A Review of Extant Data and Data Sources Related

to Breastfeeding in New Mexico and

Recommendations to Improve Breastfeeding Data

in the State

A Report Issued by the

RWJF Center for Health Policy at the University of New Mexico

Angelina L. Gonzalez-Aller, MA

aaller@unm.edu

Samuel Howarth, PhD

howarth@unm.edu

1

NOTES AND DISCLAIMER

This report and overview was compiled in preparation for the W.K.

Kellogg Foundation.

This publication is a product of the RWJF Center for Health Policy and was

commissioned by the W.K. Kellogg Foundation. The views expressed in

this report are those of the authors and do not necessarily represent those

of the RWJF Center for Health Policy, the University of New Mexico,

collaborating organizations, or funders.

Editor In-Chief: Gabriel R. Sanchez, PhD.

Location: 1909 Las Lomas Road, Albuquerque, NM 87131

Phone: 505.277.0130

Email: center@healthpolicy.edu

Copyright @ University of New Mexico – August 2016.

2

TABLE OF CONTENTS Executive Summary , Overview of Recommendations and Acknowledgements 3

Abbreviations 6

Tables and Figures 7

Part One: A Review of Extant Data and Data Sources Related to Breastfeeding

Surveillance in New Mexico 8

Part Two: Leveraging Data to Improve Breastfeeding in New Mexico 46

Part Three: Recommendations for Improving Breastfeeding Data Surveillance, Data

Availability and data Analyses in New Mexico 53

References 58

Appendix A: Healthy People 2020 Survey Instrument 65

Appendix B: Ross Mothers Survey Instrument 2010 67

Appendix C: National Immunization Survey 2002-2012 72

Appendix D: mPINC Dimensions of Care 73

Appendix E: mPINC 2013 Report Card: New Mexico 74

Appendix F: New Mexico Baby Friendly Certified Hospitals 76

Appendix G: National Survey of Children’s Health Breastfeeding Indicators 77

Appendix H: PNSS Breastfeeding Initiation 2011 78

Appendix I: HealthStyles Breastfeeding Attitudes and Opinions 79

Appendix J: New Mexico Baby Friendly Hospital Map Prototype 80

3

EXECUTIVE SUMMARY, OVERVIEW OF

RECOMMENDATIONS AND ACKNOWLEDGEMNENTS

Executive Summary

The health and economic benefits of breastfeeding are well recognized across the

globe. Breastfeeding has been shown to provide both mothers and children with health

benefits. Women who breastfeed are at lower risk of breast and ovarian cancer, while

breastfed infants have lower rates of respiratory infections and lower incidence of

sudden infant death syndrome. The U.S. Surgeon General, the U.S. Department of

Health and Human Services, the American Academy of Pediatrics, and the World

Health Organization all encourage exclusive breastfeeding for the first six months of an

infant’s life, with breastfeeding continuation until one year of age. Despite the

widespread recognition of the benefits of breastfeeding, New Mexico lags behind other

states on several breastfeeding indicators. According to results reported in the CDC’s

2014 Breastfeeding Report Card, New Mexico ranks 36th out of 50 states and the District

of Columbia on breastfeeding initiation and 33rd out of 51 for exclusive breastfeeding at

6 months. Additionally, research has demonstrated pervasive disparities in

breastfeeding rates in New Mexico when examined by race, ethnicity, acculturation,

and geography.

Because thorough and accurate data enable successful public health interventions

and the development of effective policies at the state and federal level, the objectives of

this study are as follows:

1. Identify and evaluate sources of breastfeeding data and determine if these

sources are sufficiently robust to assess the status of breastfeeding rates and

behavior throughout the state of New Mexico

2. Identify data gaps and areas where additional data collection would improve

the ability to understand breastfeeding rates and trends in the state

3. Make recommendations on how to fill these data gaps

In order to accomplish these objectives, our analysis is presented in three

corresponding parts. In Part One, we conduct a systemic and comprehensive review of

national, state, regional, and local data systems that collect breastfeeding data. In Part

Two, we present results from an online questionnaire designed and implemented by the

RWJF Center for Health Policy that assessed data needs among public health

professionals and breastfeeding advocates. In Part Three, and based on information and

findings in Parts One and Two, we offer concrete recommendations for improving or

expanding available data related to breastfeeding in New Mexico.

4

Recommendations

The analysis conducted and the findings made in this report support the

following recommendations towards improving breastfeeding data and data analyses

in New Mexico:

Expand the sample size of respondents to the PRAMS

Add questions to the PRAMS survey that ask mothers about breastfeeding

exclusivity

Support the PRAMS Toddler Survey such that it is administered every year and

administered to a large enough sample of mothers

Support current efforts to administer a Native American-specific version of a

PRAMS-like survey and support collaboration between the partners involved in

this effort

Create and support a “Kellogg Foundation PRAMS Fellow”

Work with the New Mexico Department of Health to support the creation of a

file that contains PRAMS data geocoded to birth records

Support the creation and administration of a new survey that would provide

important information on public attitudes towards breastfeeding

5

Acknowledgements

This report was conducted by the Robert Wood Johnson Foundation Center for

Health Policy at the University of New Mexico and funded by the W. K. Kellogg

Foundation. The report is a product of a collaborative effort between researchers, data

experts, and breastfeeding advocates. As such, we would like to acknowledge the

following individuals and organizations that provided insightful feedback and shared

their expertise:

Jessica Coloma,

Program Officer, W. K. Kellogg Foundation

Heidi Fredine,

Evaluation Director, New Mexico Breastfeeding Taskforce

Eirian Coronado,

Maternal Child Health Epidemiology Program Manager/PRAMS PI, NM

Department of Health

Sharon Giles-Pullen,

New Mexico WIC Program Breastfeeding Manager, NM Department of

Health

Erin Marshall,

Project Director, Baby-Friendly Hospital Initiative, New Mexico

Breastfeeding Taskforce

Members of the New Mexico Breastfeeding Taskforce

The New Mexico Department of Health

Envision New Mexico

We would also like to thank Envision New Mexico and the New Mexico

Breastfeeding Taskforce for inviting us to participate in their meetings and for their

many contributions to this report.

6

ABBREVIATIONS

AAP- American Academy of Pediatrics

BF- breastfeeding

BFHI- Baby-Friendly Hospital Initiative

CDC- Centers for Disease Control and Prevention

CLC- Certified Lactation Consultant

ECLS-B- Early Childhood Longitudinal Study Birth Cohort

FDA- Food and Drug Administration

HHS- U.S. Department of Health and Human Services

IBCLC- International Board Certified Lactation Consultants

IFPS II- Infant Feeding Practices Study II

mPINC- Maternity Practices in Infant Nutrition & Care

NCIRD- National Center for Immunizations and Respiratory Diseases

NCHS- National Center for Health Statistics

NHANES- National Health and Nutrition Examination Survey

NIH- National Institutes of Health

NIS- National Immunization Survey

NMBTF- New Mexico Breastfeeding Task Force

NMDOH- New Mexico Department of Health

NSCH- National Survey of Children's Health

PedNSS- Pediatric Nutrition Surveillance System

PNSS- Pregnancy Nutrition Surveillance System

PP- Post-partum

PRAMS- Pregnancy Risk Assessment and Monitoring System

RMS- Ross Mothers Survey

RWJF- Robert Wood Johnson Foundation

UNICEF- The United Nations Children’s Fund

WHO- World Health Organization

WIC- Special Supplemental Nutrition Program for Women Infants and Children

WPPC- WIC Participant and Program Characteristics

Y6FU- Year Six Follow Up of IFPS II

7

TABLES AND FIGURES

Table 1 National Immunization Survey: Results for 2011 Births

Table 2 National Immunization Survey: Sample Sizes 2009-2012

Table 3 New Mexico mPINC Scores: 2007-2013

Table 4 CDC New Mexico Report Card Summary: 2014

Table 5 Pregnancy Nutrition Surveillance System: Ever Breastfed 2011

Table 6 National Survey of Family Growth: Breastfeeding Indicators

Table 7 HealthStyles Selected Reponses: 2015

Table 8 IFPS Breastfeeding Indicators and Questions

Table 9 IFPS Any Breastfeeding

Table 10 New Mexico Vital Statistics Breastfeeding Initiation: 2013

Table 11 WIC Breastfeeding Initiation: October 2014-2015

Table 12 WIC Reasons for Not Initiation Breastfeeding: October 2014-2015

Table 13 Summary of Data Availability

Table 14 Summary of Datasets Assessing Breastfeeding in New Mexico

Figure 1 2013 CDC Report Card: Lactation Consultants and Counselors by State

Figure 2 National Survey of Children’s Health: Breastfeeding Indicators 2011-2012

Figure 3 Breastfeeding Initiation: WIC Mothers FFY2014

8

PART ONE: A REVIEW OF EXTANT DATA AND DATA

SOURCES RELATED TO BREASTFEEDING IN NEW

MEXICO

OVERVIEW

National, state, and regional datasets were reviewed to evaluate various

breastfeeding data and determine the status of breastfeeding surveillance throughout

the state of New Mexico. Overall, breastfeeding initiation is the most commonly

collected breastfeeding indicator, though there is significant variation in how initiation

is measured, including differences in when data is collected, how questions are worded,

and whether breastfeeding initiation is exclusive. In addition to initiation, a number of

data sources include variables on breastfeeding duration, breastfeeding exclusivity,

breastfeeding barriers, workplace policies, breastfeeding resources, hospital policies,

and support services. While the variety of available data and data sources provides an

opportunity for cross-validation and comparison, a number of data sources are

hindered by small sample sizes, or, in the case of national data sources, do not include a

sample representative of New Mexico’s state population. A brief summary of available

data sources follows, with a discussion of the status of extant data

INTRODUCTION

Worldwide, breastfeeding is recognized as beneficial for both infants and

mothers. The American Academy of Pediatrics recommends that infants be exclusively

breastfed for six months, with continuation of breastfeeding for 1 year or longer as

complementary foods are introduced (Pediatrics, 2012). Increasing exclusive

breastfeeding and the duration of breastfeeding is a major goal of the U.S. Department

of Health and Human Services (HHS) and the Centers for Disease Control and

Prevention (CDC) as outlined in the Healthy People 2020 report.1 This report includes

objectives for increasing the proportion of infants who are breastfed, increasing the

proportion of employers that have worksite lactation support programs, reducing the

proportion of breastfed newborns who receive formula supplementation within the first

2 days of life, and increasing the proportion of live births that occur in facilities that

provide care for lactating mothers and their babies.2 In order to accomplish these goals,

1 Healthy People is a national health promotion and disease prevention initiative which provides specific

objectives in an effort to address major public health issues. Healthy People 2020 was released by the

Department of Health and Human Services in 2010. 2 There are four objectives and five sub-objectives related to breastfeeding. Detailed objectives are

provided in Appendix A.

9

breastfeeding monitoring and surveillance is needed. As outlined by Chapman and

Pérez-Escamilla (2009), “national surveillance and monitoring of breastfeeding behavior

are essential for the planning, implementation, and evaluation of public health

interventions.” Breastfeeding data collection serves many public health purposes, from

determining best practices, to identifying breastfeeding trends and monitoring progress

towards goals and objectives (Heinig, 2010b). Quantitative and qualitative data may

also be used to identify and clarify common challenges to breastfeeding, thereby

enabling alternative solutions to emerge and informing the development of programs,

policies, and initiatives to reduce barriers and increase the incidence and duration of

breastfeeding. For example, more detailed statistics could be used to raise stakeholder

awareness of the value of breastfeeding as a key preventative health measure (Heinig,

2010b).

In order to assess the capacity of current breastfeeding data sets specific to New

Mexico, we evaluated the availability of data and the quality of federal, state, and

regional monitoring systems and the data collected through these systems. To identify

these data sources we contacted data experts in the state, including staff at the New

Mexico Department of Health and the New Mexico Breastfeeding Task Force. At the

federal level we spoke with experts at the Centers for Disease Control and Prevention

(CDC) and the National Institutes of Health (NIH). The datasets examined here are

those that collect or analyze data on breastfeeding within the state of New Mexico. Such

data sources include periodic surveys, one time studies and/or surveys, and evaluation

systems for federally funded programs. When available, eligible surveys and datasets

were downloaded from their respective websites. Each surveillance system was

evaluated based on the breastfeeding-related data collected, the overall study sample,

the New Mexico specific sample size, and whether the data is suitable for analysis at the

state level.3 When available, results for breastfeeding indicators are reported. For the

purpose of this study, we have identified four classifications of data sources:

Data Type 1: National Data Sources that Sample New Mexico

Data Type 2: National Data Sources that do not Sample in New Mexico

Data Type 3: New Mexico Statewide Data

Data Type 4: New Mexico Site or Region Specific Data

Data Type 5: Forthcoming Resources

3 This study was not subject to Institutional Review Board approval because no private, identifiable

information was obtained from individuals for the analyses presented in this report.

10

DATA TYPE 1: NATIONAL DATA SOURCES WITH NEW MEXICO

SUBPOPULATIONS

There are 11 federally funded datasets that include data on breastfeeding

practices and behaviors (Chapman & Pérez-Escamilla, 2009). In their review of these 11

datasets, Chapman and Perez-Escamilla found that while multiple surveys and datasets

collect breastfeeding data, extant data on breastfeeding is suboptimal for the evaluation

of breastfeeding statistics. Out of these 11 datasets, six are nationally representative and

three pertain to subpopulations of WIC participants. Ultimately, Chapman and Pérez-

Escamilla (2009) conclude that differences in sampling procedures, recall bias,

inconsistent wording on breastfeeding questions, and limited racial/ethnic category

choices constrain the extent to which results can be generalized or compared. In

addition to these 11 datasets, there are a number of additional monitoring systems,

including private data sources, independent research studies, and other types of

surveillance that provide information on breastfeeding behaviors, trends, opinions, and

policies. A brief description of each system follows.

Ross Mothers Survey

For several decades the Ross Mothers Survey (RMS) was the only source for

breastfeeding statistics at both the state and federal level.4 The Ross Mothers Survey is

an annual survey conducted by the Ross Products Division of Abbott Laboratories, one

of the major infant formula manufacturers. The RMS is usually conducted 4 times a year

by mailing questionnaires to a large sample of mothers when their infants reach six

months of age. The study was first conducted in 1954 and was still active as of 2010

(Abbott, 2002; J. Edwards, 2011). In 2000 the Ross Mothers Survey was selected as the

baseline monitoring and surveillance method for the Healthy People 2010 report.

Because the RMS is administered by a private organization and RMS data is published

on an ad hoc basis, the legitimacy of its results have been challenged throughout the

relevant literature (CDC, 2007; Grummer-Strawn & Li, 2000; Grummer-Strawn &

Shealy, 2009; Li, Zhao, Mokdad, Barker, & Grummer-Strawn, 2003; Alan S. Ryan, 2004,

2005; A. S. Ryan et al., 1991; Alan S. Ryan, Wenjun, & Acosta, 2002).

In 2007 the Healthy People 2010 objectives were updated to include two new

objectives for exclusive breastfeeding. As a result of these changes, the importance of

the RMS began to decline, and in 2010 the National Immunization Survey was

established as the official monitoring system for Healthy People 2020 objectives. While

the Ross Mothers Survey is still administered, the last publicly available RMS was

published in 2002 (NMBTF, 2014). According to 2001 survey responses, breastfeeding

initiation was 69.5% nationwide and continuation to 6 months of age was 32.5% (Alan S.

4 The Ross Mothers Survey is also known as the Ross Laboratories Mothers Survey, the Infant Food

Survey, and the National Institute of Infant Nutrition Survey.

11

Ryan et al., 2002). While Abbott Laboratories declined to provide any additional

information on their sampling methodology or estimated New Mexico sample size, the

rise in federally funded studies and surveys seems to have left the RMS to focus on its

consumer market research purposes (J. Edwards, 2011; McCormack, 2011).5

Nonetheless, the RMS survey remains one of the few information resources for

breastfeeding data throughout the 1950s-1990s before CDC data became more available.

