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                    Breastfeeding in an Inner-City Patient Population


Jessica M. Robbins, PhD
Deepam Thomas, MPH
Brian R. Torcato, MD
Louise M. Lisi, MD, MPH
Susan W. Robbins, MD, MPH

Running head: Breastfeeding in an inner-city population


Jessica M. Robbins, PhD
Deepam Thomas, MPH
Brian R. Torcato, MD
Louise M. Lisi, MD, MPH
Susan W. Robbins, MD, MPH


Jessica Robbins is a Public Health Epidemiologist with the Philadelphia Department of Public
Health. Please address correspondence to her at Philadelphia Department of Public Health/AHS,
500 South Broad Street, Philadelphia, PA 19146; (215) 685-6426; jessica.robbins@phila.gov.
Deepam Thomas, at the time of the research, was a graduate student at Thomas Jefferson

University in Philadelphia and is currently a Health Data Specialist with the New Jersey

Department of Health and Senior Services, Communicable Disease Service, in Trenton. Brian

Torcato and Louise Lisi are Pediatric Medical Specialists with the Philadelphia Department of

Public Health. Susan Robbins is Medical Director of Pediatric and Adolescent Services with the

Philadelphia Department of Public Health.
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Abstract: In order to determine the proportion of infants seen in safety-net health clinics whose

mothers initiated and sustained breastfeeding and to assess predictors of breastfeeding in this

largely minority patient population, charts were reviewed for infants treated in the eight

Philadelphia Health Centers. Breastfeeding was initiated by 42%; 7.5% breastfed for 180 or

more days. Race/ethnicity, mother's age, birth weight, and prematurity were not associated

with breastfeeding initiation or maintenance. There were differences in initiation rates between

patients born in different hospitals, and between patients seen in different health centers.

Hospital and health center differences in breastfeeding initiation and health center differences in

breastfeeding maintenance may reflect practice variations and unmeasured differences in

patient populations. While breastfeeding rates in this population remain far below targets, the

substantial proportion of mothers who did breastfeed and large variations between facilities

demonstrate that breastfeeding is possible and can be successfully promoted among

economically disadvantaged mothers.




Key words: Breastfeeding, community health centers, women’s health, urban health, minority

health.
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Breast milk is the optimal infant food. In the United States the promotion and support of

breastfeeding has emerged as a public health priority in recent years. Breastfed infants have

fewer cases of infection, including diarrheal disease, otitis media, pneumonia, and respiratory

tract infections, as well as lower rates of sudden infant death syndrome than other infants.1,2

Health benefits to mothers may include less bleeding in the immediate postpartum period, a

faster return to pre-pregnancy weight in the months after delivery, and a more rapid return of

uterine tone. Beyond the period of lactation some maternal benefits that are associated with

breastfeeding include potential lower risks of osteoporosis and of ovarian and breast cancer.3

Due to the compelling evidence that prolonged breastfeeding has multiple health benefits for

infants and their mothers both the American Academy of Pediatrics (AAP) and the World Health

Organization recommend exclusive breastfeeding for the first six months of life.4 However,

decreasing duration of hospital stay may affect breastfeeding rates because of the reduced

opportunities for education, observation, and practical instruction of correct breastfeeding

technique.5 Recent statistics indicate that the initiation and maintenance of exclusive

breastfeeding are low in the United States.6 Mothers who encounter problems with

breastfeeding often discontinue it. Support with breastfeeding problems and promotion of

exclusive breastfeeding through primary health services seems to be feasible and effective in

increasing the length of time that women exclusively breastfeed.

       Healthy People 2010 goals for breastfeeding in the U.S. are for 75% of babies to be

breastfeeding at hospital discharge, 50% to be breastfeeding at six months of age, and 25% to

be breastfeeding at 12 months of age. Goals for exclusive breastfeeding are for 40% at three

months and 17% at six months. Breastfeeding rates have increased since 1999 but fall short of

Healthy People 2010 objectives with regard to duration and exclusivity. Data from the National

Immunization Survey show that nationally, 75.0% of mothers who gave birth in 2007 reported
                                                                                                     4


that they had initiated breastfeeding, and 43.0% were still breastfeeding their infants at six

months of age; 13.3% breastfed exclusively through six months. For Philadelphia, however,

these figures were 60.6%, 28.9%, and 8.6%, respectively.6

       The Philadelphia Department of Public Health (PDPH) promotes breastfeeding in several

ways: (a) dissemination and implementation of the Philadelphia Breastfeeding Policy that

includes goals to increase public and professional awareness of breastfeeding as the best infant

feeding choice for babies; (b) information and education for agencies providing prenatal, labor

and delivery, postpartum, pediatric, and day care services; (c) commitment to update a

