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Public beliefs about breastfeeding policies in various settings
RESEARCH Research and Professional Briefs
Public Beliefs about Breastfeeding Policies in Various Settings RUOWEI LI, MD, PhD; JASON HSIA, PhD; FRED FRIDINGER, DrPH; ABEDA HUSSAIN; SANDRA BENTON-DAVIS, RD; LAURENCE GRUMMER-STRAWN, PhD
ABSTRACT To understand the public beliefs about breastfeeding policies in various settings and to examine the associations of these beliefs with sociodemographic characteristics, we analyze the data from the 2001 Healthstyles survey, which is an annual national mail survey to US adults. We found that establishing workplace breastfeeding policies and lactation rooms in public places are the most acceptable breastfeeding policies surveyed, especially among African Americans and low-income populations. The overall population appears to approve of breastfeeding in public, but less-educated or older people (aged ⱖ45 years) are less likely to do so. In general, there is relatively less public support for breastfeeding education in high schools. The results indicate that many Americans, especially African Americans and those with low household income, believe that women who breastfeed need extra support both at work and in public places. A variety of policy strategies would be appropriate to create a favorable environment for breastfeeding. J Am Diet Assoc. 2004;104:1162-1168.
R. Li is a medical epidemiologist, S. Benton-Davis is a public health nutritionist, and L. Grummer-Strawn is the branch chief, Division of Nutrition and Physical Activity, and J. Hsia is a statistician, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. F. Fridinger is an associate professor, Department of Social and Behavioral Science, School of Public Health, University of North Texas Health Science Center at Fort Worth. A. Hussain is a public health nutritionist, Southside Medical Center, Atlanta, GA; at the time of the study, she was an undergraduate student, Department of Nutrition, College of Health and Human Sciences, Georgia State University, Atlanta. Address for correspondence: Ruowei Li, MD, PhD, Centers for Disease Control and Prevention, Mailstop K-25, 4770 Buford Highway, NE, Atlanta, GA 303413717. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10407-0010$30.00/0 doi: 10.1016/j.jada.2004.04.028
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espite a wide range of benefits of breastfeeding for children and their mothers (1-3), rates of breastfeeding in the United States are low, especially when measured by duration (4). Many states have established legislation that supports breastfeeding (www. ncsl.org), and many corporations have implemented lactation support programs (5-7). Before enacting these laws and policies across the country, policymakers need to know if they will be acceptable to the citizenry. Unfortunately, to date there are no national data to indicate how much the general public would support various breastfeeding policies. The purpose of this study is to describe public beliefs about breastfeeding policies in various settings and to examine the associations of these beliefs with certain sociodemographic characteristics. METHODS We used data from the 2001 Healthstyles survey, a national mail survey of 5,065 US adults who completed that year’s DDB Needham Lifestyle survey. Three thousand seven hundred nineteen persons returned the survey instrument, yielding a 73% response rate. The study population of the Lifestyle survey was generated by quota sampling from a consumer mail panel of some half million adults and the data are weighted on seven demographic variables (age, sex, marital status, race/ethnicity, income, region, and household size) to reflect opinions of US adults aged 18 years and older. It has been demonstrated that the sample distribution of the Healthstyles survey matches that of the US census data and the survey sample reflects the general adult population in the United States (8). Details of the study design and methods are described elsewhere (9). The nine breastfeeding items surveyed are shown in the column headings of Tables 1 and 2. For each statement, respondents were asked to rate their agreement on a scale of 1 to 5, where 1⫽strongly disagree, 2⫽moderately disagree, 3⫽neither disagree nor agree, 4⫽moderately agree, or 5⫽strongly agree. For this analysis, we treated responses of 1 and 2 as indicating disagreement; 4 and 5, agreement; and 3, no opinion. We estimated the percentage of agreement with each breastfeeding statement and compared the weighted proportions of agreement within each stratum using Quantum (10). We applied multiple logistic regression to determine whether each agreement was related to a series of sociodemographic characteristics. Except for the significance test for the weighted proportional difference, all the analyses were conducted using SAS (version 8.0. 1999, SAS Institute, Inc, Cary, NC).