National Immunization Survey

Each year, the CDC’s National Center for Immunizations and Respiratory

Diseases (NCIRD), in partnership with the National Center for Health Statistics,

conducts the National Immunization Survey (NIS). In 2010 NIS became the official

surveillance instrument for the Healthy People 2020 breastfeeding objectives. The

National Immunization Survey is a random digit dialed telephone survey of

households with children ages 19-24 months (CDC, 2007). As the name of the survey

indicates, its primary purpose is to collect data on the immunization and health status

of children. Following completion of the telephone survey, additional data is collected

through a mail survey to the eligible child’s vaccination providers to validate

vaccination information. Analyses of NIS data are limited to the children whose

vaccination histories are confirmed by vaccination providers. While the sample size

varies from year to year, the number of respondents in New Mexico tends to hover

around the 300 mark.

Breastfeeding surveillance was first incorporated into rotating modules of the

NIS in 2001. This decision was a result of a November 1999, CDC sponsored, United

States Breastfeeding Committee meeting on surveillance systems for monitoring

breastfeeding behavior. Attendees recommended using existing surveillance systems to

improve data collection and, as a result, three questions on breastfeeding initiation,

duration, and exclusivity were added to the CDC’s National Immunization Study

(CDC, 2007; Grummer-Strawn & Li, 2000; Li et al., 2003). The person or caregiver who is

most knowledgeable about the child’s immunization status completes the survey and

provides information on breastfeeding (CDC, 2015f).

5 Through an online parenting blog we were able to obtain a copy of the 2010 Institute of Infant Nutrition

Survey, which is provided in Appendix B.

12

NIS Breastfeeding Questions 2006-present

Was [child] ever breastfed or fed breast milk?

How old was [child's name] when [child's name] completely stopped breastfeeding or being fed

breast milk?

How old was [child's name] when (he/she) was first fed formula?

This next question is about the first thing that [child] was given other than breast milk or

formula. Please include juice, cow's milk, sugar water, baby food, or anything else that [child]

may have been given, even water. How old was [child's name] when (he/she) was first fed

anything other than breast milk or formula?

Because children are between 19-35 months of age at the time of data collection, each

survey year collects data on children born over a three-year period.6 In order to generate

information by year of childbirth, data are combined across all relevant survey years.

Table 1. NIS Results for 2011 Births

Ever BF BF at 6

Months

BF at 12

months

Exclusive BF

at 3 months

Exclusive BF

at 6 months

National 79.2 49.4 26.7 40.7 18.8

New Mexico 76.9 45.9 28.3 43.1 16.1

NIS data is representative at both the state and national level, thereby allowing

interstate comparisons and the ability to track individual state progress as compared to

nationwide results.

Table 2. National Immunization Survey Sample Sizes

2012 2011 2010 2009

United States 15,141 14,456 15,912 23,542

New Mexico 262 247 272 381

Between 2010 and 2012 the New Mexico sample has hovered around 260. With the

exception of Texas and Pennsylvania, which have above average sample sizes, New

Mexico’s sample size is on par with the NIS average of 269 respondents per state. In

2009 (excluding Texas and Pennsylvania) the state average was 417 to New Mexico’s

reported 381 (CDC, 2015c).

6 Results on NIS breastfeeding indicators are reported in Appendix C.

13

Maternity Practices in Infant Nutrition & Care

In an effort to monitor labor and delivery service facilities in the U.S. and to

evaluate maternity care practices, the CDC began the Maternity Care Practices Survey

in 2007 (mPINC) (CDC, 2015d; R. A. Edwards & Philipp, 2010). The mPINC survey was

designed to serve as a census of facilities that routinely provide maternity care.

Questions were developed by an advisory panel to evaluate practices known to affect

successful breastfeeding (R. A. Edwards & Philipp, 2010). All hospitals with maternity

services, all free-standing birth centers, and any facility that routinely provides

maternity care services in the United States are invited to participate in the mPINC

survey every two years (CDC, 2014b). The survey is completed by an experienced staff

member on behalf of his or her institution. While all maternity care facilities are invited

to participate, participation in the survey is voluntary.

Data from each participating institution is aggregated and compiled into a state

report. Although data is collected by hospitals and birthing centers and reported to the

CDC, no site- or facility-specific data is released; only aggregated state level information

is reported. State reports summarize each state’s facilities’ strengths in breastfeeding

support and identifies areas in need of improvement. These reports provide parameters

for states to better protect, promote, and support breastfeeding mothers and infants.

Since reports are issued every two years, mPINC reports are important tools for

tracking trends over time. According to the most recent report, New Mexico has 32

eligible facilities and a response rate of 91% (CDC, 2014b). The mPINC survey contains

52 questions: 33 of these focus on hospital/birth center practices; 13 focus on staff

training and policy; and 5 relate to characteristics of the hospital birth center (R. A.

Edwards & Philipp, 2010). Questions from each of these sections are then organized into

7 scoring groups:

1. Labor and Delivery Care

2. Breastfeeding Assistance

3. Contact Between Mother and Infant

4. Feeding of Breastfed Infants

5. Facility Discharge Care

6. Staff Training

7. Structural and Organizational Aspects of Care Delivery7

The highest score possible for the mPINC survey is 100. To determine final scores the

mean of each of the 7 scoring groups is averaged again to obtain a final score.8

7 A copy of the mPINC dimensions of care is provided in Appendix D. 8 Greater detail on the mPINC scoring algorithm is available from:

http://www.cdc.gov/breastfeeding/pdf/scoring_algorithm_mpinc09-508_tagged.pdf

14

Table 3. New Mexico mPINC Results

Year Score Rank (out of) Response Rate Facilities (n)

2013 77 21 (53) 91% 32

2011 69 26 (53) 84% 31

2009 64 24 (52) 67% 30

2007 64 20 (52) 67% 30

In 2013 New Mexico received an mPINC score of 77 and ranked 21 out of 53

states and territories.9 In general, New Mexico scores higher on labor and delivery and

postpartum care such as the feeding of breastfed infants, breastfeeding assistance, and

contact between mother and infant; New Mexico scores lower on discharge care, staff

training, and structural and organizational aspects of care. New Mexico’s mPINC score

has gradually improved since the survey was initiated in 2007; however, the rate of

improvement has not changed New Mexico’s comparative ranking against other states

and territories. For the most part, New Mexico has remained in the bottom 50% of state

performances. While the response rate to mPINC has improved from 67% in 2007 to

91% in 2013, it is important to remember that mPINC is both voluntary and self-

reported.

CDC Breastfeeding Report Card

Breastfeeding Report Cards are issued by the National Center for Chronic

Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and

Obesity for the CDC. Utilizing data from various sources, they compile a “report card,”

or an assessment, for each state in the U.S. documenting their respective performance

across several breastfeeding initiative dimensions or “indicators.” These indicators are

established by the Centers for Disease Control and Prevention’s National Immunization

Survey (NIS) and the Maternity Practices in Infant Nutrition and Care Survey (mPINC),

among others.

The Report Cards focus on two primary areas: breastfeeding rates and

breastfeeding support indicators, including birth facility support, mother-to-mother

support, and professional support. State-by-state NIS data is used to track breastfeeding

initiation, exclusivity, and duration using five indicators that correspond to goals in the

Healthy People 2020 report:

1. Ever Breastfed

2. Breastfeeding at 6 months

3. Breastfeeding at 12 months

9 The 2013 New Mexico mPINC Report Card is available in Appendix E.

15

4. Exclusive Breastfeeding at 3 months

5. Exclusive Breastfeeding at 6 months

The Report Card also briefly addresses breastfeeding support indicators. These

indicators range from assessing support from birth facilities and health professionals to

childcare settings. Since 2008, results from the mPINC survey have been included to

measure breastfeeding-related maternity care practices at maternity care facilities across

the U.S. and to compare the extent to which these practices vary by state. Two of these

indicators are new to the 2013 report and originate from the 2011 CDC mPINC survey:

1. The percent of hospitals and birth centers where at least 90% of mothers and

newborn infants have skin-skin contact for at least 30 minutes within an hour of

an uncomplicated vaginal birth.

2. The percent of hospitals and birth centers where at least 90% of healthy full-term

infants are rooming with their mother for at least 23 hours per day (CDC, 2011a).

The above indicators are based on recommendations from the Baby-Friendly

Hospital Initiative (BFHI), a global program sponsored by the World Health

Organization (WHO) and the United Nations Children’s Fund (UNICEF) to both

encourage and recognize hospitals and birthing facilities that offer an optimal level of

care for lactation.10 The BFHI program is based on the WHO/UNICEF Ten Steps to

Successful Breastfeeding for Hospitals (Baby-Friendly-USA, 2013). The other two

breastfeeding indicators are:

3. The percent of live births occurring at hospitals or birth centers designated as

“Baby-Friendly.”11

4. The percentage of breastfed infants receiving formula before 2 days of age.

In addition to the outcome and breastfeeding support indicators, the Report Card

includes a mother-to-mother support indicator, which is the number of La Leche

League Leaders per 1,000 live births, and a professional support indicator, which is

measured by the number of International Board Certified Lactation Consultants

(IBCLCs) per 1,000 live births. The report also provides information on the number of

IBCLCs and Certified Lactation Counselors (CLCs) in each state.

10 BFHI was launched in 1991 in an effort to address international concerns about common marketing and

medical practices that interfered with successful breastfeeding. Since the implementation of BFHI,

research has indicated that baby friendly hospital policies result in increased breastfeeding rates. For a

concise summary see (Heinig, 2010a). 11 As of 2016, there are 7 Baby Friendly Hospitals in New Mexico. The list of BFHI approved facilities is

available in Appendix F.

16

Figure 1. Lactation Consultants and Counselors by State 2013

Lastly, a support in childcare settings indicator is included, which consists of a state’s

childcare regulation of onsite breastfeeding support (CDC, 2015f).

Table 4. 2014 Report Card Summary12

Average

mPINC

Score

% of live

births at

baby

friendly

facilities

% of BF

infants

receiving

formula

before 2

days of age

Number of

La Leche

League

leaders*

Number of

CLCs*

Number of

IBCLCs*

Childcare

laws

support

onsite BF

United

States 75 7.79 19.4 0.90 3.84 3.48 7**

New

Mexico 77 3.77 15,5 0.87 1.75 3.3 No

*per 1,000 live births

** Arizona, California, Delaware, Mississippi, North Carolina, Texas, Vermont

It is important to note that while the Report Cards do not collect any original data, they

provide a concise summary of NIS and mPINC results and provide a useful platform

for tracking state level changes over time or making state-to-state comparisons. From

2007-2014 the CDC issued yearly Report Cards. Beginning in 2014, Report Cards will be

issued every other year; it is anticipated that the next Report Card will be released in

2016.

12 CDC. (2014). Breastfeeding Report Card. Atlanta: CDC Retrieved from

http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf.

17

National Survey of Children’s Health

The National Survey of Children’s Health (NSCH) is sponsored by the Maternal

and Child Health Bureau of the Health Resources and Services Administration. The

survey examines the physical and emotional health of children ages 0-17 years of age

(CDC, 2013a). The NSCH provides a broad range of information about children’s health

and well-being sampled in a manner which permits comparisons among states as well

as nationally. For the 2011-2012 survey, a total of 95,677 NSCH interviews were

completed, approximately 1,876 in each state and the District of Columbia, ranging

from a minimum of 1,811 in South Dakota to a maximum of 2,200 in Texas

(childhealthdata.org, 2013). Survey results are adjusted and weighted to reflect the

demographic composition of non-institutionalized children and youth age 0–17 in each

state. Questionnaire topics include demographics, health and functional status, health

insurance coverage, health care access and utilization, medical home, early childhood

(0–5 years) issues, issues specific to middle childhood and adolescence (6–17 years),

family functioning, parental health status, and neighborhood and community

characteristics.

The NSCH is a cross sectional telephone survey of U.S. households with at least

one resident age 0-17 at the time of the survey. NSCH follows the sampling method of

the NIS, operating from a random digit dialed sample of landline telephone numbers

supplemented with an independent sample of cellphone numbers (CDC, 2013a). The

survey was conducted in 2003, 2007, and 2011/2012. The 2011/2012 survey includes two

indicators on breastfeeding that are asked about children ages 0-5: whether children

were ever breastfed; and whether or not they were exclusively breastfed through 6

months. To produce these two indicators, four questions are asked: whether a child was

ever breastfed or fed breast milk; the age at which breastfeeding stopped; the age at

which formula was introduced; and the age at which anything other than breast milk

was introduced (childhealthdata.org, 2013). Data for the breastfeeding indicators are

included in the early childhood health section, which is asked about children ages 0-5.

As a result, breastfeeding questions have a smaller sample size. While there were

approximately 1,870 NSCH respondents in New Mexico, approximately 500 survey

respondents participated in questions relating to breastfeeding.

18

Figure 2. NSCH 2011-2012 Breastfeeding Indicators

Results from the 2011/2012 NSCH report that approximately 19.3 % (n=83) of New

Mexico children were never breastfed of given breast milk, while 19.1% (n=90) were

exclusively breastfed for 6 months and 61% (n=302) were breastfed but not exclusively

breasted for the first 6 months (NSCH, 2013).13

Early Childhood Longitudinal Program-Birth Cohort

The Early Childhood Longitudinal Study Birth Cohort (ECLS-B) was designed to

provide policy makers, researchers, educators, and parents with detailed information

about the development of children in the United States (West). The program is

administered by the Institute of Education Sciences and focuses on children’s health,

development, care, and education during the years from birth to kindergarten entry.

ECLS-B is a one-time longitudinal study which follows a sample of 14,000 children born

13 NSCH. (2013). NSCH 2011/12. Data query from the Child and Adolescent Health Measurement

Initiative. Retrieved from http://childhealthdata.org/browse/survey/results?q=2461&r=33

Detailed comparisons of New Mexico indicators results are available in Appendix G.

19

in 2001 until the time at which they enter kindergarten (Belfield & Kelly, 2010). The

ECLS-B consists of two cohorts: a birth cohort, and a kindergarten cohort. In

combination these two cohorts provide a long range of data describing children’s

health, early learning, home life, development, and educational experiences (West).

Information is collected at 9 months, 2 years, and 4 years of age (IES, 2015). The survey

is completed through a series of in-home interviews with primary caregivers, including

a videotaping of parent-child interaction.

The birth cohort focuses on characteristics of children and their families,

including health care and in-home and out-of-home experiences (West). Breastfeeding

questions are asked in the 9-month survey and include questions related to

breastfeeding initiation, duration, and the age at which child is first given formula or

other foods. The longitudinal component of the ECLS-B provides an opportunity to

evaluate the effects of breastfeeding both at the 9-month time point and as an

independent variable on a variety of health, educational, and well-being factors later in

life. Due to the ECLS-B’s restricted-use data guidelines, we are only able to provide an

estimate of the sample size for New Mexico. In the base year of the ECLS-B (i.e., the 9-

month data collection) approximately 100 children in New Mexico participated in the

ECLS-B.14

Pediatric Nutrition Surveillance System

The Pediatric Nutrition Surveillance System (PedNSS) monitors health behavior

of low-income children in federally funded maternal and child health programs (CDC,

2009; B. E. Dalenius K, Smith B., Polhamus B., Grummer Strawn L, 2012). Data for

breastfeeding and other health factors are collected for children who are provided care

at public health clinics. Data are generally collected at the clinic level, aggregated at the

state level, and then submitted to the CDC for analysis (Grummer-Strawn & Li, 2000;

Polhamus B, 2011). Since 2004, PedNSS has monitored exclusive breastfeeding and

breastfeeding initiation. Breastfeeding duration is measured up to one year; however,

the sample of this data only includes those children turning one year of age who

received public health services during the reporting period (B. E. Dalenius K, Smith B.,

Polhamus B., Grummer Strawn L, 2012). Breastfeeding initiation is determined by “ever

breastfed” while duration is determined by “breastfed at least 6 months” and “breastfed

at least 12 months” (CDC, 2009). New Mexico participated in PedNSS from 2000-2002

and again from 2004-2010. Along with the Pregnancy Nutrition Surveillance System

(PNSS), the CDC discontinued PedNSS in 2012. The last year for which data is available

14 Sample estimate is rounded to the nearest 50. As such, there were more than 75 children and less than

125 included in the ECLS-B. As with most national studies, the ECLS-B was designed to be representative

at the national, but not state or local level.

