Breastfeeding in the USA
Are we doing enough? The new CDC study says no
This September, the Centers for Disease Control and Prevention released the Breastfeeding Report Card, a state-by-state breakdown of breastfeeding practices in the U.S. It’s a progress report on the goals outlined in Healthy People 2010, a broad government initiative to boost the country’s healthy habits.
The news was not great. The U.S. did hit one of its breastfeeding benchmarks – the one for # of mothers breastfeeding at least a little – but unfortunately the rest of the numbers stayed stubbornly where they were four years ago.
In hopes of making progress on these other factors, the Report Card also looked at how breast-friendly we are as a country – in terms of support, practices, and laws – giving states an idea of where they might need to step it up to increase their nursing stats.
We can take stock in the fact that most moms in this country do breastfeed, says the CDC. Three out of four moms start out nursing their newborns – and that’s a good turnout, meeting the government’s goals for breastfeeding initiation.
But more than half of U.S. moms stop nursing before six months, and only 22 percent make it to the end of the year. The American Academy of Pediatrics, along with other health organizations like the WHO, recommends breast milk only for six months and breast milk with complementary foods through a baby’s first birthday.
There is a big variation among states, though. For example, in Oregon, 62 percent of moms are breastfeeding at six months and 40 percent at 12 months, whereas only 20 percent of Louisiana moms breastfeed until six months and 10 percent through the year. In Utah, 90 percent of moms initiate breastfeeding, but in West Virginia, 53.
These are the percentages of moms, however, who give any breast milk to their babies. The numbers of those who would meet the AAP and WHO guidelines by doing so exclusively until six months are lower – only 13 percent nationwide and as low as 7 percent in some states.
Of course there’s debate about the importance of breast milk only. Most moms who supplement feel (rightly so) that some breast milk is better than none, although it might not be as beneficial as we’d like, since a recent study found that immunity benefits for babies came only with exclusive breastfeeding – those who were fed partial breast milk didn’t get the same protective effect against infections. This would suggest that the AAP and WHO guidelines should perhaps be taken even more seriously.
So which states get an A in breastfeeding outcomes? The CDC’s numbers tell us that moms in northwestern states are most apt to nurse – you see it in all the outcome indicators. For example, 50 percent of moms in Montana are exclusively breastfeeding at three months (the national average is 33 percent). Overall, the strongest breastfeeding states are in the northwest, along with Alaska, Hawaii, Minnesota, Massachusetts, Vermont, and New Hampshire, whereas the weakest tend to be in the South, including Kentucky, Louisiana and Mississippi.
The Report Card also gives an idea of how supportive of breastfeeding each state is, evaluating hospital practices, state legislation, and professional breastfeeding support.
For example, the survey found that an average of 25 percent of newborns in the U.S. receive formula in the first two days of life – not ideal for establishing nursing. In Texas and New Jersey it’s 35 percent and in Mississippi 38 percent – whereas in Montana and North Dakota it’s under 10 percent.
Hospital practices have a big influence on breastfeeding outcomes, so in 2007 the CDC sent a survey to all U.S. hospitals asking questions like whether skin-to-skin contact is encouraged, if infants stay with their moms for routine after-birth procedures, and how soon after birth moms are encouraged to try feeding. The result is each state’s Maternity Practices in Infant Nutrition and Care (mPINC) score. The average score for the U.S. was 65 out of 100. Here are some state mPINC highlights:
- New Hampshire and Rhode Island: 81
- Massachusetts: 79
- Washington: 75
- California: 73
- Colorado and Connecticut: 71
- New York: 67
- Georgia: 59
- Alabama: 57
- Oklahoma: 55
- Arkansas: 52
- Mississippi: 51
The survey also counted the number of certified lactation consultants in each state to get an idea how much individual support moms get. The highest number was in Vermont, which had 11 consultants for every 1,000 births. Some states, including Mississippi and Nevada, had just around 1 consultant for 1,000 births.
All states except Idaho and Nebraska have legislation to protect breastfeeding in public places, and 16 states, including California and New York, mandate employer lactation support.
What’s the message? The good news is that most moms start to breastfeed, and slowly but surely, states are stepping up support and hospitals are converting to nursing-friendly practices. But the outcomes haven’t caught up – breastfeeding numbers at the 6- and 12-month benchmarks are still very low, with no improvement over the last few years.
Stay tuned for a follow-up column next week. The topic: if so many moms start to nurse, why do so few stick with it?
Why do we have to keep discussing this? HELLOOOOO. There are many reasons that factor into the bf dropoff, but two major ones are 1)most moms cannot afford to stay at home for longer than 6 to 12 weeks at best and 2)most companies do not allow or provide adequate room/privacy for pumping.
