Breastfeeding Practices in New York State Maternity Hospitals: Results from a Statewide Survey

Abstract

Objective:

This study characterized maternity hospital breastfeeding practices in New York.

Methods:

The New York State Department of Health Breastfeeding Survey was sent to 138 hospitals providing maternity services to assess breastfeeding and rooming-in policies, infant feeding practices, breastfeeding training, staff structure, and support mechanisms. Additionally, hospital-specific exclusive breastfeeding rates were obtained from Hospital Profile data.

Results:

The response rate was 100%. Ninety-three percent of the hospitals allowed 24-hour rooming-in, in all postpartum rooms. Eighty-six percent of hospitals employed a designated lactation coordinator. Less than 1.5% of hospitals routinely gave formula, pacifiers, or glucose water to a breastfed infant. These supplements are most commonly provided because of the mother's request. The largest reported barrier to initiating breastfeeding in the hospital was presenting mothers with mixed messages, whereas the largest patient barrier was identified as the mother's culture. All hospitals provided obstetric nursing staff with lactation education, whereas 46.4% trained physicians. Among healthy births, exclusive breastfeeding was statistically more likely to occur in hospitals offering only basic care (Level I) or subspecialty care (Level III), relative to Regional Perinatal Centers delivering the highest level of care, and was more likely with hospitals outside of New York City, relative to those within the city. After controlling for hospital location and level of care, exclusive breastfeeding was statistically more likely in hospitals that initiate breastfeeding immediately following an uncomplicated vaginal or cesarean birth.

Conclusions:

Mothers should be encouraged to initiate breastfeeding immediately after birth. Practices of Level I hospitals that lead to increased breastfeeding should be identified.

Introduction

Breastfeeding provides ideal nourishment, security, and emotional support for the healthy growth and development of newborn infants, while also providing maternal benefits.¹ Health advantages for the infant include significant risk reduction for acute otitis media^2,3 and hospitalization due to lower respiratory tract infections.^4,5 There is also evidence that exclusively breastfed infants may have a reduced risk of developing type 2 diabetes, lower blood cholesterol concentrations, and marginally lower insulin concentrations in later life.^6–8 Maternal benefits of breastfeeding include a reduction in the risk for breast and ovarian cancers,^9–12 short- and long-term decrease in the mother's systolic and diastolic blood pressure, reduced risk of myocardial infarction, a reduction of postpartum weight retention in women of all prepregnancy body mass index categories,^13–15 and a decreased risk of postpartum depression.^16–18

Healthcare professionals at the hospital can promote early breastfeeding initiation and provide support to increase likelihood of success and continuation.¹⁹ Evidence suggests that a comprehensive hospital policy approach to breastfeeding promotion results in better outcomes,²⁰ including early initiation and longevity of breastfeeding, as well as continued success.^18,21–25 Maternal and child health benefits of breastfeeding have been recognized by organizations globally and in the United States.^26–28 The current breastfeeding recommendations from The United Nations Children's Fund (UNICEF)/World Health Organization (WHO) are that newborn infants be given no food or drink other than breastmilk for the first 6 months of life, unless medically indicated, establishing lactation immediately following birth by placing the infant in continuous skin-to-skin contact with the mother until the infant self-attaches and feeds, which may take up to 2 hours, practicing rooming-in, not giving infants pacifiers or artificial nipples, and referring mothers to community breastfeeding support groups.^29,30 The U.S. Department of Health and Human Services has issued a Healthy People 2020²⁷ goal for breastfeeding initiation of 81.9%, which is very close to the New York State (NYS) rate of 81.4%; however, the NYS rate of breastfeeding at 6 months is 47.4%, far short of the U.S. goal of 60.6%.³¹

Given the observed associations between hospital practices and successful breastfeeding outcomes, which translate into health care expenditures savings, the NYS Department of Health (NYSDOH) conducted a survey of all hospitals providing maternity services in NYS. The survey was designed to assess current hospital practices and identify areas in need of improvement, working toward meeting the Healthy People 2020 breastfeeding objectives.