20

is 2011. Due to data restrictions, we are unable to provide further information on

breastfeeding rates or sample size.15

Pregnancy Nutrition Surveillance System

The Pregnancy Nutrition Surveillance System (PNSS) began in 1973 with yearly

data collection until the study (along with PedNSS) was discontinued in 2012. The most

recent year PNSS was conducted was 2011. PNSS was designed to monitor the

prevalence of nutrition-related problems and behavioral risk factors for infant health.

The target population of PNSS participants were low-income, high-risk pregnant

women who participated in publicly funded health, nutrition, and food assistance

programs (Kim, 1995). PNSS focused on dietary choices and behavioral risk factors

such as smoking and alcohol consumption before and during pregnancy. Data collected

about infants included date of birth, birth weight, and breastfeeding status (B. P.

Dalenius K, Smith B, Reinold C, Grummer-Strawn L., 2012). Because PNSS focuses on

pregnancy, breastfeeding duration was not collected. Much like PedNSS, the Pregnancy

Nutrition Surveillance system (PNSS) is a program-based surveillance system that

includes data collected from federally funded public health programs serving low-

income pregnant women (CDC, 2010).

Participation in PNSS is voluntary, and not all women receiving public health

program services participate. As a result, PNSS is not representative of all low-income

pregnant women or pregnant women in the general population (CDC, 2010; B. P.

Dalenius K, Smith B, Reinold C, Grummer-Strawn L., 2012). New Mexico contributed

data to PNSS in 2009, 2010, and 2011, before data collection was discontinued in 2012.

Table 5. PNSS Breastfeeding Initiation: 2011

Percent Ever BF N

New Mexico 66.6 5,846

United States 70.1 765,791

In 2011, 5,846 New Mexico infants were included in PNSS, of whom 66.6% were “ever

breastfed” (CDC, 2011b).16 New Mexico’s rate falls below the average of the 30

states/territories who reported data to PNSS (70.1%). When comparing breastfeeding

indicators to PNSS results, it is important to remember that the PNSS sample

population is based on a non-representative sample of women who participate in public

health programs.

15 Data requests may be submitted to the Centers for Disease Control and Prevention. 16 The full table of state comparisons is available in Appendix H.

21

DATA TYPE 2: NATIONAL DATA SOURCES WITHOUT REPORTED NEW

MEXICO SUBPOPULATIONS

In addition to the studies listed above, there are a number of national surveys

that do not routinely collect data in New Mexico or collect limited data in New Mexico.

These surveillance systems provide useful platforms from which to compare data

sources and also demonstrate potential data gaps. A brief discussion of each system

follows. When available, summary findings are reported.

National Survey of Family Growth

The National Survey of Family Growth, or NSFG, was designed to be the

national fertility survey of the United States. As a result, the survey’s primary focus is

on factors that help to explain trends and group differences in birth rates such as

contraception, infertility, sexual activity, and marriage (CDC, 2015a). The NSFG is

administered by the CDC’s National Center for Health Statistics (NCHS) with the

support and assistance of a number of other organizations and individuals. The NSFG

is conducted in five-year cycles, with data made available approximated every six years

(Chandra, Martinez, Mosher, Adbma, & Jones, 2005; Grummer-Strawn & Li, 2000).

The cycles thus far are as follows:

Cycle 1, started 1973

Cycle 2, started 1976

Cycle 3, started 1982

Cycle 4, started 1988

Cycle 5, started 1995

Cycle 6, started 2002

2006-2010 NSFG

2011-2015 NSFG

The first NSFF surveys were conducted as periodic cycles in 1973, 1976, 1982,

1988, and 1995. During this period, the survey sampled women exclusively; however,

the survey was expanded in Cycle 6 to include men (NCHS, 2012). In 2006 the NSFG

shifted from a periodic (cycle based) survey to continuous interviewing. Interviews

were conducted 48 weeks of every year for four years from June 2006 to June 2010

(CDC, 2015a). NSFG continues to interview men and women ages 15-44 living in

households in the United States (CDC, 2015a). The most recent available data is the

2011-2013 NSFG, which interviewed a national sample of 10,416 men and women 15-44

years of age (CDC, 2015a). The NSFG is designed to be nationally representative based

on a representative multistage area probability drawn from 120 geographic areas across

the nation (Chandra et al., 2005).

22

Table 6. National Survey of Family Growth Breastfeeding Indicators

United States Singleton babies

born in 1997-2000*

Singleton babies

born in 2001-2005**

Singleton babies

born in 2006-2009**

Percent Ever

Breastfed 66.8% 68.1% 72.6%

Percent breastfed 3

months or more 48.0% 49.8% 50.1%

Percent breastfed 6

months or more 34.9% 37.3% 36.5%

Percent breastfed 12

months or more 17.3% 17.0% 20.0%

*(Chandra et al., 2005)

** Tabulation from NCHS available at: http://www.cdc.gov/nchs/nsfg/key_statistics/b.htm#breastfeeding

Breastfeeding questions are asked of mothers reporting births in the 5 years

preceding the survey, including questions related to breastfeeding initiation and

duration (McDowell, Wang, & Kennedy-Stephenson, 2008). The National Center for

Health Statistics declined to provide estimates of state sample sizes, indicating that any

samples within New Mexico would be small and not representative of the state.

National Health and Nutrition Examination Survey

The National Health and Nutrition Examination Survey (NHANES) is a series of

point-in-time surveys designed to assess the health and nutritional status of children

and adults throughout the United States (CDC, 2013b; Grummer-Strawn & Li, 2000;

McDowell et al., 2008). NHANES began in the early 1960s and became a continuous

program in 1999. The survey examines a nationally representative sample of about 5,000

people each year in an effort to understand the prevalence of chronic conditions in the

population and associated risk factors (CDC, 2013b). The study is unique in that data

are collected from a combination of home interviews and physical laboratory

examinations (CDC, 2013b).

Breastfeeding data are usually collected at the home interview from parents

(CDC, 2015d; Grummer-Strawn & Li, 2000). In the reproductive health questionnaire,

women who have had one or more live born children are asked about whether they

breastfed their children. Following a positive response, participants are asked whether

they breastfed their child at least a month. Following a negative response, women are

asked the reasons for not breastfeeding. Responses are grouped according to a birth

cohort based on the date of birth of the child for whom breastfeeding questions are

asked (McDowell et al., 2008). The NHANES sample is selected to represent the U.S.

population of all ages. In an effort to produce reliable data, NHANES oversamples

persons 60 and older, African Americans, Asians, and Hispanics (CDC, 2013b). It is

23

important to note that NHANES data is not obtained through random sampling

methods. NHANES data is collected via a complex, multistage probability sampling

design that selects a sample that is representative of the civilian household population

of the United States (Zipf, Chiappa, Porter, & al., 2013).17 Though it is collected, the

geographic variable “state of residence” is not made available for analysis.

HealthStyles Survey

The HealthStyles Survey is a national mail survey of men and women aged 18

years and older. The survey is conducted in two parts: the first focuses on general

media habits, product use, interests, and lifestyle. The second part focuses on health

orientations and practices. The survey has been administered annually since 1995, with

the CDC beginning to include questions related to breastfeeding in 1996 (CDC, 2015d).

These breastfeeding related questions focus on public beliefs, perceptions, opinions, and

attitudes about breastfeeding policies (CDC, 2015e).18

From 1995 to 2001, the HealthStyles survey was a part of the DDB Needham

LifeStyles consumer survey administered by Porter Novelli, a public relations firm that

conducted the survey in consultation with health professionals and experts from health

related organizations. The HealthStyles survey is mailed to persons who have

completed the DDB Needham Lifestyle Survey, which is conducted annually in April.

The HealthStyles follow up survey is usually conducted around June of the same year

(Hannan, Li, Benton-Davis, & Grummer-Strawn, 2005). The respondent list is drawn

from a consumer mail panel which consists of 500,000 households throughout the

United States that have agreed to answer mail questionnaires about their lifestyles and

media and product use (Li, Rock, & Grummer-Strawn, 2007). Since 2002, the survey has

been administered by Porter Novelli in conjunction with their Consumer Styles, or

SpringStyles survey (CDC, 2015e). Since 1999, about ten breastfeeding questions have

been included in the HealthSytles questionnaire (Li et al., 2007).

17 Approximately 12,000 people are asked to participate in the NHANES study every two years. Of these

12,000 about 10,000 complete the interview and examination (Zipf et al., 2013). 18 2015 HealthStyles Question Responses are reported in Appendix I.

24

Table 7. HealthStyles 2015 Selected Questions

N Agree Neither

Agree/Disagree Disagree

I am comfortable when mothers breastfeed their

babies near me in a public place, such as a

shopping center, bus station, etc.

4,121 57.75% 23.13% 19.12%

I believe women should have the right to

breastfeed in public places. 4,117 63.74% 23.03% 13.24%

Women should be encouraged to breastfeed. 4,117 62.91% 32.55% 4.54%

Public buildings need to have a room where

women could breastfeed and pump milk for their

babies.

4,120 57.31% 28.88% 13.81%

A mother needs lots of support to breastfeed her

baby. 4,116 49.17% 35.06% 15.77%

I believe employers should provide extended

maternity leave to make it easier for mothers to

breastfeed.

4,120 46.67% 33.30% 20.02%

I would support financial incentives for employers

who make special accommodations to make it

easier for mothers to breastfeed.

4,115 41.07% 37.84% 21.09%

There should be paid maternity leave to workers. 4,122 69.72% 20.45% 9.83%

*All items are coded on the likert scale of 1 to 5 from strongly disagree, moderately disagree, neither

disagree nor agree, moderately agree, or strongly agree (CDC, 2015e).

HealthStyles data is widely utilized in publications focusing on breastfeeding

perceptions and public beliefs, changes in attitudes, and regional or demographic

variation in breastfeeding public opinion (Hannan et al., 2005; Li, Fridinger, &

Grummer-Strawn, 2002, 2004; Li, Hsia, et al., 2004; Li et al., 2007). In recent years total

participation in the study has hovered at around 4,000 respondents. The sample is

drawn to be representative of all U.S. adults, with an oversample to compensate for low

response rates among low-income individuals and minorities. Because the data are

products of both the CDC and a private organization, sample details are not provided.

A CDC representative, however, did indicate that any sample within New Mexico

would not be representative and would be unsuitable for analysis.

Infant Feeding Practices Study II and Year Six Follow Up

The Infant Feeding Practices Study II (IFPS II) was conducted by the CDC and

the Food and Drug Administration (FDA) from 2005-2007. Developed to provide

greater understanding of mothers’ breastfeeding practices, the IFPS II is a longitudinal

study that assesses the diets and behaviors of women from late pregnancy through their

infants’ first year of life (CDC, 2015d; DHHS, 2011). The study evaluates infant feeding

behavior, including breastfeeding, formula feeding, solid food intake, and the feeding

25

of other complementary foods and liquids. IFPS II was conducted using a monthly hard

copy mailed questionnaire. On average, members of the study group had higher levels

of education, were older, more likely to be white, had a middle level income, and were

more likely to be employed than the overall U.S. female population (DHHS, 2011). In

2012 the FDA and CDC conducted a follow-up study of mothers and children who

participated in the IFPS II to evaluate the health, development, and dietary patterns of

the children at six years of age (CDC, 2014a, 2015d).

Table 8. IFPS Breastfeeding Indicators and Questions

Questions addressed by the Infant Feeding Practices Study II

Use of Consumer Products

What types of formulas do infants consume and how?

What are consumers' experiences with breast pumps?

When and why do women express or pump milk?

Maternal Dietary Intake During Pregnancy and at Four Months Postpartum

What are the dietary practices of pregnant women and lactating and non-lactating postpartum

women?

What dietary supplements do women take during pregnancy and lactation?

How are these practices different from non-pregnant women?

Characteristics of Infant Feeding Patterns

When and how are complementary foods introduced?

How is breastfeeding practiced among U.S. infants?

Do U.S. infants consume teas or herbal preparations?

Are feeding patterns of infants with a family history of allergy different from infants without this

family history?

Determinants and Benefits of Breastfeeding

Do birth hospitals in the U.S. adhere to the Ten Steps to Successful Breastfeeding?

Where do mothers receive information regarding infant feeding?

What are the reasons for women do not initiate breastfeeding or stop breastfeeding?

Is breastfeeding intention related to a woman's perception of social support?

Does maternity care practice affect exclusivity of breastfeeding?

Does postnatal depression affect exclusivity of breastfeeding?

Is workplace or childcare breastfeeding support important for women to continue breastfeeding?

Is the use of breast pumps related to breastfeeding duration?

Do mothers who share a bed with their infants breastfeed longer?

Are pre-pregnant weight and gestational weight gain related to breastfeeding patterns?

Does breastfeeding reduce maternal weight retention following birth?

Recommendations and Evaluation

How effective was the National Breastfeeding Awareness Campaign?

Are the AAP recommendations for vitamin D supplementation for breastfeeding infants being

followed?

How have infant feeding practices changed from a decade ago?

(CDC, 2014a)

26

The IFPS II is unique in that it is one of the only longitudinal studies that collects

breastfeeding data. Questionnaires were mailed to mothers at 2, 3, 4, 5, 6, 7, 8, 10.5, and

12 months after their child’s birth. All participants in the study were mothers of infants

born between May 2005 and March 2006 (Ruowei Li, 2008). In addition to questions

about breastfeeding initiation and duration, the study includes a comprehensive series

of questions related to reasons for discontinuing breastfeeding (Ruowei Li, 2008). IFPS

includes a robust series of questions and indicators ranging from the use of consumer

products like infant formula and breast pumps to maternal diet during pregnancy and

postpartum. Moreover, a series of indicators are included in an effort to address

breastfeeding determinants such as the effectiveness of support services, the role of

workplace policies, and co-sleeping on the initiation and duration of breastfeeding.

Table 9. Infant Feeding Practices Study II Any Breastfeeding Percent of babies fed any breast milk in the past 7 days19

Infant age in months

Neonatal 2 3 4 5 6 7 9 10 12

ALL(n) 3,002 2,546 2,381 2,232 2,178 2,092 2,017 1,942 1,804 1,802

(%) 72.4 63.8 60.4 56.9 53.7 49.8 45.6 41.6 37.1 25.2

The IFPS utilizes a convenience sample that is not nationally representative. The

sample is drawn from a U.S. consumer opinion panel of approximated 500,000

households. Approximately 4,900 pregnant women above the age of 18 participated in

the IFPS II prenatal survey, and, of these, approximately 2,000 received one neonatal

and nine postnatal questionnaires. As a result, the study only includes 27 mothers

sampled from New Mexico.

DATA TYPE 3: NEW MEXICO STATEWIDE DATA

Currently, there are a number of federal data collection programs that evaluate

breastfeeding throughout the state, including Vital Statistics, WIC participant data, and

the Pregnancy Risk Assessment and Monitoring System (PRAMS). These programs

have the benefit of collecting data in New Mexico as independent data sources available

to state health officials. Unlike federal studies, which include New Mexico in their

samples but are only representative at the national level, state level data collection

programs are designed specifically to provide data representative of New Mexico’s own

population. A summary of state level data sources follows.

19 Tabulation by the Centers for Disease Control and Prevention Report on the Infant Feeding Practices

Study II (CDC, 2015h)

27

Vital Statistics: Standard Certificate of Live Birth

In 2003 the U.S. Standard Certificate of Live Birth (SCLB) was revised to include

a question on breastfeeding (Chapman, Merewood, Armah, & Pérez-Escamilla, 2008).

