternal behaviors and experiences before, during, and after pregnancy (24).

In 2010, PRAMS surveys were administered by 37 states and New York City (all of which are referred to as states in this report). New York City and New York State have separate vital registration systems; therefore, they are included as separate geographic entities. Each month, participating states select a stratified random sample from birth certificate records of 100–300 women with recent live births, for an annual sample of approximately 1,300–3,400 women in each participating state. A questionnaire is mailed to mothers 2–6 months after delivery. The participating sites use a standard core questionnaire to which they can add questions. Women receive up to three questionnaire mailings and receive follow-up by telephone if they do not respond. The PRAMS 2010 question on prenatal breastfeeding counseling was: "During any of your prenatal care visits, did a doctor, nurse, or health-care worker talk with you about any of the things listed below?" Among a list of 12 items, one focuses on breastfeeding: "Breastfeeding my baby," with response options of no or yes. The estimation of breastfeeding counseling coverage is only among mothers who reported receiving prenatal care; however, because <1% of women reported not having had prenatal care, nearly all women in the sample are included. Although the 2010 PRAMS data were collected in 38 states, only 26 states are included in this analysis; nine states did not reach the 65% response rate threshold set by CDC PRAMS for the release of data, and three states did not have weighted data available. States included in the analysis were Alaska, Arkansas, Colorado, Delaware, Georgia, Hawaii, Massachusetts, Maryland, Maine, Minnesota, Missouri, Nebraska, New Jersey, New York, New York City, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Washington, West Virginia, and Wyoming.

PRAMS data were weighted to take into account complex survey design, nonresponse, and noncoverage for each state. Calculated prevalence estimates and 95% confidence intervals were stratified by state and maternal sociodemographic variables, including age, race/ethnicity, parity, body mass index, poverty-income ratio (PIR), education, language of survey, marital status, prenatal care initiation, insurance type at prenatal visit, and receipt of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services during pregnancy. Chi-square tests were used to test for statistically significant differences in the prevalence estimates; p values of <0.05 were considered statistically significant. All analyses were conducted using statistical software.

Results

Overall, 82.7% of women reported receiving advice about breastfeeding during their prenatal care visits (Table 1). The prevalence of receipt of prenatal breastfeeding advice was higher among women aged <20 years (92.5%) than among those aged ≥25 years (75.9%–83.5%). Non-Hispanic white women (79.4%), women with a PIR >200% (76.9%), and women with more than a high school education (77.9%) all reported a lower prevalence of receipt of prenatal breastfeeding advice than non-Hispanic black (91.3%) and Hispanic (87.8%) women, women with a PIR <200% (85.1%–89.7%), and women with a high school education or less (88.2%–89.8%), respectively. A higher prevalence of receipt of prenatal breastfeeding advice at prenatal visits was also reported by women who had Medicaid (89.8%) compared with women who had private insurance at prenatal visits (75.7%) and by women who reported receiving WIC services during pregnancy (90.8%) compared with those who did not (75.2%).

The overall prevalence of prenatal breastfeeding advice was consistently high across states, with approximately 80% of women reporting receipt of prenatal breastfeeding advice in all states except two (New Jersey and Utah) (Table 2). In three states (Georgia, Massachusetts, and Vermont), approximately 90% of women reported receiving prenatal breastfeeding advice.

Discussion

Although the overall prevalence of women who received breastfeeding advice in 2010 was high, 17% of women who received prenatal care reported that they did not receive any advice during their prenatal care visits. Some variations by state and maternal sociodemographic characteristics were observed. Geographic variations noted in the prevalence of prenatal breastfeeding advice ranged from 69.3% to 90.9%, a 21.6 percentage point difference. In general, women known to have lower breastfeeding rates (e.g., women who are non-Hispanic black, of low socioeconomic status, or live in the southeastern United States) (17) were more likely to report receiving prenatal breastfeeding advice than women who tend to have higher rates of breastfeeding (e.g., women who are non-Hispanic white, of high socioeconomic status, or live in areas other than the southeastern United States). Although the exact reasons for this observation are unknown, black women and women of lower socioeconomic status might be more likely to be identified as in need of prenatal breastfeeding advice because of the documented disparities in breastfeeding (17). No published research was found on the costs or cost-effectiveness of prenatal breastfeeding counseling.

