Effect of the Affordable Care Act on Breastfeeding Outcomes

Quantifying the Association Between Pump Use and Breastfeeding Duration

OBJECTIVE

To quantify the extent to which pump use is associated with breastfeeding duration.

STUDY DESIGN

We conducted a cross-sectional analysis of weighted CDC Pregnancy Risk Assessment Monitoring System data from Maine, Michigan, New Mexico, and Utah between 2016 and 2021. Included respondents had a live-born infant at survey completion, initiated breastfeeding, and had non-missing data for reported pump use and breastfeeding duration. Using Cox proportional hazard regression, we quantified the hazard of breastfeeding cessation and median duration (weeks) of breastfeeding by pump use. Pump use was suspected to be differentially impacted by race and ethnicity; an interaction was tested in our regression model.

RESULTS

Our sample included 19,719 mothers (weighted N= 723,808) with mean age (SD) 29.5 years (5.6). Mothers with age <18 years, Medicaid enrollment, race and ethnicity other than non-Hispanic White, lower income or education, and unmarried status demonstrated lower pump use (p<0.001). Pump use was associated with 37% lower hazard of breastfeeding cessation (aHR 0.63; 95% CI: 0.56-0.70) and 21 additional weeks of breastfeeding on average. The association varied by race and ethnicity (significant interaction observed between pump use and non-Hispanic Black mothers, p=0.013); stratified analysis demonstrated the lowest hazard of breastfeeding cessation among non-Hispanic Black and Native American pump users (aHR 0.47 [0.40-0.54] and 0.51 [0.37-0.70], respectively).

CONCLUSION

Pump use was associated with longer breastfeeding duration; the greatest magnitudes of association were found among non-Hispanic Black and Native American participants, groups disproportionately affected by breastfeeding inequities. Future research examining the context around and causal impact of pump use on breastfeeding outcomes is needed.

Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

Beliefs and Decision-Making of First-Time Mothers Planning to Use a Breast Pump

Beliefs and decision-making processes associated with breast pump use in first-time mothers providing human milk to healthy, term newborns soon after birth are explored in this qualitative, descriptive study. Eight women participated in an individual semistructured interview in a community hospital in the southeastern United States. Guided by the theory of planned behavior, conventional content analysis about prenatal and early postpartum beliefs of planning and utilizing breast pumps yielded themes of Resource Gathering, Intention Refining, and Behavior Navigating. An understanding of these beliefs gives insight into ways health professionals can increase collaboration with expectant and new mothers about the selection and safe use of breast pumps, resource availability at various stages, and infant-feeding goals.

Affordable Care Act and Breastfeeding

In 2010, the Patient Protection and Affordable Care Act was the first federal legislation to protect breastfeeding on a broad scale. Since its implementation, several provisions have been made, including the recent Providing Urgent Maternal Protections for Nursing Mothers (PUMP) Act, which went into effect in April 2023. In this column, I review current breastfeeding recommendations, the policy landscape related to state and federal laws that protect breastfeeding, research findings on breastfeeding policies, and recommendations from professional organizations that support women's breastfeeding decisions.

Exclusive Breastfeeding in Health Personnel: Incidence and Barriers

Exclusive breastfeeding for 6 months (EBF) in healthcare personnel is challenging due to work schedules, high workloads, or separation issues. This study aimed to evaluate the incidence and factors related to EBF in our hospital personnel.

MATERIAL AND METHODS

This was a cross-sectional study. Female employees who took maternity leave within 2 years were approached. A questionnaire regarding factors associated with EBF was sent to participants. Factors associated with EBF were analyzed using logistic regression analysis.

RESULTS

There were 110 mothers enrolled. The mean maternal age was 32.5 ± 4.21 years, 66.36% came from the nursing department, the infant's age was 6-24 months, and 46.4% of mothers had previous breastfeeding experience. Our EBF for 6 months rate was 63.6%. Breastfeeding attitude (OR = 1.12, 95%CI 1.08-1.38), perception of breastfeeding obstacle (OR = 1.45, 95%CI 1.26-1.66), breastfeeding behavior (OR = 1.17, 95%CI 1.08-1.26), and support from health system (OR = 1.09, 95%CI 1.01-1.19) were significantly associated with EBF. From multiple logistic regression models, perception of breastfeeding obstacles (aOR 1.55, 95%CI 1.27-1.90), breastfeeding behavior (aOR 1.12, 95%CI 1.01-1.24), and support from health care system (aOR 0.84, 95%CI 0.72-0.97) remain the significant factors associated with successful EBF.