Breastfeeding Resource Handbook for health care professionals working with pregnant women,

postpartum women, and nursing infants on an ongoing basis; and (d) dissemination of

educational material to mothers, health care providers, and the business community, subject to

the availability of funding. In addition, PDPH operates eight neighborhood health centers

providing full primary care services, including prenatal and well child care, to Philadelphia

residents. The health centers serve disadvantaged Philadelphia residents: most clients are

Black, Hispanic, and/or immigrants, and 97% report household incomes below 200% of the

federal poverty level (FPL). The health centers treat over 2,000 infants each year,

approximately 10% of all Philadelphia resident infants.

       This study was conducted for the PDPH Pediatric and Adolescent Quality of Care

Committee to assess the frequency with which infants treated in the Philadelphia Health Centers

operated by PDPH were breastfed, and to determine whether breastfeeding initiation and

maintenance in this patient population was associated with sites of delivery and infant care,

with clinical characteristics of the birth, or with maternal demographic characteristics, in order

to inform efforts to promote breastfeeding of infants served by the Health Centers.
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Methods

Subjects were patients of the Health Centers of the Philadelphia Department of Public Health

who were born between June 2005 and May 2007 and had at least one well-child visit in the

Health Centers during the first year of life. A complete list of eligible patients in each Health

Center was generated from the Health Centers management information system, each patient

was assigned a random number using the RAND function in Excel 2003, and the lists were

sorted in descending order. One of the authors [DT] reviewed medical records for selected

patients, in order, until 100 charts were reviewed at each of the eight Health Centers. Data

were extracted from nursery discharge reports and physician and nurse notes on outpatient

visits during the first year of life.

         Variables. Variables extracted included month and year of birth, maternal age in years,

race/ethnicity, delivery hospital, birthweight, gestational age, and feeding method documented

on hospital nursery discharge papers present in the infant’s medical record and at each well-

child visit. Birth weight was classified as less than 1500g, 1500- <2500g, 2500-<4000g, more

than 4000g, or not recorded. Preterm birth was defined as a gestational age of less than 37

weeks.

         Analysis. We operationalized initiating breastfeeding as the mother who had ever

breastfed her infant regardless of the length of time. Among mothers who initiated

breastfeeding, duration of breastfeeding was defined as the age of the infant at the last visit at

which breastfeeding was reported. Bivariate analyses were performed to see if initiating

breastfeeding was associated with maternal demographic characteristics (race/ethnicity and

age), newborn characteristics (preterm birth and low birthweight), and health care facility
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(birthing hospital and outpatient Health Center). Logistic regression was used to conduct

multivariable analyses controlling simultaneously for potential predictors of breastfeeding.

Because equal numbers of patients were selected from each Health Center despite three-fold

differences in the number of infants treated, observations were weighted by the inverse of the

probability of selection for all analyses reported. Weighted and unweighted results were similar,

except for the demographic characteristics of the study sample. The data analysis for this paper

was generated using SAS software (Copyright, SAS Institute Inc. SAS and all other SAS Institute

Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc.,

Cary, NC, USA).

       This study was qualified as exempt by the Philadelphia Department of Public Health

Institutional Review Board.




Results

The (unweighted) study sample was 62% Black, 12% Hispanic, 8% Asian, and 4% White.

Among the 715 mothers whose age was recorded, 390 were in their 20s; 132 were teenagers

and 193 were 30 years of age or older (see Table 1).

                       PRODUCTION: INSERT TABLE 1 ABOUT HERE

       Breastfeeding was initiated by 42% of the mothers and continued for a (weighted)

mean of 85.6 days—7.5% of all infants were breastfed for 180 days or more.

       Breastfeeding initiation and maintenance rates did not differ significantly by

race/ethnicity in this population. There were marginally significant increases in breastfeeding

initiation and maintenance rates with maternal age (p = .06 for initiation and p = .07 for

maintenance). One third (33%) of mothers younger than 20 years old initiated breastfeeding
                                                                                                      7


compared with almost half (47%) of those 30 years of age and older. Maintenance rates ranged

from 4% to 9% in the same age categories. Birthweight also had a marginally significant (p =

.07) association with initiating breastfeeding (heavier babies were more likely to be breastfed)

but not with maintenance of breastfeeding. Neither initiation nor maintenance of breastfeeding

was associated with preterm birth.

