Appx C-3 CDC MMWR Vital Signs

Morbidity and Mortality Weekly Report

Vital Signs: Hospital Practices to Support Breastfeeding —
United States, 2007 and 2009
On August 2, 2011, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).

Abstract
Background: Childhood obesity is a national epidemic in the United States. Increasing the proportion of mothers who
breastfeed is one important public health strategy for preventing childhood obesity. The World Health Organization and
United Nations Children’s Fund (UNICEF) Baby-Friendly Hospital Initiative specifies Ten Steps to Successful Breastfeeding
that delineate evidence-based hospital practices to improve breastfeeding initiation, duration, and exclusivity.
Methods: In 2007 and 2009, CDC conducted a national survey of U.S. obstetric hospitals and birth centers. CDC
analyzed these data to describe the prevalence of facilities using maternity care practices consistent with the Ten Steps to
Successful Breastfeeding.
Results: In 2009, staff members at most hospitals provide prenatal breastfeeding education (93%) and teach mothers
breastfeeding techniques (89%) and feeding cues (82%). However, few hospitals have model breastfeeding policies (14%),
limit breastfeeding supplement use (22%), or support mothers postdischarge (27%). From 2007 to 2009, the percentage
of hospitals with recommended practices covering at least nine of 10 indicators increased only slightly, from 2.4% to
3.5%. Recommended maternity care practices vary by region and facility size.
Conclusion: Most U.S. hospitals have policies and practices that do not conform to international recommendations for
best practices in maternity care and interfere with mothers’ abilities to breastfeed.
Implications for Public Health Practice: Hospitals providing maternity care should adopt evidence-based practices
to support breastfeeding. Public health agencies can set quality standards for maternity care and help hospitals achieve
Baby-Friendly designation. Because nearly all births in the United States occur in hospitals, improvements in hospital
policies and practices could increase rates of exclusive and continued breastfeeding nationwide, contributing to improved
child health, including lower rates of obesity.

Introduction
Obesity is a national epidemic in the United States, and
children are not exempt. Currently, 21% of children aged 2–5
years are at least overweight, and half of those children are obese
(1). Obese children and adolescents are more likely to have
elevated cholesterol and blood pressure levels, breathing and
joint problems, and to become obese adults (2). Substantial
epidemiologic evidence now establishes breastfeeding as an
important public health strategy for preventing childhood
obesity (3). In a meta-analysis, children who were breastfed had
reduced odds for obesity at various ages compared with those
who were formula fed (4). In a separate meta-analysis, children
breastfed for 9 months had a more than 30% reduced odds of
becoming overweight compared with children never breastfed,

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and the two studies that examined exclusive breastfeeding
showed a stronger effect (5). Breastfeeding affords infants
and mothers additional benefits. When mothers formula
feed or discontinue breastfeeding early, the risk for infectious
illnesses in their children is increased, as is the mother’s risk
for developing breast and ovarian cancer (6).
The American Academy of Pediatrics recommends exclusive
breastfeeding (breast milk with no solids or other liquids except
vitamin/mineral supplements or medications) for about the
first 6 months of infancy, and then continued breastfeeding,
along with the introduction of iron-rich foods, for at least the
first year of an infant’s life (7). Although approximately 80%
of women in the United States indicate before delivery that
they intend to breastfeed (8), and 75% initiate breastfeeding, at

Morbidity and Mortality Weekly Report

1 week half of women have already given their infant formula,
and only 31% are breastfeeding to any extent at 9 months (9).
For women who plan to breastfeed, experiences and support
during the first hours and days after birth influence their
later ability to continue breastfeeding. Because nearly all U.S.
births occur in hospitals, policies that determine hospital
practices can influence the feeding behaviors of more than
11,000 infants born each day.* In 1991, the World Health
Organization (WHO) and United Nations Children’s Fund
(UNICEF) developed the Baby-Friendly Hospital Initiative,†
the core of which is the Ten Steps to Successful Breastfeeding.
These evidence-based steps outline best practices in hospital
settings to help mothers initiate and continue breastfeeding,
thus increasing exclusivity and duration of breastfeeding well
beyond the hospital stay (10). In one study of women who
intended to breastfeed for longer than 2 months, 30% of them
stopped breastfeeding early if they experienced none of the Ten
Steps to Successful Breastfeeding in the hospital, compared
with only 3% who experienced six steps (11). The American
Academy of Pediatrics endorsed the Ten Steps to Successful
Breastfeeding in 2009 and the White House Task Force on
Childhood Obesity Report to the President recommended
improving maternity care practices in 2010 (3). This report uses
data from the national Maternity Practices in Infant Nutrition
and Care (mPINC) survey to describe maternity care practices
in the United States.§

