Att 3l_CDC MMWR Vital Signs 2015

Morbidity and Mortality Weekly Report

Vital Signs: Improvements in Maternity Care Policies and Practices That
Support Breastfeeding — United States, 2007–2013
Cria G. Perrine, PhD1; Deborah A. Galuska, PhD1; Jaime L. Dohack, MS2; Katherine R. Shealy, MPH1; Paulette E. Murphy, MLIS1;
Laurence M. Grummer-Strawn, PhD3; Kelley S. Scanlon, PhD1

On October 6, 2015, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).

Abstract
Background: Although 80% of U.S. mothers begin breastfeeding their infants, many do not continue breastfeeding as
long as they would like to. Experiences during the birth hospitalization affect a mother’s ability to establish and maintain
breastfeeding. The Baby-Friendly Hospital Initiative is a global program launched by the World Health Organization
and the United Nations Children’s Fund, and has at its core the Ten Steps to Successful Breastfeeding (Ten Steps), which
describe evidence-based hospital policies and practices that have been shown to improve breastfeeding outcomes.
Methods: Since 2007, CDC has conducted the biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey
among all birth facilities in all states, the District of Columbia, and territories. CDC analyzed data from 2007 (baseline),
2009, 2011, and 2013 to describe trends in the prevalence of facilities using maternity care policies and practices that
are consistent with the Ten Steps to Successful Breastfeeding.
Results: The percentage of hospitals that reported providing prenatal breastfeeding education (range = 91.1%–92.8%)
and teaching mothers breastfeeding techniques (range  =  87.8%–92.2%) was high at baseline and across all survey
years. Implementation of the other eight steps was lower at baseline. From 2007 to 2013, six of these steps increased by
10–21 percentage points, although limiting non–breast milk feeding of breastfed infants and fostering post-discharge
support only increased by 5–6 percentage points. Nationally, hospitals implementing more than half of the Ten Steps
increased from 28.7% in 2007 to 53.9% in 2013.
Conclusions: Maternity care policies and practices supportive of breastfeeding are improving nationally; however, more
work is needed to ensure all women receive optimal breastfeeding support during the birth hospitalization.
Implications for Public Health Practice: Because of the documented benefits of breastfeeding to both mothers and children,
and because experiences in the first hours and days after birth help determine later breastfeeding outcomes, improved hospital
policies and practices could increase rates of breastfeeding nationwide, contributing to improved child health.

Introduction
The American Academy of Pediatrics recommends that
infants be exclusively breastfed (i.e., breast milk with no
solids or other liquids except vitamin/mineral supplements
or medications) for about the first 6 months of life, and that
they continue to be breastfed for at least 12 months, with
introduction of nutrient-rich complementary foods at about
age 6 months (1). Eighty percent of infants in the United States
begin breastfeeding (2); however, by age 6 months, just over
half of all infants are receiving any breast milk, and only 21.9%
exclusively breastfeed for the recommended first 6 months of
life (2). These low rates of exclusive and continued breastfeeding have implications for public health: babies who are
breastfed are at a reduced risk for ear, respiratory, and gastrointestinal infections; asthma; sudden infant death syndrome;
and necrotizing enterocolitis (3,4). In addition, evidence

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suggests that breastfeeding is associated with a reduction in
the risk for obesity and diabetes in children (3). Mothers who
breastfeed have a reduced risk for breast and ovarian cancers,
diabetes, and cardiovascular disease (3,5). The health effects
for both mothers and infants from suboptimal breastfeeding
rates contribute substantially to health care costs (6,7).
Sixty percent of mothers who stopped breastfeeding during the first year reported that they stopped earlier than they
desired (8). Lactation is a time-sensitive physiologic process,
and experiences in the first hours and days after birth affect
a mother’s ability to continue breastfeeding after she leaves
the hospital (9). Recognizing this, in 1991, the World Health
Organization (WHO) and United Nations Children’s Fund
(UNICEF) established the Baby-Friendly Hospital Initiative.
To be designated as Baby-Friendly, a hospital must implement
the Ten Steps to Successful Breastfeeding (Ten Steps) and

Morbidity and Mortality Weekly Report

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 (10). The Ten Steps outline evidence-based
maternity care policies and practices that have been shown to
increase rates of breastfeeding initiation, duration, and exclusivity (11,12). The American Academy of Pediatrics endorsed
the Ten Steps in 2009.* In 2011 CDC produced a Vital Signs
report showing hospital adherence to the Tens Steps in 2007
and 2009 (13); this report updates that information with
additional data from 2011 and 2013.

the U.S. territories other than Puerto Rico, only one to three
hospitals exist; because CDC does not share hospital identifiable
information publicly, data from American Samoa, Guam, the
Northern Mariana Islands, and the Virgin Islands are presented
in aggregate as “island territories.” In 2007, only one island territory hospital had data on all of the Ten Steps; therefore, the
percentage of island territory hospitals implementing more than
half of the Ten Steps is not presented for 2007. Thus a total of
52 states were included in the state-level analysis in 2007, and
53 states were included in all other survey years. No inferential
statistics were calculated, as mPINC is a census, not a sample.