       Breastfeeding initiation was significantly different for infants born in different hospitals

(p = .02). Among mothers in our sample who gave birth at the four area hospitals at which the

majority of births were reported, those at one hospital had a significantly lower initiation rate

(33%) and those at another had a significantly higher rate (49%) than the others.

       Rates of breastfeeding initiation also varied significantly between Health Centers (p <

.001), from a low of 22% to a high of 60%.

       Among mothers who initiated breastfeeding, there were no statistically significant

predictors of six-month breastfeeding maintenance.

       In multivariable analyses, breastfeeding initiation rates did not differ significantly by

race/ethnicity, maternal age, preterm birth, or birth weight category. Hospital and HCC

continued to be significantly associated with breastfeeding initiation. Demographic and

pregnancy-related variables did not attain statistical significance (except for birthweight as a

continuous variable, which was associated with a small but statistically significant increase in

breastfeeding) and were not confounders of the associations between hospital and

breastfeeding or health centers and breastfeeding (see Table 2).

                           PRODUCTION: INSERT TABLE 2 ABOUT HERE




Discussion
                                                                                                       8


This study examined the initiation of breastfeeding in an inner-city population and the factors

associated with initiation and maintenance of breastfeeding in this population. Though previous

studies have documented racial differences in breastfeeding initiation, in this population race

and ethnicity did not play a major role in breastfeeding initiation rates. This is consistent with

other studies that have found that community health center patient populations exhibit fewer

racial and ethnic health disparities, probably reflecting both shared socioeconomic disadvantage

and access to the same health care resources.7-9 Breastfeeding initiation rates did vary

significantly for different birth hospitals and among the eight health centers, even after

controlling for demographic and clinical variables potentially related to breastfeeding rates. The

odds of initiating breastfeeding at the birth hospital with the highest rates were over 2.6 times

as high as at the hospital with the poorest rates. The odds of initiating breastfeeding at the

health center with the highest rates were over six times as high as at the health center with the

lowest rates. Some of these differences are likely due to unmeasured confounders that were

not available in our data. However, it is likely that institutional and provider factors play a role

as well. Studies have suggested that prenatal breastfeeding advice from physicians, nurses, and

nutrition counselors can increase the rates of breastfeeding.10 In spite of the well-documented

resistance to breastfeeding in some disadvantaged communities, a substantial proportion of

mothers of infants served by the Philadelphia Health Centers do initiate breastfeeding. The

variations between health centers and between hospitals suggest that more effective

breastfeeding policies at the lower-performing institutions should be able to improve these

results. Since we did not study breastfeeding promotion practices at the hospitals and did not

access prenatal and perinatal records pertaining to the deliveries of our study population, we

cannot show that the presence or absence of any such practices was responsible for the

differences that we noticed in this population. The literature, however, suggests that the
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implementation of programs such as the UNICEF/WHO Baby Friendly Hospital Initiative

increases the likelihood of breastfeeding rates in a low-income, predominantly Black population

to rates comparable to the overall U.S. population at six months.11 (No hospital in Philadelphia

has earned the Baby Friendly designation. 12)

       Breastfeeding rates have increased nationally since 1999 but still continue to fall short of

Healthy People 2010 objectives with regard to duration and exclusivity. Hospital administrators

are turning to programs such as those at Boston Medical Center, a UNICEF/WHO-designated

Baby Friendly Hospital, but while medical authorities promote breastfeeding's health benefits,

society is often ambivalent about it. By statute, the Commonwealth of Pennsylvania allows

mothers to breastfeed in public without penalty, and breastfeeding is not to be considered a

nuisance or an indecent exposure. But a 2005 study by the Families and Work Institute in New

York found that while 60% of young mothers worked, only a third of large companies provided

a private, secure area where mothers could express breast milk. Health care professionals,

legislators, employers, business owners, and community and family members will have to work

together to increase the number of women who start breastfeeding and the length of time they

continue to breastfeed.