The SCLB is a template birth certificate that may be edited and adjusted by individual

states. By May of 2008, over thirty states had updated their certificate of live birth to

include a question on breastfeeding (Navidi, Chaudhuri, & Merewood, 2009). New

Mexico is one of several states that collect breastfeeding status with the question “Is the

infant breastfed at discharge?” with the available responses of “yes” and “no” listed.

Since a SCLB is issued for every live birth in the state, SCLB data reflects the total

population and is the only data source that is not based on a sub-sample of births.

However, it does not directly assess breastfeeding initiation, does not specify whether

breastfeeding is exclusive, and, since it is collected at discharge, reflects only very early

postpartum behavior.

Table 10. Vital Statistics 2013 Breastfeeding Initiation New Mexico

N Percent

Yes 20,308 77.39

No 4,033 15.37

Unknown 1,901 7.24

Total 26,242 100

In addition to breastfeeding initiation, the SCLB contains information on paternal

variables such as age, education, birthplace, race/ethnicity, and other relevant maternal

variables such as delivery method, height, pre-pregnancy weight, WIC participation,

and infant variables such as gestational age and birth weight (Chapman et al., 2008). As

a result, breastfeeding data derived from New Mexico birth certificates presents a

unique opportunity to analyze breastfeeding initiation with a sample of the complete

New Mexico birth population. While the SCLB only collects breastfeeding initiation

shortly following birth and does not specify whether breastfeeding is exclusive, vital

statistics data present a particularly useful comparison source for other data sources

that are collected on a population sample.

Newborn Screening

Newborn Screening is a state administered public health program which uses

blood sample testing to screen newborn infants for certain diseases. Each year, millions

of babies in the U.S. are routinely screened, using a few drops of blood from the

newborn's heel, for certain genetic, endocrine, and metabolic disorders (CDC, 2016).

The State of New Mexico mandates that two Newborn Genetic Screens be collected on

every newborn born in New Mexico. The newborn screen blood sample is obtained by a

28

health care provider, typically a hospital nurse. In addition to capturing a blood sample,

the screening also collects information on the breastfeeding status of the infant.20

Breastfeeding Data Collected Through Newborn Screening

Total number of births per calendar year

Infants feeding method at the time the screen is obtained

Exclusive breastfeeding is defined as ONLY breast milk – no other liquids.

Any breastfeeding is defined as a combination of breast milk and any other infant

feeding method.

Since the primary purpose of newborn screening is diagnostic, the data collected is not

usually made publicly available. Access to newborn screening data may be requested

through the New Mexico Department of Health.

Pregnancy Risk Assessment Monitoring System for New Mexico

The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing,

multi-year, state-based population survey used to identify and monitor selected

maternal behaviors and experiences occurring before, during, and after pregnancy. The

goal of the PRAMS is to improve the health of mothers and infants by reducing

unfavorable outcomes such as low birth weight, infant mortality and morbidity, and

maternal morbidity. The PRAMS was piloted by the CDC in 1989 and consists of three

parts: a series of core questions that all states use, a bank of standardized optional

questions that states may select from, and state-developed questions that are usually

used only by the state that developed them (CDC, 2015b). The core portion of the

questionnaire includes questions about the following:

Attitudes and feelings about the most recent pregnancy

Content and source of prenatal care

Maternal alcohol and tobacco consumption

Physical abuse before and during pregnancy

Pregnancy-related morbidity

Infant health care

Contraceptive use

Mother’s knowledge of pregnancy-related health issues, such as adverse effects

of tobacco and alcohol, the benefits of folic acid, and the risks of HIV(CDC,

2015g)

20 Thanks to Heidi Fredine of the New Mexico Breastfeeding Taskforce who provided this information.

29

Currently 40 states and the District of Columbia participate in the PRAMS. In

1998 a collaboration between the NM Department of Health and the Centers for Disease

Control and Prevention brought the first installment of the PRAMS to New Mexico.21

Using a sampling frame from resident in-state birth records with a monthly sample of

around 1 out of every 12 live births, the PRAMS provides ongoing surveillance of public

health issues throughout New Mexico. PRAMS samples are stratified by maternal race

and/or ethnicity, including non-Hispanic white, Hispanic native born, American Indian,

and all other reported race-ethnicities. The data are collected through hard copy

questionnaire mailings with incentives, phone follow-up, and hand delivery for non-

responders, with a $10 gift card for completion. The surveys are administered

approximately 2–6 months after women give birth.

PRAMS Breastfeeding Behavior Questions

Did you ever breastfeed or pump breast milk to feed your new baby after delivery, even for a

short period of time?

Are you currently breastfeeding or feeding pumped milk to your new baby?

How many weeks or months did you breastfeed or pump milk to feed your baby?

How old was your new baby first time he or she drank liquids other than breast milk (such as

formula, water, juice, tea, or cow’s milk?)

(NMDOH, 2012)

Because mothers receive the survey between 60 and 120 days postpartum, breastfeeding

duration estimates are limited to nine weeks (Weng, Coronado, & Nadler, 2005).22 In

addition to questions on breastfeeding behavior, PRAMS also asks questions about

breastfeeding services in hospitals, including whether staff provided information about

breastfeeding, assisted in breastfeeding or provided a breast pump, and reasons for

discontinuing breastfeeding.

21 NM PRAMS started with July 1997 births. 22 Indirect estimates are available for longer durations.

30

Breastfeeding Discontinuation Question

What were your reasons for stopping breastfeeding? Check all that apply:

My baby had difficulty latching or nursing

Breast milk alone did not satisfy my baby

I thought my baby was not gaining enough weight

My nipples were sore, cracked, or bleeding

It was too hard, painful, or too time consuming

I thought I was not producing enough milk

I had too many other household duties

I felt it was the right time to stop breastfeeding

I got sick and was not able to breastfeed

I went back to work or school

My baby was jaundiced

Other, Please tell us

(NMDOH, 2012)

In addition to the aforementioned measures profiled, the 2008-2012 NM PRAMS

also responded to the increase in goals for breastfeeding in Healthy People 2020 as well

as to an amendment to NM law NMSA 1978 which supports breastfeeding in the

workplace. In response the PRAMS system added additional components to the survey

to evaluate the status of workplace breastfeeding policies.

Workplace Policy Question

New Mexico state law requires that all employers provide a clean, private location for mothers to

breastfeed or pump milk for their infants. What happens when a mother wants to breastfeed or pump

milk for her baby at your current or most recent workplace?

She can breastfeed or pump milk at anytime

She can breastfeed her baby during break times only

She has flexible break times to breastfeed or pump milk

She has a clean private place that is not a bathroom, where she can breastfeed or pump milk

She is not allowed to breastfeed or pump milk at work

I don’t know

(NMDOH, 2012)

The PRAMS provides a series of useful breastfeeding questions ranging from

breastfeeding behavior from initiation, reasons for termination, workplace policies, and

support services. The study population is all New Mexican resident mothers with a

registered live birth for the sampling year. About 1 in 12 mothers are selected for the

survey sample (NMDOH, 2012). In recent years the sample size for the New Mexico

PRAMS has ranged from a maximum of 1,615 in 2000 to a minimum of 977 in 2012.23

23 2012 is the most recent year for which we have available data. With Kellogg funding, 2012-2015 PRAMS

included a significant oversample.

31

Despite the fact that PRAMS has a large New Mexico sample size, the sample is still

relatively small, hovering at around the 1,400 mark, which requires combinations of

sample years in order to be able to disaggregate by demographic indicators such as race

or ethnicity, county or region, or education or income. Moreover, breastfeeding

duration is limited to 6 months with subsamples of duration responses, as surveys are

mailed to mothers when their infant is 2-6 months of age.

Women, Infants and Children program for New Mexico

The Women, Infants and Children Program (WIC) is the federal Special

Supplemental Food Program for women, infants, and children administered by the

United States Department of Agriculture (USDA), Food and Nutrition Service and the

New Mexico Department of Health, Public Health Division. WIC services are also

available through select Indian Tribal Organizations. WIC provides supplemental food

to program participants along with nutrition education, information on breastfeeding,

and referrals to health and social programs. In order to quality for WIC, one must live

in New Mexico and be a pregnant, breastfeeding, or postpartum mother to an infant

under one year of age or a child of less than 5 years of age. Additionally, WIC eligibility

requires mothers to meet the income requirement of an income at or below 185% of the

federal poverty income level.24 Lastly, participants must be at nutritional risk as

determined by an initial health and diet screening at a WIC clinic.

Table 11. WIC Breast Feeding Initiation: New Mexico Infants Born October 2014-

201525

Yes No No Answer Total

Initiated

Breastfeeding

12,949 3,107 52 16,108

80.4% 19.3% 0.3% 100%

Following the passage of the Child Nutrition and WIC Reauthorization Act of

1989, WIC strengthened its breastfeeding promotion efforts for pregnant and

postpartum participants (Johnson et al., 2013). As a result of this legislation, WIC

programs expanded to include a range of strategies aimed at increasing breastfeeding

initiation and duration. These programs included new data collection efforts, individual

and group education programs, breastfeeding peer counselor programs and support

groups, staff education and training, breast-pump loan programs, and community

partnerships (Johnson et al., 2013). In 1994 federal legislation passed requiring the

24 According to a 2015 memo from the USDA, in 2013 there were 14,420 infants (<12 months of age) who

were at or below 185% of the federal poverty line. 25 Data was provided by the NM WIC Program. For additional information, please contact Sharon.Giles-

Pullen@state.nm.us

32

USDA to report breastfeeding incidence and duration rates of WIC participants

(Johnson et al., 2013). Consequently, WIC is the largest public breastfeeding promotion

program in the nation (nwica.org, 2015).

Table 12. Reasons for not Initiating Breastfeeding

New Mexico Infants Born October 2014-2015 N Percent

Embarrassment 108 3.5%

Family or friend’s influence 70 2.3%

Lack of confidence 1,627 52.4%

Lack of hospital support 221 7.1%

Lack of professional support postpartum 54 1.7%

Lack of professional support prenatally 12 0.4%

Lifestyle restrictions 328 10.6%

Other 230 7.4%

Valid Medical Contraindications 123 4.0%

Work or School 21 0.7%

No Response 313 10.1%

Total 3,107 100%

Breastfeeding data is collected from WIC participants by WIC staff after a mother

has delivered her baby and usually when the mother visits a WIC clinic to be recertified

as a breastfeeding or postpartum (non-breastfeeding) client. Mothers are asked if they

have ever breastfed, how long they breastfed, their use of a breast pump and whether

they participated in the breastfeeding peer counselor program, and their reason(s) for

discontinuing breastfeeding. Demographic data is also collected and reported. For

example, in 2014, breastfeeding initiation for WIC infants was reported at 80.9%.

However, breastfeeding initiation rates were considerably higher in central and western

New Mexico than eastern New Mexico (NMDOH, 2015).

33

Figure 3. Breastfeeding Initiation: WIC Mothers Who Gave Birth in FFY2014

While the data provided by the WIC report are informative, comprehensive, and

specific across several dimensions, it is important to note that the instrument itself was

designed for and administered to mothers enrolled in WIC benefits in New Mexico

only. Thus, the data reflect a specific subpopulation of mothers in the state. Moreover,

while duration and discontinuation data is collected, a data management complication

in the MIS data management system does not permit reports to be issued for these

indicators. Although WIC staff is able to view the data for individual clients, they

cannot aggregate responses for statewide analysis. As result, currently WIC data only

provides information on breastfeeding initiation and reasons for not initiating

breastfeeding.

Data Type 4: Site or Regional Surveillance and Data

In addition to the large federal and state surveillance systems previously

discussed, there are other, independent efforts to improve breastfeeding rates in New

Mexico. These efforts range from community meetings to studies conducted by the

University of New Mexico and other research institutes. Although these efforts usually

produce data and information on a smaller scale than large federal and state surveys,

34

they provide valuable insights into a variety of information areas related to

breastfeeding. For example, many healthcare facilities within the state have their own

internal data systems, and research efforts by the University of New Mexico and the

New Mexico Breastfeeding Task Force have produced a number of reports that provide

useful details on breastfeeding behaviors, barriers, and opinions.

New Mexico Breastfeeding Task Force: BBER Economic Benefits of Breastfeeding

Study

In 2013 the New Mexico Breastfeeding Task Force (NMBTF) commissioned the

University of New Mexico’s Bureau of Business and Economic Research (BBER) to

complete a study on cost savings attained by increasing statewide breastfeeding rates

(Bhandari & Nepal, 2014). The report, “Cost-Benefit Analysis of Increasing

Breastfeeding Rate in New Mexico,” was issued in July of 2014 and was modeled after

the seminal 2010 study by Melissa Bartick.26 As part of the cost-benefit analysis, BBER

conducted a survey of New Mexico businesses regarding the cost and availability of

nursing rooms, maternity leave flex-time, awareness of laws pertaining to breastfeeding

and breast milk pumping in the workplace, and business performance. BBER sent the

survey to over 17,000 New Mexico businesses and received 274 usable responses. BBER

concluded that New Mexico could save upwards of $32.5 million per year by increasing

statewide breastfeeding rates.

New Mexico Breastfeeding Task Force: Lake Research Partners Report

In 2013 the NMBTF commissioned a survey report from Lake Research Partners

to evaluate public opinion on breastfeeding throughout the state. Lake Research

designed and administered a telephone survey of 500 New Mexico residents, including

an oversample of 100 Latino residents. The goals of the study were to gauge public

opinion and knowledge on breastfeeding, gain an understanding of how breastfeeding

is promoted in certain demographic groups, and determine which breastfeeding

support messages and phrases New Mexicans find most convincing. Overall, findings

of the study suggest that New Mexicans feel positively toward breastfeeding and are

comfortable around women who breastfeed.27 The Lake Research report is one of the

few information sources on breastfeeding attitudes and opinions in New Mexico.

Envision New Mexico: Systems of Support for Breastfeeding Report

In late 2015 Envision New Mexico released a report titled “Systems of Support

for Breastfeeding in Select New Mexico Communities” (McGrath et al., 2015). Utilizing

26 (Bartick & Reinhold, 2010) 27 Thanks to Heidi Fredine and Lissa Knudsen from the New Mexico Breastfeeding Taskforce who

provided us with access to the Lake Report.

35

a mixed methods approach, the analysis consists of three parts: a focused community

assessment compromised of eight focus groups and six key informant interviews; a

statewide hospital readiness survey designed to ascertain barriers and facilitators to

Baby Friendly Designation status among maternity care hospitals in New Mexico; and

an analysis of NM PRAMS data from 2008-2012. Findings from the report suggest that

statewide efforts are needed to improve breastfeeding support systems. The Envision

report identifies approaches for improving breastfeeding rates, including addressing

hospital settings, normalizing public breastfeeding, and increasing knowledge of

breastfeeding resources and support services. The study also found evidence that

breastfeeding disparities exist in New Mexico by race, ethnicity, acculturation, and

geography (McGrath et al., 2015). The study was released in December 2015 by Envision

New Mexico and funded by the W. K. Kellogg Foundation.

New Mexico Breastfeeding Taskforce Hospital Report Cards

While the mPINC survey collects hospital-based information on breastfeeding,

results are only reported at the state level, and no individual facility-based data is

released. In an effort to inform hospitals of their current breastfeeding status and

provide areas for targeted improvements, the New Mexico Breastfeeding Taskforce has

prepared and released Hospital Report Cards. Hospital Report Cards were sent to 29 of

the 30 New Mexico maternity hospitals in October of 2015.28 Using results from

Newborn Genetic Screening data, Report Cards report breastfeeding initiation or “any

breastfeeding rate” as well as exclusive breastfeeding rate and number of births at the

facility. Report Cards also rank hospitals’ breastfeeding performance against facilities of

the same size and all facilities in the state.29 Due to data restrictions on the use of

Newborn Screening data, Report Cards are issued directly to facilities and are not made

publicly available.

