RESEARCH AND PRACTICE

Hospital Practices and Women's Likelihood of Fulfilling TheirIntention to Exclusively BreastfeedEugene Declercq, PhD, Miriam H. Labbok, MD, MPH, Carol Sakata, PhD, MPH, and MaryAnn O'Hara. MD, MPH

Exclusive breastfeeding through at least the

first 6 months is the physiologically appropriate

approach to infant feeding,' Mixed or formula

feeding canics with it increased lisks of inleclion,

developmental probkims, mortality, and long-

ailments such as diabetes and cancers For

child." "' In support of the

evidence, the American Academy of Pediatrics,'^

American College of Obstetrics and Gynecol-

i.)gy, the American Public Health Association"

the World Heidth Organization," iuid many

other medical and heallli pfofes,sioiial organiza-

tions'"""'" recommend that infants consume only

mother's milk (exdusive breastfeeding) for at

least the first 6 months of life, followed by

continued breastfeeding with age-^propriate

nutrient ridi complementaiy foods. The

irvised US Healthy P{!ople 2010 national objec-

tives call for 17"/(i of new mothers to be

exclusively breastfeeding at 6 montlis.''

Nonetlieless. national statistics indicate that less

tlian 12'yu of mottier-baby pairs achieve this

goal."*

The "Ten Steps for the FYotection, Promo-

tion and Support of Breastfeeding"'" are the

centr-al part of the Baby-Friendly Hospital

initiative, along with adherence to the hitema-

tional Code of Marltelitig of Breast-Milk Substitule.'i

and subsequent World I leatth Orgaiiiy^Eion

resolutions."' 'Ihi'se pracücts have been

reported to support breastfeeding behaviors

iuid influence outc»mes,''''" t h o u ^ in some

cases ihcy have been subjecis of political dis-

[jutca,'' However, with the exception of a

I ecent Centere for Disease Control and

ñ-evendon stiidy*^" and sum«! data fi-orn

hos|jitals that have achieved "Baby-Friendly"

status, little is known about the prevalenœ of

these practices in haspitals acrass the United

States.

Grizzard et al.^' assessed Massachusetts hos-

pitals and noted tliat hos¡iil;ils witli high or

moderately liigb levels of implementation signif-

icantly differed fi'om hospitals with paitial

implementation vnth respect to pacifier usage

(F=.i)()2) and postpattiim breastfeeding

Objectives. We sought to assess whether breastfeeding-related bospital prac-tices reported by mothers were associated with achievement of tbeir intentionsto exclusively breastfeed.

Methods. We used data from Listening to Mothers II, a nationally represen-tative survey of 1573 mothers wbo bad given birtb in a hospital to a singleton in2005, Mothers were asked retrospectively about their breastfeeding intention,infant feeding at 1 week, and 7 bospital practices.

Results. Primíparas reported a substantial difference between tbeir intentionto exclusively breastfeed (70%) and tbis practice at 1 week (50%). They alsoreported bospitat practices that conflicted witb the Baby-Friendly Ten Steps,including supplementation (49%) and pacifier use (45%|. Primíparas wbo deliv-ered in hospitals that practiced 6 or 7 of tbe steps were 6 times more likely foracbieve their intention to exclusively breastfeed than were tbose in hospitals thatpracticed none or 1 of the steps. Mothers wbo reported supplemental feedings fortbeir infant were less likely to acbieve tbeir intention to exclusively breastfeed.primíparas (adjusted odds ratio [A0R]=4.4; 95% confidence interval |CI1 = 2.1,9.3); multiparas (AOR = 8.8; 95% CU4.4, 17.6).

Conclusions. Hospitals should implement policies that support breastfeedrtigwitb particular attention to eliminating supplementation of heallby newborns.{Atn J Public Health. 2009;99:929-936. doi:10.2105/AJPH.2008.135236)

instRiction (/'< .001 ). Acceptance of fi-ee fomiula

was significantly assodatfîd (7^.03) with overall

Ten Steps implementation. Althougti several in-

ternational studies iiave eoneluded that even

some progress toward "Baby-Friendly Hospil^"

status is assodated with ino-eases in breastfeed-

ing, availaliie US data"" on the achievement of

exdusive breastfeeding in relation to the nuniber

of steps in place are limited.

