illinois breastfeeding blueprint - data appendix

Illinois Breastfeeding Blueprint

Quantitative Data Appendix:

Data Sources, Methodology, and Additional Analyses

Table of Contents

Section 1. Illinois Breastfeeding Data Sources…………………………………………………………………………………………1

Section 2. Notes about Race/Ethnicity………………………………………………….……………………………………………….. 2

Section 3. Creation of Low Income Index………………………………………………………………………………………………..3

Section 4. Hispanic Sub-Group Analyses………………………………………………………………………………………………… 4

Section 5. WIC Client Breastfeeding Continuation Analysis……………………………………………………………………. 8

Section 6. Effect of Hospital Practices on Breastfeeding Continuation and Exclusivity………………………….10

1

Section 1: Illinois Breastfeeding Data Sources ** indicates data source used in the Illinois Breastfeeding Blueprint report

Birth Certificates (starting with 2010 births)

As of 2010, Illinois revised the birth certificate to include a question about breastfeeding. The question is worded:

““Is the infant being breastfed at discharge?” with the option of responding yes or no. Once 2010 birth certificate

data are complete, the Illinois Department of Public Health will be able to examine the responses and report

differences in breastfeeding rates throughout the state, including by delivery hospital. This will provide the state

with important information about geographic and demographic differences in early breastfeeding behaviors, as

well as documenting the association of early breastfeeding with later infant and child health. Hospital level data

on the birth certificate breastfeeding question is publically available on the Illinois Hospital Report Card website

(http://www.healthcarereportcard.illinois.gov).

Cornerstone

Cornerstone is the administrative database for many Illinois Department of Human Services programs, including

the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Family Case

Management (FCM). For infants enrolled in WIC, breastfeeding information is recorded and updated over time,

so this system can provide information about breastfeeding initiation, duration, and length of exclusive

breastfeeding.

Maternity Practices in Infant Nutrition and Care (mPINC) **

mPINC is a survey of hospital representatives about policies and practices related to breastfeeding conducted

biannually by the Centers for Disease Control and Prevention (CDC). Questions are asked about specific practices

related to: labor and delivery care, feeding of breastfed infants, breastfeeding assistance, contact between the

mother and infant, facility discharge care, staff training, and structural/organizational aspects of care. The results

of this survey are publicly available by state, so Illinois’ scores may be compared to those of other states and the

nation overall. The first version of the survey was administered in 2007 and all hospitals in Illinois were invited to

participate. Illinois, however, had a low response rate compared to other states, with only 59% of hospitals

completing the survey compared to a national average of 80%. The mPINC survey was repeated in 2009, and data

will be publicly available in summer 2011. Please check the CDC mPINC website for updated data

(http://www.cdc.gov/breastfeeding/data/mpinc/index.htm).

National Immunization Survey (NIS)

NIS is an annual survey conducted by the Centers for Disease Control and Prevention. It surveys a representative

sample of families of children 19-35 months old. While the major focus of the survey is immunizations, NIS asks

questions about breastfeeding initiation, duration, and exclusivity. Estimates of breastfeeding for all women

giving birth in each State are available yearly and may be compared to those in other states and the nation

overall.

Pregnancy Risk Assessment Monitoring System (PRAMS) **

PRAMS is an annual survey of Illinois women who recently delivered a live birth that collects information about

maternal attitudes and experiences before, during, and shortly after pregnancy. Participants are typically

surveyed by mail or phone 3 to 6 months after delivery. Women are asked about their breastfeeding behaviors

(such as initiation, duration, and length of exclusivity), reasons why they chose not to breastfeed or to stop

breastfeeding, and whether or not they experienced specific hospital practices during their delivery

hospitalization. There is a rich amount of information available in this survey, which is linked to the birth

certificate for infants of participating mothers.

2

Section 2: Notes about Race/Ethnicity

In the Illinois Breastfeeding Blueprint, we examine the data by race/ethnicity after dividing women into four

groups: non-Hispanic white, non-Hispanic black, Hispanic, and Asian. These classifications were made based on

the woman’s race and ethnicity as noted on her infant’s birth certificate. The birth certificate asks two separate

questions about race and Hispanic ethnicity; these responses were combined to create the racial/ethnic groups.