       The Breastfeeding Report Card — United States, 2008 shows how breastfeeding is being

protected, promoted, and supported in each state and allows comparisons across states,

making it an important tool for increasing breastfeeding nationwide. Nearly half of U.S. states

have achieved national Healthy People 2010 objectives for breastfeeding initiation, though

fewer have achieved objectives for breastfeeding duration and exclusive breastfeeding. Only 10

states—California, Colorado, Hawaii, Idaho, Montana, New Hampshire, Oregon, Utah, Vermont,

and Washington—have met all five Healthy People 2010 federal targets for breastfeeding,

according to the Centers for Disease Control and Prevention, which bases its results on its
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National Immunization Survey of U.S. children born between 1999 to 2006. State-specific data

show that 65%-74% of mothers ever breastfed while the maintenance rate at six months was

between 30%-39% in Pennsylvania.

       Limitations. There are several limitations of this study. This was an analysis of a

secondary data source. The data were collected from infants’ medical records. Data on

exclusivity was not sufficiently reliable to include in this analysis. This data source reflected

contemporaneous rather than retrospective reporting, avoiding some potential biases, but did

not allow us to ascertain mothers’ reasons for not initiating or discontinuing breastfeeding.

Previous studies have suggested that it is also important to consider the prevalence of maternal

contraindications to breastfeeding when evaluating breastfeeding initiation. Other demographic

factors, such as mother’s country of origin and acculturation, have been found to be associated

with breastfeeding rates13 and may have confounded the associations of breastfeeding with

specific hospitals and health centers in this study, particularly as larger numbers of immigrant

populations from various nations and ethnic groups are seen at some sites compared with

others. Breastfeeding duration was estimated conservatively as the age of the infant at the last

well-child visit at which the mother reported continuing to breastfeed—essentially the minimum

duration consistent with the data.

       Health centers and birth hospitals were significantly associated with breastfeeding

initiation rates in this low-income, safety-net health center patient population. These results in

combination with previous research indicate that there is room for improvement among health

centers and birth hospitals to promote breastfeeding and identify methods to influence mothers

to opt for this infant feeding choice. Although none of the hospitals or health centers are

meeting national goals for breastfeeding, the substantial variations we found demonstrate that

even in economically disadvantaged populations breastfeeding is possible and can be
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successfully promoted. The PDPH is studying the results with the goal of improving

breastfeeding rates, especially in the hospitals and health centers with low breastfeeding rates.
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REFERENCES

1. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in
developed countries (AHRQ Publication No. 07-E007). Evidence report/technology assessment
no. 153 (prepared by Tufts-New England Medical Center Evidence-based Practice Center, under
contract no. 290-02-0022). Rockville, MD: Agency for Health care Research and Quality, April
2007.

2. Rudan I, Boschi-Pinto C, Biloglav Z, et al. Epidemiology and etiology of childhood pneumonia.
Bulletin of the World Health Organization. 2008 May;86(5):408-16.

3. Labbok MH. Health sequelae of breastfeeding for the mother. Clin Perinatol. 1999
Jun;26(2):491-503,viii-ix.

4. The American Academy of Pediatrics (policy statement: section on breastfeeding).
Breastfeeding and the use of human milk. Pediatrics. 2005 Feb;115(2):496-506.

5. Manganaro R, Marseglia L, Mami C, et al. Effects of hospital policies and practices on
initiation and duration of breastfeeding. Child Care Health Dev.2009 Jan;35(1):106-11. Epub
2008 Nov 24.

6. National Center for Chronic Disease Prevention and Health Promotion. Breastfeeding among
U.S. children born 1999—2006 (CDC national immunization survey). Atlanta, GA: Centers for
Disease Control and Prevention, 2009.

7. Shi L, Tsai J, Higgins PC, et al. Racial/ethnic and socioeconomic disparities in access to care
and quality of care for US health center patients compared with non–health center patients. J
Ambul Care Manage. 2009 Oct-Dec;32(4):342–50.

8. Shi L, Stevens GD, Wulu JT, et al. America's Health Centers: reducing racial and ethnic
disparities in perinatal care and birth outcomes. Health Serv Res. 2004 Dec;39(6 Pt 1):1881-
901.

9. Robbins JM, Webb DA. Hospital admission rates for a racially diverse low-income cohort of
patients with diabetes: the Urban Diabetes Study. Am J Public Health. 2006 Jul;96(7):1260-4.
Epub 2006 May 30.
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10. Persad MD, Mensinger JL. Maternal breastfeeding attitudes: association with breastfeeding
intent and socio-demographics among urban primiparas. J Community Health. 2008
Apr;33(2):53-60.

11. Merewood A, Patel B, Newton KN, et al. Breastfeeding duration rates and factors affecting
continued breastfeeding among infants born at an inner-city US baby-friendly hospital. J Hum
Lact. 2007 May:23(2):157-64.