Methods
In 2007, CDC began the biennial mPINC survey to
characterize U.S. maternity practices related to breastfeeding.
The mPINC is a census survey, assessing practices at all
facilities in all states, the District of Columbia, and four U.S.
territories that provide maternity services. In 2007, a total of
2,690 facilities participated, and 2,672 facilities participated
in 2009; the response rate each time was 82%. Because 96%
of respondents in both survey years were hospitals, with the
remaining respondents being free-standing birth centers, in
this report the term “hospital” refers to all respondents. The
mPINC survey is mailed to each hospital and completed by a
key informant identified in advance via a screening telephone
call as the person best able to answer questions about infant
feeding routines. Data from 2007 and 2009 were analyzed
for 10 indicators consistent with WHO/UNICEF’s Ten
Steps to Successful Breastfeeding: 1) existence of a model
* National Vital Statistics System birth data available at http://www.cdc.gov/
nchs/births.htm.
† Additional information available at http://www.babyfriendlyusa.org/eng/03.html.
§ Additional information available at http://www.cdc.gov/breastfeeding/data/
mpinc/index.htm.

breastfeeding policy,¶ 2) staff competency assessment, 3)
prenatal breastfeeding education, 4) early initiation of
breastfeeding, 5) teaching breastfeeding techniques, 6) limited
supplementation of breastfeeding infants, 7) rooming-in, 8)
teaching feeding cues, 9) limited use of pacifiers, and 10)
post-discharge support.** The prevalence of hospitals with
recommended policies and practices in 2007 and 2009 for each
of the 10 indicators were assessed. Data for 2009 were analyzed
to describe variations by geographic area and hospital annual
number of births. Because the mPINC survey is a census rather
than a sample, no statistical tests were conducted.

Results
In 2009, most hospitals reported providing prenatal
breastfeeding education (92.8%), teaching women breastfeeding
techniques (89.1%), and teaching women how to recognize
and respond to infant feeding cues (81.8%) (Table 1). For all
other indicators, half or fewer hospitals followed recommended
practices. The lowest prevalence of recommended practices
related to having a model breastfeeding policy (14.4%);
limiting use of formula, water, or glucose supplements for
healthy, full-term breastfed infants (21.5%); and providing
adequate breastfeeding support to breastfeeding mothers at
hospital discharge (26.8%). From 2007 to 2009, the percent
of hospitals implementing recommended practices improved
at least 1 percentage point for seven indicators, but less than 1
percentage point for three indicators. The majority of hospitals
were implementing three to five recommended practices
(60.5% in 2007 and 54.3% in 2009), with only 2.4% of
hospitals implementing at least nine recommended practices in
2007, and 3.5% in 2009 (Figure). Fewer than 1% of hospitals
implemented all 10 policies and practices either year.
The Northeast had the highest prevalence of hospitals with
recommended practice for most indicators (Table 2). However,
even in the Northeast, the prevalence of recommended practice
¶ A