CONCLUSION

Successful EBF was prevalent in mothers who had good attitudes to breastfeeding, perceived low levels of obstacles, and had support from the health care system.

Breastfeeding Initiation Trends by Special Supplemental Nutrition Program for Women, Infants, and Children Participation and Race/Ethnicity Among Medicaid Births

OBJECTIVE

Describe long-term breastfeeding initiation trends by prenatal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation and race/ethnicity.

DESIGN

Cross-sectional study of birth certificate data from 2009 to 2017 in 24 states that adopted the 2003 birth certificate revision by 2009.

PARTICIPANTS

Term births with hospital costs covered by Medicaid (N = 6,402,704).

MAIN OUTCOME MEASURES

Breastfeeding initiation.

ANALYSIS

The descriptive characteristics of WIC participants and WIC-eligible nonparticipants were compared by year and race/ethnicity using the chi-square test of independence or t tests. Adjusted breastfeeding initiation prevalence was estimated using linear regression models with county fixed effects, controlling for sociodemographic and obstetric/health factors. Trends were compared by WIC status overall and within racial/ethnic groups. Differences and P values were assessed using interaction terms between WIC and year.

RESULTS

Breastfeeding initiation increased for WIC participants and nonparticipants. Special Supplemental Nutrition Program for Women, Infants, and Children participants had lower adjusted breastfeeding initiation (2009: 69.0%; 2017: 78.5%) than nonparticipants (2009: 70.8%; 2017: 80.1%) (P < 0.001 per year). Breastfeeding initiation increased more rapidly in WIC participants than in nonparticipants for non-Hispanic Asian/Pacific Islander (21.4% and 8.6%, respectively; P < 0.001) and American Indian/Alaskan Native (13.6% and 8.1%, respectively; P = 0.02)-narrowing the gap between WIC participants and nonparticipants over time.

CONCLUSIONS AND IMPLICATIONS

Annual birth certificate data provide detailed information for monitoring trends and disparities in breastfeeding initiation by prenatal WIC status. These findings can inform WIC and maternal child health program efforts to improve breastfeeding promotion for populations with low-income and racial/ethnic groups.

Innovations in Breastfeeding Support

Despite the numerous benefits that breastfeeding confers to those who breastfeed and their infants, the United States' exclusive breastfeeding rates and any breastfeeding rates at 12 months remain low and inequitable. This public health crisis has been prioritized in the US Healthy People 2030 goals. Current evidence-based practices to support lactation have afforded limited progress, thus, achieving national breastfeeding goals requires innovative ideas in thinking, technology, and care. This article highlights potential innovative strategies in the field of lactation to improve outcomes and work toward achieving health equity, while underscoring the critical role that perinatal caregivers play in lactation support.

Low Job Control and Racial Disparities in Breastfeeding

BACKGROUND

Low job control may predict shorter breastfeeding (BF) among working mothers and may contribute to racial disparities in BF.

METHODS

We used demographic, employment, and health data for n = 631 observations from the Panel Study of Income Dynamics. Job control scores came from a job-exposure matrix.Using path analysis, we assessed whether job control predicted BF and mediated Black-White BF differences. We controlled for education, working hours, marital status, and low birthweight.

RESULTS

Lower job control predicted decreased odds of BF for at least 6 months (odds ratio, 0.61; 95% confidence interval, 0.31-0.90; reference, no BF). Low job control explained 31% of the Black-White difference for both shorter-term and longer-term BF.

CONCLUSIONS

Low job contributes to shorter BF and to BF disparities by race. Intervening to enhance job control could improve BF.

Impact of Insurance Status on Initiation of Breast Milk Feeding Among Infants With CL ± P

To evaluate rates of breast milk feeding among infants with cleft lip with or without cleft palate (CL ± P) enrolled in Medicaid compared to Private Insurance/Self-Pay.

This was a population-based retrospective cohort study.

The 2018 US National Vital Statistics System-Natality component (NVSS-N) was used to examine nationwide birth certificate data.