Any woman reporting Hispanic ethnicity on the birth certificate was considered to be “Hispanic”, regardless of her

race. We recognize that Hispanics in the United States are a heterogeneous group of people, representing many

different cultures and varying levels of acculturation. Section 4 of this appendix has more detailed data about

Hispanic women who gave birth in Illinois.

Pacific Islander women were included in the “Asian” category. While Asian and Pacific Islander women in the

United States also represent many diverse cultures, we could not examine sub-groups of Asian women. First,

information on country of origin, immigration date, or levels of acculturation were not available in the PRAMS

dataset. Secondly, even if additional information were available, the sample size would not have been sufficient

for sub-group analysis because Asians comprise only a small proportion (4.5%) of the Illinois population.

Women who were reported to be of American Indian, Alaska Native, or “other” race/ethnicity were excluded

from the race/ethnicity analyses because only a very small sample of women (0.2%) fell into this category.

For all our race/ethnicity group labels (“non-Hispanic white”, “non-Hispanic black”, “Hispanic”, and “Asian”), we

opted to match the race and ethnicity language on the birth certificate. For some of these groups, other labels,

such as “Caucasian”, “African-American”, and “Latina” could have been used. We opted, however, to remain

consistent with the wording of the original birth certificate questions to avoid confusion or changing the meaning

of the constructs. For example, a recent immigrant from Africa might describe herself as might describe herself as

“black” and “non-Hispanic”, but not as “African-American”.

We recognize that there may be errors in birth certificate information on race/ethnicity because the mother may

not have answered the race and ethnicity questions herself. Race and ethnicity could have selected for the

woman by the person completing the birth certificate. If given the chance, the woman might have selected a

different race or ethnicity for herself, or selected multiple races. This could result in misclassification of a

woman’s race/ethnicity, though we expect that such misclassification would be rare. Additionally, these

measures of race and ethnicity were the only ones available to us in the PRAMS dataset.

3

Section 3: Creation of Low Income Index

To compare women of different social situations and explore the relationship between social class and

breastfeeding, we classified women as either low income or non-low income. This classification was made on the

basis of responses to several questions in the PRAMS survey. Women were classified as low income if they

reported at least one of the following: 1) Medicaid as the health insurance payer for prenatal care and/or delivery,

2) Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation during pregnancy and/or

after delivery, 3) Temporary Assistance for Needy Families (TANF) receipt during pregnancy, 4) Food Stamps

receipt during pregnancy, or 5) an annual household income less than $25,000 per year. If women reported that

they did not participate in any of the listed programs and that their household income was $25,000 or higher,

they were classified as non-low income.

As shown in Figure A-1, low income status varied across racial/ethnic groups in the population of women

surveyed. Thirty-seven percent (37%) of non-Hispanic white women who gave birth and 36% of Asian women

who gave birth were considered low income by our classification scheme. In contrast, 91% of non-Hispanic blacks

who gave birth and 88% of Hispanics who gave birth were classified as low income by our index. This reveals the

strong correlation between race/ethnicity and income in our state, particularly among women of reproductive

age, and should be taken into consideration when comparing racial groups overall.

4

Section 4: Hispanic Sub-Group Analyses

Hispanics in the United States are a heterogeneous group of people, representing many different cultures. Many

studies have demonstrated the association of country of origin, immigration status, and level of acculturation with

health behaviors, utilization of health services, and the health status of Hispanics in the U.S.

To try to capture the differences among Hispanics, we wanted to find a way of examining Hispanic sub-groups for

our analysis. We did not have country of origin, immigration status, or primary language available from the

PRAMS survey. We did, however, know which language the mother chose to take the survey in. PRAMS may be

taken in either English or Spanish and women are given the option of which survey language they prefer. While

survey language may serve as an indication of Hispanic women’s comfort with English, it is clearly not a

comprehensive measure for acculturation. Because it was the only option available to us, we used survey

language as a way of dividing Hispanic women who gave birth into two groups.

