DOI: 10.1542/peds.2008-1662 2008;122;e1159-e1163 Pediatrics

Pérez-Escamilla Donna J. Chapman, Anne Merewood, Robert Ackatia Armah and Rafael

Breastfeeding Status on US Birth Certificates: Where Do We Go From Here?

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ARTICLE

Breastfeeding Status on US Birth Certificates: WhereDo We Go From Here?Donna J. Chapman, PhD, RDa, Anne Merewood, MPH, IBCLCb, Robert Ackatia Armah, BSc, MPhilb, Rafael Perez-Escamilla, PhDa

aDepartment of Nutritional Sciences, Center for Eliminating Health Disparities Among Latinos, University of Connecticut, Storrs, Connecticut; bDivision of GeneralPediatrics, Boston Medical Center, Boston, Massachusetts

The authors have indicated they have no financial relationships relevant to this article to disclose.

What’s Known on This Subject

In 2003, the US SCLB was revised and for the first time included a question on breast-feeding; however, states are required neither to use the SCLB nor to adopt the exactwording of SCLB questions.

What This Study Adds

InMay 2008, 79% of US states reported that breastfeeding datawere currently collectedon the birth certificate or would be collectedwithin the next 2 years. Thewording of thebreastfeeding question is not standardized. Suggestions are provided for revision.

ABSTRACT

OBJECTIVES. The objectives of this study were to assess the extent to which statescollected breastfeeding data on the birth certificate, to verify the wording of thebreastfeeding questions used, and to develop recommendations for future revisionsof the breastfeeding question asked on the US Standard Certificate of Live Birth.

METHODS.Registrars of vital statistics in US states and territories were contacted viatelephone with e-mail follow-up between April 2006 and May 2008 to determinewhether their state/territory collected breastfeeding data on its birth certificate.Responses were categorized as follows: (1) breastfeeding data currently collected; (2)breastfeeding data not currently collected but implementation date set; or (3) breast-feeding data not currently collected and no implementation plans.

RESULTS. In May 2008, 56.6% (30 of 53) of US states and territories were collecting dataon breastfeeding status at hospital discharge on their birth certificate. The questionsused to collect breastfeeding data, however, had not been standardized. Approxi-mately one quarter (12 of 53) reported that they were not yet collecting breastfeed-ing data on their birth certificate but that an implementation date had been set.Approximately one fifth (11 of 53) indicated that their state birth certificate did notplan to collect breastfeeding data by January 2010.

CONCLUSIONS.A total of 79% of the registrars reported that breastfeeding data werecollected on the birth certificate or that the process would begin within the next2 years. Future revisions to the Standard Certificate of Live Birth breastfeeding question should assess breast-feeding exclusivity. The revision process should include feedback from health professionals who collect thesedata, pretesting of the revised question for feasibility, and extensive training before data collection. Pediatrics2008;122:e1159–e1163

ELEVEN FEDERALLY FUNDED US surveys/data sets collect data on breastfeeding practices; however, issues such assampling procedures, recall bias, inconsistent wording of the breastfeeding questions, and limited racial/ethnic

category choices constrain the extent to which these data can be generalized.1 In 2003, the US Standard Certificateof Live Birth (SCLB) was revised and for the first time included a question on breastfeeding. The SCLB is a model ortemplate birth certificate that can be adopted or modified by individual states. In the “newborn” section of thisdocument, breastfeeding status is assessed by using the question, “Is the infant breastfed at discharge?” with theresponses listed as “yes” and “no.”2

This question is designed to capture breastfeeding status at hospital discharge, and because SCLB breastfeedingdata should be collected for all newborns in participating states, these data should be representative at the state level.It has limitations, however, because it does not directly assess breastfeeding initiation and does not measurebreastfeeding exclusivity. Given the limitations of the federally funded surveys in assessing US breastfeedingoutcomes, the inclusion of a carefully constructed breastfeeding question on the SCLB has the potential to make avaluable contribution to our knowledge on breastfeeding practices during the early postpartum period. The SCLBcontains a wealth of information on relevant confounders that may affect breastfeeding rates, including maternal andpaternal variables (age, education, birthplace, and race/ethnicity), maternal variables (height; prepregnancy weight;marital status; smoking status; participation in Special Supplemental Nutrition Program for Women, Infants, and

www.pediatrics.org/cgi/doi/10.1542/peds.2008-1662

doi:10.1542/peds.2008-1662

KeyWordsbreastfeeding, Standard Certificate of LiveBirth, birth certificate, US birth certificate,exclusive breastfeeding

