Associations Between Breastfeeding Initiation and Infant Mortality in an Urban Population.

Background: Breastfeeding promotion and support are not universally accepted in the United States as a strategy to reduce infant mortality. We investigated associations between breastfeeding and infant mortality in an urban population with high infant mortality and low breastfeeding rates. Methods: A retrospective epidemiologic study linked birth-infant death data for 148,679 live births in Shelby County, Tennessee from January 2004 to December 2014. Births <500 g, deaths ≤7 days, deaths because of congenital anomalies or malignant neoplasms, and records with missing breastfeeding status were excluded. Main outcomes were infant death before the first birthday, neonatal death <28 days, and postneonatal death ≥28 days by ever or never breastfed. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for breastfeeding initiation were adjusted for maternal factors and infant factors. Results: Initiation of breastfeeding was associated with a significant reduction in total infant mortality (OR = 0.81, 95% CI = 0.68-0.97, p = 0.023). Neonatal mortality was also significantly reduced with any breastfeeding (OR = 0.49, 95% CI = 0.34-0.72, p = 0.001). Postneonatal mortality was not significantly associated with breastfeeding initiation in the overall population (OR = 0.95, 95% CI = 0.78-1.17, p = 0.65), but was significant in the nonblack population (OR = 0.63, 95% CI = 0.41-0.98, p = 0.039). An association was observed between breastfeeding initiation and infant mortality from infectious disease (OR = 0.49, 95% CI = 0.32-0.77, p = 0.002). Conclusions: In an urban area with high infant mortality and low breastfeeding rates, initiation of breastfeeding was significantly associated with reductions in overall infant mortality, neonatal mortality, and infection-related deaths. Breastfeeding promotion, protection, and support should be an integral strategy of infant mortality reduction initiatives.

A Statewide Quality Improvement Collaborative to Increase Breastfeeding Rates in Tennessee.

BACKGROUND AND OBJECTIVES: Tennessee has low breastfeeding rates and has identified opportunities for improvement to enhance maternity practices to support breastfeeding mothers. We sought a 10% relative increase in the aggregate Joint Commission measure of breastfeeding exclusivity at discharge (TJC PC-05) by focusing on high-reliability (≥90%) implementation of processes that promote breastfeeding in the delivery setting. METHODS: A statewide, multidisciplinary development team reviewed evidence from the WHO-UNICEF "Ten Steps to Successful Breastfeeding" to create a consensus toolkit of process indicators aligned with the Ten Steps. Hospitals submitted monthly TJC PC-05 data for 6 months while studying local implementation of the Ten Steps to identify improvement opportunities, and for an additional 11 months while conducting tests of change to improve Ten Steps implementation using Plan-Do-Study-Act cycles, local process audits, and control charts. Data were aggregated at the state level and presented at 12 monthly webinars, 3 regional learning sessions, and 1 statewide meeting where teams shared their local data and implementation experiences. RESULTS: Thirteen hospitals accounting for 47% of live births in Tennessee submitted data on 31,183 mother-infant dyads from August 1, 2012, to December 31, 2013. Aggregate monthly mean PC-05 demonstrated "special cause" improvement increasing from 37.1% to 41.2%, an 11.1% relative increase. Five hospitals reported implementation of ≥5 of the Ten Steps and two hospitals reported ≥90% reliability on ≥5 of the Ten Steps using locally designed process audits. CONCLUSION: Using large-scale improvement methodology, a successful statewide collaborative led to >10% relative increase in breastfeeding exclusivity at discharge in participating Tennessee hospitals. Further opportunities for improvement in implementing breastfeeding supportive practices were identified.

Lessons Learned in a Breastfeeding Media Campaign.

Breastfeeding is well accepted as the optimal nutrition for babies. The American Academy of Pediatrics states that infant feeding should no longer be thought of as a lifestyle choice, but rather as a public health issue. In Shelby County, Tennessee, rates of breastfeeding continue to be disparately low. To address this public health problem, a focus group study was conducted with the Shelby County population least likely to breastfeed. Following participants' suggestion to use a billboard campaign with pictures of local mothers and families, one highway billboard and ten bus stop signs were placed around the city in areas of the lowest breastfeeding rates. Self-administered surveys were completed by convenience sampling in target population areas with women least likely to breastfeed, both before placing the signs and 6 months later. No significant differences were noted in knowledge, attitudes, or practices after the media campaign, but trends toward increased intention to breastfeed were noted among expectant mothers. With collapsed data (pre and post), a majority of participants believed that breastfeeding is the best way to feed a baby and they were significantly more likely to plan to breastfeed if they knew about health benefits to the baby and to themselves. If they had heard about breastfeeding on the TV or radio, they were more likely to believe breastfeeding is important for long-term health. These findings suggest that a media campaign could have a complementary role in promoting breastfeeding among women with low initiation rates.

Changes in Breastfeeding Attitudes in a Metropolitan Community in Tennessee.

BACKGROUND: The Southern United States has low breastfeeding rates, particularly among African Americans. Breastfeeding rates are influenced by community attitudes and norms. OBJECTIVE: This study aimed to examine changes in breastfeeding attitudes and demographic factors related to these attitudes. METHODS: Cross-sectional data from a community-based survey, repeated annually from 2004 to 2008, were analyzed. Univariable analysis examined trends over time and log binomial regression estimated the strength of the association between year of the survey, demographic factors, and outcome responses related to the survey questions. RESULTS: After adjusting for sex, race, marital status, age, and education, compared to 2004, 2008 respondents were 26% more likely to rate breastfeeding as extremely important compared to formula feeding (prevalence ratio [PR] = 1.26; 95% confidence interval [CI], 1.10-1.43). Similarly, 2008 respondents were 29% more likely to rate the importance of breastfeeding for long-term health as extremely important (PR = 1.29; 95% CI, 1.14-1.46). Comfort levels with breastfeeding outside the home also increased. Respondents to the 2008 survey were more likely to report that they were comfortable with a mother breastfeeding in their workplace (PR = 1.20; 95% CI, 1.11-1.31) and in a mall or restaurant (PR = 1.15; 95% CI, 1.06-1.26). After controlling for demographic factors, there were no significant differences in responses between African Americans and other races. CONCLUSION: Despite significantly lower breastfeeding rates among African Americans, this analysis revealed significant positive changes in attitudes regarding breastfeeding between 2004 and 2008, regardless of race. These changes in attitude coincided with increased breastfeeding initiation rates, suggesting that federal, state, and local breastfeeding promotion efforts had an effect.

Barriers to breastfeeding in the African American population of Shelby County, Tennessee.

Breastfeeding is recommended exclusively for the first 6 months of life, with continuation after the addition of complementary foods for at least 1 year of life. Breastfeeding rates are low in the Southeastern United States, especially among African Americans. Disparities in breastfeeding rates between African Americans and whites are especially pronounced in Memphis (Shelby County), TN. Our research objectives were to explore this disparity using focus groups, specifically to identify perceived barriers, and also to seek possible solutions from the target population. Focus groups were conducted in nine community settings within the county. Groups primarily consisted of women of childbearing years, but groups with men, grandmothers, and teens were also conducted. Common barriers for breastfeeding that were identified included pain, embarrassment with public nursing, going back to work, concern about "partying" and breastfeeding, and "just not wanting to" breastfeed. A notable finding was a substantial concern about sexuality and breastfeeding. As a possible solution, participants recommended putting breastfeeding educational materials widely across the county in many venues. Barriers to breastfeeding in Memphis are similar to those in other areas, with key concerns about sexuality and partying. Involving the target population yielded specific recommendations to improve breastfeeding promotion efforts.