Overall, Hispanic women made up about 25% of women who give birth in Illinois each year. Of Hispanic women

who took the PRAMS survey, about 35% took the survey in English and 64% took the survey in Spanish.

The charts on the following pages show the differences in breastfeeding initiation, duration, and exclusivity for

Hispanic women based on their survey language. These results demonstrate that not all Hispanic women are

equal in terms of breastfeeding.

5

In 2008, approximately 88% of the

Hispanic women who took the

Spanish survey started

breastfeeding their infants,

compared to 84% of Hispanic

women who took the English

survey. This difference was not

statistically significant and both

groups met the Healthy People

2020 objective of 81.9% for

breastfeeding initiation.

Over time, the breastfeeding

initiation rates for both groups of

Hispanics increased.

Among low income Hispanic

women, 78% of those who took

the English survey and 88% of

those who took the Spanish survey

started breastfeeding their infants.

This difference was statistically

significant.

Among higher income Hispanic

women, there was no difference in

breastfeeding initiation by survey

language. Both groups had high

initiation rates, meeting the

Healthy People 2020 objective.

Additionally, among Hispanic

women who took the Spanish

survey, income did not affect

breastfeeding initiation. For those

who took the English survey, lower

income was associated with lower

breastfeeding rates.

6

Among Hispanic women who

started breastfeeding, there were

differences in breastfeeding

duration by survey language. The

difference becomes pronounced

around 4 weeks after delivery,

when a greater percent of those

who took the English survey

stopped breastfeeding compared

to those who took the Spanish

survey.

At 12 weeks after delivery, only

52% of Hispanic women who took

the English survey were still

breastfeeding, compared to 59%

of Hispanic women who took the

Spanish survey.


women who started

breastfeeding, 41% of those who

took the English survey, compared

to 60% of those who took the

Spanish survey were still

breastfeeding their infants 12

weeks after delivery.


women who started


took the English survey, compared

to 52% of those who took the

Spanish survey were still

breastfeeding their infants 12

weeks after delivery.

7

Survey language did not make a

difference in breastfeeding

exclusivity among Hispanic women

who started breastfeeding.

At 12 weeks after delivery, among

Hispanic women who started


took the Spanish survey were

exclusively breastfeeding their

infants compared to 21% of those

who took the English survey.

Survey language and income made

very little difference in the

proportion of Hispanic women

who exclusively breastfed their

infants for at least 12 weeks.


women who started


took the English survey and 23% of


were exclusively breastfeeding

their infants 12 weeks after

delivery.


women who started


took the English survey and 28% of


were exclusively breastfeeding

their infants 12 weeks after

delivery.

8

Section 5: WIC Client Breastfeeding Continuation Analysis

Data on breastfeeding is available from Cornerstone for WIC Participants in Illinois. Using these data, a method

called “life tables” was used to describe the pattern of breastfeeding duration among WIC participants who

initiated breastfeeding. The Hazard function shows the likelihood of women stopping breastfeeding at particular

points in time. If women were more likely to stop breastfeeding at a particular point in time, the hazard rate at

that point would be elevated.

9

Results

Among WIC participants who initiated breastfeeding:

• Less than 50% overall continued for 12 weeks

• Less than 20% overall continued for at least one year

• There were differences in breastfeeding continuation by race/ethnicity

• Black infants were least likely to continue breastfeeding and Hispanic infants were most likely to

continue breastfeeding

• More than 50% of black and white infants had already stopped breastfeeding by 8 weeks

• Only about 10% of black and white infants breastfed for at least one year, compared to 20% of

Hispanic infants

• Within each racial-ethnic group, the hazard rate is highest in the first six weeks. This demonstrates that

the fastest drop-off in breastfeeding occurs during this time period.

• The differences in hazard rates between racial/ethnic groups decrease the longer breastfeeding is

continued

Conclusions

• The majority of Illinois infants born to mothers who participate in WIC are not benefiting from the

recommended duration of breastfeeding.