© 2004 by the American Dietetic Association
RESULTS AND DISCUSSION Among all the breastfeeding items surveyed (Table 1), the statement that shopping malls should provide private places to help women breastfeed had the highest percentage agreement (52%), with rates significantly higher among women, African Americans (vs whites), low-income households (⬍$20,000/year) vs households with income ⱖ$50,000/year, and the Mid-Atlantic and East South Central regions (vs West South Central). The items with the lowest level of agreement were No. 4 (tax incentives for employers, 27%) and No. 8 (showing women breastfeeding on television programs, 27.9%). Although the percentage of agreement varied widely, about one third of the population had no opinion across all breastfeeding items (data not shown). To reduce the responses to the nine breastfeeding items surveyed to a set of underlying constructs, we applied exploratory factor analysis with Varimax rotation (11). Because exploratory factor analysis identified four distinct constructs among all the responses with each construct representing a different dimension of data, we present and discuss the results by the following four factors: Factor I (Workplace Breastfeeding Policies), workplaces should have policies to support breastfeeding; Factor II (Lactation Rooms in Public Places), there should be lactation rooms in public buildings or shopping malls; Factor III (Breastfeeding in Public), breastfeeding in public is appropriate; and Factor IV (Breastfeeding Education in High School), high schools should offer education on breastfeeding. These four factors account for 78.6% of the total variance of all the data (data not shown). With regard to Factor I (Workplace Breastfeeding Policies), at least 43% of the population surveyed believes employers should provide flexible work schedules, extended maternity leave, and a private room for pumping breastmilk, but only 27% support providing tax incentives to employers who make special accommodations (Table 1). Women with infants and children are the fastest-growing segment of the US labor force. Studies in the United States suggest that employment may have little influence on breastfeeding initiation, but the timing of return to paid employment is a key factor influencing breastfeeding duration (12,13). Even though the federal legislation provides up to 12 weeks of job-protected, unpaid maternity leave (14), many exceptions to this law exist, including employees in small companies or businesses (⬍50 employees), those working less than an average of 24 hours per week, and employees with less than 1 year of continuous service. Low-income populations, among whom African Americans and Hispanics are overrepresented, may be particularly affected by lack of paid maternity leave and return to paid work soon after childbirth (15). This may partially explain why we found African Americans about three times as likely and Hispanics two times as likely as whites to believe employers should provide extended maternity leave to make it easier for mothers to breastfeed (Table 2). Thus, more favorable treatment of mothers, such as paid leave and allowance for flexible time, might be critical to reaching higher levels of continued breastfeeding, particularly among women whose jobs offer low pay or little status, or both. The analysis of Factor II (Lactation Rooms in Public
Places) indicates substantial support in the US adult population for having public buildings or shopping malls provide lactation rooms to help women breastfeed, with agreement levels of 41% and 52%, respectively (Table 1). For this factor, we found greater support among African Americans than whites and among those with low household incomes than those whose household made $50,000 or more (Table 2). Breastfeeding in public places is often seen as embarrassing and unacceptable in modern societies (16). Our previous study indicates that more than one third of US adults find it embarrassing for a mother to breastfeed in front of others (17). Women often feel vulnerable and nervous and generally sense that people are reluctant to approach them while they are nursing their babies in public places (18). To make women feel at ease about breastfeeding in public places, societal norms need to evolve so breastfeeding is considered a normal occurrence. In the meantime, women need to be prepared with strategies to better cope with the difficulties they encounter. There are mothers who prefer to breastfeed with some privacy when outside the home and this option should be available to them. Establishing lactation rooms in shopping malls or public buildings could help remove some of the barriers to breastfeeding in public places. For Factor III (Breastfeeding in Public), although we found good support (43% agreement) for women’s right to breastfeed in public places, only 28% of persons surveyed think it is appropriate to show a woman breastfeeding on television (Table 1). Men are more likely than women to support breastfeeding in public, whereas people who are ⱖ45 years old or less educated are less likely to support these items than their younger or more educated counterparts (Table 2). Modern American society pays great attention to the sexual and aesthetic functions of women’s breasts, which may make people perceive that breastfeeding should be hidden from the media. Therefore, it is important to encourage the media to portray breastfeeding as a normal, desirable, and achievable activity for women of all cultures and socioeconomic levels as stated in the Department of Health and Human Services’ Blueprint for Action on Breastfeeding (19). Factor IV includes only one item, Breastfeeding Education in High School. Each year in the United States, 800,000 to 900,000 adolescents become pregnant, resulting in about a half million live births (20,21). Unfortunately, young mothers are less likely than older women to breastfeed (22,23). Teenagers not only share the barriers faced by adults, but also face additional barriers. These barriers include lack of support, going back to school, being unmarried, being African American, having an unwanted pregnancy, and belonging to a low socioeconomic group (24-32). Although there is relatively less support for breastfeeding education in high school among the population surveyed, school-based interventions that integrate breastfeeding information into school health education programs can be effective (33). Because education, support, and exposure come from multiple sources and interact with each other, a successful teenage breastfeeding promotion program would probably be a multifaceted intervention involving school, home, and clinical settings.