Methods

Results

Since 2007, CDC has conducted the biennial Maternity
Practices in Infant Nutrition and Care (mPINC) survey, under
contract with Battelle, to characterize U.S. maternity practices related to breastfeeding. The mPINC survey is a census
administered to all birth facilities in all states, the District of
Columbia, and U.S. territories (states). The response rate for the
mPINC surveys to date has exceeded 80%, with 2,665–2,742
facilities participating in each survey. Approximately 95% of
participating facilities are hospitals, and the remainder are
freestanding birth centers; in this report, the term “hospital” is
used to refer to all facilities. For each survey cycle, the mPINC
survey is sent to a member of the hospital staff who is identified during a screening telephone call as the person best able
to answer questions about the hospital’s routine maternity care
and infant feeding practices. Respondents are encouraged to
obtain input from other key staff in completing the survey.
Each participating hospital receives an individualized report†
showing how its practices compare with other hospitals nationally, in the same state, and of a similar size.
CDC identified 10 indicators in the mPINC survey
consistent with WHO/UNICEF’s Ten Steps to Successful
Breastfeeding. These indicators are 1) existence of a model
breastfeeding policy, 2) staff competency assessment,
3) prenatal breastfeeding education, 4) early initiation of
breastfeeding, 5) teaching breastfeeding techniques, 6) limited provision of non–breastmilk fluids for healthy breastfed
infants, 7) rooming-in, 8) teaching feeding cues, 9) limited
use of pacifiers, and 10) post-discharge support. CDC calculated the percentage of hospitals implementing these steps
in 2007 (baseline), 2009, 2011, and 2013 to describe trends
in U.S. maternity care policies and practices that support
breastfeeding and, among hospitals with complete data for all
Ten Steps (n = 2,181–2,479), the percentage implementing
more than half of the Ten Steps, nationally and by state. In

At baseline and across survey years, most U.S. hospitals reported providing prenatal breastfeeding education
(range = 91.1%–92.8%) and teaching mothers breastfeeding
techniques (range = 87.8%–92.2%) (Table). Reported implementation of the eight other steps was lower at baseline. For
six of these steps, substantial improvement in reported hospital
implementation occurred from 2007 to 2013, including having
a model breastfeeding policy (11.7% to 26.3%), assessment of
staff competency (44.6% to 60.2%), early initiation of breastfeeding (43.5% to 64.8%), rooming-in (30.8% to 44.8%),
teaching feeding cues (77.0% to 87.3%), and limiting use of
pacifiers (25.3% to 45.0%). However, less progress occurred in
limiting non–breast milk feeding of breastfed infants (20.6%
to 26.4%), and in providing optimal post-discharge support
(26.8% to 32.2%). Nationally, the percentage of hospitals
reporting implementing more than half of the Ten Steps
increased from 28.7% in 2007 to 53.9% in 2013, and this
increase was reported across states. From 2007 to 2013 the
number of states with ≥60% of hospitals implementing more
than half of the steps increased from 4 to 21 (Figure). In
contrast, the number of states with <20% of hospitals implementing more than half of the steps decreased from 15 to 0.

* Available at http://www2.aap.org/breastfeeding/files/pdf/TenStepswosig.pdf.
† Available at http://www.cdc.gov/breastfeeding/pdf/mpinc/sample-benchmarkreport.pdf.

Conclusion and Comments
From 2007 to 2013, several key aspects of maternity care
supportive of breastfeeding have shown consistent improvement. Individualized mPINC reports sent to each participating
hospital compare the hospitals’ maternity care policies and
practices with recommended standards, describe the evidence
behind these standards, and identify improvement opportunities. Dissemination of these individualized reports, as well as
dissemination of surveillance data from the mPINC survey,
including state reports§ and key publications (13), might have
contributed to these improvements in maternity care practices.
The Surgeon General’s Call to Action to Support Breastfeeding,¶
§ Available at http://www.cdc.gov/breastfeeding/data/mpinc/state_reports.html.
¶ Available at http://www.surgeongeneral.gov/library/calls/breastfeeding/

calltoactiontosupportbreastfeeding.pdf.