Infants with cleft lip with or without cleft palate and either Medicaid or Private Insurance/Self-Pay were included.

Breast milk feeding rates among infants with CL ± P, as a function of insurance status.

Chi-square tests of independence revealed that of 896 infants with CL ± P and insured by Medicaid, 527 (58.8%) were breast milk fed at discharge. Of 865 infants with CL ± P and insured by Private Insurance/Self-Pay, 621 (71.8%) were breast milk fed at discharge. Using logistic regression models and controlling for baseline demographic differences, results indicated that infants with CL ± P in the Medicaid group had reduced odds of breast milk feeding compared to the Private Insurance/Self-Pay group (OR = 0.08; 95% CI 0.56, 0.96).

Breast milk support services are often necessary for the initiation of breast milk feeding among infants with CL ± P. However, these resources are likely not as readily available for those enrolled in Medicaid. These results suggest that infants with CL ± P, enrolled in Medicaid, may experience reduced breast milk feeding rates due to limited resources to initiate breast milk feeding. Factors that may promote breast milk feeding among this population are discussed.

ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance

BACKGROUND

The Patient Protection and Affordable Care Act (ACA) required new private insurance plans to provide breast pumps with no cost sharing beginning August 2012, and in January 2014 expanded this requirement to Marketplace plans and expanded Medicaid coverage. We first examined the associations between the ACA reforms in 2012 and 2014 with rates of breast pump claims between Medicaid enrollees and those with private insurance. We next examined the associations between the monthly rate of breast pump claims with breastfeeding initiation and duration by insurance type.

METHODS

Using 2011-2015 public and private health insurance claims in All-Payer Claims Databases from Massachusetts, Maine, and New Hampshire, we conducted a linear regression model to evaluate the associations between the 2012 and 2014 ACA health insurance reforms with rates of breast pump claims by health insurance status. We then linked the monthly rates of breast pump claims per 1,000 live births to the Pregnancy Risk Assessment Monitoring System with self-reported breastfeeding initiation and duration. We estimated probit regression models to examine the associations between monthly rates of breast pump claims per state, insurance type, age group, and breastfeeding outcomes.

RESULTS

For the 2012 ACA reform, breast pump claims increased by 183.4 (143.7-223.1) per 1,000 live births for women with private insurance, but decreased for Medicaid enrollees (-99.3 [-139.0 to -59.6]). For the 2014 ACA reforms, the opening of health insurance Marketplaces had no effect on breast pump claims for women with private insurance (8.3 [-43.6 to 60.2]), whereas Medicaid expansion increased claims by 119.4 (67.5-171.3) per 1,000 live births for Medicaid enrollees. Every additional 10 breast pump claims per 1,000 live births was associated with a 1.08 percentage point increase in breastfeeding initiation among women with private insurance (0.108 [0.018-0.198]), but not Medicaid enrollees (0.076 [-0.078 to 0.230]). In contrast, every additional 10 breast pump claims per 1,000 live births was associated with a 1.79 percentage point increase in breastfeeding for 4 or more weeks for women with private insurance (0.179 [0.063-0.294]) and a 2.05 percentage point increase among women with public insurance (0.205 [0.033-0.376]). Interaction analysis revealed no significant differences in associations by insurance type across breastfeeding outcomes.

CONCLUSIONS

The ACA breastfeeding coverage requirements fill a gap for women wanting to obtain a breast pump to support breastfeeding. The monthly rate of breast pump claims, as an indicator of access, translated into higher levels of breastfeeding for women with private and public insurance with the potential to reduce socioeconomic disparities.