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Table 1. Summary of the percentage agreement with each statement about breastfeedinga
Believe employers should provide extended maternity leave to make it easier for mothers to breastfeed
3,714
49.7
1,400 2,314
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Sample sizeb
Believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers
Total agreement Sex Male Female Race/ethnicity White African American Hispanic Age (yrs) 18-29 30-44 45-64 65⫹ Household income ⬍$20,000 $20-49,900 $50,000⫹ Education ⱕHigh School ⬎High School Marital status Married Unmarried Employed Yes No Population density Rural Suburban Urban
Believe employers should provide a private room for breastfeeding mothers to pump their milk at work
Public buildings need to have a Would support room tax incentives where for employers women who make could special accommodations breastfeed and pump to make it milk for easier for their mothers to babies breastfeed
Shopping malls should provide private places to help women breastfeed their babies
Believe women should have the right to breastfeed in public places
Believe breastfeeding education It is appropriate should be available as to show a part of a woman breastfeeding high school health her baby education on TV curriculum programs
47.4
43.1
27.0
40.7
52.1
43.1
27.9
33.5
45.8 53.4c
42.5 51.8c
39.7 46.2c
25.5 28.5
37.7 43.5c
47.9 56.0c
45.2 41.3
30.7d 25.2
34.8 32.3
2,822 411 341
48.3 54.3 53.2
44.3 58.9e 54.5e
41.4 48.2e 44.8
25.4 34.0e 27.2
38.3 47.6e 45.7e
50.8 57.7e 49.5
43.1 38.8 46.4
27.2 27.5 33.1
33.6 33.5 31.9
268 1,563 1,347 536
62.1f 50.7g 43.7 43.6
58.5f 49.0g 40.2 43.4
43.8 45.0h 40.1 43.8
30.0 29.3h 22.8 26.5
45.9h 41.7h 36.9 39.1
55.7 53.2 49.3 50.8
52.4g 47.0g 39.1i 30.9
36.3g 31.8g 24.1i 15.7
32.4 32.6 33.6 36.5
704 1,296 1,714
54.2j 49.9 47.3
56.4k 47.0 43.1
47.6j 42.6 41.2
30.8j 27.5 24.8
49.9j 41.1j 35.6
57.4j 52.2 49.4
40.3 43.2 44.5
24.6 31.2l 26.7
37.0 31.6 33.4
1,271 2,387
48.6 49.8
49.5 46.3
45.0 43.3
27.9 26.8
43.8 40.0
53.5 51.7
36.1 46.8m
23.4 29.7m
32.3 34.1
2,648 1,057
49.5 49.9
47.4 47.4
44.9 40.6
27.8 25.7
41.3 39.4
53.9 49.4
45.5n 39.8
27.5 28.7
32.5 35.0
2,563 1,130
48.1 53.5o
45.4 51.9o
40.9 48.3o
25.3 31.3o
38.9 44.8o
50.8 55.0
43.8 41.9
30.4p 22.1
32.4 36.1
811 1,706 1,197
54.0q 45.8 52.1q
51.5q 44.6 48.6
44.0 42.2 43.7
27.4 27.0 26.9
44.3 39.0 40.7
53.9 50.9 52.6
45.5 43.9 40.8
28.8 28.5 26.6
35.7 31.8 34.3 (continued)
Region New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific a
171 552 616 288 666 278 397 252 494
53.1 49.2 47.9 49.6 49.2 50.2 47.2 54.0 52.8
44.3 45.6 47.2 44.8 47.9 51.0 43.6 52.6 49.9
41.5 43.3 41.5 40.5 44.8 49.4 41.0 46.3 41.8
23.6 28.4 26.0 23.6 28.3 26.6 27.8 23.0 29.9
40.2 44.0 42.3 38.9 38.3 43.6 36.0 41.8 41.4
54.9 55.6s 54.6 52.7 51.2 56.8s 46.1 50.4 49.1
44.2 40.6 37.7 41.3 41.1 37.2 43.2 58.8v 50.3x
35.9r 27.1 25.1 27.2 24.6 20.4 30.8u 36.1w 31.3