The goal of our study was to provide dinica!

and hospital administi'ative dedsion-makers

with the infonnation they need to institute

policies and practices that enhance a woman's

ability to achieve her intended duration of

exclusive breastfeeding. We examined tbe re-

sults of a national survey tliat asked mothers

about their feeding intentions "as [they] came

to tbe end t)f ftheirl pregnancy" «md their actual

feeding patterns 1 week after tbe birth. We also

asked motliers to report on their experiences

with hospital practices kiiown to influence

breastfeeding success. Based on past research,

we expected that hospital pracUcc-s would be

related to tlie fulfillment of a plan to exclusively

breastfeed.

METHODS

We present rt"suft.s from a 2006 national

sui-vey of 1573 women aged 18 to 45 yeai-s

who had given birth in 2005 in a hospital to a

singleton, sdll-living infant. The survey, entitled

Listening to Mothers II,"" was devclo|.xd

thiougli a collalioration between Childbirtli

Connection iuid tlie Boston Univci'sity School of

I'ublic Heaitii and was conducted by Hanis

Interactive. The standard tclcpbone sam|)ling

approadi of random-digit dialing, though ad-

vaiitageous for reaching a divei-se population, is

not feasible for a national sui'vey of new motliers

becaii.se tlic number of US birtlis (4 million

annually) Ls small in proptJiüon to the number of

boiiseholcfs (IU million); tlierefore, respondents

were drawn fi om 2 oth(?i' sourcts.

Tbe Internet portion of tlie sample was

drawn from Hanis Interactive's ongoing Inter-

net panel of more tlian 5 million individuals

who agree to periodically pajtidpate in tlieir

surveys. To ensure a more representative

overall sample, a telephone sample was also

drawn. Respondents in tliis sample were

May 2009, Vol 99, No. 5 , American Joumal of Public Health Declercq et al. Peer Reviewed Research and Practice 929

RESEARCH AND PRACTICE

limited to non-White mothei-s and were iden-

Liiied through tlie useofapropnetaiy list" tliat

contained telephone numbers and zip eodes of

motliers who had given hirth in 2005. House-

holds in ziji codfis willi lai ge non-White popu-

lations were called and respondents were

screened to eiisuR' nol only thai they met llie

original inclusion aiteria hut also that they were

non-Hispanic Black or Hispanie. The combined

survey resulLs wen' weighttid by 1 lanis with tlieir

validated "propensity sa)re" metliodology {G.

Terhanian et al., unpublished data, 2000; avail-

ahle from authors on request) to adjust for

|X)tentiiiJ biases associated witli online res|N)n-

dents. We applied population wei^ts to statisti-

cal analyses by using ciurently available options

m S I ^ version 15.0 (Sf'SS Inc, Chicago, IL).

Survey

Details on the survey metliodology are

available elsewhere.^"^ The survey sample se-

lection and consent process complied with the

codes and standards ol' the Council ol' American

Survey Reso^eh Oi^anizations and the code of

the National Council of Public Polls, Data were

(Xitiectpd and housed secur<!ly hy Harris Intnr-

active and the authors had acass only to a

deidentified file provided by Harris Interactive.