Methods

Survey instrument

The survey was developed by reviewing previous survey instruments used by the NYSDOH and the New York City (NYC) Department of Health and Mental Hygiene. Questions from each data collection instrument were included based upon their relevance from other studies. After approval by the NYSDOH Institutional Review Board, the survey tool contained 49 questions that provided a comprehensive data collection mechanism for identifying the hospital practices impacting breastfeeding initiation, duration, and exclusivity, as well as family perceptions of breastfeeding.

Study design

A cross-sectional study design was used to collect data on breastfeeding-related hospital practices from all 138 hospitals in NYS that provide maternity services. The survey described above was e-mailed in November 2009 to a maternity department representative at each hospital. After follow-up with outstanding hospitals, all surveys were returned by January 2010.

The survey data were supplemented with exclusive breastfeeding data obtained from the NYSDOH Web site under “Hospital Maternity-Related Procedures and Practices Statistics” as part of the NYSDOH annual hospital assessment.³² These data are based on certificates of live birth in 2008, the most recent data available at the time of the survey, and are not expected to vary significantly from the year 2009.

These supplemental data may help identify practices that can improve exclusive breastfeeding prior to hospital discharge, a Joint Commission National Quality Core Perinatal Measure.³³

Hospitals were grouped according to their NYSDOH-designated perinatal level of care, with Level I providing basic maternity care for low-risk births, Level II providing specialty care, Level III providing subspecialty care, and Level IV being Regional Perinatal Centers (RPCs), which are capable of handling the most complex births and provide education, consultation, and support to affiliate hospitals within their regional perinatal network. Neonatal intensive care units are required at all birthing hospitals above Level I.

Data analysis

Characteristics of the hospitals and their breastfeeding practices were illustrated through descriptive statistics. Hospital practices and policies on breastfeeding were further evaluated after accounting for other hospital variables that have been shown to have an effect and may act as confounders. This multivariable analysis was accomplished through negative binomial regression³⁴ using SAS version 9.2 (SAS Institute, Cary NC), where the response variable is the number of infants exclusively breastfed, offset by the number of healthy births (infants not admitted to a neonatal intensive care unit or transferred to or from another hospital). The effects of breastfeeding practices and policies were presented as relative risk values, both with and without controlling for hospital level and region.

Results

Surveys were received from 138 NYS hospitals with maternity services (100% response). Statewide, there were 59 (42.8%) perinatal Level I hospitals, 25 (18.1%) Level II, 36 (26.1%) Level III, and 18 (13.0%) RPCs (Table 1). The majority of hospitals within NYC (34/41 [82.9%]) were Level III or RPCs with no Level I hospitals, and all but one hospital had over 1,000 annual births (40/41 [98%]).

Table 1.

Characteristics of New York State Hospitals with Maternity Services, 2009

Category	Total (%)	Rest of state	NYC only (%)
Location	138 (100%)	97 (70.3%)	41 (29.7%)
Number of healthy births^a	225,072 (100%)	111,196 (49.4%)	113,876 (50.6%)
Level of perinatal care
Basic (Level I)	59 (42.8%)	59 (60.8%)	0 (0.0%)
Specialty care (Level II)	25 (18.1%)	18 (18.6%)	7 (17.1%)
Subspecialty care (Level III)	36 (26.1%)	12 (12.4%)	24 (58.5%)
Regional Perinatal Centers	18 (13.0%)	8 (8.3%)	10 (24.4%)
Annual births per hospital
<499	30 (21.7%)	30 (30.9%)	0 (0.0%)
500–999	26 (18.8%)	25 (25.8%)	1 (2.4%)
1,000–1,999	28 (20.3%)	19 (19.6%)	9 (22.0%)
2,000–2,999	30 (21.7%)	16 (16.5%)	14 (34.1%)
>3,000	24 (17.4%)	7 (7.2%)	17 (41.5%)

NYC is defined as Bronx, Kings, New York, Queens, and Richmond Counties. The rest of the state is all counties outside of NYC.

A healthy birth is defined as an infant not admitted to a neonatal intensive care unit or transferred to or from another hospital.

Of the 137 hospitals (99.3%) with a breastfeeding policy, 112 (81.8%) reported communicating its contents at least annually with obstetric nursing staff, 51 (37.2%) informed physicians, and 24 (17.5%) did not inform either nursing or physician staff. Ninety-seven percent of hospitals reported that their breastfeeding policy encourages contact between the mother and infant within the first half-hour after birth, breastfeeding on demand, and breastfeeding at the mother's bedside at any time day or night.