Workplace Leave and Breastfeeding Duration Among Postpartum Women, 2016-2018

Objectives. To examine associations of workplace leave length with breastfeeding initiation and continuation at 1, 2, and 3 months. Methods. We analyzed 2016 to 2018 data for 10 sites in the United States from the Pregnancy Risk Assessment Monitoring System, a site-specific, population-based surveillance system that samples women with a recent live birth 2 to 6 months after birth. Using multivariable logistic regression, we examined associations of leave length (< 3 vs ≥ 3 months) with breastfeeding outcomes. Results. Among 12 301 postpartum women who planned to or had returned to the job they had during pregnancy, 42.1% reported taking unpaid leave, 37.5% reported paid leave, 18.2% reported both unpaid and paid leave, and 2.2% reported no leave. Approximately two thirds (66.2%) of women reported taking less than 3 months of leave. Although 91.2% of women initiated breastfeeding, 81.2%, 72.1%, and 65.3% of women continued breastfeeding at 1, 2, and 3 months, respectively. Shorter leave length (< 3 months), whether paid or unpaid, was associated with lower prevalence of breastfeeding at 2 and 3 months compared with 3 or more months of leave. Conclusions. Women with less than 3 months of leave reported shorter breastfeeding duration than did women with 3 or more months of leave. (Am J Public Health. 2021;111(11):2036-2045. https://doi.org/10.2105/AJPH.2021.306484).

Understanding Factors Influencing Breastfeeding Outcomes in a Sample of African American Women

OBJECTIVES

Persistent disparities in breastfeeding rates among African American (AA) women compared to other population groups have motivated researchers to understand factors influencing breastfeeding choices using a variety of methods. Quantitative surveys are more commonly reported, however, qualitative work that amplifies voices of AA women is limited.

METHODS

Participants were recruited from a randomized controlled feasibility trial focused on breastfeeding support for AA women in Detroit, MI. Thirteen women were enrolled in the qualitative portion of the study described here. Using the Socioecological model (SEM) as the theoretical foundation, semi-structured qualitative interviews were conducted to explore perceived facilitators and barriers to breastfeeding. Interviews were digitally recorded, transcribed, and analyzed using Theoretical thematic analysis.

RESULTS

Women reported factors ranging from micro to macro SEM levels that discouraged or reinforced breastfeeding. Key challenges included breastfeeding-related discouragement issues, including factors that decreased confidence and led women to terminate breastfeeding (e.g., problems with latching, pumping, lack of comfort with breastfeeding in public, and work constraints). Facilitators included perceived mother and infant benefits, perseverance/commitment/self-motivation, pumping ability, and social support. Participant suggestions for expanding breastfeeding promotion and support included: (1) tangible, immediate, and proactive support; (2) positive non-judgmental support; (3) "milk supply" and "use of pump" education; and (4) self-motivation/willpower/perseverance.

CONCLUSIONS FOR PRACTICE

Despite the identification of common facilitators, findings reveal AA women face many obstacles to meeting breastfeeding recommendations. Collaborative discussions between women and healthcare providers focused on suggestions provided by AA women should be encouraged.

Work, race and breastfeeding outcomes for mothers in the United States

Background

In the United States, mothers’ employment status and occupation are related to breastfeeding. However, it is unclear whether not working leads to longer breastfeeding duration even when compared to professional/managerial jobs, which tend to accommodate breastfeeding better than service/manual labor jobs. Furthermore, occupation and breastfeeding are racially patterned, and it is possible that race could moderate the relationships between mother’s work and breastfeeding.

Methods

Using data from the Panel Study of Income Dynamics, we modeled breastfeeding duration based on mother’s employment/occupation (not working, professional/managerial work, or service/labor work) during the first 6 months postpartum, as well as mother’s race (White, Black or other) and other potential confounders. We used zero-inflated negative binomial regression models and tested an interaction between employment/occupation type and race. Predictive margins were used to compare breastfeeding duration among subgroups.

Results

Mothers working in service/labor occupations had the shortest breastfeeding duration of the three employment/occupation groups, and there was no significant difference in duration between not working and professional/managerial occupation. White mothers had longer breastfeeding duration than Black mothers on average. When we included an interaction between employment/occupation and race, we found that among White mothers, non-working mothers breastfed the longest, while mothers in service/labor work breastfed for the shortest duration, but among Black mothers, mothers in professional/managerial work breastfed for longer than mothers in the other two work categories.

Discussion

Race moderated the relationship between employment status/occupation type and breastfeeding such that, for White mothers, not working was the most advantageous circumstance for breastfeeding, in line with traditional work-family conflict theory. In contrast, for Black mothers, professional/managerial work was the most advantageous circumstance. These findings support the idea of the Market-Family Matrix, which allows that different work scenarios may be more or less advantageous for parenting behaviors like breastfeeding, depending on mothers’ circumstances.