Questions related to hi'eastfeeding were a

brief part oí the 3(>minute survey that also

ineluded questions on prenatal, intrapartiim,

and postpartum experiences: maternal atti-

tudes related to bittli; and demogi'aphic ehar-

aeteristies.^' AU phone and Internet interviews

were conducted between January 20 and Feb-

niaiy 21, 2006; no niotlier was askefl to recdl

experiences from morí* than 13 months earlier,

and for most mothers the recall time period was

much sootiei'. The average i-eK[>oiident had given

birtb 7.3 months before completing the survey

(online, 7.4 months; telephone, fi.4 montlis). Past

researdi has found tliat mothei-s are able to

validly recall estimates of breastfeeding initiation

and duration up to 3 years.""*

The resulting sample of mothers who had

given birth in 2005 was generally representa-

tive (within 1 to 3 percentajie points) of the

comparable national population of hiilhing

mothers—aged 18 to 45 years; singleton, hos-

pital births—based on the most recent US

tinta" ' available for comparison. A table sum-

marizing the compajTson was published in a

related article.^'' Survey respondents {»me from

all 50 states and the Distiid of Columbia In

tenus of age. nZ' 'ii of the study ¡xipulation and

52% of the comparable birthing population were

aged between 25 and 34 years. Non-Hispanic

Black mothers made up 12'I'd and I iisparuc

mothers 21% of the study sample, compaied with

14'Vi) and 23"''i). respectively, in the birthing

population. Finally, tlie breastfeeding ratis we

report are generally comparable to 2005 rates

repoited by the Centers ft)i" Disease Contnil

and IVeverition hasi-d on the National Immuni-

zation Survey. Althou^ the spedfic questions

were not the same, the overall rate of any

bi^eastfeetling at ;ill at 1 week iu oui" sample

{73"/()) matches tlie 73.1< /(i reported as any

breastfeeding at 7 days in the 2005 National

biununization Sur\'ey."^^

MeasurementsWe retrospectively asked motlitirs about

their infant feeding intention at the end of their

pregnancy, their feeding practices at 1 week

(summarized in Table I), their experience with

hospital stafî related to 7 specific practices

associated with exclusive breastfeeding (help-

ing mother get stalled breastfeeding, showing

mothers how to position baby, encouraging

feeding on demand, infomiing mothers about

community breastfeeding rtisoui'ces, supple-

menting breastfeeding with fonnula or water,

giving tbe baby a pacifier, providing free for-

mula samples to mothers), and a global ques-

tion about tiw. hrt^astfeeding support they re-

ceived from hospital staff. Where possible,

these items were taken directly from the Raby-

Friendly Hospital Initiative Ten Steps,''^ with

spedfic Baby-Friendly Hospital Initiative steps

conesponding to survey questions nottxl in 1 a-

hte 2. Mothers were given 3 [ios.sible ways to

dfscribe the pattern of feeding intended during

late pn'gnancy and practiced at 1 week: (1)

exclusive breasUetniing, (2) exclusive formula

feeding, or (3) mixed feeding. In a separate pml

of the questionnairi', we also asked the mother's if

tliey experienced "rooming in" and induded thai

vaiiable in the muitivariate analysis.

We tabulated these results with a particufar

foais on wheUier women who intended to

exdusively breastfeed at the end of pregnancy

had in fact established exdusive breastfeeding

1 week postpartum. We recognize tbat many

women make mfaiit feeding dedsions at an

earlier point in time and that many women who

establish breastfeeding continue beyond

1 week. We selected these time points to

examine the assodation between hospital

TABLE 1-lnfant Feeding Intentions Compared With Actual Practice at 1 Week Postpartum

Among US Mothers Who Gave Birth in 2005, hy Parity: Listening to Mothers II Survey

Feeding Practice'' at 1 Week Postpartum

Primiparas

Exclusive breastfeeding

Mixed (breastfeeding and formula)

Exclusive formula

Total

Multiparâs

Exclusive breastfeeding

Mixed (breastfeeding aid formula)

Exclusive fomiiiia

Total

Exclusive

Breastfeeding, %

4420

6

70

17

7

3

57

Feeding Intention

Mixed (Breastfeeding

and Formula), %

48

416

5

U5

21

Exclusive

Formula, %

1

01314

1

12122

Total,' %

50

28

22

100

53

18

29100

Note. For primiparas, n '519. For multíparas, n-1052.

*Women were asked, "As you came to tfie end of your pregnancy, bow liad you fioped to feed your baby? Options:

breastfeeding alone, formula only, a combination of breastfeeding and formula."

'^omen were asked, "One week after you gave birth, how were you feeding your baby? Options: breastfeeding alone, formula

only, a combination of breastfeeding and formula,"

" Totals are rounded.