I agree. Could we let this issue go for awhile? I think most of us are sold on the benefits of breastmilk BUT it isn’t the end of the world if you have to supplement or substitute breastmilk with formula. We did the experiment already – a whole generation or two were raised on formula. They did (largely) fine. Breastfeeding takes time and resources that some mothers don’t have and are never going to have. Pumping SUCKS. Continuing to beat mothers over the head about this issue is unhelpful.
A tired discussion. Most women have to go back to work. Many women have no realistic way to pump at work. Many women can’t afford breastpumps. Had I not had a supportive boss, fairly decent statewide pro-pumping legislation, and an office with a door that closes, I wouldn’t have breastfed past my (hardwon) four-month maternity leave. And I’m one of the lucky ones. I’ve had it pounded into my head for twenty years that BREAST IS BEST, so more education is not really the answer. The answer is paid maternity leave, not the unpaid six-week joke we now get under FMLA. It’s subsidized breastpump purchases. It’s countrywide legislation forcing employers to provide pumping breaks and decent facilities for nursing employees.
But, wait! What you ladies are saying is that mothers’ choices are constrained, and women are not breastfeeding as much as *they themselves wanted to.*
I don’t think gathering data is ever bad, and I also don’t think that this knowledge automatically constitutes “beating mothers over the head.”
If anything, it supports legislation that would correct the problems you’ve identified. I.e., California meets every single benchmark, and we have 12 weeks state-funded maternity leave, and then strong legal protections for breastfeeding thereafter.
C’mon Laura! Can’t afford a breast pump? The manual Playtex spring return type works just fine can be had for $30. As for ‘realistic’ way to pump at work – my wife did it working at GE in Lynn Mass almost 30 years ago. I agree it ought to be completely lawful (and perfectly acceptable to all) for a nursing mother to expose a breast for feeding or pumping milk. Going into a lavatory is degrading and an unnecessary added exposure to germs but it is still ‘realistic’ because it worked…
Mike, I’m glad to hear you were able to pump your breasts 2-3 times per day for 10 months using a $30 manual breast pump while still keeping your job. Why, if you can do it, anyone can!
I have a great room to pump in, and nobody complains about me doing it. But my pumping schedule certainly isn’t taken into consideration when meetings are scheduled, or if I have to drive 3 hours for a site visit where the best place to pump would be my car or a port-o-potty. It isn’t my employer being an ass, it’s just the reality of my job, which I’m sure is the case with most other working moms. I’m still pumping at 9+ months, but that is largely due to a slow down in my workload. Formula is ok, and I too am getting a little tired of the discussion.
I disagree w Laura. I bouhgt a Llodyd B. pump for $30. back in 1980. that lasted many yrs, when I went to buy another for my grandchildren, in 2005. It was still only $35! And it still beats most other pumps on the market, that are far more expensive & cumbersome! I nursed 7 babies over 14 yrs, w/o a break, simultaneously holding down jobs, sometimes even as many as 3 jobs at once. Where there’s a will, there’s a way! Necessity is the mother of invention. Oh, I rarely pumped, & NEVER bought formula either. If I could do it, anybody can.
I meant to say ALMOST anybody can. There are rare exceptions of women who really can’t nurse no matter how hard they try. My sympathy goes out to them, I didn’t mean to trivialize their dilemma!
Is it just me or do I hear women defend choosing formula by saying, “But our kids turned out okay”? Okay?? I don’t know about you but I want my kids to turn out to be the best they can be and the healthiest they can be! “Okay” is not good enough! Why is it we should accept mediocre for our future generations? I don’t understand this.
BTW- I am a rare exception and cannot exclusively breastfeed. However I get donor milk for my child and have traveled across states to do so and it was still cheaper than buying formula. Some may settle for less but I refuse to do so.
I suppose I should not be surprised about some of the more visceral responses here. I completely agree that this is a larger systems issue, in terms of many women working and needing more support to be able to pump or continue nursing as they go back to work – especially in lower-income, blue-collar job settings.
However.
I work in a children’s hospital where we see a rather large number of moms who stay at home full-time and formula feed, so I don’t think we can safely say this is strictly a working and pumping issue. There are cultural taboos regarding breastfeeding, especially among the lower-income population at this time. Which likely explains why the breastfeeding rates are lower overall in states that have higher rates of poverty. (And that to me is a conundrum, since breastfeeding is largely free and it breaks my heart to see families feeding their babies by stretching the formula out and thinning it with water.)