Most (110 [80%]) hospitals reported having a written procedure for 24-hour rooming-in implementation. Of the hospitals without a rooming-in policy, 26 of 28 (93%) allowed rooming-in at the mother's request. The most common reported barrier to establishing a rooming-in policy was placement in semiprivate rooms. Of the hospitals with a 24-hour rooming-in policy, only 28% (31/110) reported that >90% of mothers participate; however, this rate depends on the hospital's level of care. Among Level I hospitals, 43% (20/47) reported that >90% of mothers participated in 24-hour rooming-in, whereas 13% (2/15) of RPCs reported this. The majority of hospitals documented that an infant is breastfeeding in the mother's chart (129 [94%]) or in the infant's chart (116 [84%]). A sticker or card was placed in a breastfeeding infant's bassinet at 74 hospitals (54%), whereas two hospitals (1.5%) did not have a mechanism to identify breastfeeding infants.

All hospitals provided breastfeeding education for obstetric nurses, which commonly occurred bedside (123 [89%]) or in a classroom (106 [77%]). However, less than half of hospitals (64 [46%]) provided breastfeeding education to their physicians, typically during residency training (37 [27%]). A designated lactation coordinator was employed at 114 (83%) hospitals, with 88 (77%) having an International Board Certified Lactation Counselor and 29 (25%) having a Certified Lactation Consultant. Percentages added to over 100% as some (eight) lactation coordinators held both designations. Lactation counselors were available most often during the workweek day shift (72 [52%]), followed by evenings (58 [42%]) and the overnight shift (57,] [41%]). On weekends, lactation counselors were available more often during the day (65 [47%]) than during the evening (60 [44%]) and overnight shifts (60 [44%]). All 138 hospitals reported that if a lactation counselor was unavailable, another staff member would be able to assist a breastfeeding mother.

During the postpartum stay, educational topics related to breastfeeding that were covered by >95% of hospitals included “benefits for the baby,” “benefits for the mother,” “nutritional needs of the mother,” “positioning and latch,” “signs that nursing is going well,” and “common concerns and/or questions.” Topics less commonly discussed include “HIV and breastfeeding” (56 [41%]), “birth control and breastfeeding” (83 [60%]), and “the role of the partner” (107 [78%]). Of the 130 hospitals (94%) providing a childbirth education class, 122 (93%) incorporated a segment on breastfeeding. Additionally, 87 hospitals (63%) had a prenatal care clinic, of which 83 (95%) informed women in attendance about the benefits of breastfeeding.

At 87 hospitals (63%), staff observed the mother and baby at the initial feeding, 84 hospitals (60%) did so at the mother's request, and 77 (56%) observed breastfeeding at the discretion of the nursing staff. In addition, 55 (40%) hospitals reported observing a mother breastfeeding before discharge, and 110 hospitals (80%) observed a mother breastfeeding at least once every shift.

The most commonly identified barrier to breastfeeding at the hospital was “mixed messages among the professional members of the staff,” reported by 99 hospitals (71.7%). Other areas identified as barriers were “lack of financial resources/support” by 49 (36%) and “time restraints for lactation coordinators” by 66 (47%). Commonly identified familial barriers that interfere with breastfeeding included the “culture of the family and mother” by 102 (74%), “mother not receptive to breastfeeding” by 90 (65%), and “lack of mother's preparedness for breastfeeding” by 77 (56%).

The feeding practice assessment encompassed glucose-water, formula, and pacifier practices during the hospital stay. Seventy-four of the hospitals (53%) reported not administering glucose-water under any circumstance, 56 (41%) administered it with physician's order in special circumstances, and two (1.5%) did this routinely for all breastfeeding newborns. Reasons for formula and pacifier utilization differed from water/glucose-water administration. Hospitals reported the following reasons for giving formula: “maternal request” by 126 (91%), “physician's order under special circumstances” by 118 (86%), “at the discretion of the nursing staff” by 17 (12%), and “at night, while a mother is sleeping” by 18 (13%). Pacifiers were most often given to a breastfeeding infant at “the request of the mother” by 102 (74%), followed by “at the discretion of the nursing staff” by 26 (19%). Within the “other” category, 13 hospitals (9%) reported that they use pacifiers as pain control during procedures.