930 I Research and Practice | Peer Reviewed | Declercq et al. American Joumal of Public Health 1 fulay 2009, Vol 99 , No, 5

RESEARCH AND PRACTICE

TABLE 2-Hospital Practices Reported by US Mothers Who Gave Birth in 2005 and Who

intended to Exclusiveiy Breastfeed, by Parity: Listening to Mothers II Survey

Hospital Practice (6FHI Step' Primiparas, % Multipafas, % All, %

On ttie whole would you say Ihe staff, (BFHI 3)

Encouraged breastfeeding

Encouraged formula feeding

Expressed no preference

Other hospital practices

Helped you get started breastfeeding when you and your

baby were ready (BFH! 4) '

Gave you free formula samples or offers"

Showed you how to position your baby to limit nipple soreness (BRil

Encouraged you to feed "on demand" (BFHI 8) '

Told you about community breastfeeding support resoun:es for

ongoing help (BFHI 10)'

Provided formula or water to supplement your breastmilk (BFHI 6)"

Gave your baby a pacifier (BFHI 9 f

815

15

731

26

762

22

89 70 77

7478

80

69

49

45

6159

75

64

29

40

6566

77

65

37

42

Note. BFHI-Baby-Friendly Hospital Initiative. Data excludes mothers with babies ir the neonatal intensive care unit. Forprimíparas, n-338. For multíparas, n' '577. For the total sample, N = 915.^Most closely related BFHI step noted in parentheses. The 10 steps are available at: http://www.ünicef,org/nutntion/index_24806,html.'Violates Ititernational Cotie of Marketing Breast-Milk Substitutes.^

practices and initial fulfillment of intention toexclusively breastfeed. Past research has foundwide variations in exclusive breastfeeding byparity.^^'^^ so we stratified all analyses to dis-tinguish primiparas from multíparas. Because ourintention was to examine the typical pos^artumhospital experienœ for mothers, we limitedanalyses to those cases where the infant was notin the intensive care unit, resulting in the toss of6% (100) ofthe respondents (Table 2, Table 3,and Figure 1).

Analyses

We conducted data analyses with SPSS ver-sion 15.0 (SPSS Inc, Chicago, IL). We per-formed multiple logistic regression methods toexamine the association between ñüfillment ofintention to exclusively breastfeed, varioushospital practices, and related demographicvariables for each parity stratum.

RESULTS

Table 1 compares intended and 1-week ratesof feeding types, by parity. Mothers' repoi-ts offulfilling their feeding intention (exclusivebreastfeeding, exclusive formula, or mixed)

differed by parity, with 65% of primiparas and79''/ii of multiparas feeding the baby at 1 weekin the way they had intended at the end ofpregnancy. The largest group were thosemothers who intended to, and at 1 week were.exclusively breastfeeding their babies. Mostwho did not achieve their intention to exclu-sively breastfeed (2O"/o of piimipaious women;7% of multiparous women) practiced mixedfeeding. There were some respondents (4' /i) ofprimiparas and 5"/o of multiparas) who hadintended to use mixed feeding but were ex-clusively breastfeeding at 1 week.

Overall, 61"/(! of respondents indicated thatthey had intended to exclusively breastfeed,and about half of the mothei-s (51%) wereexclusively breastfeeding at 1 week. Whenthese findings were stratified by parity anddemographic characteiistics of mothers, wefound substantial variance across groups(data not shown). TTiose most likely to intendto and aclually exclusively breastfeed at I weekwere mothers who were non-Hispanic White,better educated, had higher incomes, had pri-vate insurance, or were employed pmt-time.When we stratified the results by parity, wefound that first-time mothei-s with the largest

discrepancy between intent and exclusivebreastfeeding to be those mothers with areported income of $25000 to $49999 (78%intention vs 49"/o actual exclusive breastfeed-ing at 1 week), Hispanic mothers (59% vs 32"Vo,respectively), non-Hispanic Black mothers(59% vs 33'y(i, respectively), or mothersemployed part-time (78'Vo vs 51'ya, respec-tively). Among multiparas the same generalpatterns emerged, though the difîei-ence be-tween intent and actual exclusive breastfeedingwas mudi smaller.