Ongoing changes in the U.S. health-care system offer opportunities to improve the use of clinical preventive services among infants, children, and adolescents. The Patient Protection and Affordable Care Act of 2010 (as amended by the Health Care and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (25). Comprehensive breastfeeding support and counseling from trained providers during pregnancy, in the postpartum period, or both, as well as access to breastfeeding supplies for pregnant and nursing women, is recommended in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) specifically for women (26). The use of interventions during pregnancy and after birth to promote and support breastfeeding, which can include breastfeeding counseling, is recommended by USPSTF as a Grade B recommendation (20). Nongrandfathered private health plans (ACA § 1001) and qualified health plans on the new Health Insurance Marketplace (or Health Insurance Exchange) that went into effect starting in 2014 (ACA § 1001) are required to cover these services at no additional cost to the beneficiary.* Although ACA does not require traditional Medicaid/Children's Health Insurance Programs to cover the HRSA-supported and USPSTF-recommended preventive services, states that choose to expand Medicaid to legal residents with incomes up to 138% of the federal poverty level must provide all newly eligible adults with a benchmark benefit package that must cover those recommended services (ACA § 2001). In addition, effective January 1, 2013, states became eligible for an increased federal medical assistance percentage if they covered such preventive services, including breastfeeding counseling, with no co-pay (ACA § 4106). States have the flexibility to cover breastfeeding services in numerous different ways under Medicaid, including inpatient and outpatient hospital services. ACA provides additional support for breastfeeding by requiring employers to provide employees who are breastfeeding with time and a private place for breastfeeding activities (ACA § 4207).

Although the prevalence of breastfeeding intention (80%) and initiation (77%) are high, breastfeeding duration rates in the United States do not meet the Healthy People 2020 objectives (ever breastfed, 81.9%; breastfed at 6 months, 60.6%; breastfed at 1 year, 34.1%; exclusively breastfed through 3 months, 46.2%; and exclusively breastfed through 6 months, 25.5%)(18,27,28). The data in this report show that a high prevalence of women received prenatal breastfeeding advice, indicating that although prenatal breastfeeding counseling is important, other factors also play important roles in increasing breastfeeding duration. As outlined in the Surgeon General's Call to Action to Support Breastfeeding, to help women overcome the numerous barriers to breastfeeding, the support of family members, communities, clinicians, health-care systems, and employers is crucial (29). A 2012 review found evidence that formal breastfeeding education, as well as peer counseling and lactation consultation, during pregnancy appear to increase breastfeeding duration (30). Furthermore, evidence suggests that interventions with combined prenatal and postnatal components might be the most effective way to increase breastfeeding duration (31,32). Adequate education and training of health-care professionals who work with mothers and infants also are essential because health-care providers have a substantial influence on women's decision and ability to breastfeed (33,34).

The high prevalence of prenatal breastfeeding counseling found in this report combined with the relatively low breastfeeding duration rates in the United States suggest that expanding the focus of programs beyond a single intervention to a more multicomponent approach might be needed to improve breastfeeding outcomes. Several national programs use various approaches to promote and support breastfeeding. The U.S. Department of Agriculture's WIC program has federal regulations that specify the actions state agencies must take to encourage women to breastfeed and to provide appropriate nutritional support for breastfeeding women (35,36). AAP's Safe and Healthy Beginnings program, a framework for continuity of care from the prenatal period through childbirth to the postpartum period and beyond, provides a resource toolkit to hospitals and physicians' offices that covers key topics, including support for breastfeeding mothers (37). Best Fed Beginnings, led by the National Initiative for Children's Healthcare Quality in close partnership with Baby-Friendly USA and with support from CDC, is a nationwide effort to help hospitals improve maternity care and increase the number of hospitals that receive the baby-friendly designation in the United States (38). The Maternity Practices in Infant Nutrition and Care Survey monitors changes in maternity care practices and serves as a quality improvement tool for participating facilities (39).

Limitations

The findings in this report are subject to at least three limitations. First, because PRAMS only provides population-based data for each participating state, results are not generalizable to other states or to the entire United States. Second, because PRAMS data are self-reported, breastfeeding behavior and actual receipt of prenatal breastfeeding counseling cannot be confirmed. Third, prenatal breastfeeding counseling as assessed in PRAMS does not include the quality of the prenatal breastfeeding advice offered to women, such as content or frequency of counseling.

Conclusion

Overall, approximately 17% of mothers reported that their physician, nurse, or other health-care worker did not talk about breastfeeding during their prenatal care visits. Multicomponent interventions and supports, including prenatal breastfeeding counseling, are needed to help mothers start and continue breastfeeding. By expanding access both to comprehensive support and counseling from trained providers and to breastfeeding supplies, ACA might have an impact on breastfeeding rates in the United States. PRAMS data provide important insight into the prevalence of prenatal counseling about breastfeeding among women with recent live-born infants. This information might be useful in identifying groups that might benefit from additional programs aimed at increasing prenatal breastfeeding counseling rates.

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