model breastfeeding policy includes all of the following elements: 1) inservice training, 2) prenatal breastfeeding classes, 3) asking about mothers’
feeding plans, 4) initiating breastfeeding within 1 hour of uncomplicated
vaginal birth, 5) initiating breastfeeding after recovery for uncomplicated
cesarean deliveries and/or showing mothers how to express milk and maintain
lactation if separated from infant, 6) giving only breast milk to breastfed
infants, 7) rooming-in 24 hours/day, 8) breastfeeding on demand, 9) no
pacifier use by breastfed infants, and 10) referral of mothers with breastfeeding
problems and/or referral of mothers to appropriate breastfeeding resources at
discharge. Inclusion of these elements was derived from the Academy of
Breastfeeding Medicine’s Model Breastfeeding Policy. Additional information
available at http://www.bfmed.org/Media/Files/Protocols/English%20
Protocol%207%20Model%20Hospital%20Policy.pdf.
** Strategies include home visit and hospital postpartum follow-up visit (physical
contact); follow-up telephone call after discharge (reaching out); and hospital
telephone number to call, hospital-based support group, other breastfeeding
support group, lactation consultant, etc. (referrals).

MMWR / August 5, 2011 / Vol. 60 / No. 30

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Morbidity and Mortality Weekly Report

TABLE 1. The Ten Steps to Successful Breastfeeding* and national prevalence of hospitals with corresponding recommended practices, as measured
by indicators consistent with the Ten Steps — Maternity Practices in Infant Nutrition and Care (mPINC), United States, 2007 and 2009
Ten Steps to Successful Breastfeeding*

mPINC indicator

2007 ​
(%)†

2009 ​
(%)†

1. Have a written breastfeeding policy that is routinely
communicated to all health care staff

Model breastfeeding policy: hospital has a written breastfeeding policy
that includes 10 model policy elements§

11.7

14.4

2. Train all health care staff in skills necessary to
implement this policy

Staff competency assessment: nurses/birth attendants are assessed for
competency in basic breastfeeding management and support at least
once per year

44.6

49.7

3. Inform all pregnant women about the benefits and
management of breastfeeding

Prenatal breastfeeding education: breastfeeding education is included as
a routine element of prenatal classes

92.5

92.8

4. Help mothers initiate breastfeeding within an hour
of birth

Early initiation of breastfeeding: ≥90% of healthy full-term breastfed
infants initiate breastfeeding within one hour of uncomplicated vaginal
birth

43.5

50.9

5. Show mothers how to breastfeed, and how to
maintain lactation even if they should be separated
from their infants

Teach breastfeeding techniques: ≥90% of mothers who are breastfeeding
or intend to breastfeed are taught breastfeeding techniques (e.g.,
positioning, how to express milk, etc.)

87.8

89.1

6. Give breastfeeding newborn infants no food or drink
other than breast milk unless medically indicated

Limited use of breastfeeding supplements: <10% of healthy full-term
breastfed infants are supplemented with formula, glucose water, or water

20.6

21.5

7. Practice rooming in - that is, allow mothers and infants
to remain together 24 hours per day

Rooming-in: ≥90% of healthy full-term infants, regardless of feeding
method, remain with their mother for at least 23 hours per day during the
hospital stay

30.8

33.2

8. Encourage breastfeeding on demand

Teach feeding cues: ≥90% of mothers are taught to recognize and
respond to infant feeding cues instead of feeding on a set schedule

77.0

81.8

9. Give no artificial teats or pacifiers to breastfeeding
infants

Limited use of pacifiers: <10% of healthy full-term breastfed infants are
given pacifiers by maternity care staff members

25.3

30.1

10. Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from
the hospital or clinic

Post-discharge support: hospital routinely provides three modes of
post-discharge support to breastfeeding mothers: physical contact, active
reaching out, and referrals¶

26.8

26.8

* As designated by Baby-Friendly USA. The U.S. steps are the same as those recommended by the World Health Organization/UNICEF, except for step 4, which in the
United States recommends that mothers should initiate breastfeeding within 1 hour of birth, compared with 30 minutes elsewhere.
† Number responding varied slightly from totals (2007 = 2,679, 2009 = 2,665) for each of the prevalence estimates.
§ Model policy elements are 1) in-service training, 2) prenatal breastfeeding classes, 3) asking about mothers’ feeding plans, 4) initiating breastfeeding within 1 hour
of uncomplicated vaginal birth, 5) initiating breastfeeding after recovery for uncomplicated cesarean delivery and/or showing mothers how to express milk and
maintain lactation if separated from infant, 6) giving only breast milk to breastfed infants, 7) rooming-in 24 hours/day, 8) breastfeeding on demand, 9) no pacifier
use by breastfed infants, 10) referral of mothers with breastfeeding problems and/or referral of mothers to appropriate breastfeeding resources at discharge.
¶ Physical contact = home visit, hospital postpartum follow-up visit; active reaching out = follow-up telephone call to patient after discharge; referrals = hospital
phone number to call, hospital-based support group, other breastfeeding support group, lactation consultant/specialist, outpatient clinic.