Another big piece of this is the complete lack of understanding of how important breastfeeding is – people say we’ve heard it before, yada yada. But to understand the science behind it, in terms of emotional and physical development, made me a believer in it. Not to how exclusive breastmilk for the first six months or so, builds a completely healthy gut which is crucial to our overall health and strong immune system response.
Unfortunately, so few doctors are well-educated, or even educated at all, on it. And many of the moms I know, while well-intentioned, persist in following outdated advice that was never evidence-based, like baby’s first food being rice cereal and at four months of age. I’m not blaming anyone for following that advice, because that’s what we’re told. But when is pediatrics going to start backing up their recommendations on infant feeding with solid evidence-based research? (Off soap box now).
But here’s the thing. The science DOESN’T back up the many of claims about the benefits breastmilk. If you read the original studies on Entrez-Pubmed (not, say, the glorified summaries on the Dr. Sears site) you’ll find that a) there is still a raging debate, and b) in the study that is considered the best so far (PROBIT) clearly showed the breastmilk-fed children are healthier (they have one less infection/year on average). All the other claims (enhanced cognitive abilities, say) are far more controversial, since the differences seen between breastfed children and formula fed children are extremely small or do not rise to being significant. I understand that all of us want to do the very best for our own children and, it seems, everyone else’s children. The health benefits make it worth persisting with breastfeeding if you can, however the science does not back up attempts to make you feel guilty if you can’t. Your baby will be just fine.
So, if this discuss is tiring, what should we do? Nothing?
Thinking is not enough, we have to act. I am not American citizen, if I were I would write congressmen and women and ask for better support of bf. I think it is striking that the rate of bf in American has not changed in 4 years, despite all the evidence that exclusive bf for 6 months has a huge protective effect against infections.
I searched this myself (swear didn’t look at Dr. Sears website) and think there is convincing scientific evidence to support the recommendation for exclusive bf for 6 months:
- Anderson J, Malley K, Snell R. Is 6 months still the best for exclusive breastfeeding and introduction of solids? A literature review with consideration to the risk of the development of allergies. Breastfeed Rev. 2009 Jul;17(2):23-31. Review.
- Yang YW, Tsai CL, Lu CY. Exclusive breastfeeding and incident atopic dermatitis in childhood: a systematic review and meta-analysis of prospective cohort studies. Br J Dermatol. 2009 Aug;161(2):373-83. 2009 Feb 23. Review.
- Fiocchi A, Assa’ad A, Bahna S; Adverse Reactions to Foods Committee; American College of Allergy, Asthma and Immunology. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 2006 Jul;97(1):10-20; quiz 21, 77.
- Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2002;(1):CD003517. Review.
- Duijts L, Jaddoe VW, Hofman A, Moll HA. Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy. Pediatrics. 2010 Jul;126(1):e18-25. 2010 Jun 21.
- Ladomenou, F., Moschandreas J., Kafatos A., et al. Protective effect of exclusive breastfeeding against infections during infancy: a prospective. Study. Arch Dis Child. Published online September 27, 2010.
- Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol. 2004;554:63-77.
Hmmm. I’m not sure you read all those papers. I took a look at just one at random (I’m at work!), Exclusive breastfeeding and incident atopic dermatitis in childhood: a systematic review and meta-analysis of prospective cohort studies. Br J Dermatol. 2009 Aug;161(2):373-83. 2009 Feb 23 and looked up the abstract. I’m no statistician but their conclusion is pretty clear “There is no strong evidence of a protective effect of exclusive breastfeeding for at least 3 months against AD, even among children with a positive family history.” But I digress, I’m really not looking to fight about the short-term health benefits of breastfeeding. Although I’m not convinced that they are AS significant as the advocates make out, I am sure if I looked through all the papers you cite, there would be significant trend towards breast-fed children being slightly more healthy on average. What is, in fact, highly contentious is the long term benefits of breastfeeding. Does breastfeeding make your kids smarter, for example? You can cite me papers that suggest that might be the case, but there are plenty of papers that where people found that the differences are not significant (as was found in the original PROBIT study).
I was lucky enough to bf to 10 months, and pumped to 8, after going back to work at month 3. I manage an office building and have a private office on which I was able to install a lock (by the way, the Easy Expressions pump halter is the best invention ever for a working mom who wants to pump – allowed me to pump while working the keyboard, an unfortunate necessity for me), so continuing to bf was relatively easy for me. In any event, I would WELCOME a law that required me to provide a pumping room in my 400,000sf office building. I don’t own the building so it’s not up to me to decide how to allocate rentable space to something that isn’t revenue earning no matter how much I personally support bf-ing. If a law required that an office building of a certain size provide such space it would support the many cube-working moms who find it very difficult to make breastfeeding part of their work day. I also happen to be in Seattle, WA which is a very bf-friendly part of the country. A few of our larger tenants provide space for their employees but it is by far the exception and not the rule. I’m glad this conversation continues to take place. I hope more research will prove whether there are real benefits or not. All I know is my 7yr old son had only 2 ear infections as a child, has been remarkably healthy and is smart as a whip, is skinny in a healthy way, and very well attached to both parents and friends/family. I believe all of these were at least supported if not caused by breastfeeding.