Formula representatives had access to staff members at 97 hospitals (70%), and formula companies provided 125 hospitals (91%) with free formula. Ninety-eight hospitals (71%) gave materials provided by formula companies to breastfeeding mothers, and 42 hospitals (30%) gave breastfeeding mothers discharge packs with formula. The majority of hospitals (91 [66%]) had considered implementing “Baby Friendly Hospital” protocols. Of those, 29 (32%) cited fiscal difficulties as a reason for not doing so, in particular the added expense of purchasing infant formula.

All responding hospitals had at least one type of lactation support after a mother is discharged, and 128 hospitals (93%) provided mothers with breastfeeding instructions at discharge. Additional lactation support included a referral to the Women, Infants and Children (WIC) nutritional program (116 [83%]), the availability of a 24-hour telephone number (112 [81%]), lactation consultant referral (93 [67%]), and referral to a community-based support group (82 [59%]).

Many hospitals provided services to breastfeeding staff members. One hundred sixteen hospitals (84%) provided staff with a “private room to express and store milk,” while 114 (83%) provided “breaks to express milk.” At 101 hospitals (73%), a “lactation consultant or specialist is available,” and 109 (79%) provided “electric breast pumps.”

Further analysis used NYS Hospital Profile data to pair the number of healthy deliveries at each hospital with their exclusive breastfeeding rates, determined upon discharge. Table 2 illustrates the association through descriptive statistics of several variables with exclusively breastfed infants. After an initial review, variables were identified that demonstrated a potential effect on exclusive breastfeeding rates. Two such associations are hospital classification and the region of the hospital.

Table 2.

New York State Department of Health Breastfeeding Survey Aggregate Responses Paired with Number of Exclusively Breastfed Infants

Survey question	Survey response	Number of hospitals selected (n=138) (%)^a	Total number of healthy births ^b	Total number exclusively breastfed infants (%) ^c
County	NYC	41 (29.71%)	113,876	35,022 (30.75%)
	Rest of state	97 (70.29%)	111,196	59,336 (53.36%)
How does NYSDOH classify your hospital?	Basic care (Level I)	59 (42.75%)	35,796	21,678 (60.56%)
	Specialty care (Level II)	25 (18.12%)	44,913	16,511 (36.76%)
	Subspecialty care (Level III)	36 (26.09%)	80,832	30,838 (38.15%)
	Regional Perinatal Center	18 (13.04%)	63,531	25,331 (39.87%)
Does your hospital have a written policy about breastfeeding?	Yes	137 (99.28%)	224,395	94,028 (41.90%)
If yes, is the policy reviewed at least once a year by all obstetric staff?	Nurses/physicians	50 (36.50%)	91,604	33,051 (36.08%)
	Nurses only	62 (45.26%)	92,758	45,666 (49.23%)
	Physicians only	1 (0.73%)	399	87 (21.80%)
	Neither	24 (17.52%)	39,634	15,224 (38.41%)
Does the policy encourage breastfeeding on demand?	Yes	133 (97.08%)	217,511	90,529 (41.62%)
Does the policy allow for a mother to request the infant be brought to her to be breastfed, at anytime of the day or night?	Yes	135 (98.54%)	222,397	93,206 (41.91%)
Does the hospital policy allow for a mother to hold the baby within the first half-hour of birth?	Yes	133 (97.08%)	222,444	93,077 (41.84%)
If yes, does the policy encourage women to breastfeed during this period of early contact?	Yes	134 (100%)	223,249	93,479 (41.87%)
If your hospital has a written breastfeeding policy, what percent of mothers participate in 24-hour rooming in?	Rarely (<10%)	14 (12.73%)	32,272	12,481 (38.67%)
	Some (10–40%)	30 (27.27%)	61,956	30,654 (49.48%)
	Half (41–60%)	14 (12.73%)	28,646	9,948 (34.73%)
	Most (61–90%)	20 (18.18%)	28,671	11,711 (40.85%)
	Almost all (>90%)	31 (28.18%)	28,317	12,385 (43.74%)
What percentage of mothers who had vaginal births without complications begin to breastfed in the delivery room?	Rarely (<10%)	1 (0.72%)	724	247 (34.12%)
	Some (10–40%)	23 (16.67%)	43,375	11,607 (26.76%)
	Half (41–60%)	22 (15.94%)	34,849	10,651 (30.56%)
	Most (61–90%)	31 (22.46%)	66,380	28,831 (43.43%)
	Almost all (>90%)	59 (42.75%)	77,620	41,592 (53.58%)
What percentage of mothers who had a cesarean section without complications begin to breastfeed in the recovery room?	Rarely (<10%)	58 (42.03%)	85,667	23,614 (27.56%)
	Some (10–40%)	18 (13.04%)	30,610	14,704 (48.04%)
	Half (41–60%)	13 (9.42%)	25,737	13,893 (53.98%)
	Most (61–90%)	22 (15.94%)	44,014	21,624 (49.13%)
	Almost all (>90%)	24 (17.39%)	35,399	18,869 (53.30%)
Does your hospital employ a designated lactation coordinator?	Yes	114 (82.61%)	188,137	80,207 (42.36%)
If yes, what are the lactation coordinator's credentials?	IBCLC	88 (77.19%)	163,656	71,393 (43.6%)
	CLC	29 (25.44%)	34,300	12,136 (35.4%)
Does your hospital receive infant formula at no charge?	Yes	125(90.58%)	202,306	83,965 (41.50%)
	No	13 (9.42%)	22,766	10,393 (45.65%)
Does your hospital provide breastfeeding mothers with formula company-produced materials at the time of discharge?	Commercial packs with formula	42 (30.43%)	65,721	24,295 (36.97%)
	Commercial packs without formula	48 (34.78%)	67,758	28,085 (41.45%)
	No	38 (27.54%)	68,935	32,689 (47.42%)
	Both commercial packs with and without formula	8 (5.80%)	17,654	8,360 (47.35%)