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TABLE. Percentage of hospitals with ideal practice on indicators of the Ten Steps to Successful Breastfeeding, CDC’s Maternity Practices in
Infant Nutrition and Care (mPINC) survey, by year — United States,* 2007–2013
% of hospitals
Ten Steps to Successful Breastfeeding

mPINC Indicator

2007
2009
2011
2013
(n = 2,679)† (n = 2,665)† (n = 2,742)† (n = 2,667)†

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

19.3

26.3

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

54.9

60.2

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

92.8

91.1

4. Help mothers initiate breastfeeding
within one 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

56.5

64.8

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

90.8

92.2

6. Give breastfeeding newborn infants
no food or drink other than
breastmilk, unless medically indicated

Limited non–breast milk feeds of breastfed infants: <10% of
healthy full-term breastfed infants are given formula, glucose
water, or water

20.6

21.5

23.0

26.4

7. Practice rooming-in—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

37.0

44.8

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

84.8

87.3

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

25.3

30.1

36.3

45.0

Post-discharge support: Hospital routinely provides 3 modes of
post-discharge support to breastfeeding mothers: physical
contact, active reaching out, and referrals¶

26.8

26.8

28.4

32.2

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

* Includes United States, District of Columbia, and U.S. territories.
† n varies slightly 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 one
hour of uncomplicated vaginal birth, 5) initiating breastfeeding after recovery for uncomplicated Cesarean sections 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 hr/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 phone call to patient after discharge; referrals = hospital phone
number to call, hospital-based support group, other breastfeeding support group, lactation consultant/specialist, U.S. Department of Agriculture Special Supplemental
Nutrition Program for Women, Infants, and Children, outpatient clinic.

the National Prevention Strategy,** and the addition of maternity care objectives to Healthy People 2020†† have also helped
increase focus on the importance of maternity care in helping
women establish breastfeeding.
A variety of other efforts are also likely contributing to the
observed improvements in maternity care. As stated earlier,
to be designated as Baby-Friendly, a hospital must implement
the Ten Steps to Successful Breastfeeding and comply with
the International Code of Marketing of Breast-milk Substitutes
(10). In 2011, as part of the First Lady’s Let’s Move! in Indian
Country campaign, the Indian Health Service committed to
achieving Baby-Friendly designation for all 13 of its federal
** Available at http://www.surgeongeneral.gov/priorities/prevention/strategy/
healthy-eating.pdf.
†† Available at http://www.healthypeople.gov/2020/topics-objectives/topic/
maternal-infant-and-child-health/objectives.
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maternity hospitals, a goal that was recently achieved.§§ Under
a cooperative agreement with CDC, the National Institute for
Children’s Health Quality led the Best Fed Beginnings project,
which helped 89 hospitals from 29 states work toward BabyFriendly designation. This effort recruited hospitals with a large
number of annual births and which serve populations with
lower breastfeeding rates. As of August 2015, 50 of these hospitals have been designated Baby-Friendly and approximately
155,000 additional babies are now born in Baby-Friendly
hospitals each year.¶¶ Through funding agreements and technical assistance, CDC also supports state health departments
§§ Available at http://www.ihs.gov/newsroom/pressreleases/2014pressreleases/
all13ihsobstetricfacilitiesdesignatedbabyfriendly.
¶¶
Available at http://www.nichq.org/sitecore/content/breastfeeding/
breastfeeding/solutions/best-fed-beginnings.

Morbidity and Mortality Weekly Report

FIGURE. Percentage of hospitals implementing more than half of the Ten Steps to Successful Breastfeeding,* by state or jurisdiction —
Maternity Practices in Infant Nutrition and Care (mPINC) Survey, United States, 2007–2013
2007

2009

DC
PR

DC
PR
IT

2013

2011

DC
PR
IT

<20%

20%–<40%

DC
PR
IT

40%–<60%

≥60%

Abbreviations: DC = District of Columbia; IT = Island Territories, including American Samoa, Guam, Northern Mariana Islands, and Virgin Islands; PR = Puerto Rico.
* These are mPINC indicators consistent with the Ten Steps to Successful Breastfeeding as described in the table.

in improving maternity care practices; currently 33 states are
using CDC funds to improve maternity care practices that
support breastfeeding.
Despite substantial improvement, as of 2013, implementation of several of these maternity care practices and policies
was far from optimal. Just over one quarter of hospitals have a
model breastfeeding policy, which is the foundation for many
of the other steps. In addition, fewer than half of hospitals
reported routinely keeping healthy infants with their mothers
throughout the hospital stay, a practice that allows mothers
to become more familiar with their babies’ hunger cues, and
increases opportunities for breastfeeding (12).