We also examined the bivariatc relationshipbetween intrapartuni experiences and fulfill-ment of intention to exclusively breastfeed(data not showi). Among primiparas, factorsthat were related in bivaiiatc analysis toachievement of intent to exclusively breastfeedincluded having an obstetrician (rather than afamily doctor or midwife) as the ¡jrenaLal careprovider and not having a cesarean delivery.Among multipaius. there were more factorsrelated to achievement of intention to exclu-sively breastfeed, including not having an epi-dural or a cesarean delivery, having the baby incontact witli the mother immediately afterbirth, rooming in with the baby, and a post-partum length of stay of 2 days or less. TTiesevariables were included in the multivariateanalysis.

Table 2 presents responses concerning hos-pital practices related to breastfeeding frommothers who intended to exclusiveiy bi'east-feed and whose babies were not in tlic neonatalintensive care unit. Responses are sti atified byparity. More than four fifths of priniipai-as(81"/ü) who intended to exclusively breastfeedindicated that the staff encouraged breastfeed-ing. In terms of specific hospital practices,primiparas reported that in some cases staffwere highly supportive in providing help get-ting started (89%), encouraging breastfeedingon demand (8O'fo). and showing how to posi-tion the baby (78'Wi). However, almost half{49%) of those first-time mothers who intendedto exclusively breastfeed reported that theirbaby was given water or formula for supple-mentation, 45% reported that their baby hadbeen given a pacifier, and 74% of thoseintending to exclusively breastfeed reportt dbeing given free formula samples or ofTei-s. Onthe whole, the pattern for multiparas involvedless vaiiation tban primiparas across the

May 2009. Vol 99. No. 5 American Journal of Public Health Declercq et al. Peer Reviewed Research and Practice i 931

RESEARCH AND PRACTICE

TABLE 3-Percentage of US Mothers Who Gave Birth in 2005 Who Intended to Exclusively

Breastfeed and Were Exclusively Breastfeeding at 1 Week, by Parity and Reported Hospital

Practices: Listening to Mothers il Survey

Primíparas Multíparas

Mother Mother Did

Experienced Not Experience

Practice, Practice,

% (No.) % (No.)

Mother Mother Did

Experienced Not Experience

Practice. Practice.

% (No.) % (No.)

Hospital practice

Helped yoL gel started hreastfeeding when

you and your baby were ready

Gave you free formula samples or offers

Showed yoj how to position your hshy to

limit nipple soreness

Encouraged you to feed "on demand"

Told you about community breastfeeding

support resources for ongoing help

Provided fomuia or water to supplement

your breastmilk

Gave your baby a pacifier

Hospital staff attitude

Hospital staff encouraged breastfeeding

Hospital staff encouraged formula

Hospital staff expressed no preference

69 (301) 33 (36) <.O01" 83 (403) 82 (173) ,691

61 (249)69 (263)

69 (271)

73 (231)

74 (90)49 (75)

50 (66)

48 (106)

.002

.002

.004

<.0Ol

7782

87

84

(349)(339)

(432)

(367)

92 (228)83 (238)

70 (144)

81 (210)

<.OO1.883

<,001

.334

49(166) 81(172) <,001 56(169) 94(407) <.O01

57 (152) 71 (186)

67

40

60

.009

,071

82 (228) 83 (349)

85

78

.640

.115

Note. Data eKcluöes motfiers witfi babies in the neonatai intensive care unit.

''P values reflect x^ test on comparisons of within parity group breastfeeding rate at 1 week across hospital practices.

clifîerent hospital practices. An analysis of tJicscpractices by racc/cthnicity (data not shown)loiind that non-Hi.spaiiic White primiparasintending lo exclusively breastfeed were muchless likely to report supplementation wilh wateror formula (40"'o) than were non-HispanicBlack (71%) or Hispanic (74"/ii) mothers withthis intention.

Table 3 presents data on Ehe percentages ofmothers who Ililhlled llieir intention to exclu-sively breastfeed. In this table, the columnsrepresent different levels of painty and whetherthe mother reported that the hospital engagedin a paiiiailar practice. For example, (i9'Vi) ofthe mothers who intended to exclusivelybi'eastfeed and repoited iliat hospital staffhelped them get stalled hreastCeeding wereexclusively breastfeeding at 1 week. This find-ing can be compai ed with 33"/o of piiniiparasfulfilling their intention to exclusively breast-feed at 1 week in hospitals where they reportedthat they did not get help in starting to

breastfeed. .-Vmong primiparas there was asignificant difference in the rate of achievingtheir intention by whether a hospital engagedin each ofthe practices, partiailariy supple-mentation, with slightly less than half (49"''o)achieving their intention to exclusively breast-feed compared with 81"/n in cases where therewas no supplementation.