Not all responses add to 138, as some questions were left blank or did not require a response.

Data retrieved from New York State Hospital Profile Data, 2008.

Percentage derived from dividing the number of exclusively breastfed infants by the total number of healthy births, defined as infants not admitted to the neonatal intensive care unit or transferred to or from another hospital.

CLC, Certified Lactation Consultant; IBCLC, International Board Certified Lactation Conselor; NYSDOH, New York State Department of Health.

A healthy infant born outside of NYC was approximately twice as likely to exclusively breastfeed, relative to healthy infants born in NYC. Meanwhile, the likelihood of an infant exclusively breastfeeding at a Level I hospital was 1.51 times greater than infants born at an RPC (relative risk=1.51, 95% confidence interval 1.08–2.07, p=0.0135). When NYC hospitals were excluded, the likelihood of an infant exclusively breastfeeding at a Level I hospital was 1.35 times greater than that for infants born at a RPC (Table 3).

Table 3.

New York City and Hospital Class Effect on Exclusive Breastfeeding Rates, 2009

Category	Relative risk	95% confidence interval	p value
NYC effect
NYC only	1^a
Rest of state	1.99	1.52, 2.61	< 0.0001
Perinatal hospital level effect^b
Basic (Level I)	1.35	1.07, 1.68	0.0095
Specialty care (Level II)	1.10	0.86, 1.42	0.4447
Subspecialty care (Level III)	1.47	1.12, 1.92	0.0056
Regional Perinatal Center	1^a

Reference group.

Excluding New York City.

Given the strong influence of region (NYC vs. rest of state) and hospital level of care, these factors were controlled for when evaluating the effects of hospital practices on exclusive breastfeeding rates, as reported in Table 4. Infants were over 1.4 times more likely to exclusively breastfeed if born in a hospital where “almost all” (<90%) mothers began breastfeeding immediately after birth. This significant effect was observed for uncomplicated vaginal deliveries, relative to hospitals where “some” (10–40%) mothers began breastfeeding in the delivery room, and for uncomplicated cesarean deliveries, relative to hospitals where mothers “rarely” (<10%) began breastfeeding in the recovery room.

Table 4.