Breastfeeding is Possible: A Systematic Review on the Feasibility and Challenges of Breastfeeding Among Breast Cancer Survivors of Reproductive Age

BACKGROUND

Breastfeeding is the biologically normative mode of feeding human infants, and reduces the risk of breast cancer for mothers. This systematic review assesses engagement in breastfeeding and the factors associated with breastfeeding among breast cancer survivors.

METHODS

An online literature search was performed using the PubMed, Embase, CINAHL, PsychInfo, and Web of Science databases. Inclusion criteria were original research articles written in English, published in peer-reviewed journals from 1 January 1990 to 25 November 2019, and included data on breast cancer survivors who attempted breastfeeding.

RESULTS

Thirteen studies were included in the systematic review. Between 7.7 and 90.9% of women attempted breastfeeding. Breastfeeding among participants varied from a few weeks to approximately 2 years. Common factors leading to breastfeeding were use of the contralateral breast, support from others, lactation counseling and advice from an International Board-Certified Lactation Consultant, being motivated to breastfeed, frequent feedings, and use of galactagogues. Common barriers were medical counseling against breastfeeding, insufficient milk production, lack of support, refusal of the infant to breastfeed from the treated breast, and being tired from relying on one breast.

CONCLUSIONS

Breastfeeding from the unaffected breast is feasible for some breast cancer survivors. Successful breastfeeding may require multilevel support and expert advice.

Support for Breastfeeding Employees: Assessing Statewide Worksite Lactation Support Recognition Initiatives in the United States

BACKGROUND

Although the reasons for discontinued breastfeeding are multifactorial, an unsupportive work environment is consistently reported as a barrier to continued breastfeeding. In the United States, several state breastfeeding advocates have taken a distinctive approach to promote worksite lactation support by developing statewide recognition initiatives aimed at incentivizing employers to support breastfeeding employees by offering public recognition for the worksites' efforts.

RESEARCH AIM

To identify and describe statewide worksite lactation support recognition initiatives in the United States.

METHODS

Between May 2016 and June 2017, semi-structured phone interviews were conducted with breastfeeding experts in each U.S. state (N = 60 participants) for this cross-sectional study. Experts in states with a recognition initiative were asked about the background, structure, and requirements of the initiative.

RESULTS

Twenty-six states had a current initiative, and some had requirements for providing a private space (n = 19; 73%) and time (n = 18; 69%) for employees to express human milk, as well as a written worksite lactation support policy (n = 10; 38%).

CONCLUSIONS

This was the first study in which researchers systematically identified ongoing worksite lactation support recognition initiatives in the United States. The results of this work also served to highlight both the similarities and the variety between initiatives. Future researchers should aim to determine the components of an initiative that increase employer support and, in turn, breastfeeding rates.

Medicaid expansion and infant mortality, revisited: A difference-in-differences analysis

OBJECTIVE

To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.

DATA SOURCES

State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.

STUDY DESIGN

The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.

PRINCIPAL FINDINGS

Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).

CONCLUSIONS

Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.

Trends in Food Consumption Patterns of US Infants and Toddlers from Feeding Infants and Toddlers Studies (FITS) in 2002, 2008, 2016

The Feeding Infants and Toddlers Study (FITS) is the largest survey of dietary intake among infants and young children in the United States. Dietary patterns in early childhood are a key component of prevention of diet-related chronic diseases, yet little is known about how food consumption patterns of infants and young children have changed over time. The objective of this study is to examine trends in food and beverage consumption among children ages 6–23.9 months using data from the FITS conducted in 2002, 2008, and 2016. A total of 5963 infants and young children ages 6–23.9 months were included in these analyses. Food consumption data were collected using a multiple-pass 24-h recall by telephone using the Nutrition Data System for Research. Linear trends were assessed using the Wald’s test in a multivariable linear regression model. Positive significant findings include increases in breast milk consumption and decreases in the consumption of sweets, sugar-sweetened beverages, and 100% fruit juice. More troubling findings include decreasing infant cereal consumption, stagnant or decreasing whole grain consumption, and stagnant consumption of vegetables. Our findings suggest some promising improvements in dietary intake among infants and toddlers in the United States over the past 15 years, but further policy, programmatic, and industry efforts are still needed.

National Trends in the Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infants

IMPORTANCE

Human milk confers important health benefits to very low-birth-weight (VLBW) infants (≤1500 g). The extent to which the use of human milk has changed over time and the factors associated with human milk use nationally in this population are poorly understood.