AbbreviationsSCLB—Standard Certificate of Live BirthPRAMS—Pregnancy Risk AssessmentMonitoring System

Accepted for publication Aug 15, 2008

Address correspondence to DonnaJ. Chapman, PhD, RD, University ofConnecticut, Department of NutritionalSciences, 3624 Horsebarn Rd Extension, Storrs,CT 06269-4017. E-mail: donna.chapman@uconn.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2008 by theAmerican Academy of Pediatrics

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Children; parity; pregnancy risk factors; delivery method;and insurance status), and infant variables (birth weight,Apgar scores, and gestational age). Thus, the SCLB datacould be analyzed for determinants of breastfeeding out-comes.

Breastfeeding data derived from birth certificateshave been used to evaluate factors that affect breastfeed-ing initiation3–7; however, states are required neither touse the SCLB nor to adopt the exact wording of SCLBquestions. The objectives of this study were to assess theextent to which US states and territories collected breast-feeding data on the birth certificates, to verify the word-ing of the breastfeeding questions used, and to developrecommendations for future revisions of the SCLBbreastfeeding question.

METHODSTo assess the extent to which breastfeeding data werecollected on birth certificates, the registrar of vital statis-tics in each of the 50 states plus New York City, Wash-ington, DC, and 4 US territories (Puerto Rico, Guam, USVirgin Islands, and American Samoa) were contacted viatelephone by a research assistant in Spring 2006, withe-mail follow-up beginning in August 2006. Duringthese contacts, registrars were asked whether their statewas collecting breastfeeding data on their birth certifi-cate. Responses were recorded as follows: (1) breastfeed-ing data currently collected; (2) breastfeeding data notcurrently collected but a planned implementation dateset; or (3) breastfeeding data not currently collected andno planned implementation date. Registrars who re-sponded that breastfeeding data were collected wererequested to verify the wording of their breastfeedingquestion, either by sending an electronic template of thebirth certificate worksheet or by providing the verbatim

text of their question to the research assistant. New YorkCity was included as a separate entity from the state ofNew York in our analyses. This was done because, asreported in other analyses of birth certificate data,8,9 NewYork City and New York State use different birth certif-icates.

Follow-up e-mail surveys were sent approximatelyevery 4 months to recontact registrars who had notresponded. Registrars who did not respond by July 1,2007, were recontacted by telephone to verify their in-formation. States that were categorized as not collectingbreastfeeding data (with or without implementationdates) were recontacted by telephone and e-mail every 3months between December 2007 and May 2008 to de-termine whether their status had changed. Data weretabulated in Microsoft Excel (Redmond, WA). This studywas not subject to institutional review board approvalbecause no private, identifiable information was ob-tained.

RESULTSResponses were received from 100% of the state vitalstatistics registrars (including Washington, DC, and NewYork City) and from 1 of the 4 registrars in a US territory(Puerto Rico). Among those who responded, 56.6% (30of 53) were collecting data on breastfeeding status ontheir state birth certificate (Fig 1). Approximately onequarter of the registrars (12 of 53) reported that theywere not yet collecting breastfeeding data on their birthcertificate but that they had a scheduled date to beginimplementation of a revised birth certificate that wouldcollect breastfeeding data. Approximately one fifth (11of 53) indicated that their state birth certificate did notplan to collect breastfeeding data by January 2010. Intotal, 79% (42 of 53) of the registrars reported that their

FIGURE 1US map indicating status of breastfeeding data collection on birth certificates.

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state was already collecting breastfeeding data on thebirth certificate or had a planned implementation date todo so.