Relative Risk of Selected Hospital Practices That Influence Exclusive Breastfeeding Rates, After Controlling for Effects Due to Hospital Level of Care and Region (New York City vs. Rest of the State)

Category	Relative risk	95% confidence interval	p value
Associations related to timing of breastfeeding initiation
Following an uncomplicated vaginal delivery, exclusive breastfeeding rates of infants at hospitals where “almost all” (>90%) mothers began to breastfeed in the delivery room versus “some” (10–40%)	1.45	1.13, 1.88	0.0035
Following an uncomplicated cesarean section, exclusive breastfeeding rates at hospitals where “almost all” (>90%) mothers begin to breastfeed in the recovery room versus “rarely” (<10%)	1.46	1.11, 1.92	0.0083
Associations related to staff
Exclusive breastfeeding rates at hospitals who conducted physician training versus those who did not provide this instruction	1.01	0.79, 1.28	0.9371
Exclusive breastfeeding rates at hospitals who have a lactation coordinator versus those who do not	1.17	0.64, 1.09	0.1873
Associations regarding 24-hour rooming-in policy
Hospitals with a 24-hour rooming-in policy versus those without	1.21	0.99, 1.38	0.0537

Table 4 also reveals no statistically significant effects of staff training policies, although there appears to be some positive association between exclusive breastfeeding and the presence of a lactation coordinator. Furthermore, hospitals that employed a policy regarding 24-hour rooming-in are 1.21 times more likely to have exclusively breastfed infants than hospitals who did not have a policy.

Discussion

All maternity hospitals completed the survey, enabling a comprehensive assessment of breastfeeding practices throughout NYS. Almost all hospitals had a written breastfeeding policy that allows mothers to hold their infants within 30 minutes of birth and encourages breastfeeding during this period. Variation existed in the number of lactation counselors available at hospitals. However, all hospitals reported that if a lactation counselor was not available 24/7, another staff member was able to assist a lactating mother. These practices are consistent with best practices to establish successful breastfeeding.

Institutional breastfeeding obstacles included “mixed messages from professional staff members” and “lack of financial resources.” In addition, the majority of hospitals allowed formula representatives to visit obstetric staff, receive free infant formula, and give breastfeeding mothers discharge packs with materials produced from formula companies. This practice may be influenced by financial resources in hospitals. To address these mixed signals, policies addressing the provision of free formula and the access of formula representatives should be examined.

Survey results indicate that some hospitals provided supplementation and artificial nipples to breastfeeding infants other than when medically indicated, most often at the request of the mother. Discussing complications of such practices during prenatal education may discourage breastfeeding mothers from making these requests. Positive breastfeeding attitudes may be encouraged through education, discussing common fears and rebutting myths that may prevent women of all cultures from breastfeeding.

Current recommendations and the New York Codes Rules and Regulations Title 10–part 405.21 state that a mother should be assisted in establishing lactation. The amount of assistance a mother needs to establish and maintain lactation will vary. Four of five hospitals had personnel visit the mother at least once every shift to supply lactation assistance. In addition, 60% of the hospitals reported visiting the mother at her request. Assessing the mother's breastfeeding practices and offering support at each feeding will enhance a mother's ability to breastfeed.

All hospitals provided some form of breastfeeding support once a mother is discharged. Some hospitals referred patients to community breastfeeding organizations such as La Leche League and the WIC program; this practice should be encouraged among all hospitals as it is a relatively easy to implement. From the survey it was reported that four out of five hospitals discussed the role of the partner in lactation. Because the attitude of the partner has been shown to influence success of breastfeeding after discharge,³⁵ this provides an opportunity for improvement.

Currently, almost all hospitals providing childbirth education classes or hospitals with an associated prenatal clinic provide education on breastfeeding. Increased prenatal education has been identified to increase exclusive breastfeeding rates as it may give a mother more opportunities to further prepare and ask questions. Because not all hospitals discuss breastfeeding prenatally, it provides a focused area for improvement.

The survey results obtained in this study differ from responses in the Centers for Disease Control and Prevention's Maternity Practices in Infant Nutrition and Care (mPINC) of New York facilities.³⁶ Our results tend to be more positive in relation to supporting breastfeeding with regard to supplementation, staff training, and discharge care. This may reflect a difference in the way questions were posed.