UNM Early Childhood Survey

In 2015, with support from the Robert Wood Johnson Foundation and the

Kellogg Foundation, the University of New Mexico completed a study aimed at better

understanding the ways in which some New Mexico families interface with the early

care and education and health systems. Towards this end, The Robert Wood Johnson

Center for Health Policy, the Center for Education Policy Research, and the Center for

Community Behavioral Health designed a survey that was administered to families

28One IHS Hospital was not identifiable in the Newborn Screening data set. 29 It is worth noting that several hospitals reported back to the NMBTF that the number of births listed on

their Report Card was inaccurate—affecting the denominator and overall breastfeeding rates and

rankings. This means there is likely a problem with accurate reporting on the part of the hospitals or

recording/data-collecting within the NM DOH Newborn Screening Program.

36

with a child four years old or younger. Questions related to breastfeeding fit into two

broad categories:

1. Questions related to breastfeeding behaviors such as breastfeeding initiation and

duration

2. Questions related to breastfeeding support services

The survey was administered in September of 2015 and is specific to families living in

rural New Mexico and the South Valley of Albuquerque. The survey was administered

both in person and over the phone or web.

UNM Early Childhood Survey: Breastfeeding Behavior Questions

Did you (or anyone in the household) ever breastfeed for pump breast milk to feed the child?

When did breastfeeding for this child begin?

How long was the child breastfed or fed pumped breast milk?

Is the child still being breastfed or fed breastmilk?

126 families living in the South Valley completed the survey in person, and 656

families from rural New Mexico and the South completed the survey by phone or

through the web (total n of 782). The survey was conducted in both Spanish and

English, depending on the respondent’s preference.

UNM Early Childhood Survey: Breastfeeding Support Questions

When your child was being breastfed, did you (or the person in the household breastfeeding) receive

support from any of the following?

A hospital or clinic

Your employer

A breastfeeding counselor, midwife, or doula

Family members or friends

Other healthcare providers like nurses, doctors, or promatoras

Some hospitals are trying to provide extra supports to help mothers be able to breastfeed their

babies. How helpful would these supports be to you or someone in the household?

Not at all helpful

Not very helpful

Somewhat helpful

Very helpful

Survey response data is in the process of being cleaned, coded, and merged. It is

anticipated that analyses of survey responses, including breastfeeding indicators

included here, will be published in 2016.

37

Community Conversations, Focus Groups, and Breastfeeding Support Efforts

A number of organizations, including, but not limited to, the New Mexico

Breastfeeding Task Force, WIC, the Navajo Nation Breastfeeding Coalition, La Leche

League New Mexico, UNM’s Women’s Resource Center, Tewa Women United, as well

as health care based programs, offer breastfeeding support services which provide

insights into attitudes, practices, and obstacles to successful breastfeeding.30 Many of

these organizations facilitate community meetings, focus groups, and support groups

aimed at increasing and extending breastfeeding rates. While public data is not made

available, these organizations likely have some of the richest qualitative information on

the subject.

Data Type 5: Forthcoming Resources

Baby Friendly Hospital Map

The New Mexico Breastfeeding Taskforce is currently developing an interactive

Baby-Friendly Hospital Map to provide statewide information on breastfeeding rates

and the status of hospital and birth facility progress towards the WHO’s Baby Friendly

Hospital Initiative. The map will be made available on the New Mexico Breastfeeding

Taskforce website and will allow users to identify birth facilities that are BFHI

approved, on the pathway to BFHI approval, or not on the pathway. The map also

presents geographic information on PRAMS breastfeeding rates at 9 weeks, allowing for

comparison between New Mexico counties.31

WIC Duration Data

The New Mexico Department of Health and the states of Texas and Louisiana are

currently developing a completely new data collection system that will remedy the

issues in the current MIS data management system. The new system is expected to

begin running in 2017, after which point WIC duration and other longitudinal

information should become available.

PRAMS Toddler Survey

The New Mexico Department of Health is currently developing a follow up

survey to the annual PRAMS surveillance of mothers and children 6 months of age and

30 For example, Presbyterian Health Services offers a breastfeeding hotline as well as classes and support

groups. Mountain View Regional and Dar A Luz Birth Center in Las Cruces offer a breastfeeding support

group every Wednesday. 31 Thanks to Heidi Fredine from the NMBTF who generously provided this information. A prototype of

the map is provided in Appendix J.

38

younger. This new survey will collect new health data on the population of two-year

old children. A number of states have already implemented a PRAMS follow up survey,

including Oklahoma’s Toddler Survey (TOTS), Alaska’s Childhood Understanding

Behaviors Survey (CUBS), and Oregon’s PRAMS-2. New Mexico’s statewide survey is

being designed to monitor and answer key questions on a wide variety of health

outcomes, including the presence of certain health conditions, health care access and

utilization, developmental screening, family stressors, and items specific to maternal

experiences. Key focus measures include: presence of certain health conditions, health

care utilization and access (including barriers to care), routine well-child checks,

presence of health insurance, child care, immunizations, nutrition and physical activity,

child safety, breastfeeding, and developmental delay. While the survey is currently still

in development, it is expected to address a number of breastfeeding indicators,

including breastfeeding initiation, duration, exclusivity, reasons for discontinuing

breastfeeding, and support services used during breastfeeding.

PRAMS Toddler Survey: Proposed Breastfeeding Measures

Was your two-year-old ever breastfed or fed (pumped/expressed) breast milk?

Yes

No

If No, what were your reasons for never breastfeeding? Check all that apply.

I thought I would not produce milk.

My baby didn’t latch on.

I had too many other demands.

I was taking medication I didn’t want to expose my child to.

My health provider or pediatrician advised me not to breastfeed.

I didn’t want to breastfeed.

Husband or partner said no

I had too many other demands.

I had no help or support.

I didn’t breastfeed my other children.

Other (please tell us)

How long did you breastfeed or pump breast milk to feed your child?

less than one week of age/birth

_____ weeks or _____ months

I am still breastfeeding or feeding pumped breast milk to my child.

How old was your two-year-old when (he/she) was first fed formula, water or juice?

less than one week

_____ weeks or _____ months

Don’t Know

What were your reasons for deciding to stop breastfeeding your child? Check all that apply.

I achieved the goal I set for nursing.

My baby was not gaining weight.

Breast milk supply was not adequate

My baby lost interest.

39

Too hard to pump at work or school

I had too many other demands/time consuming

No support, help or resources available

I was tired of pumping.

It was painful to breastfeed or pump.

I was taking a medication and I didn’t want to expose my child.

Family or friends suggested that I stop breastfeeding.

My health provider or pediatrician advised me to not breastfeed.

I am still breastfeeding or feeding pumped breast milk to my child.

Other (please tell us)

During the time you breastfed or if you still breastfeed, which of the following supported you to

continue?

Support from my partner/spouse

Support from family or friends

Support from my employer

Support from a health care provider

Support from WIC staff

Support from a WIC Breastfeeding Peer Counselor

Home visitor

Which of the following helped you to keep breastfeeding? Check all that apply.

Convenience to me

Cost savings

Benefits to my child

Benefits for myself

My own commitment to breastfeed

My baby was not ready to stop breastfeeding

The New Mexico Toddler Study (NMTS) is intended to provide a continuous

public health surveillance system that can be used for descriptive, inferential, and

methodologic data. The longitudinal aspect of the NMTS will include measures specific

to maternal and parental experience such as: social/emotional support, contraceptive

use, pregnancy history, maternal smoking status, family stressors, employment history,

household income, parental education levels, and marital status with family size. The

survey is anticipated to launch in June with a sample size of approximately 1,000

respondents per year. Like PRAMS, data will be available approximately 11 months

after collected, and data sharing agreements will permit researchers and organizations

access to data that has not been available previously.32

FINDINGS AND DISCUSSION

A variety of large and small surveillance systems collect data related to

breastfeeding in New Mexico. Table 13 provides a summary of data availability, and

32 Thanks to Eirian Coronado and Christopher Whiteside of the NMDOH who generously provided this

information.

40

Table 14 summarizes relevant background information of each data source. In recent

years breastfeeding statistics for the state of New Mexico have become both more

comprehensive and more available. Until new surveys and studies were launched in the

late 1990s, the primary source for statistical information on breastfeeding rates for the

United States was the Ross Mothers Survey administered by Ross Laboratories. With

the exception of the Pediatric Nutrition Surveillance System, Pregnancy Nutrition

Surveillance System, and Infant Feeding Practices Survey, which are already retired, all

the other surveillances presented here are still ongoing either annually or periodically.

Table 13: Data Availability

Survey Initiation Exclusivity Duration

< 3 mo.

Duration

<6 mo.

Duration

<12 mo.

Race or

Ethnicity Notes

ECLS-B

Exclusivity determined by asking

when infant was first given formula or food other than breast milk. NM

sample size is small (~100) and not

representative

IFPS II

NHANES

NHANES I & II: initiation and

duration. NHANES III and later: initiation, duration, and exclusivity.

NIS

NSCH

NSFG

Exclusivity rates are often not reported; NM sample size is

negligible.

PedNSS

Breastfeeding duration is measured

up to one year; however, the sample of this data is contingent on children

who turn one year of age who

receive public health services during the reporting period.

PNSS

Incidence, duration up to 2 months,

introduction of formula. Sample

consists of low-income populations only.

PRAMS

Breastfeeding duration estimates are

limited to nine weeks; indirect estimates are available for longer

durations.

SCLB

WIC

Sample represents women and

children in nutrition assistance

program.

The overwhelming majority of data pertains to indicators of breastfeeding

behavior such as breastfeeding initiation and duration. The mPINC survey provides

limited data on facility practices and services to support breastfeeding while the

PRAMS survey includes a few questions that address breastfeeding barriers. As a result,

our discussion here is focused on variations and issues related to breastfeeding

indicators. A comprehensive discussion of data voids, such as facility and attitudes

data, is available in part two of this analysis.

41

Summary Findings: Sample Size and Demographic Factors

While a number of nationally representative studies include New Mexico

samples, these studies, such as the ECLS-B or NSCH, are designed to be representative

at the national, but not state or local, level. Consequently, while these studies provide

some information related to breastfeeding behavior within the state, the data are

generally not representative of the New Mexico population and therefore are not

appropriate for analysis at the state level. Moreover, national level studies, which use

convenience samples such as HealthStyles and the IFPS, are not representative and

generally have very small sample sizes. As such, these data sources are also not

appropriate for state level assessments. Surveillance systems that are representative at

the state level include the National Survey of Children’s Health (n~500), The National

Immunization Survey (n~260), Vital Statistics (total birth population), and PRAMS

(n~1,400).

Improving breastfeeding rates in New Mexico requires a comprehensive and

targeted approach that includes identifying low success rate regions and focused efforts

to improve breastfeeding across the state. The ability to disaggregate data by region,

race or ethnicity, income, or education is critically important to these efforts. While most

studies collect pertinent demographic indicators, small sample sizes make

disaggregation difficult and often require the use of “rolling averages” or combined

sample years. For example, while PRAMS is conducted annually, most surveillance

reports are based on multiple birth years. Similarly, while NIS data is representative of

the state population, the small sample size does not permit reliable disaggregation by

race or ethnicity at the state level, and breastfeeding rates for racial and ethnic groups

are only reported at the national level. Although WIC data is not representative at the

state level, the large scale of participation in the WIC program permits analysis at

varying degrees of specificity, including race or ethnicity, region, and socio-economic

status.

Summary Findings: Initiation

Across all surveys that collect breastfeeding data in New Mexico, the most

common measure is breastfeeding initiation, or “ever breastfed.” As illustrated in Table

13, breastfeeding initiation is the most frequently and reliably collected breastfeeding

indicator. While there is variation in when and how this data is collected, we believe

there are sufficient data for accurate breastfeeding initiation comparisons between and

across data sources.33

33 When comparing breastfeeding initiation, it is important to evaluate comparable data years. For

example, NIS data are aggregated by birth year, while the 2011/2012 NSCH survey reports data for

children under the age of 6, and while the PRAMS survey is conducted annually, most surveillance

reports are based on combined birth years.

42

Summary Findings: Duration and Exclusivity

As compared to initiation, breastfeeding duration data are substantially more

limited in New Mexico. The American Academy of Pediatrics recommends exclusive

breastfeeding until 6 months of age and breastfeeding continuation with the

introduction of complementary foods until one year of age. It is worth nothing that

definitions of “exclusivity” vary, with some definitions requiring the infant be given

nothing other than breast milk, with other definitions permitting the child to have

breast milk and water. Both definitions are included as measures of exclusivity in this

study. Table 13 illustrates the availability of breastfeeding duration and exclusivity

measures. Only the NIS and NSCH surveys provide state representative samples and

collect both duration and exclusivity measures. As such, options for assessing

breastfeeding duration and exclusivity at the state level are limited, as the samples for

NSCH and NIS are 500 and 260, respectively.

Moreover, while a number of studies include some measure to determine

duration, there is tremendous variation on when and how breastfeeding duration data

are collected. Research indicates that most women accurately recall breastfeeding

duration when the recall period is less than three years (Li, Scanlon, & Serdula, 2005).

With the exception of the NSFG, which has a maximum recall time of 18 years, and the

NHANES, which has a maximum recall of 6 years, the studies included here all have a

recall period of less than 3 months.

Additionally, due to variation in when data are collected, there are major

limitations to the reliability and availability of duration measures. For example, while

the maximum recall period for PRAMS is six months, surveys are conducted and

completed when infants are between 2-6 months of age. As a result, PRAMS

breastfeeding duration estimates are limited to 9 weeks, with smaller samples reported

for longer durations. Similarly, the PedNSS survey provides duration data up to one

year of age, but the sample is contingent on data collected during visits to public health

clinics. The most rigorous duration data are collected on the IFPS II survey, though its

usefulness for evaluating breastfeeding duration in New Mexico is null due to the use

of a non-representative consumer opinion panel convenience sample and an

exceptionally small sample (n=27) in New Mexico.

43

Table 14: Summary of Datasets Assessing Breastfeeding Variables in New Mexico

Survey Methods Format Timing of Data

Collection

Languages

Conducted

Year Last

Conducted

Frequency Nationally

Representative

NM

Sample

ECLS-B Longitudinal

study with

cross-

sectional

assessment of

BF status

In person

interviews and

self-administered

questionnaires

BF questions

included on the 9

month survey

English, Spanish 2010-2011

(Birth cohort)

Not previously

conducted,

likely a one

time study

Yes ~100*

IFPS II Longitudinal One telephone

interview, multiple

mailed

questionnaires

Data collected

prenatally,

postpartum, 3

weeks pp and 2,

3, 4, 5, 6,7, 9, 10,

12 months

English 2007 Previously

conducted in

1993/1994

No, convenience

sample of

consumer opinion

panel

27*

NHANES Cross-

sectional

In-person

interviews and

physical exam

Varies, BF asked

for each 6 year

old child

English, Spanish,

other languages if

required

Ongoing Biennial Yes Not

Available*

NIS Cross-

sectional

Telephone

interview

19-35 months PP English, Spanish

other languages

via AT&T

language line

Ongoing Annual Yes 262*

(2012)

NSCH Cross-

sectional

Telephone

interview

BF questions

asked of children

ages <6

English, Spanish

other languages

via AT&T

language line

2012 Every four

years

Yes ~500 (2012)

NSFG Cross-

sectional

In-person home

interviews

BF question

asked of women

reporting a birth

within the past 5

years.