exceeded 50% for only six indicators, and only 32% of hospitals
had a model breastfeeding policy. Although the Mountain
Plains and Southwest regions each had the lowest prevalence
of recommended practice on each of several indicators, no
specific region was consistently the lowest across all indicators.
Larger hospitals were more likely to have model breastfeeding
policies. Despite such policies, the largest hospitals (≥5,000
births annually) had the lowest prevalence of recommended
practice on each of several indicators, including only 7.9%
with limited hospital use of breastfeeding supplements
(Table 2). The prevalence of recommended practice on
institutional indicators, including having a model policy,
assessing staff breastfeeding competency, and providing
prenatal breastfeeding education, was lower among smaller
hospitals. However, smaller hospitals had a higher prevalence

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of adherence to recommended practice on other indicators,
including early initiation of breastfeeding, limited use of
supplements, rooming-in, and providing discharge care.

Conclusions and Comment
Improving breastfeeding rates is one strategy to address
childhood obesity. For women who intend to breastfeed, the
hospital experience is critical. These data illustrate the persistent
use of practices that are inconsistent with best-practice
standards and do not support breastfeeding. To give infants
the best start in achieving a healthy life, including reduced
obesity, mothers must be supported immediately after birth
to establish breastfeeding. Suboptimal breastfeeding in the
United States annually results in an estimated $2.2 billion in
additional direct medical costs (12). Recognizing the important

Morbidity and Mortality Weekly Report

FIGURE. Percentage of hospitals that implemented recommended
maternity care practices related to breastfeeding* — Maternity
Practices in Infant Nutrition and Care Survey (mPINC), United States,
2007 and 2009
70
2007
2009

60

Percentage

50
40
30
20
10
0

0–2

3–5

6–8

9–10

No. of recommended practices implemented
* Recommended maternity care practices are indicators of the Ten Steps to
Successful Breastfeeding (available at http://www.babyfriendlyusa.org/
eng/10steps.html), as measured in the mPINC survey.

role of hospitals in helping women begin breastfeeding, Healthy
People 2020 added two objectives related to breastfeeding and
maternity care: reducing the proportion of breastfed newborns
who receive formula supplementation within the first 2 days
of life (MICH-23), and increasing the proportion of live
births that occur in facilities that provide recommended care
for lactating mothers and their babies (MICH-24) (13). Even
infants of mothers who choose to feed their infants both breast
milk and formula should not be given formula in the hospital
unless medically indicated, as hospital supplementation is
associated with early discontinuation of breastfeeding (14).
Recognizing exclusive breastfeeding as a quality-of-care issue,
the Joint Commission, the organization that accredits and
certifies U.S. hospitals, added exclusive breast milk feeding
in the hospital as a new quality of care measure in 2010 (15).
The Baby-Friendly Hospital Initiative recognizes hospitals
with best practices in supporting breastfeeding. To be
designated as Baby-Friendly, a hospital must implement the
WHO/UNICEF Ten Steps to Successful Breastfeeding and
comply with the International Code of Marketing of Breastmilk Substitutes, which requires hospitals to pay fair market
value for infant formula and not promote items detrimental to
breastfeeding, including discharge bags that contain formula
(16). The percent of U.S. infants born at Baby-Friendly
hospitals increased from 1.8% in 2007 to 4.5% in 2011 (17).
The mPINC survey assesses the Ten Steps to Successful
Breastfeeding using a key informant interview, a methodology
that is not directly comparable to the Baby-Friendly designation
process, which incorporates direct observation and interviews