By linking survey responses to Hospital Profile data, it was shown that healthy infants born in NYC hospitals are less likely to be exclusively breastfed compared with healthy infants in the rest of the state. This study does not address the reasons for this, but it may be due to the demographics of NYC, the number of annual births per hospital, the majority of hospitals classified as Level III or RPCs, or an additional regional effect not identified. This variation may influence potential outreach measures to increase breastfeeding rates.

After controlling for NYC and hospital level, hospitals where almost all mothers (>90%) began breastfeeding in the delivery room following a vaginal delivery without complications were more likely to have exclusively breastfed infants. This further supports the proposal that the immediate initiation following birth is important in establishing exclusive breastfeeding. This pattern also holds true for uncomplicated cesarean sections. Considering that one in three births in NYS were by cesarean section and that the exclusive breastfeeding rates were low for this population, promotion and encouragement of breastfeeding among infants born via cesarean section would provide an opportunity for substantial improvement.

After controlling for NYC and hospital level, physician training on breastfeeding did not show a significant difference in exclusive breastfeeding rates. This may reflect the fact that physicians at the delivering facility do not have a large effect on a mother's choice on how to feed her infant and that this education must occur prenatally. When specialists such as obstetricians, family practice physicians, and pediatricians all address and encourage breastfeeding, breastfeeding rates may be impacted.

Limitations

As with any survey, responses are self-reported, which may affect the accuracy of the data.

Conclusions

Even though all hospitals with a breastfeeding policy reported that a mother may hold her infant and encourage breastfeeding during the first 30 minutes of birth, the survey tool did not address the updated WHO recommendations regarding skin-to-skin contact and uninterrupted self-attachment. Further follow-up is necessary to get a true assessment on the measure.

Formula supplementation and pacifier use have been linked as barriers to the success of breastfeeding. The most common reasons for giving pacifiers and formula is at the request of the mother, which indicates a need to concentrate on this during prenatal breastfeeding education.

All hospitals reported that if a lactation counselor was unavailable, another staff member was available to assist a new mother with breastfeeding. Further studies should consider if more staff proficient in lactation assistance would be beneficial to establishing successful lactation, especially at hospitals with a high volume of births. In addition, some hospitals reported that they are unable to observe a lactating mother at least once a shift or at the mother's request. These findings suggest that breastfeeding support may be improved by observing the mother more often and through increasing the staff who are more proficient in lactation counseling.

Even when controlling for hospital level and location (NYC vs. rest of the state), the initiation of breastfeeding in the delivery room among uncomplicated vaginal and cesarean section deliveries had statistically significant effects on the number of exclusively breastfed infants. Knowing this, hospital policies and practices should encourage mothers who wish to breastfeed to begin immediately after a vaginal delivery or as soon as possible after a cesarean section.

Some hospital professional staff members are providing mothers with contradictory information regarding breastfeeding. It was reported that mothers are given mixed messages from different interactions with different members of the staff as well as the majority of mothers are given discharge materials produced by formula companies. The hospital needs to send a consistent message regarding the benefits of breastfeeding and provide breastfeeding information on discharge support as the mother returns to her community.

Future studies should consider the use of pacifiers as a pain control measure in order to more accurately access the prevalence of this practice and its effect on exclusive breastfeeding rates. In addition, the practices of Level I hospitals, which are more likely to have exclusively breastfed infants, should be examined in order to see if aspects of care can be replicated in all levels of hospitals.

Additionally, hospitals can participate in the mPINC survey that is administered by the Centers for Disease Control and Prevention, using these results to self-monitor improvement in maternity care practices with respect to other facilities in New York and other similar size facilities throughout the country.

The NYSDOH is actively working to improve breastfeeding rates, and this study serves as a baseline to measure improvement. Since this survey, there has been an assessment of the compliance of hospital policies to NYS Rules and Regulations that support breastfeeding and follow-up with hospitals for improvement. There has also been an active hospital collaborative focusing on improving breastfeeding in targeted facilities. This survey will be repeated, and results will be compared between the two time periods to measure the impact of these efforts.

Footnotes

Acknowledgments

We wish to thank Kevin Leadholm, M.P.H., for survey development and facilitation of data collection. We acknowledge Ashley Giambrone, M.S., and Kathy Clancy, M.P.H., for additional support in data management and analysis.

Disclosure Statement

The authors state that there are no commercial, financial, or other relationships that would create a conflict of interest with respect to this article and study survey results.

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