• Even among WIC infants who start breastfeeding, disparities in duration exist. Black infants are least

likely to continue breastfeeding, though white infants are not far behind them. Hispanic infants are most

likely to continue breastfeeding.

• The first 6 weeks after delivery is when all groups of women are most likely to stop breastfeeding.

• The early postpartum period sets the trajectory for the continuation curve. Helping women continue

breastfeeding through this early period will improve overall breastfeeding duration.

10

Section 6: Effect of Hospital Practices on Breastfeeding Continuation and Exclusivity Women who initiated breastfeeding were included in a study of how maternity care practices impact

breastfeeding duration and exclusivity at 6 weeks postpartum. Among these women who started breastfeeding,

women who reported experiencing certain maternity hospital practices were compared to women did not

experience those practices.

Table A-1. Adjusted Odds Ratios (a-OR) of Continuing Breastfeeding and Exclusive Breastfeeding for at

Least 6 Weeks among Women Who Initiated Breastfeeding

Delivery Hospital Practice

BF ≥6 Wks

a-OR*

(95% CI)

Exclusive BF ≥6 Wks

a-OR*

(95% CI)

Breastfed in the hospital 2.32

(1.89 - 2.84)

1.79

(1.44 - 2.22)

Breastfed in the first hour after delivery 1.79

(1.57 - 2.05)

1.82

(1.61 - 2.06)

Baby fed only breast milk in the hospital 3.42

(2.93 - 3.99) Not assessed**

Hospital staff gave a BF support phone number 1.31

(1.10 - 1.57)

1.22

(1.03 - 1.45)

Hospital gave information about breastfeeding 0.90

(0.68 - 1.19)

0.90

(0.70 - 1.16)

Baby stayed in mom's hospital room 1.41

(1.20 - 1.65)

1.45

(1.25 - 1.69)

Hospital helped with breastfeeding 0.85

(0.72 - 1.02)

0.87

(0.75 - 1.01)

Hospital told mother to breastfeed on demand 1.51

(1.29 - 1.77)

1.39

(1.19 - 1.62)

Hospital gave a formula gift pack 0.74

(0.64 - 0.99)

0.62

(0.53 - 0.73)

Baby given pacifier in hospital 0.62

(0.54 - 0.71)

0.60

(0.54 - 0.68)

*Final regression models adjusted for: maternal race/ethnicity, age, education, marital status, parity, and pregnancy

intention. No race/ethnicity*hospital practice interaction terms were statistically significant.

**This relationship could not be assessed because infants fed anything other than breast milk in hospital were all not

exclusively breastfed at six weeks postpartum

11

About Odds Ratios: Odds Ratios (OR) show the strength of the relationship between maternity care practices and

breastfeeding continuation and exclusivity. ORs higher than 1 indicate that a hospital practice is associated with improved

breastfeeding continuation and exclusivity; ORs lower than 1 indicate that a hospital practice is associated with reduced

breastfeeding continuation and exclusivity. An OR shown in bold indicates that the finding is statistically significant.

Eight delivery hospital practices were significantly associated with improved breastfeeding duration for WIC

participants:

• Breastfeeding in hospital

• Breastfeeding within first hour after delivery

• Feeding infant only breast milk in hospital

• Giving a breastfeeding support phone number

• Rooming-in

• Encouraging breastfeeding ‘on-demand’

• NO formula gift pack

• NO pacifier use

Seven delivery hospital practices were significantly associated with improved exclusive breastfeeding duration for

WIC participants:

• Breastfeeding in hospital

• Breastfeeding within first hour after delivery

• Giving a breastfeeding support phone number

• Rooming-in

• Encouraging breastfeeding ‘on-demand’

• NO formula gift pack

• NO pacifier use

Illinois hospitals can support breastfeeding by encouraging these practices that are shown to be effective at

improving breastfeeding continuation and exclusivity.

illinois breastfeeding blueprint - data appendix

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