Key Points
• Breastfeeding for 9 months reduces a child’s odds of
becoming overweight by more than 30%.
• Although 75% of U.S. women begin breastfeeding,
only 31% are still breastfeeding at 9 months.
• Suboptimal breastfeeding in the United States results
in an estimated $2.2 billion annually in additional
direct medical costs.
• Hospital policies and practices to support breastfeeding
are critical for improving breastfeeding rates. However,
in 2009 only 3.5% of U.S. hospitals were following at
least nine of the 10 practices consistent with the BabyFriendly Ten Steps to Successful Breastfeeding.
• Facilities providing maternity care need to adopt evidencebased practices to support breastfeeding. Government and
public health agencies can help by working with hospitals
to achieve Baby-Friendly designation.
• Additional information is available at http://www.cdc.
gov/vitalsigns.
with mothers. However, reports from the mPINC survey
provide all hospitals an opportunity to identify practices that
inhibit mothers’ abilities to breastfeed. Every hospital that
participates in the mPINC survey receives a report of its own
results showing how its practices compare with recommended
practices and with practices of hospitals around the country.
These reports can help hospitals develop and implement a
plan to improve care to better support breastfeeding, with
the goal of preparing hospitals to move more quickly toward
Baby-Friendly designation.
A strong breastfeeding policy is the foundation of quality
hospital breastfeeding support and sets standards for the
remaining nine steps. These data illustrate that in most states
few hospitals have established breastfeeding policies that fully
support and encourage mothers to breastfeed. The Northeast
had the highest prevalence of having a model policy and also
the highest prevalence of recommended practice on many
indicators. However, policy does not necessarily indicate
practice. To improve practice, hospitals will need to ensure
that staff members are sufficiently trained to carry out strong
breastfeeding policies, and routinely assess adherence.
Although hospital support is critical for helping mothers
establish breastfeeding, it is not the only support needed
to help them continue breastfeeding. As documented in
the Surgeon General’s Call to Action to Support Breastfeeding,
families, communities, employers, health-care providers, and
government and nonprofit agencies all have critical roles to play

MMWR / August 5, 2011 / Vol. 60 / No. 30

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Morbidity and Mortality Weekly Report

TABLE 2. Percentage of hospitals that had implemented recommended practices on indicators consistent with the Ten Steps to Successful
Breastfeeding,* by region and hospital annual births — Maternity Practices in Infant Nutrition and Care (mPINC) Survey, United States, 2009

Steps implemented
1. Model
breast­
feeding
policy ​(%)

2. Staff
competency
assessment ​
(%)

3. Prenatal
breast­
feeding
education ​
(%)

4. Early
initiation of
breast­
feeding ​(%)

5. Teach
breast­
feeding
technique ​
(%)

6. Limited use
of breast­
feeding
supplements ​
(%)

9. Limited
7.
8. Teach
use of
Rooming-in ​ feeding cues ​ pacifiers ​
(%)
(%)
(%)

10.
Postdischarge
support ​
(%)

Hospital location/
births

Participants
(%)

Region†
Western
Southwest
Southeast
Northeast
Mountain Plains
Midwest
Mid-Atlantic