This report also describes two key indicators that were low
at baseline and showed less progress: limiting the provision of
fluids other than breast milk to healthy breastfed infants and
the provision of optimal post-discharge support. The provision
of non–breast milk fluids to healthy breastfed infants has been
associated with suboptimal breastfeeding behaviors, shorter
breastfeeding duration, and mothers being less likely to meet
their own breastfeeding intentions (14,15). The percentage
of hospitals that limited giving fluids other than breast milk
to health breastfed infants increased from 20.6% in 2007 to
26.4% in 2013. In recognizing the provision of non–breast
milk fluids to breastfed infants as a quality-of-care issue, in
2010, The Joint Commission, a major organization that
accredits and certifies U.S. hospitals, added exclusive breast
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milk feeding during the newborn’s entire hospitalization as a
new quality of care measure. In 2014 The Joint Commission
required reporting of this measure by all hospitals with
≥1,100 births per year, and as of January 2016, will require
reporting by all hospitals with ≥300 births per year, thus
encompassing approximately 80% of all birth hospitals.***
Reporting of this measure might help increase awareness of
the importance of exclusive breastfeeding, and reduce hospital
provision of non–breast milk fluids to breastfeeding infants
when there is no medical indication for it.
From 2007 to 2013, the percentage of hospitals providing adequate post-discharge support increased by only 20%.
Problems with breastfeeding, such as trouble getting the baby to
latch, pain, and a perception of insufficient milk, are common
among new mothers and are associated with shorter durations
of breastfeeding (16). In a study of first-time mothers that
assessed concerns with breastfeeding at several time points
during the first 2 months of life, these problems were most
pronounced at 3 and 7 days postpartum (16), which is after
most women have left the hospital, but before they might be
connected to other types of community support. These early
breastfeeding problems can often be overcome with early
support and management. To receive this support, however,
mothers need to have a continuum of care that extends from
the hospital to other providers and programs in the first few
weeks postpartum.
The findings in this report are subject to at least three limitations. First, the survey is completed by a key respondent on
behalf of each hospital and might not accurately reflect the
hospital practices assessed. However, to ensure that the data
obtained were of highest quality possible, CDC requested that
the survey be sent to the person most knowledgeable about the
hospital’s maternity practices, and that it be completed in consultation with other knowledgeable persons. Second, although
approximately 80% of hospitals participated in each survey,
practices might differ between those that participated and
those that did not. Third, the mPINC indicators included here
are consistent with the Ten Steps to Successful Breastfeeding,
but might not indicate implementation of each of the steps as
required for Baby-Friendly designation.†††
The national improvements in maternity care supportive
of breastfeeding from 2007 to 2013 are substantial; however,
more work is needed to ensure that all women have access to
evidence-based maternity care policies and practices supportive
of breastfeeding. Currently, among the approximately four million babies born in the United States every year, only about 14%
are born in Baby-Friendly hospitals, and as of August 2015, only
*** Available at http://www.jointcommission.org/assets/1/23/jconline_
June_24_2015.pdf.
††† Av a i l a b l e a t h t t p s : / / w w w. b a b y f r i e n d l y u s a . o r g / g e t - s t a r t e d /
the-guidelines-evaluation-criteria.
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Key Points
• Breastfeeding provides health benefits to both the infant
and mother.
• Although the majority of mothers in the United States
begin breastfeeding, many are not breastfeeding for as
long as they would like.
• Hospital policies and practices to support breastfeeding
are important for improving breastfeeding rates and
helping women meet their own breastfeeding goals.
• The percentage of hospitals implementing more than
half of the Ten Steps to Successful Breastfeeding
increased from 28.7% in 2007 to 53.9% in 2013.
• 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.
289 (9%) of the approximately 3,300 U.S. birth facilities were
designated Baby-Friendly.§§§ Several CDC efforts are underway to continue supporting improvements in maternity care,
including continuation of the mPINC survey, the EMPower
breastfeeding project¶¶¶ to support up to 100 hospitals in
achieving Baby-Friendly designation, and continued support
of state health departments to support breastfeeding initiatives.
§§§ Available at https://www.babyfriendlyusa.org/find-facilities/
designated-facilities--by-state.
¶¶¶ Available at http://empowerbreastfeeding.org.
1Division of Nutrition, Physical Activity, and Obesity, National Center for
Chronic Disease Prevention and Health Promotion, CDC; 2 Battelle,
Columbus, Ohio; 3Department of Nutrition for Health and Development,
World Health Organization.

Corresponding author: Cria G. Perrine, [email protected], 770-488-5183.

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