To question whether or not breastfeeding is, at the end of the day, better for babies is absolutely ridiculous. Of course it is. There is no comparison between something natural your body makes specifically for your child and something formulated in a lab. The problem is, as has been mentioned, our country’s support of breastfeeding women – maternity support altogether. It should not be a guilt trip for mothers, but it should be something that we just DO, that is as natural as rocking, cuddling and loving our children, because it IS natural. Our country needs to get on the boat and women need to stand up for themselves and demand that breastfeeding be destigmatized and supported in the workplace and in public. I know too many mothers in my own area, (the South) who never even initiated breastfeeding because of fear, or thinking it would be “too hard” or that it was “gross”. So, there is clearly still a place for education, especially for young, poor mothers who receive free formula through WIC instead of breastfeeding support, as well as in our workplaces where family and healthy family development is prioritized.
That would be, “is NOT prioritized”. It needs to be.
I can tell you why more women don’t stick with it: it places the entire burden of feeding the infant on the mother. It means she cannot have excessive coffee, drink alcohol, etc. Yes, you can “pump and dump,” but if you want to have 3 cups a coffee a day, you’re dumping too much milk to feed your child adequately. It can also be very isolating and confining.
I nursed my son until 16 months, and while I knew I was doing the best I could by him, it was still difficult on me personally. People just seem to brush aside this aspect of the issue, while I’m sure it is a huge determining factor in breastfeeding rates.
I think that all the stress and difficulty when a mom starts breastfeeding comes from outside people that think they know it all and will not allow the mother to set a pace with their newborn.
My biggest help with my first baby was the lactation consultant. She was awesome and very understanding. When I got home, my mom was telling me all the things I was supposed to do but since I did my homework I was able to pick and choose what tips I would use.
The lactation consultant was so great that when I had my daughter earlier this year, it was easier for me to figure out her feedings.
I breastfed our daughter and then twins! It really should not be an issue which path you choose. Bottom line, some women cannot breastfeed. They just do not produce enough or they have inverted nipples, or their child has a genetic disorder which causes them to have to use a special formula. I think the happy medium is of course to use both. Your body will adjust to produce what your child needs. Trust me, this I know. At the same time, formula is fine. Of course there are studies that find that breastfeeding is better. What do you expect? Your body produces it without you even thinking about it! I think that we need more support during this important time. More maternity leave (and paternity for that matter). More understanding that the costs of putting your precious one in childcare is outrageous. More understanding that yes I have to leave work because my child is sick, hurt, has an app. or happens to not have school this day. More understanding that we are all as different as are our children. We need to stick together as families (whatever they may look like) and demand more for our children instead of arguing with each other. I am so tired of this debate just as I am tired of the co-sleep debate and the sahm vs working mom debate. Get over yourselves! Be strong and know that as long as your family is happy and healthy and you are doing what you believe is right for your family, you are doing a good job!
As a side note, WIC does encourage mothers to breastfeed. They have other women who were in the WIC program trained as breastfeeding peers. These women are on call to help in anyway they can. If you choose to breastfeed, instead of formula the individual is given food to help supplement diet.
I find it ironic that the CDC sets breastfeeding goals, while the IRS does not allow breastfeeding related expenses to be deducted in an HSA account. Aspirins, pimple cream and suppositories are covered, but not breastfeeding expenses.
I believe that the government is not doing all it can to support breastfeeding. If we could just get the CDC and the IRS to sit down and talk, that would be a great first step.
we as women can search and find many reasons for not breastfeeding or adding supplements of formula when feeding our babies. Take a moment and really read what formula is made from..i promise you you would not drink it yourself
I enjoyed reading this article and thought the author made some great points. I do want to point out though that the reference to the one study that found no link between partial breastfeeding and immune benefits is a very misleading. There is a whole body of research that does link partial or predominant breastfeeding to increased immune benefits over formula feeding alone. This summary of breastfeeding research, for example, reveals benefits from partial breastfeeding across a number of studies: http://www.linkagesproject.org/media/publications/Technical%20Reports/BOB.pdf
In other words, the sum total of the research shows that some breast milk is better than no breast milk!