The differences for multiparas were gener-ally less pronounced, with the exception ofsupplementation: 94% of the mothers who didnot report supplementation occuning achievedtheir intention to exclusively breastfeed, com-pared with 56%) where supplementation wasreported. The provision of formula samples orcoupons'"' was associated with a significantrcHiuction in achievement of intention to exclu-sively breastfeed for both primiparas and mul-tiparas.

We examined whether there was a dose-response relationship between the number ofsupportive practices mothers reported that

hospitals engaged in and the achievement ofexclusive breastfeeding, f-igure 1 displays astrong cumulative effect of these polides forboth parity groups. Primiparas who reportedexperiencing at least 6 of the 7 practices were 6times more likely (86% vs 14%) to fulfill theirintention to exclusively breastfeed thanmothers experiencing 1 or none of these prac-tices, Multiparous mothers in the same com-parison were more than twice as likely (93'Vi) vs45"/o),

Finally we examined what factors weremost strongly related to achievemeni of ex-clusive breastfeeding intention in a multi-variate analysis. Because of the substantialdifferences consistently noted for parity, weran separate models for primiparEis andmultiparas. Consistent with our focus on therelationship between hospital practices andachievement of intention to exclusivelybreastfeed, we included the 7 hospital prac-tices as well as key intrapartum variables(prenatal care provider, epidural use, methodof delivery, rooming in, where the habywas in the first hours after birth, and post-partum length of stay), and demographicvariables (age, education, income, race/eth-nicity, employment status, and third-partypayer source) associated with feedingchoices.

When we controlled for all the other noteddemographic and intrapartum variables,among pnmiparas. only 4 hospital practiceswere statistically significantly assocjated witlithe likelihood of achieving hreastfeeding in-tention; (1) helping mothers get started (ad-justed odd.s ratio [AORl—6.3; 95"/() confidenceinterval [a] = 1.8, 21,6). (2) hospital staff notsupplementing with formula or water(AOR = 4.4; 95% Cl = 2.1, 9.3). (3) tellingmothers about community resources forbreastfeeding support (AOR=2,3; 95%CI = 1.1, 4.9), and (4) staff not giving the baby apadñer(AOR = 2.3; 95"/.iCI = 1.2, 4.4). Amongmultiparas, 2 hospital practices significantlyimpacted fulfillment of intention; hospital staffnot supplementing (A0R=a.8; 95% CI=4,4,17.6) and hospital staff encouraging feeding ondemand (AOR=3.4; 95% CI=1.7, 6.8). Noneof the demographic or intrapartum eventsremained significantly related to iiilfillment ofintended exclusive breastfeeding duration inthese models.

932 [ Research ancf Practice | Peer Reviewed Declercq et al. American Joumal of Public Health I May 2009, Vol 99, No. 5

RESEARCH AND PRACTICE

2-3 fl-5 6-7

Number of the 7 Policies Mothers Reponed Hoîpiials Practicing

iVoíes. Hospital practices: (1) staff fielped mother get stafted breastfeeding, (3) staff showed mother how to position baby,{3) staff encouraged feeding on demand, (4) staff directed motbers to community breastfeeding resources, (5) staff did notencourage supplementing breastfeeding with formula or water, (6) staff did not encourage pacifier use. (7) staff did not giveout free formula or offers. Differences in fulfillment are statistically significant across numbers of policies (P<,01),

FIGURE 1-Hospital support and breastfeeding success among US mothers who gave birth in

2005: Listening to iVIothers ii Survey.