The questions that were used to assess early breast-feeding practices varied by state (Table 1). Among the 30localities (29 states and New York City) that collectedbreastfeeding data, 40% (12 of 30) used the wording ofthe breastfeeding question on the SCLB (“Is the infantbeing breastfed at discharge?”). Five of these states usedthe responses specified on the SCLB (“yes/no”), whereas7 added the option to respond “unknown.” Two addi-tional states used a nearly identical question (“Is theinfant being breastfed at time of discharge?”), each witha different set of potential responses. Eight states used aslightly abbreviated form of the SCLB breastfeedingquestion and asked “Is infant being breastfed? (yes/no).”Eight states or municipalities developed their ownunique question. Half of these birth certificates (NewJersey, New York State, New York City, and Washing-ton, DC) included language that permitted analysis ofthe exclusivity of breastfeeding. Some of the states thatreported not collecting breastfeeding data on their birthcertificate indicated that these data were being collectedby using other systems, such as a Newborn ScreeningTest form or via the Pregnancy Risk Assessment Moni-toring System (PRAMS) survey.

DISCUSSIONIn the majority of states, breastfeeding data are col-lected on the birth certificate, or this process will beginwithin the next 2 years; however, the questions that

are being used to collect breastfeeding data are notstandardized. Only 5 states use the exact wording ofthe breastfeeding question and responses specified bythe SCLB. Six states plus New York City and Wash-ington, DC, have developed their own questions. Thewide variation in the wording of the breastfeedingquestion adopted for use on individual state birthcertificates suggests dissatisfaction with the breast-feeding question originally specified in the US SCLB.Because the SCLB is periodically revised, we offersome suggestions for the future modifications of thebreastfeeding question.

We strongly recommend that future revisions of theSCLB breastfeeding question assess breastfeeding exclu-sivity during hospitalization. Increasing exclusive breast-feeding is a national public health priority,10 but, unfor-tunately, a high percentage of breastfed infants startreceiving formula during their hospitalization.11 Data onin-hospital rates of exclusive breastfeeding would beuseful at the state, county, and hospital levels to assessthe adequacy of breastfeeding promotion efforts andmonitor progress toward improvement in breastfeedingpractices. It should be recognized that these exclusivebreastfeeding data are likely to overestimate the trueincidence of exclusive breastfeeding. Because of timeconstraints, the review of feeding practices may be lim-ited to the last 24 hours of the hospital stay, as done inNew Jersey.3 Thus, infants who were supplemented withnon–breast milk substances early during their hospitalstay and then received only breast milk for the remain-der of their hospitalization would be misclassified as

TABLE 1 Summary of the Questions Used to Assess Breastfeeding Status on State Birth Certificates

Wording of Questiona No. ofStates

Specific States

1. Is the infant being breastfed at discharge?(Yes/no) 5 Delaware, Iowa, Montana, Vermont, Wyoming(Yes/no/unknown) 6 Indiana, Kansas, New Hampshire, New Mexico,

Ohio, Oregon(Yes/no/infant transferred, status unknown) 1 Texas

2. Is infant being breastfed at time of discharge?(Yes/no) 1 South Dakota(Yes/no/unknown) 1 North Dakota

3. Is infant being breastfed? (Yes/no) 8 Florida, Idaho, Kentucky, Nebraska, Pennsylvania,South Carolina, Tennessee, Washington

4. Is infant being breastfed, even partially? (no, unknown, yes) 1 Georgia5. Is the infant receiving breast milk at discharge? (yes/no) 1 Colorado6. Are you breastfeeding or do you intend to breastfeed?

(yes/no)1 Massachusetts

7. Breast feeding initiated, planned or not planned?(Initiated, planned, not planned, unknown) 1 Michigan

8. Feeding at discharge (check one)(Breast feeding, formula, combination, other) 1 New Jersey

9. How is infant being fed at discharge? (select one)Breast milk only, formula only, both breast milk andformula, other, do not know

1 New York State

10. How is infant being fed (check one): breast milk only,formula only, both, neither (ie, infant may be onintravenous fluids)

1 New York City

11. Method of feeding: (bottle, breast, or both) 1 Washington, DCa Slight variations in wording are grouped together.

PEDIATRICS Volume 122, Number 6, December 2008 e1161 by on June 2, 2009 www.pediatrics.orgDownloaded from

exclusively breastfed. Despite this limitation, these dataare extremely useful, because they provide valuable in-sights regarding the adequacy of in-hospital lactationsupport and allow benchmarking comparisons amonghospitals, counties, and states.