12. Clinical Pediatrics. Baby-friendly hospitals and birth centers. Thousand Oaks, CA: Sage
Publications, 2010.

13. Sussner KM, Lindsay AC, Peterson KE. The influence of acculturation on breast-feeding
initiation and duration in low-income women in the US. J Biosoc Sci. 2008 Sep;40(5):673-96.
Epub 2007 Nov 29.
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Table 1.

DEMOGRAPHICS AND BREASTFEEDING INITIATION AND MAINTENANCE,
PHILADELPHIA HEALTH CENTERS, 2005-2007

              Total      Initiated    Maintained 180+ Mean Length
                      Breastfeeding        Days       Breastfeeding
                           N (%)           N (%)         (Days)

Total           800   336     42%       60     8%          85
Race
     Black      498   209     42%       40      8%         84
     White       35    14     40%        1      3%         69
     Asian       62    21     34%        1      1%         77
     Hispanic    96    43     45%       12     12%         96
     Other       45    26     58%        3      3%         88
     Not         64    23     36%        3      4%         95
  recorded
Maternal Age (year)
     < 20       132    44     33%        5     4%          62
     20-29      390   165     42%       29     7%          85
     30+        193    90     47%       18     9%          93
     Unknown     85    37     44%        8     9%          92
Birthweight (g)
     < 1500       5     1     20%       0      0%          59
     1500-       60    18     30%                          68
  2499                                  2      3%
     2500-      666   290     44%                          87
  3999                                  52      8%
     4000+       24    11     46%        3     12%         100
     Unknown     45    16     36%        3      7%          62
Gestational Age
     Preterm    174    73     42%       13     7%          100
     Full-term  626   263     42%       47     8%           82
Hospital
     A          270   117     43%       15      5%          77
     B          149    73     49%       15     10%          87
     C          137    45     33%       12      8%          73
     D          125    58     46%       10      8%         103
     Other       89    33     37%        4      4%         106
                                                                                 15

Table 2.
MULTIVARIATE ASSOCIATIONS WITH BREASTFEEDING INITIATION, PHILADELPHIA HEALTH
CENTERS, 2005-2007

                                        Model 1                 Model 2
                                     all variables       significant variables
Variable                          OR        95% CI       OR        95% CI
Hospital
    A                               1      reference       1       reference
    B                             0.53   (0.31 – 0.93)   0.52    (0.30 – 0.89)
    C                             0.36   (0.19 – 0.68)   0.38    (0.20 – 0.71)
    D                             0.60   (0.31 – 1.15)   0.61    (0.32 – 1.16)
    Other                         0.43   (0.24 – 0.77)   0.44    (0.25 – 0.71)
HCC
    A                               1      reference       1       reference
    B                             1.72   (0.77 – 3.84)   1.55     (0.73 -3.30)
    C                             1.25   (0.60 – 2.65)   1.08    (0.54 – 2.17)
    D                             0.88   (0.45 – 1.71)   0.72    (0.40 – 1.30)
    E                             0.88   (0.40 – 1.92)   0.99    (0.48 – 2.02)
   F                              0.33   (0.15 – 0.71)   0.32    (0.16 – 0.64)
     G                            0.32   (0.13 – 0.79)   0.26    (0.11 – 0.60)
     H                            0.31   (0.14 – 0.66)   0.24    (0.12 – 0.48)
Race
     Black                          1      reference
     Hispanic                     1.38   (0.76 – 2.39)
     Asian                         0.9   (0.45 – 1.78)
     White                        1.09   (0.54 – 2.21)
     Other                        1.52   (0.80 – 2.87)
Mother’s age Group (year)
      < 20                        0.79   (0.50 - 1.25)
     20 - 29                        1      reference
     30+                          1.16   (0.80 - 1.68)
     not recorded                 1.45   (0.84 - 2.53)
Birthweight Cat (g)
     Very LBW (<1499)             0.78   (0.11 - 5.56)
     Moderately LBW (1500-2499)   0.40   (0.20 - 0.78)
     Normal (2500-3999)             1      reference
     Macrosomia (4000+)           1.22   (0.49 - 3.00)
     (not recorded)               0.77   (0.36 - 1.64)
Preterm
     Full term (37+ weeks)        1.19   (0.80 - 1.77)
     Preterm (< 37 weeks)           1      reference

OI=Odd Ratios
CI=Confidence Interval
HCC=Health Care Centers
LBW=Low Birth Weight
16

				
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