DISCUSSION

We itkîiitihed several hospital practices, asreported by mothers, that were strongiy relatedto rates of exclusive breastfeeding. We used aiarge. representative national sample to focuson a cridcai time in estabiishing exciusivebreastfeeding and examined how hospitalpractices were positiveiy and negativeiy asso-ciated with the likeiihood that a mother whointended to exclusively breastfeed her infantwas actuaiiy doing so 1 week after birth. Wealso doaimented hospitai practices from aunique pei'speilive—that of niothei-s—ratherthan stated policies or rcpoils nom hospitalstíüT. In this way, our study can serve as acomplement to a recent Centers for DiseaseConti'oi and Prevention survey of hospitaipractices and policies reiated to breastfeedingas reported by hospital staff at the fadiitylevei.^"

We found a substantiai difference betweenprimipai-as' intention to exclusively breastfeed(7O"/o) and their actual rate of exclusivebreastfeeding 1 weei< after birth (50"/ii). Theseshifts between intention and practice representa huge lost opportunity to encourage ajid

support breastfeeding in the United States.Applying these differences to national dataresults in a totai of more than 400000 infantsannually (10% of all US births) whose mothersintended lo exclusiveiy breastfeed as theycompleted their pregnancies but were not do-ing so 1 week after birth.

Experiencing hospital practices that inhibitexclusive breastfeeding (i.e., staff supplement-ing breastfeeding with formula or water, beinggiven free fomiula samjjies, babies given pac-ifiers) was significantly assodated with mothers'failure to fuifill their intendon to exdusivelybreastfeed, in cases where mothers reported acomprehensive pacicage of supportive prac-tices, primiparas were 6 times more iikely andmultiparas twice as iikely to achieve theirintention to exclusively breastfeed.

The practice of hospital staff providing for-mula or water to supplement breastfeeding wassigiiificantiy related to failure to achieve ex-dusive breastfeeding. Mothers whose babiesdid not experience supplementation were 4.4dmes {primíparas) or 8.8 dmes (muldparas)more iikely to achieve their intention to exclu-sively breastfeed. ITie Worid Health Organi-zadon 1998 compendium. Evidence for (he Ten

Steps to Successful Breastfeeding, confirms thatthere is substandal evidence beiiind Step 6,"Give newborn infants no food or drink otherthan breastmiik, unless medically indicated,"repoiting that the feiding of supplements dis-rupted breastfeeding,'" a condusion supportedby studies from Honduras and italy.'"' '

Comparison With Other StudiesFew studies have examined hospital prac-

tices as predictors of success at (exclusivebreastfeeding."" '" A recent shidy of Coloradomothers' descripdons of hijspitai pracdces andtheir inlant feeding exix'riences found a signifi-cant relation between hospital pracdces unsup-pordve of breastfeeding and discontinuation ofbreastfeeding at 8 weei«. The study also found,as we did, a aimuladve effect of hospital prac-dces, but did not .sti-atify mothers by ¡jaiity- orperform a muttivariate analysis on their resuits."'These studies, which invoived different method-ologies and were done in different settings,reinforce Hie need for hospital practices sup-porting inidadon ajid later suca^ssful continua-tion of exdusive breastfeeding.

LimitationsOur study was based on a US nadonal

sample drawn from a combinadon of internetand teiephone respondents. Internet-basedsamples ai-e increasingly being used in publicopinion research,'' and our data weœ .supple-mented with a telephone survey of non-White,English-speaking mothers. The aimbined samplewas weighted to adjust for the nadonal úv.ma-graphic dLstribudon of tlie childbeamig ¡jopiila-don and the propensity to be online. The result isa sample that is generally representadve of theUS birthing populadon and US breastfeiKlingrates. Althou^ the resiiits mirror the demo-graphic chai acterisdcs of tlie US birthing popu-ladon, we cannot be ceiiain that our respondentswere representadve of ali hospital and breast-feeding experiences of birtliing women in theUnited States. However, there were no indica-tions suggesdJig a likelihood of bias in the results.