English and

Spanish

2010 Every six years

(data is

collected over

five-year

cycles)

Yes Not

Available*

44

Table 14 Continued: Summary of Datasets Assessing Breastfeeding Variables in New Mexico

* Sample is not representative at the state level

Survey Methods Format Timing of Data

Collection

Languages

Conducted

Year Last

Conducted

Frequency Nationally

Representative

NM Sample

PedNSS Program

based

surveillance

Predominantly

WIC data

Varies, BF

assessed through

24 months of age

English, Spanish,

other languages

spoken in WIC

offices

2012 Annual,

discontinued in

2012

No, reflects

participants in

public health

programs

Not

Available

PNSS Program

based

surveillance

Predominantly

WIC data

2-5 months PP English, Spanish,

other languages

spoken in WIC

offices

2012 Annual,

discontinued in

2012

No, reflects

participants in

public health

programs

5,846*

(2012)

PRAMS Cross-

sectional

Predominantly

mail, telephone

follow up with

non-responders

Survey mailed

approximated 2-

6 months PP

English and

Spanish

Ongoing Annual Representative of

state populations,

40 states currently

participating

~1,400

RMS Cross-

sectional

Mailed

questionnaire

Mailed when

infant reaches 6

months of age

English Ongoing Annual Yes, data is private

and shared at the

discretion of Abott

Laboratories

Not

Available

WIC Cross-

sectional

Utilizes WIC

program data

Varies English, Spanish,

other languages

spoken in WIC

offices

Ongoing Annual No, reflects WIC

population only

Varies by

participation

~16,500/yr*

SCLB Cross-

sectional

Questionnaire Post-partum,

usually at

discharge of

hospital

English, Spanish,

other languages

spoken by

providers

Ongoing Annual No, statewide data Total birth

population

45

CONCLUSION

Improving breastfeeding initiation and duration in New Mexico requires the

development of timely, culturally sensitive, and well-developed interventions.

Surveillance and monitoring of breastfeeding behavior is essential to the planning,

implementation, and evaluation of these interventions.34 Throughout the state there are

several organizations and agencies that work to promote healthy breastfeeding

behaviors. Most of these organizations rely on the data sources discussed here. Namely,

the New Mexico PRAMS and CDC Report Card on breastfeeding by state are the only

two data sources relied upon by the following agencies to conduct research: the March

of Dimes, NM Public Health, New Mexico WIC, Breastfeeding New Mexico, New

Mexico’s Indicator Based Information System, the New Mexico Breastfeeding Taskforce,

and the La Leche League. While these data are informative and assist in researching and

better understanding breastfeeding initiatives, they serve as virtually the sole data

sources for various organizations and agencies and do not provide information beyond

the scope of their respective instruments. Thus, these organizations and agencies are not

able to provide new additional information but rather rely on echoing the information

released from NM PRAMS or the CDC.

Across the surveillance systems presented here only Vital Statistics, PRAMS,

NSCH, and NIS are representative of the state population. However, the sample sizes of

these surveys are too small to permit disaggregation by demographic indicators, or, in

the case of Vital Statistics, have only limited breastfeeding information (duration only).

NIS and PRAMS are collected annually, while NSCH is conducted every four years.

PRAMS is also the only representative survey to assess breastfeeding services, barriers,

and reasons for discontinuing breastfeeding. While the mPINC survey provides useful

data on hospital services and care, the inability to assess services at the site or regional

level presents complications in improving breastfeeding services across the state. In

general, site- or region-specific data is substantially limited across all surveillance

systems. In regards to breastfeeding behaviors, initiation data appears to be quite

abundant while duration and exclusivity have substantial limitations. In an effort to

better assess data needs and gaps we have implemented an online survey interview

with breastfeeding experts and advocates in order to refine the findings presented here.

Part two presents findings from that survey and further discusses the status of

breastfeeding data and surveillance in the state of New Mexico.

34 For such a discussion see Chapman and Pérez-Escamilla (2009).

46

PART TWO: LEVERAGING DATA TO IMPROVE

BREASTFEEDING RATES IN NEW MEXICO

OVERVIEW

Across the globe, exclusive breastfeeding is considered the best choice for infant

nutrition and immunologic protection (DHHS, 2011; Komodiki et al., 2014; Pediatrics,

2012). Despite the well-known public health benefits of breastfeeding, the rate and

duration of breastfeeding in the United States are low (HHS, 2010; Li et al., 2004). This is

especially true for New Mexico, which lags behind national averages for breastfeeding

initiation and duration (CDC, 2014). As demonstrated in part one, a number of

surveillance systems monitor breastfeeding behavior in the state. These data play an

important role in state and federal public health, providing platforms for epidemiologic

assessments such as identification of target populations and providing important

insights for program development and evaluation.

In order to assess specific data needs in the state of New Mexico, the Robert

Wood Johnson Foundation Center for Health Policy at the University of New Mexico

developed and conducted an online questionnaire to gather information on existing and

potential breastfeeding data collection and use. The questionnaire was administered

from January to April of 2016. Breastfeeding professionals, stakeholders, and advocates

were invited to participate through email. Initial participants were recruited from the

New Mexico Breastfeeding Taskforce and subsequent participants were included

through snowball sampling as participants were asked to recommend other contacts.

Eighty individuals were contacted yielding 51 complete or partial responses.

Participation in the questionnaire was voluntary and no incentives were provided.

RWJF Breastfeeding Data Questionnaire Objectives

Identify information sources collecting data on breastfeeding in New Mexico

Understand which data sources are frequently used by breastfeeding advocates and

professionals

Solicit suggestions for improving available data and collecting new data to improve

breastfeeding rates

The survey was completed by medical professionals, such as pediatricians,

midwives, nurses, healthcare providers, doulas and lactation consultants, as well as

public health researchers, policy advocates, home visitors, and breastfeeding peer

counselors. Below we present results from the questionnaire. It is important to

remember that the goal of the questionnaire was to gather a snapshot on data use and

47

data needs. The questionnaire is based on a convenience sample, and findings should

be considered as guidelines in conjunction with the assessment from part one.

RWJF BREASTFEEDING QUESTIONNAIRE RESULTS

A majority of respondents use the CDC Breastfeeding Report Card, mPINC,

PRAMS, and WIC data. Figure 1 illustrates data sources used by respondents of the

questionnaire. Six respondents cited using data other than the sources listed.35

Figure 1. Data Use Among Respondents

As discussed in part one, the CDC Breastfeeding Report Card does not collect

any original data but instead reports summary findings from the mPINC and NIS

surveys. As a result, we believe the popularity of the CDC Report Card is due to the

way in which information presented and its accessibility. The Breastfeeding Report

Card and mPINC survey provide direct, easy to use information in a concise format.

While surveys such as the NIS and PRAMS have equally rich data, these data are more

difficult to access and require an individual to find reports or publications that report

breastfeeding data from the survey. Moreover, the popularity of the CDC Report Card

and mPINC survey is likely due to the number of healthcare providers completing the

35 “Other” sources included research articles, the New Mexico Breastfeeding Taskforce, the WHO, the

UNM BBER study, the Baby-friendly hospital map, and facility specific data.

48

questionnaire.36 PRAMS data is popular with researchers and policy advocates.

Data Needs Assessment Questions

What New Mexico specific breastfeeding data would you like to have that is currently not

available?

What would you use these data for?

How would you suggest that the data that you would like to have be gathered?

To assess data needs by breastfeeding professionals and advocates, we also

provided respondents an opportunity to tell us what data they would like to have that

is currently not available. We also asked respondents to provide suggestions on how

data could be collected. Table 1 provides a summary of questionnaire findings, and a

brief discussion of each data request follows.

Table 1. Data Questionnaire: Summary Findings

Data Request Suggested

Method Purpose and Goals

Demographic and regional

data: BF initiation and

duration by race/ethnicity,

region and income

PRAMS

Toddler,

PRAMS, NIS

-Identify which counties need breastfeeding support

-Develop & evaluate interventions and programs

-Reduce breastfeeding disparities

Exclusivity 3, 6, 12 months

PRAMS

Toddler,

PRAMS, NIS

-Identify which counties need breastfeeding support

-Develop & evaluate interventions and programs

-Reduce breastfeeding disparities

Duration 3, 6, 12 months

PRAMS

Toddler,

PRAMS, NIS

-Identify which counties need breastfeeding support

-Develop & evaluate interventions and programs

-Reduce breastfeeding disparities

Breastfeeding barriers,

reasons mother are not

breastfeeding

PRAMS, Home

visitation

programs

-Develop & evaluate interventions and programs

-Reduce breastfeeding disparities

Breastfeeding Initiation

by Birth Facility

Newborn

Screening, Vital

Statistics, BFHI

-Hospital reform: tracking and improving hospital

breastfeeding rates

-Encourage collaboration between facilities

Breastfeeding knowledge

and opinions by region

(rural vs urban) and

race/ethnicity including

tribal areas.

Other large

survey

-Normalizing breastfeeding among key populations

-Development and evaluation of interventions and

programs

36 The CDC Report Card and the mPINC survey report data pertinent to healthcare providers such as

state rankings on labor and delivery care, staff training, the number of Certified Lactation Counselors,

and the percent of infants receiving formula before 2 days of age.

49

Increase Detail of Demographic and Regional Indicators

A frequent request is for greater specificity in the analysis of breastfeeding

variables. Common requests include breaking breastfeeding behavior down by

demographic and geographic variables such as race/ethnicity, region or county, age,

and income. While these variables are available in a number of data sources, small

sample sizes often limit the ability to disaggregate data by specific demographic or

geographic indicators. For example, demographic variables are collected on the NIS, but

the small sample size does not permit disaggregation by race or ethnicity at the state

level. While the PRAMS survey has a sample size over five times larger than NIS, the

sample size still requires combining survey years to achieve a reliable disaggregation by

demographic indicators. For example, the most recent 2012 PRAMS surveillance report

provides results from 2009-2010 while the 2010 surveillance report uses data averages

from 2006-2008 (NMDOH, 2010, 2012). Reliable demographic data plays an important

role in public health efforts. Improving breastfeeding rates requires targeting high-risk

populations with low breastfeeding rates and creating corresponding interventions that

work best in specific populations (Morrow & Lutter, 2012). Increasing the frequency

and availability of demographic data on existing and additional breastfeeding

indicators is an important step toward improving breastfeeding rates throughout the

state.

Improve Exclusivity and Duration Measures

As outlined in part one, New Mexico has limited information related to

breastfeeding duration and exclusivity. The most frequent data request was to have

reliable and timely breastfeeding duration and exclusivity data. The American

Academy of Pediatrics recommends exclusive breastfeeding for the first six months, the

introduction of complementary foods at six months, and breastfeeding continuation

until one year (Pediatrics, 2012). The AAP recommendation is accepted around the

globe as promoting health benefits for both mother and baby (Morrow & Lutter, 2012).

However, reliable duration and exclusivity data is difficult to find in New Mexico and

across the nation (DHHS, 2011; Flaherman, Chien, McCulloch, & Dudley, 2010; Greiner,

2014). Accurate measurement of the duration and exclusivity of breastfeeding is

complicated by a number of factors, including variations in the definitions of

“exclusivity,” the timing, duration of recall, methods of analysis, and sample biases

(Greiner, 2014).

Accurate measurements of breastfeeding initiation, duration, and exclusivity are

necessary to assess progress towards public health goals (Flaherman et al., 2010). The

primary source for duration and exclusivity data in New Mexico is the National

Immunization Survey which tracks state progress towards Healthy People 2020

Breastfeeding Objectives. As discussed above, the small sample size of the NIS (n ~ 260)

50

only permits the analysis of breastfeeding rates at the aggregate state level. The PRAMS

survey assesses breastfeeding duration up to nine weeks with indirect estimates up to 6

months. New data on breastfeeding duration and exclusivity will be produced by the

PRAMS Toddler Survey, which is expected to launch in summer of 2016 and have data

available the following year. Much like the existing PRAMS data, the PRAMS Toddler

Survey has an anticipated sample size of 1,000, which will require combining survey

years in order to disaggregate data by demographic indicators.

Report Breastfeeding Indicators by Birth Facility

A frequent theme that emerged from questionnaire responses was the desire to

have facility-specific data available. Strong evidence suggests that hospital maternity

practices play a key role in breastfeeding initiation and exclusivity rates both in the

hospital and duration after discharge (Hawke, Dennison, & Hisgen, 2013). Providing

facility-specific data could also increase the collaboration between facilities to improve

breastfeeding rates through prenatal and postpartum services. For example, one New

Mexico hospital administrator points out that if facility-specific data were available they

could “use it to compare breastfeeding rates and ask other hospitals for assistance if

they are doing well, or provide assistance if we are doing better than them.” Another

respondent pointed out, “we need breastfeeding duration for local areas and for

hospitals! We have CDC data but it is based on small numbers and you can’t use it to

evaluate your local area or hospital.”

While the mPINC survey collects facility-specific data, only state-level aggregate

results are reported. Facility-specific data is collected but not reported in New Mexico.

For example, New Mexico’s standard certificate of live birth includes the question “is

the infant being breastfed at discharge?” and the Newborn Screening program collects

“any” and “exclusive” breastfeeding responses at the time the screen is obtained.37

Additionally, since the PRAMS sample is drawn from the Vital Statistics records, it may

be possible to link PRAMS data to birth facility. However, a data expert at the New

Mexico Department of Health has stated that publishing data at the birth facility level

using data from either the standard certificate of live birth or Newborn Screening

program would require permission from each birth facility center.38 In efforts to

improve and track breastfeeding rates, a number of states publicly report breastfeeding

initiation and/or exclusivity by birth facility.39 California utilizes Newborn Screening

data to publish in-hospital “any breastfeeding” and “exclusive breastfeeding” by birth

37 New Mexico Vital Records stripped facility identification prior to 2008 and again in 2015. Vital statistics

data from 2009-2014 should still include a facility ID. 38 As part of the Baby Friendly Hospital Initiative certification process, hospitals are required to collect

information on breastfeeding rates. There are currently seven BFHI approved facilities and another 13 on

the pathway to certification. 39 California and New York State report facility-specific data as required by state law (Hawke et al., 2013).

51

facility.40 Pennsylvania also utilizes data from certificates of live birth to publish

breastfeeding initiation by hospital of delivery.41

Breastfeeding Barriers, Knowledge, and Attitudes

A final theme in the responses to our questionnaire was that breastfeeding

advocates want better information on public beliefs about breastfeeding. In particular,

respondents expressed interest in having data on breastfeeding knowledge, opinions,

attitudes, and perceived barriers to breastfeeding. At the federal level, the annual

HealthStyles survey provides information on public attitudes towards breastfeeding.42

As discussed in part one, the HealthStyles survey is uses a convenience sample and

does not include a sample suitable for analysis at the state level. In an effort to provide

some background information on breastfeeding attitudes and knowledge, the New

Mexico Breastfeeding Taskforce’s 2013 Lake Report provides a snapshot of point-in-

time data on breastfeeding knowledge, attitudes, and opinions. The Lake Report is

based on findings from a statewide telephone survey of 500 New Mexico residents with

an oversample of 100 Latino residents. As such, while the Lake Report provides some

insights into public opinion on breastfeeding, the study is limited in its ability to

address variations in public opinion based on demographic and geographic variables.

In addition to information on breastfeeding knowledge and opinions, several

respondents indicated a desire to better understand breastfeeding barriers. One public

health advocate responded that information was needed on “factors inhibiting exclusive

breastfeeding during first 1-6 weeks postpartum” and another succinctly stated,

“Reasons NM mothers are NOT breastfeeding.” Understanding breastfeeding barriers

is a complicated endeavor. The Surgeon General’s 2011 Call to Action to Support

Breastfeeding identifies seven breastfeeding barriers:

1. Lack of Knowledge

2. Social Norms

3. Poor Family and Social Support

4. Embarrassment

5. Lactation Problems

6. Employment and Child Care

7. Barriers Related to Health Services

40 https://www.cdph.ca.gov/data/statistics/Pages/InHospitalBreastfeedingInitiationData.aspx 41

http://www.health.pa.gov/My%20Health/Womens%20Health/Breastfeeding%20Awareness/Pages/Birth-

Certificate.aspx#.VypIlT8WwhD 42 See for example (Hannan, Li, Benton-Davis, & Grummer-Strawn, 2005; Li et al., 2004; Li, Rock, &

Grummer-Strawn, 2007)

52

Breastfeeding barriers have been shown to have a negative influence on breastfeeding

initiation and duration (DHHS, 2011). Understanding the rates at which New Mexican

mothers experience or encounter breastfeeding barriers is an important step in the

process to reduce breastfeeding barriers and increase breastfeeding initiation and

duration. Providing breastfeeding advocates with more in-depth information on

breastfeeding attitudes, opinions, and the frequency at which mothers experience

specific breastfeeding barriers could aide in the development of more effective

breastfeeding interventions and programs.