The exact wording of this question should be devel-oped with guidance from experts in the areas of lactationand public health and those currently involved in datacollection. It would be essential to obtain feedback fromVital Records Registrars in New Jersey, New York State,New York City, and Washington, DC, where data onbreastfeeding exclusivity are currently collected on thebirth certificate. Once developed, the breastfeedingquestion should be pilot tested for feasibility. Two states(Michigan and Massachusetts) ask about both breast-feeding intentions and initiation in a single question.This seems particularly confusing, because different re-sponses may be obtained, depending on the timing ofthe question (prenatal versus postpartum). Given thatfeeding intentions are not always predictive of infantfeeding practices,12 we recommend that breastfeedingintentions should not be documented on the birth cer-tificate.

In addition to standardized wording, the adminis-tration of the birth certificate breastfeeding questionshould be standardized. The breastfeeding questiontypically appears on the Facility Worksheet, designedto be completed by health professionals. Process eval-uation should be conducted to determine exactly howthis question is currently answered and by whom. Forexample, is the mother interviewed, is the medicalchart/infant feeding record reviewed, or are the dataentered from an electronic source? If mothers areinterviewed, then accurate translation of the stan-dardized question should be developed in multiplelanguages. The timing of the data collection should beconsistent, to capture accurately the desired out-comes. If the phrase “at discharge” is included infuture revisions, then it will be necessary to specifythe meaning of “at discharge.” For example, does “atdischarge” refer to last 24 hours of hospitalization as iscurrently the case in New Jersey3? Alternatively,should only the last 2 to 4 documented in-hospitalfeedings be assessed, to capture feeding practices clos-est to discharge? We do not recommend the use of thelast hospital feeding to answer this question, becausethis would misclassify mixed feeders as either breast-feeding or formula feeding. Thorough training ofhealth professionals who collect birth certificatebreastfeeding data are essential, to maximize the use-fulness of these data for breastfeeding surveillancepurposes.

Given all of the relevant demographic and biomedicaldata collected at birth, the birth certificate represents avery useful data source for breastfeeding researcherswho are interested in examining breastfeeding outcomesfrom a health disparities perspective and for policy mak-ers who wish to improve hospital practice. Obviously,these data are only useful if they are made publiclyavailable. To date, several peer-reviewed publications

have resulted from analysis of birth certificate–derivedbreastfeeding data.3–7,12

Ten states and Puerto Rico indicated that they do nothave plans to collect breastfeeding data on their birthcertificates. Some of these states are collecting breast-feeding data through alternative sources, such as thenewborn screening programs. Other states reported col-lecting these data with PRAMS; however, given thesmaller sample size and the longer recall period involvedwith the PRAMS survey, this does not represent anadequate substitute for collection of breastfeeding dataon the birth certificate.

CONCLUSIONSWithin the next 2 years, nearly 80% of US states areexpected to be collecting breastfeeding data on theirbirth certificate. This represents a significant contribu-tion to our national breastfeeding surveillance efforts,because data should be collected for every newborn inevery participating state, thereby avoiding the potentialfor sampling bias. Because birth certificates also collectdata on several relevant variables that are known toaffect breastfeeding outcomes, the inclusion of a breast-feeding question on birth certificates has a strong poten-tial to improve breastfeeding surveillance in the UnitedStates. Consistent with the Healthy People 2010 guide-lines, we strongly encourage all states and US territoriesto collect exclusive breastfeeding data on their birthcertificates and to monitor this outcome closely. Standard-ization of the breastfeeding question that is used on statebirth certificates should be a priority so that breastfeedingoutcomes can be compared across states. The revision ofthis question should involve a process that includes feed-back from health professionals who collect these data, pre-testing of the revised question for feasibility, and training ofprofessionals who collect these data.

ACKNOWLEDGMENTSThis research was supported by National Institutes ofHealth NCMHD EXPORT grant P20 MD001765. Wethank Lisa Phillips, Khara Leon and Ellen Meisterling fortheir assistance.

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DOI: 10.1542/peds.2008-1662 2008;122;e1159-e1163 Pediatrics

Pérez-Escamilla Donna J. Chapman, Anne Merewood, Robert Ackatia Armah and Rafael

Breastfeeding Status on US Birth Certificates: Where Do We Go From Here?

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