Our study relied on mothers' recall and wasnot validated by recoids review. Past researdihas shown that mothers are generally accuratein their reports of their own birth experi-ences.''^ Nonetheie.ss, it is possible that somerespondents could have based their rétrospectiveresponse regarding intention on their actuai

May 2009, Vol 99, No. 5 , American Journal of Public Health Declercq ei al. Peer Reviewed I Research and Practice | 933

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bit'astfcetiing experience. To pR)tec1 againstUlis possibility, tlie survey was stnictui-ed to beneutral and nonjudgmental about feetling choice.It is also fx)ssib!e that motliei-s who stoppedbreastfeeding chose to "blanu!" hospital practicesfor theii- decision. To minimize this possibleefFect, we asked the question on breastfeeding at1 wec'k after the questions on haspital practice.Also the comparable national data most oftenusetl in reporting breastfeeding trends, the Na-tional Immunization Survey, as well as data fromRoss Laboratories Mothers Surveys'''"' relied onmatemal recall."*" and a study of maternal recallof bi'eastfeeding experiences Ibiuid motheiï' i"e-sponses both valid and reliable.'"''

ConclusionsBreastfeeding protection, promotion, and

suppoil may rely on identifying and using"teachable moments"' to increase motheiV in-tention to achieve exclusive breastfeeding, andthese findings present opportunities and raisequestions in 2 ai eas. First, should we bepleased or disappointed that 7O"/o of first-timeand 57''^ of experienced mothers had theintention late in their pregnancy to exdusivelybreastfeed? We need to consider why almosthalf of thf nuiltiparoiis mothofs in 2005ix'poited no intention to exdusively breast-feed their baby. Clearly some efïbris areneeded to promote a gi"eater interest in exclu-sive breastfeeding among all mothers, particu-larly among those who have given birth beforeand may have had adverse experiences. Im-proving in-hospital breastfeeding support forfirst-time mothers may have the added benefitof promoting exdusive breastfeeding in subse-quent diildren.

Second, why are those hospital practices thathave been repeatedly shown to increasebreastfeeding among new mothers not moreconsistently instituted in Uniled States hospi-tals? A large proportion of mothers stop ex-dusive breastfeeding within the first week, andthat action was strongly related to hospitalpractices. As policy statements from theAmerican Public Health Assodation and otherleading oi ganizations declare, these practicesmust be changed at the hospital and profes-sional levels to ensure that the hospitaJ expe-rience more consistently contributes to tliehealth and welfare of mothers and babies.implementatioÈi of the updated Baby-Friendly

Hospital Initiative will contribute to increasingthe proportion of mothers who are given tliesupport tliey need to fulfill their intention toexclusively breastfeed. •

About the Authors.-^t the time oftkestudi/. Eugene Declercq tvas With School ofPublic Health, Boston Uniivi'siti/. \fA. Miriam H. Lohhcikwas with the School of Public Hetillh, Universitif of NorthCarolina. Chapel Hill. Carol Sakala was with ChildbirthCannectinns, .Veit' York. iVV. Mary.Ann O'Hara wtii with theUniversittf of Washington. Seattle.

Requests for reprints can be sent to Eugene Declercq.Department of Matermd ami Child Health. Boston Uni-verstty School of Puhlic Heohh. 71 ñ .Mhany St, TalhotW5-40. ihston. .MA 021 IS (e-mail: declercq@bu.edu).

Tliis article was accepted October 7. 2008.

ContributorsE. Dedercq designed the sttidy, wrote the first draft of(he "Methotis" mid "Rcsulls" sections, and did the dataanalysis. M. H. I.abbok, M. O'Hara. and C. Sakala did Üicliterature review and wrote the first draft of the Intro-duction and "Discussion" sections. C. Sakala and E.Declercq were iTivolved in the design of the tinestion-nairc thai wai Ihc basis tor the siin'cy. All autliors wereinvolved in writing subsequent drafts.

AcknowledgmentsThis research was .suppoited by the Roheit WoodJohnson I'oiiiidation and Childhirth Connection.

KobJn Young assisted witJi tlie data analysis.

Human Participant ProtectionThis study was ruled exempt by the institutional reviewboard office of the Bost[>n University School of Medidjiebecaii.se autliors only had access to a rieidentified file.Original data are securely stored al Harris Interactive.

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May 2009, Vol 99, No. 5 | American Jojmal of Public Healtb Declercq et al. i Peer Reviewed | Research and Practice | 935