OBJECTIVES

To describe US trends in the provision of human milk at hospital discharge for VLBW infants during the past decade according to census region and maternal race/ethnicity, quantify associations of census region and maternal race/ethnicity with the provision of human milk at hospital discharge, and examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted of 346 248 infants, born at 23 to 29 weeks' gestation or with a birth weight of 401 to 1500 g, who were cared for at 802 US hospitals in the Vermont Oxford Network from January 1, 2008, to December 31, 2017. The US census region was categorized as West, Midwest, Northeast, and South (reference). Maternal race/ethnicity was categorized as non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian and Pacific Islanders, and Native American.

MAIN OUTCOMES AND MEASURES

Any provision of human milk at hospital discharge, defined as the use of human milk as the only enteral feeding or the use of human milk in combination with fortifier or formula.

RESULTS

Of the 346 248 infants in the study (172 538 boys and 173 710 girls), 46.2% were non-Hispanic white, 30.1% were non-Hispanic black, 18.3% were Hispanic of any race, 4.7% were Asian and Pacific Islanders, and 0.8% were Native American. Any provision of human milk at hospital discharge increased steadily among all infants, from 44% in 2008 to 52% in 2017. There were increases across all US census regions and racial/ethnic groups. Any provision of human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19), compared with the South, and was higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) and lower among Hispanic (among singleton births: adjusted prevalence ratio, 0.98; 95% CI, 0.96-1.01; among multiple births: adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91), Native American (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69), and non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60), compared with non-Hispanic white mothers. These results were robust to adjustment for birth year and infant characteristics. Wide regional and state variations were found in any provision of human milk at hospital discharge.

CONCLUSIONS AND RELEVANCE

Overall prevalence of any provision of human milk at hospital discharge among VLBW infants has steadily increased during the past decade. Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.

Clinician's Guide to Supporting Women With Breast Milk Pumping

The benefits of breastfeeding and breast milk are well established. Women may intend to exclusively breastfeed their infants, but they often need to provide expressed breast milk upon returning to employment or other activities. Without specialized lactation services, women may turn to health care providers, social media, and Web-based information for support and education. Nurses can support breastfeeding women and help them make informed decisions by providing factual, practical information about breast pumps, expression and storage of breast milk, options for testing breast milk, and available resources.

Exploring Human Resource Managers' Decision-Making Process for Workplace Breastfeeding-Support Benefits Following the Passage of the Affordable Care Act

Objectives To explore factors that shape decisions made regarding employee benefits and compare the decision-making process for workplace breastfeeding support to that of other benefits. Methods Sixteen semi-structured, in-depth interviews were conducted with Human Resource Managers (HRMs) who had previously participated in a breastfeeding-support survey. A priori codes were used, which were based on a theoretical model informed by organizational behavior theories, followed by grounded codes from emergent themes. Results The major themes that emerged from analysis of the interviews included: (1) HRMs' primary concern was meeting the needs of their employees, regardless of type of benefit; (2) offering general benefits standard for the majority of employees (e.g. health insurance) was viewed as essential to recruitment and retention, whereas breastfeeding benefits were viewed as discretionary; (3) providing additional breastfeeding supports (versus only the supports mandated by the Affordable Care Act) was strongly influenced by HRMs' perception of employee need. Conclusions for Practice Advocates for improved workplace breastfeeding-support benefits should focus on HRMs' perception of employee need. To achieve this, advocates could encourage HRMs to perform objective breastfeeding-support needs assessments and highlight how breastfeeding support benefits all employees (e.g., reduced absenteeism and enhanced productivity of breastfeeding employee). Additionally, framing breastfeeding-support benefits in terms of their impact on recruitment and retention could be effective in improving adoption.

Awareness of Breastfeeding Laws and Provisions of Students and Employees of Institutions of Higher Learning in Georgia

BACKGROUND

Over the past 2 decades, southern states in the United States have recorded the lowest breastfeeding rates. It is not known whether awareness of breastfeeding laws and provision of resources play any role in their breastfeeding practices.

RESEARCH AIMS

The aims were (a) to describe awareness of breastfeeding laws and provisions by students and employees of institutions of higher learning in the state of Georgia, (b) to describe awareness by race and ethnicity, and (c) to determine factors associated with awareness of breastfeeding laws and provisions among students and employees within Georgia institutions of higher learning.