16.4
13.0
16.6
9.2
14.9
20.2
9.8

15.7
11.9
10.3
31.8
8.1
15.4
13.0

49.4
48.0
55.1
64.8
38.1
45.6
54.7

90.4
82.4
93.6
97.6
92.6
97.7
94.1

59.1
39.1
42.6
58.5
55.6
51.7
50.6

87.4
84.9
89.0
93.1
87.3
91.4
92.3

26.8
17.5
12.7
27.3
23.4
22.6
21.7

67.9
40.1
26.8
23.7
28.5
20.3
19.5

81.7
77.9
80.3
91.1
75.8
84.3
84.9

42.8
29.2
23.3
51.2
18.2
24.4
32.1

26.7
20.4
21.7
34.0
31.7
31.2
20.8

Annual births
<250
250–499
500–999
1,000–1,999
2,000–4,999
≥5,000

22.5
17.2
20.8
19.9
17.4
2.4

7.0
11.6
11.8
19.2
22.7
25.0

33.2
41.8
51.6
61.6
60.8
63.5

83.7
90.4
95.4
97.5
97.2
100.0

61.6
54.1
49.2
49.1
39.7
38.7

85.7
89.4
88.8
91.5
90.7
90.5

38.7
21.1
17.5
16.7
11.5
7.9

47.0
27.2
29.9
27.1
32.7
30.7

77.9
83.0
79.8
86.3
83.1
82.5

40.7
23.4
25.0
26.7
31.9
41.3

34.6
27.5
23.8
27.3
20.3
17.5

* Recommended maternity care practices are indicators of the Ten Steps to Successful Breastfeeding (available at http://www.babyfriendlyusa.org/eng/10steps.html), as measured in the
mPINC survey.
† Western = Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Nevada, Oregon, Washington; Southwest = Arkansas, Louisiana, New Mexico, Oklahoma, Texas; Southeast =
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee; Northeast = Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island,
Vermont; Mountain Plains = Colorado, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, South Dakota, Utah, Wyoming; Midwest = Illinois, Indiana, Michigan, Minnesota, Ohio,
Wisconsin; Mid-Atlantic = Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Puerto Rico, Virginia, U.S. Virgin Islands, West Virginia.

(18). Ongoing efforts and initiatives in these areas include the
Affordable Care Act, which amended the Fair Labor Standards
Act to require employers with more than 50 employees to
provide reasonable break time and a private location (other
than a bathroom) for breastfeeding mothers to express milk.††
Additionally, the U.S. Department of Agriculture’s Special
Supplemental Nutrition Program for Women, Infants, and
Children (WIC), which supports approximately 50% of all
infants born in the United States, recently revised its program
to support breastfeeding more effectively by modifying the
mother’s food package to be more supportive of women who
are breastfeeding, and increasing peer counseling support
for breastfeeding.§§ CDC produces an annual Breastfeeding
Report Card, which provides state-level data on breastfeeding
rates and key types of community breastfeeding support,
showing where states have been successful and where more
work is needed to promote and support breastfeeding.¶¶
The findings in this report are subject to at least two
limitations. The survey was completed by one key informant
at each hospital and might not accurately reflect actual hospital
practices. To ensure data were as valid as possible, CDC requested
that the survey be completed by the person most knowledgeable
†† Patient Protection and Affordable Care Act (as amended through May 1, 2010).

Pub, L, No. 114–48. Available at http://docs.house.gov/energycommerce/
ppacacon.pdf.
§§ Additional information available at http://www.fns.usda.gov/wic/breastfeeding/
mainpage.htm.
¶¶ Additional information available at http://www.cdc.gov/breastfeeding/data/
reportcard.htm.

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of the hospital’s maternity practices, in consultation with other
knowledgeable persons, as needed. Second, although more than
80% of hospitals participated in each survey, practices in those
that participated and those that did not might differ.
Hospitals provide care to nearly all women giving birth in the
United States; however, in most hospitals, this care falls short
of evidence-based best practices that fully support mothers
to be able to breastfeed. Systematically improving maternity
care practices, including increased adherence to the Ten Steps
to Successful Breastfeeding, will help women who intend to
breastfeed get the support they need to be able to start and
continue breastfeeding, and by so doing, reduce child obesity
and improve other aspects of child health.
Reported by

Cria G. Perrine, PhD, Katherine R. Shealy, MPH, Kelley S. Scanlon,
PhD, Laurence M. Grummer-Strawn, PhD, Deborah A. Galuska,
PhD, Div of Nutrition, Physical Activity, and Obesity; Deborah L.
Dee, PhD, Div of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion; CDC. Jennifer H. Cohen,
PhD, Battelle Centers for Public Health Research and Evaluation,
Seattle, WA. Contributing correspondent: Cria G. Perrine, CDC,
770-488-5183, [email protected].
Acknowledgments
Hospitals and birth centers that participated in the mPINC survey.
Persons involved in developing and implementing the survey.

Morbidity and Mortality Weekly Report

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