As outlined in Part One, the PRAMS survey includes two questions related to

breastfeeding barriers; one asks about reasons for discontinuing breastfeeding and the

other focuses on workplace policies. The forthcoming PRAMS Toddler survey will

provide new data on breastfeeding support, reasons for discontinuing breastfeeding,

and reasons for not initiating breastfeeding. Providing breastfeeding professionals and

advocates with more complete information of statewide variation in breastfeeding

knowledge, attitudes, opinions, and the barriers women face while breastfeeding could

contribute to the development of more sophisticated and targeted interventions and

programs.

Discussion

In an effort to evaluate data priorities in the state of New Mexico, we contacted

50 breastfeeding professionals and/or advocates in order to improve our understanding

of data needs among breastfeeding stakeholders. Our questionnaire sought information

on data sources used and areas for improvement and expansion, yielding a number of

helpful suggestions for improving breastfeeding data and surveillance. The results from

the questionnaire parallel many of the findings presented in Part One of this analysis.43

The most commonly cited data request is to improve and expand duration and

exclusivity measures. This request is consistent with our findings in Part One where we

determined that measures of duration and exclusivity have substantial room for

improvement. Respondents also cited the need to have greater information on

breastfeeding rates according to geographic area. This also mirrors findings in Part One

where we demonstrated that most breastfeeding data have small sample sizes, thereby

limiting the ability to disaggregate by demographic and/or geographic indicators.

Responses to the questionnaire also show that there is a high demand for data on

breastfeeding rates by birth facility. Given the key role that hospital maternity practices

play in breastfeeding initiation, providing data at the birth facility level could lead to

43 It is important to note that the results of the questionnaire are not intended to be decisive but rather

informative. A large number of respondents to the questionnaire are medical professionals, and therefore

the results are likely skewed to represent the specific data needs of the nurses, lactation consultants, and

pediatricians who responded to the survey.

53

inter-facility collaboration to improve breastfeeding rates across the state. Lastly, New

Mexico lacks a broader understanding of the experience of breastfeeding in the state;

little information on public attitudes towards breastfeeding exists, and relatively little is

known about regional or demographic variation in breastfeeding knowledge and

opinions. Taken in sum, we believe the findings in Parts One and Two of this analysis

point to a number of paths toward improving breastfeeding surveillance in the state.

Moreover, we believe that the following, more specific recommendations for improving

breastfeeding-related data collection and analyses could translate into improved

understandings of breastfeeding in New Mexico which, in turn, could be used to

support efforts to improve breastfeeding initiation, duration and exclusivity in the state.

PART THREE: RECOMMENDATIONS FOR IMPROVING

BRESTFEEDING DATA SURVEILLANCE, DATA

AVAILABILITY, AND DATA ANALYSES IN NEW MEXICO

The more specific recommendations presented here are based on our review of

the current data related to breastfeeding in New Mexico, our review of the types of data

available elsewhere in the country, our identification of breastfeeding data gaps in New

Mexico, and the input of many in the state’s breastfeeding community of practice who

offered thoughtful input regarding the types of data and analyses they would find

helpful. These recommendations are presented in no particular order.

Recommendation 1: Expand the sample size of respondents to the PRAMS

The New Mexico Pregnancy Risk and Assessment Monitoring System (PRAMS)

is the only regularly administered survey of a representative sample of new mothers in

the state. As such, it is recommended that the PRAMS survey be expanded in two

ways. First, the sample size participating in the survey each year should be expanded.

Currently, approximately 1 in 12 new mothers respond to the survey each year. If a

greater number of mothers were surveyed, the resulting data sets would then allow for

more nuanced analyses of the data. For example, the data could then provide much

better information about breastfeeding rates in smaller geographies (counties and/or

regions) or, for example, the race/ethnicity, age, or income of the mothers.

This increase to the sample size should be discussed with New Mexico

Department of Health PRAMS administrators to determine the best ways to increase the

sample size. For example, it probably does not make sense to simply increase the size

of the representative sample in the state as this will do very little to increase the

numbers of mothers responding in, for example, very rural, unpopulated counties;

rather, it would make better sense to use a targeted approach through which certain

54

geographies, like moderately populated counties or border regions, or certain

populations, such as Native Americans or African Americans, are oversampled such

that the number of respondents from these geographies or groups are large enough to

conduct more co-variate analyses. For example, if New Mexico needs more

representation from medium-sized counties or sub-county geographies where there is a

feasible number of births to analyze, New Mexico could increase the number of mothers

surveyed in those areas to achieve more statistical power without having to aggregate

so many years of birth data. It would also, for example, it may be optimal to increase

the number of African-American births within those geographies, or across those

boundaries where possible.

Therefore, we recommend that conversations begin with New Mexico

Department of Health officials overseeing the PRAMS to determine the best way to

expand the sample to allow the for these additional and more nuanced analyses and

support expansion of the sampling frame.

Recommendation 2: Add questions to the PRAMS survey that ask mothers about

breastfeeding exclusivity

The PRAMS survey is administered to mothers of children between the ages of

two and six months. Due to the young age of the infants whose mothers are surveyed,

a complete understanding of breastfeeding exclusivity cannot be determined using this

survey alone (Many mothers breastfeed beyond 6 months and this survey would not,

then, help us to understand the diets of infants beyond six months of age.). With this

said, there is still value in understanding more about breastfeeding exclusivity amongst

this population. As such, we recommend that questions related to the whole diet of

these infants be included in the PRAMS to determine 1) if infants are breastfed

exclusively and, if so, for how long, 2) if infants are also fed formula or other nutrients

and, if so, what percentage of these infants’ diet is breast milk and what percentage is

formula or other nutrients.

This information would then allow for better analyses that would determine the

rates of breastfeeding exclusivity in the state and subgeographies, and by other

demographic characteristics of New Mexican mothers.

Recommendation 3: Support the PRAMS Toddler Survey such that it is administered

every year and administered to a large enough sample of mothers

The NM Department of Health is in the process of developing a PRAMS Toddler

Survey that will be administered to mothers of two year olds. While this survey is

designed to gather information on a wide verity of health outcomes, it will also include

key questions related to breastfeeding initiation, duration and exclusivity. Asking

such questions of mothers of two year olds will generate very rich information related

55

to these aspects of breastfeeding and will provide, perhaps, the best information on

breastfeeding from a representative group of New Mexican mothers.

As indicated in Recommendation 1, the sample size for the PRAMS survey and

the PRAMS Toddler Survey should be large enough to allow for analyses of the data by

small geographies (counties and regions) and other demographic factors such as

race/ethnicity, age, or mothers’ income. It is our understanding that the current intent is

to administer the PRAMS Toddler Survey to mothers who previously participated in

the PRAMS survey two years prior. While this is an excellent start, and will allow for

strong longitudinal analyses, there may be value in expanding the PRAMS Toddler

Survey sample to include additional two year olds, perhaps to include a subpopulation

of WIC and/or Medicaid recipients.

As such, we would recommend that conversations with New Mexico

Department of Health PRAMS administrators take place to determine how best to

gather a representative sample of New Mexican mothers with two year olds and how

best to oversample certain subgeographies and populations within the state.

Further, it is our understanding that current W. K. Kellogg Foundation support

for the Toddler survey will expire in 2019. The W. K. Kellogg Foundation (or another

foundation or organization) may wish to consider funding this project for a longer

period of time such that, for example, the New Mexico Department of Health

(NMDOH) is able to gather at least five years of toddler data. Although the NMDOH is

exploring other funding possibilities, and has limited funds from other sources, secure

funding would help assure that this effort is maintained over a longer period of time

(and not be susceptible to potential swings in state general fund or other support).

Recommendation 4: Support current efforts to administer a Native American-specific

version of a PRAMS-like survey and support collaboration between the partners

involved in this effort

It is our understanding that a Native American-specific version of the PRAMS

survey is in development and will be coordinated through the Navajo Nation

Epidemiology Center and the Albuquerque Area Southwest Tribal Epidemiology

Center (AASTEC). Because the Department of Health is already in the process of

building capacity and providing technical assistance to this effort, it is recommended

that this work be supported, that it continue to be coordinated with the New Mexico

Department of Health Maternal Child Health Epidemiology/ PRAMS Office and that

data sharing agreements between the two be continued. It is important that all who are

gathering and analyzing PRAMS (and other local breast feeding-related data)

understand what each other are doing so as not to work at cross purposes or to

duplicate efforts; similarly, it is important to leverage existing and to-be-gathered data

to the maximum extent possible. Towards this end, we recommend that this effort be

56

supported by encouraging appropriate stakeholders with the Navajo Nation

Epidemiology Center, the Albuquerque Area Southwest Tribal Epidemiology Center

and the New Mexico Department of Health

Recommendation 5: Create and support a “ PRAMS Fellow”

The W. K. Kellogg Foundation or another foundation or funding source may

wish to fund a full time PRAMS Fellow to conduct analyses of existing and pending

PRAMS, PRAMS Toddler Survey (and potentially WIC) data. While the NM

Department of Health staff and others have been able to conduct many valuable

analyses, this additional resource would allow for a significant number of new analyses

using these rich data sources. This Fellow could potentially be housed at the New

Mexico Department of Health, at a university or at a not-for-profit organization within

the state. Funding, perhaps, could be provided for one year to determine the value of

this additional resource.

Recommendation 6: Work with the New Mexico Department of Health to support the

creation of a file that contains PRAMS data geocoded to birth records

In order to have meaningful data that allows for a deeper examination of

concentrated disadvantage, “lifecourse” metrics and other social determinants of health

on an ecologic level there would be value in linking PRAMS data to census tract coded

geographies. This currently does not occur. As such, we would recommend that

conversations with the NM Department of Health also include discussion of this

possibility. This ability to tie survey responses to census tract geographies would

support efforts to better understand and evaluate improvements or risks in perinatal

and health service outcomes over time.

Recommendation 7: Support the creation and administration of a new survey that

would provide important information on public attitudes towards breastfeeding

As mentioned in Parts One and Two of this report, surveys such as the

HealthStyles survey or the New Mexico Breastfeeding Taskforce’s 2013 Lake Report

gather and present information related to people’s breastfeeding knowledge, attitudes,

and opinions. Currently, there is no formal mechanism to gather such information

specific to New Mexico on a regular basis such that changes over time can be examined

and better understood. (The New Mexico sample included in the HealthStyles survey is

too small to generalize for the state.)

As such, the we recommend that foundations and other organizations interested

in improving breastfeeding rates in the state explore the possibility of developing and

administering a New Mexico-specific survey designed to assess New Mexican’s

breastfeeding knowledge, attitudes, and opinions overtime. This information could

57

then be used concretely to inform efforts to reduce barriers to breastfeeding in New

Mexico.

58

References

Abbott. ( 2002). Breastfeeding Trends 2002. Retrieved from Columbus, OH:

http://web.archive.org/web/20070101180255/http://www.ross.com:80/images/libr

ary/BF_Trends_2002.pdf

Baby-Friendly-USA. (2013). Baby-Friendly Hospitals and Birth Centers as of June 2013.

Retrieved from http://www.babyfriendlyusa.org

Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the

United States: a pediatric cost analysis. Pediatrics, 125(5), 1048-1056.

Belfield, C. R., & Kelly, I. R. (2010). The Benefits of Breastfeeding Across the Early Years of

Childhood. Retrieved from Cambridge, MA:

http://www.nber.org/papers/w16496.pdf

Bhandari, D., & Nepal, N. (2014). Cost-Benefit Analysis of Increasing Breastfeeding Rate in

New Mexico. Retrieved from

https://bber.unm.edu/pubs/CostBenefitBreastfeedingRateNM.pdf CDC. (2014). Breastfeeding Report Card. Atlanta: CDC Retrieved from

http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf. CDC. (2007). Breastfeeding Trends and Updated National Health Objectives for

Exclusive Breastfeeding --- United States, Birth Years 2000--2004 Morbidity and

Mortality Weekly Report (MMWR). Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a2.htm

CDC. (2009, October 29, 2009). PedNSS Health Indicators. What Is PedNSS/PNSS?

Retrieved from

http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm

CDC. (2010, March 4, 2010). What data are collected and analyzed? What is

PedNSS/PNSS? - What is PNSS? Retrieved from

http://www.cdc.gov/pednss/what_is/pnss/what_data.htm

CDC. (2011a). 2011 CDC Maternity Pracitces in Infnat Nutrition and Care Survey. Retrieved

from Atlanta GA: http://www.cdc.gov/breastfeeding/data/mpinc/index.htm

CDC. (2011b). Table 8D 2011 Nutrition Surveillance: Comparison of Infant Health

Indicators by Contributor. Retrieved from

http://www.cdc.gov/pednss/pnss_tables/html/pnss_national_table8.htm

CDC. (2013a). 2011-2012 National Survey of Children’s Health Frequently Asked Questions.

Retrieved from

ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch_2011_2012/01_Frequent

ly_asked_questions/NSCH_2011_2012_FAQs.pdf

CDC. (2013b). Overview: National Health and Nutrition Examination Survey 2013-2014.

Retrieved from http://www.cdc.gov/nchs/data/nhanes/survey_content_99_14.pdf

59

CDC. (2014a, September 2, 2014). Infant Feeding Practices Study II and Its Year Six

Follow-Up. Division of Nutrition, Physical Activity, and Obesity. Retrieved from

http://www.cdc.gov/breastfeeding/data/ifps/index.htm

CDC. (2014b). mPINC 2013 Survey New Mexico Results Report. Retrieved from Atlanta:

http://www.cdc.gov/breastfeeding/pdf/mpinc/states/2013/newmexicompinc13_5

08tagged.pdf

CDC. (2015a). About the National Survey of Family Growth. Retrieved from

http://www.cdc.gov/nchs/nsfg/about_nsfg.htm

CDC. (2015b). Are PRAMS data available to outside researchers? Retrieved from

http://www.cdc.gov/prams/researchers.htm

CDC. (2015c, July 31, 2015). Breastfeeding among U.S. Children Born 2002–2012, CDC

National Immunization Surveys. Retrieved from

http://www.cdc.gov/breastfeeding/data/NIS_data/

CDC. (2015d, June 17). Data & Statistics. Retrieved from

http://www.cdc.gov/breastfeeding/data/index.htm

CDC. (2015e). HealthStyles Survey — Public Beliefs and Attitudes About Breastfeeding:

2015. Retrieved from

http://www.cdc.gov/breastfeeding/data/healthstyles_survey/survey_2015.htm

CDC. (2015f). National Immunization Survey Methods. Retrieved from

http://www.cdc.gov/breastfeeding/data/NIS_data/survey_methods.htm

CDC. (2015g, July 29, 2015). PRAMS Questionaires. Retrieved from

http://www.cdc.gov/prams/questionnaire.htm

CDC. (2015h, June 19). Web Tables Report for the Infant Feeding Practices Study

(IFPS2). Retrieved from http://www.cdc.gov/breastfeeding/data/ifps/results.htm

- ch3

CDC. (2016, March 03, 2016). Newborn Screening. Retrieved from

http://www.cdc.gov/newbornscreening/

Chandra, A., Martinez, G., Mosher, W., Adbma, J., & Jones, J. (2005). Fertility, family

planning, and reproductive health of U.S. women: Data from the 2002 National Survey

of Family Growth. Retrieved from

http://www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf

Chapman, D. J., Merewood, A., Armah, R. A., & Pérez-Escamilla, R. (2008).

Breastfeeding status on US birth certificates: Where do we go from here?

Pediatrics, 122(6), e1159-e1163. doi:10.1542/peds.2008-1662

Chapman, D. J., & Pérez-Escamilla, R. (2009). US National Breastfeeding Monitoring

and Surveillance: Current Status and Recommendations. Journal of Human

Lactation. doi:10.1177/0890334409332437

60

childhealthdata.org. (2013). 2011-2012 NSCH: Child Health Indicator and Subgroups SAS

Codebook, Version 1.0. Retrieved from http://childhealthdata.org/docs/nsch-

docs/sas-codebook_-2011-2012-nsch-v1_05-10-13.pdf

Dalenius K, B. E., Smith B., Polhamus B., Grummer Strawn L. (2012). Pediatric Nutrition

Surveillance 2010 Report. Retrieved from Atlanta:

Dalenius K, B. P., Smith B, Reinold C, Grummer-Strawn L. (2012). Pregnancy Nutrition

Surveillance 2010 Report. Retrieved from Atlanta:

DHHS. (2011). The Surgeon General's Call to Action to Support Breastfeeding. U.S.