METHODS

A cross-sectional online survey of students ( n = 1,923) and employees ( n = 1,311) associated with five institutions within the University System of Georgia ( N = 3,271) was completed. Convenience sampling was used. Data were collected through Qualtrics. Chi-square test was used to examine differences between groups, while logistic regression was used to examine associations.

RESULTS

Participants included 33.3% undergraduate, 26.2% graduate students, 24.6% staff, 14.2% faculty, and 1.7% administrators. Over two thirds were female and white. Almost one third reported having a child or children. Awareness of breastfeeding laws and provisions was very low among respondents, with 26.6 and 9.6% aware of federal and state provisions, respectively. While less than 10% were familiar with the Baby Friendly Hospital Initiative program, 52.6% reported their institution provides a supportive environment for breastfeeding. Being a student and being a minority were negatively associated with awareness of laws and provisions that support breastfeeding.

CONCLUSION

The need for focused efforts on increasing awareness of legislative and institutional provisions and support for breastfeeding exists.

A Pilot Study of Mothers' Breastfeeding Experiences in Infants With Cleft Lip and/or Palate

BACKGROUND

Despite the recognized importance of human milk (HM) use, breastfeeding is often discouraged for infants with cleft lip and/or palate because of their anatomical abnormalities. Poor weight gain may require formula for calorie supplementation. Stresses associated with caring for infants with cleft lip/palate may decrease rates of HM provision to these infants.

PURPOSE

This study investigates the experiences of mothers of infants with cleft lip/palate (CL/P) to determine choices and factors associated with providing HM to their infants.

METHODS

A retrospective telephone survey was administered to a cohort of mothers of infants with CL/P.

RESULTS

Fifty mothers agreed to participate in the survey. Most (78%) initiated use of HM for a median duration of 4 months, 32% provided HM for 6 months or more, and 79% exclusively expressed their HM. Poor supply was the most frequent challenge to providing HM and led to cessation in 46% of the mothers. Formula was used to supplement for poor supply or poor infant weight gain in 90% of the mothers. The best predictors of a mother's use of HM were child not in day care, genetic diagnosis, and gestational age at birth. Only 36% of mothers reported individual encouragement to provide HM, and 18% reported they were specifically discouraged from providing HM for their infants.

IMPLICATIONS FOR PRACTICE

Although initiation rates were high, there are opportunities to improve support for mothers to increase duration of HM provision in children with CL/P.

IMPLICATIONS FOR RESEARCH

This study establishes a baseline for future prospective studies looking at the impact of active encouragement and provision of lactation support within the cleft team setting.

Beverage Consumption Patterns among Infants and Young Children (0⁻47.9 Months): Data from the Feeding Infants and Toddlers Study, 2016

(1) Background: Data about early life beverage intake patterns is sparse. We describe beverage patterns among infants and young children from the Feeding Infants and Toddlers Study (FITS) 2016. (2) Methods: FITS 2016 is a cross-sectional survey of U.S. parents/caregivers of children 0⁻47.9 months (n = 3235). Food and beverage intakes were collected by 24-h dietary recalls to describe beverage consumption patterns including: a) prevalence of consumption, per capita and per consumer intake, b) contribution to intake of calories and key nutrients, and c) prevalence according to eating occasions. (3) Results: Breast milk and infant formula were commonly consumed among <12-month-olds. Among 12⁻23.9-month-olds, the most commonly consumed beverage was whole milk (67% consuming), followed by 100% juice (50% consuming). Plain drinking water was consumed by 70% of 12⁻23.9-month-olds and 78% of 24⁻47.9-month-olds. Among 12⁻47.9-month-olds, milks provided more energy and key nutrients than all other beverages. Across eating occasions, sugar-sweetened beverage (SSB) consumption, especially in the form of fruit-flavored drinks, was higher among 24⁻47.9 compared to 12⁻23.9-month-olds. Only 23⁻32% of ≥12-month-olds consumed milk or water at lunch or dinner. (4) Conclusions: Opportunities exist to improve beverage patterns. Future interventions may benefit from focusing on timely introduction of age-appropriate beverages and reducing consumption of SSBs.