Department of Health and Human Serices, Office of the Surgeon General.

Edwards, J. (2011, February 7). Time for Abbott to Come Clean About Its Deceptive

Baby Formula Research. CBS News Money Watch. Retrieved from

http://www.cbsnews.com/news/time-for-abbott-to-come-clean-about-its-

deceptive-baby-formula-research/

Edwards, R. A., & Philipp, B. L. (2010). Using Maternity Practices in Infant Nutrition

and Care (mPINC) Survey Results as a Catalyst for Change. Journal of Human

Lactation. doi:10.1177/0890334410371212 Flaherman, V. J., Chien, A. T., McCulloch, C. E., & Dudley, R. A. (2010). Breastfeeding Rates

Differ Significantly by Method Used: A Cause for Concern for Public Health Measurement. Breastfeeding Medicine, 6(1), 31-35. doi:10.1089/bfm.2010.0021

Greiner, T. (2014). Exclusive breastfeeding: measurement and indicators. International Breastfeeding Journal, 9, 18-18. doi:10.1186/1746-4358-9-18

Grummer-Strawn, L. M., & Li, R. (2000). US National Surveillance of Breastfeeding

Behavior. Journal of Human Lactation, 16(4), 283-290.

doi:10.1177/089033440001600403

Grummer-Strawn, L. M., & Shealy, K. R. (2009). Progress in Protecting, Promoting, and

Supporting Breastfeeding: 1984–2009. Breastfeeding Medicine, October(4(s1), S-31-S-

39.

Hannan, A., Li, R., Benton-Davis, S., & Grummer-Strawn, L. (2005). Regional Variation

in Public Opinion About Breastfeeding in the United States. Journal of Human

Lactation, 21(3), 284-288. doi:10.1177/0890334405278490 Hawke, B. A., Dennison, B. A., & Hisgen, S. (2013). Improving Hospital Breastfeeding Policies

in New York State: Development of the Model Hospital Breastfeeding Policy. Breastfeeding Medicine, 8(1), 3-7. doi:10.1089/bfm.2012.0030

healthypeople.gov. (2010). Maternal, Infant, and Child Health Objectives. Healthy People

2020.

Heinig, M. J. (2010a). Looking Back on a Decade of Hospital Policy Research. Journal of

Human Lactation, 26(1), 7-8. doi:10.1177/0890334409359925

Heinig, M. J. (2010b). Using Data to Drive and Shape Change. Journal of Human

Lactation, 26(4), 359-361. doi:10.1177/0890334410387574

61

HHS. (2010). Health People 2020. Retrieved from

http://www.cdc.gov/breastfeeding/policy/hp2010.htm

IES. (2015). The Early Childhood Longitudinal Study (ECLS) program Retrieved from

https://nces.ed.gov/ecls/

Johnson, B., Thorn, B., McGill, B., Suchman, A., Mendelson, M., Patlan, K. L., . . .

Connor, P. (2013). WIC Participant and Program Characteristics 2012. Retrieved

from Alexandria, VA:

Kim, I. (1995). CDC Pregnancy Nutrition Surveillance System. WHO Bulletin,

Supplement(73), 85-86. Komodiki, E., Kontogeorgou, A., Papastavrou, M., Volak, i. P., RMidw, Genitsaridi, S., &

Iacovidou, N. (2014). Breastfeeding in Public: A Global Review of Different Atititudes Towards It. Journal of Pediatrics & Neonatal Care, 1(6).

Li, R., Fridinger, F., & Grummer-Strawn, L. (2002). Public Perceptions on Breastfeeding

Constraints. Journal of Human Lactation, 18(3), 227-235.

doi:10.1177/089033440201800304

Li, R., Fridinger, F., & Grummer-Strawn, L. (2004). Racial/Ethnic Disparities in Public

Opinion about Breastfeeding: The 1999–2000 Healthstyles Surveys in the United

States. In L. Pickering, A. Morrow, G. Ruiz-Palacios, & R. Schanler (Eds.),

Protecting Infants through Human Milk (Vol. 554, pp. 287-291): Springer US.

Li, R., Hsia, J., Fridinger, F., Hussain, A., Benton-Davis, S., & Grummer-Strawn, L.

(2004). Public beliefs about breastfeeding policies in various settings. Journal of

the American Dietetic Association, 104(7), 1162-1168.

doi:http://dx.doi.org/10.1016/j.jada.2004.04.028

Li, R., Rock, V. J., & Grummer-Strawn, L. (2007). Changes in Public Attitudes toward

Breastfeeding in the United States, 1999-2003. Journal of the American Dietetic

Association, 107(1), 122-127. doi:http://dx.doi.org/10.1016/j.jada.2006.10.002

Li, R., Scanlon, K. S., & Serdula, M. K. (2005). The Validity and Reliability of Maternal

Recall of Breastfeeding Practice. Nutrition Reviews, 63(4), 103-110.

doi:10.1111/j.1753-4887.2005.tb00128.x

Li, R., Zhao, Z., Mokdad, A., Barker, L., & Grummer-Strawn, L. (2003). Prevalence of

Breastfeeding in the United States: The 2001 National Immunization Survey.

Pediatrics, 111(5), 1198-1201.

McCormack, L. (2011). This Breastfeeding Survey Belongs in Diaper Pail. Retrieved

from http://womensenews.org/story/our-daily-lives/110201/breastfeeding-

survey-belongs-in-diaper-pail

McDowell, M. M., Wang, C.-Y., & Kennedy-Stephenson, J. (2008). Breastfeeding in the

United States: Findings from the National Health and Nutrition Examination

Surveys, 1999–2006. NCHS Data Brief, 5(April).

62

McGrath, J., McKinney, C., Otero, M., Sebastian, R., Shair, E., & Ramos, M. (2015).

Systems of Support for Breastfeeding in Select New Mexico Communities. Retrieved

from Albuquerque, NM: Morrow, A. L., & Lutter, C. K. (2012). Strategic Global Approaches to Improve Breastfeeding

Rates. Advances in Nutrition: An International Review Journal, 3(6), 829-830. doi:10.3945/an.112.002725

Navidi, T., Chaudhuri, J., & Merewood, A. (2009). Accuracy of Breastfeeding Data on

the Massachusetts Birth Certificate. Journal of Human Lactation, 25(2), 151-156.

doi:10.1177/0890334408330615

NCHS. (2012). Fact Sheet: National Survey of Family Growth

http://www.cdc.gov/nchs/data/factsheets/factsheet_nsfg.pdf: National Center of

Health Statistics, Center for Disease Control and Prevention.

NMBTF. (2014). Breastfeeding Statistics. Retrieved from

http://www.breastfeedingnewmexico.org/get-involved/resources/breastfeeding-

statistics NMDOH. (2010). PRAMS Surveillance Report 2008 births with 2006-2008 averages.

Retrieved from http://nmhealth.org/data/view/maternal/1736/

NMDOH. (2012). Pregnancy Risk Assessment Monitoring System Surveillance Report: Birth

Years 2009-2010. Retrieved from http://nmhealth.org/data/view/maternal/1737/:

http://nmhealth.org/data/view/maternal/1737/

NMDOH. (2015). Breastfeeding Initiation for WIC Infants Born in FFY2014. Available

from <Sarah.Flores-Siever@state.nm.us>.

NSCH. (2013). NSCH 2011/12. Data query from the Child and Adolescent Health

Measurement Initiative. Retrieved from

http://childhealthdata.org/browse/survey/results?q=2461&r=33

nwica.org. (2015). How WIC Impacts the People of New Mexico. Retrieved from

https://s3.amazonaws.com/aws.upl/nwica.org/newmexico2015.pdf

Pediatrics, A. A. o. (2012). Policy Statement: Breastfeeding and the Use of Human Milk.

Pediatricts, 129(3), e827-841.

Polhamus B, D. K., Mackintosh H, Smith B, Grummer-Strawn L. . (2011). Pediatric

Nutrition Surveillance 2009 Report. Retrieved from Atlanta:

Ruowei Li, S. B. F., Jian Chen, Laurence M. Grummer-Strawn. (2008). Why Mothers

Stop Breastfeeding: Mothers' Self-reported Reasons for Stopping During the First

Year. Pediatrics, 122(Supplement 2).

Ryan, A. S. (2004). The Truth About the Ross Mothers Survey. Pediatrics, 113(3), 626-627.

Ryan, A. S. (2005). More About the Ross Mothers Survey. Pediatrics, 115(5), 1450-1451.

doi:10.1542/peds.2005-0237

Ryan, A. S., Pratt, W. F., Wysong, J. L., Lewandowski, G., McNally, J. W., & Krieger, F.

W. (1991). A comparison of breast-feeding data from the National Surveys of

63

Family Growth and the Ross Laboratories Mothers Surveys. American Journal of

Public Health, 81(8), 1049-1052.

Ryan, A. S., Wenjun, Z., & Acosta, A. (2002). Breastfeeding Continues to Increase Into

the New Millennium. Pediatrics, 110(6), 1103-1109.

Weng, S., Coronado, E., & Nadler, S. (2005). NM PRAMS Surveillance Report: Year 2001-

2001 births. Retrieved from Santa Fe, NM:

West, J. Early Childhood Longitudinal Study Birth Cohort. Retrieved from Washington, DC:

http://www.researchconnections.org/childcare/resources/1357/pdf

Zipf, G., Chiappa, M., Porter, K., & al., e. (2013). National Health and Nutrition

Examination Survey: Plan and operations 1999-2010. Retrieved from

http://www.cdc.gov/nchs/data/series/sr_01/sr01_056.pdf

64

APPENDICES

Appendix A Healthy People 2020 Breastfeeding Objectives

Appendix B Ross Mothers Survey Instrument 2010

Appendix C National Immunization Survey 2002-2012

Appendix D mPINC Dimensions of Care

Appendix E mPINC 2013 Report Card: New Mexico

Appendix F New Mexico Baby Friendly Certified Facilities

Appendix G National Survey of Children’s Health Breastfeeding Indicators

Appendix H PNSS Breastfeeding Initiation 2011

Appendix I HealthStyles Breastfeeding Attitudes and Opinions

Appendix J New Mexico Baby Friendly Hospital Map Prototype

65

APPENDIX A: Healthy People 2020 Breastfeeding Objectives

Healthy People 2020: Infant Care

MICH-21.1 Increase the proportion of infants who are ever breastfed

Revised

Baseline: 74.0 percent of infants born in 2006 were ever breastfed, as reported in 2007–09

Target: 81.9 percent

Target-Setting Method: Projection/trend analysis

Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.2 Increase the proportion of infants who are breastfed at 6 months

Revised

Baseline: 43.5 percent of infants born in 2006 were breastfed at 6 months, as reported in 2007–09

Target: 60.6 percent

Target-Setting Method: Projection/trend analysis

Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.3 Increase the proportion of infants who are breastfed at 1 year

Revised

Baseline: 22.7 percent of infants born in 2006 were breastfed at 1 year, as reported in 2007–09

Target: 34.1 percent

Target-Setting Method: Projection/trend analysis

Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.4 Increase the proportion of infants who are breastfed exclusively through 3 months

Revised

Baseline: 33.6 percent of infants born in 2006 were breastfed exclusively through 3 months, as reported

in 2007–09

Target: 46.2 percent

Target-Setting

Method: Projection/trend analysis

Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.5 Increase the proportion of infants who are breastfed exclusively through 6 months

Revised

Baseline: 14.1 percent of infants born in 2006 were breastfed exclusively through 6 months, as reported

in 2007–09

Target: 25.5 percent

Target-Setting

Method: Projection/trend analysis

Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-22 Increase the proportion of employers that have worksite lactation support programs

Baseline: 25 percent of employers reported providing an onsite lactation/mother’s room in 2009

Target: 38 percent

Target-Setting Method: Projection/trend analysis

66

Data Sources: Employee Benefits Survey, Society for Human Resource Management (SHRM)

MICH-23 Reduce the proportion of breastfed newborns who receive formula supplementation within the first

2 days of life

Baseline: 24.2 percent of breastfed newborns born in 2006 received formula supplementation within the

first 2 days of life, as reported in 2007–09

Target: 14.2 percent

Target-Setting

Method: Projection/trend analysis

Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-24 Increase the proportion of live births that occur in facilities that provide recommended care for

lactating mothers and their babies

Baseline: 2.9 percent of 2007 live births occurred in facilities that provide recommended care for lactating

mothers and their babies, as reported in 2009

Target: 8.1 percent

Target-Setting

Method: Projection/trend analysis

Data Sources: Breastfeeding Report Card, CDC/NCCDPHP

67

APPENDIX B: Ross Mother’s Survey 2010

68

69

70

71

72

APPENDIX C: National Immunization Survey

73

APPENDIX D: mPINC Dimensions of Care

74

APPENDIX E: New Mexico 2013 mPINC Report Card

75

76

APPENDIX F: New Mexico Baby Friendly Hospitals

New Mexico BFHI Certified Birth Centers as of 2016

Gallup Indian Medical Center Gallup, NM 11/14

Gila Regional Medical Center Silver City, NM 07/15

Mountain View Regional Medical Center Las Cruces, NM 12/13

Northern Navajo Medical Center Shiprock, NM 10/14

Presbyterian Hospital Albuquerque, NM 04/15

University of New Mexico Health Sciences Center Albuquerque, NM 10/14

Zuni Comprehensive Health Center Zuni, NM 11/13

77

APPENDIX G: National Survey of Children’s Health

78

APPENDIX H: PNSS Breastfeeding Initiation 2011

Table 8D: 2011 Pregnancy Nutrition Surveillance

Comparison of Infant Health Indicators by Contributor

Ever Breastfed

Contributor Number Included

in Analysis

% Rank

Alabama 0 * *

Arizona 45,387 68.3 (16)

AZ I/Tribal Council 2,499 68.1 (17)

Cheyenne River-SD 122 50.8 (29)

Connecticut 10,318 74.6 (8)

D.C. 4,203 58.3 (26)

Florida 122,388 74.5 (9)

Hawaii 9,061 88.2 (2)

Idaho 9,859 86.1 (3)

Illinois 62,252 69.2 (15)

Indiana 42,656 67.6 (18)

Iowa 14,010 62.0 (24)

Kansas 18,328 74.2 (10)

Massachusetts 0 * *

Michigan 58,402 60.5 (25)

Minnesota 24,650 73.5 (11)

Montana 3,535 77.6 (5)

Nebraska 9,261 75.6 (7)

New Hampshire 4,315 73.0 (12)

New Jersey 38,674 66.8 (19)

New Mexico 5,846 66.6 (20)

New York 119,782 76.9 (6)

North Dakota 2,704 64.8 (21)

Ohio 54,777 54.3 (28)

Oregon 22,697 92.4 (1)

Puerto Rico 0 * *

Rhode Island 5,214 62.3 (23)

Rosebud Sioux-SD 288 71.2 (14)

Standing Rock-ND 112 57.1 (27)

Vermont 2,972 79.6 (4)

Virginia 29,328 63.9 (22)

West Virginia 12,674 44.5 (30)

Wisconsin 29,477 72.3 (13)

Nation 765,791 70.1

(1) Reporting period is January 1 through December 31.

(2) Excludes records with unknown data or errors.

(3) Rank compares one contributor's rate to other contributors. Rank 1 = best rate.

(4) <2500 g.

(5) >4000 g.

(6) <37 weeks gestation.

(7) 37 or more weeks gestation and <2500 g.

* Percentages are not calculated if <100 records are available for analysis after exclusions.

79

APPENDIX I: HealthStyles Breastfeeding Attitudes and Opinions

80

APPENDIX J: Baby Friendly Hospital Map Prototype