Values except for sample size represent the percent of agreement with each statement. Sample size may not add to total N because of missing values. c Significantly greater than males at P⫽.05 using special t statistics. d Significantly greater than women at P⫽.05 using special t statistics. e Significantly greater than whites at P⫽.05 using special t statistics. f Significantly greater than 30-44 years, 45-64 years, and ⬎65 years groups at P⫽.05 using special t statistics. g Significantly greater than 45-64 years and ⬎65 years groups at P⫽.05 using special t statistics. h Significantly greater than 45-64 years group at P⫽.05 using special t statistics. i Significantly greater than ⬎65 years group at P⫽.05 using special t statistics. j Significantly greater than ⬎$50,000 group at P⫽.05 using special t statistics. k Significantly greater than $20,000-$49,900 and ⬎$50,000 groups at P⫽.05 using special t statistics. l Significantly greater than ⬍$20,000 and ⬎$50,000 groups at P⫽.05 using special t statistics. m Significantly greater than ⱕHigh School at P⫽.05 using special t statistics. n Significantly greater than unmarried group at P⫽.05 using special t statistics. o Significantly greater than employed group at P⫽.05 using special t statistics. p Significantly greater than not employed group at P⫽.05 using special t statistics. q Significantly greater than Suburban group at P⫽.05 using special t statistics. r Significantly greater than East North Central, South Atlantic, and East South Central groups at P⫽.05 using special t statistics. s Significantly greater than West South Central group at P⫽.05 using special t statistics. t Significantly greater than West North Central group at P⫽.05 using special t statistics. u Significantly greater than East South Central group at P⫽.05 using special t statistics. v Significantly greater than New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, and West South Central groups at P⫽.05 using special t statistics. w Significantly greater than East North Central, South Atlantic, and East South Central groups at P⫽.05 using special t statistics. x Significantly greater than Middle Atlantic, East North Central, South Atlantic, and East South Central groups at P⫽.05 using special t statistics. b
29.0 36.3t 35.9t 23.8 34.9t 32.7 31.1 40.9t 32.4
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Table 2. Adjusted odds of agreement with each breastfeeding statement using multiple logistic regression analysis
Factor I Workplace Breastfeeding Policies
Sex Female (Ref) Male Race/ethnicitya White (Ref) African-American Hispanic Age (yrs) 18-29 30-44a 45-64 65⫹ Household income ⬍$20,000 $20-49,900 $50,000⫹a Education ⱕHigh School ⬎High Schoola Marital status Marrieda Unmarried
Factor II Lactation Rooms in Public Places Public buildings need to have a Would support room tax incentives where for employers women who make could special accommodations breastfeed and pump to make it milk for easier for their mothers to babies breastfeed
Believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers
Believe employers should provide extended maternity leave to make it easier for mothers to breastfeed
Believe employers should provide a private room for breastfeeding mothers to pump their milk at work
— 0.82
— 0.70*
— 0.80
— 0.87
— 1.58* 1.07
— 3.42* 2.27*
— 1.69* 1.12
1.41 — 0.74* 0.55*
1.66 — 0.72* 0.61*
1.37 1.11 —
Factor IV Breastfeeding Education in High School
Shopping malls should provide private places to help women breastfeed their babies
Believe women should have the right to breastfeed in public places
It is appropriate to show a woman breastfeeding her baby on TV programs
Believe breastfeeding education should be available as part of a high school health education curriculum
— 0.88
— 0.77*
— 1.39*
— 1.49*
— 1.35*
— 2.04* 1.05
— 2.25* 1.46
— 1.84* 0.98
— 1.11 1.00
— 1.17 1.13
— 1.15 0.98
0.90 — 0.92 0.93
0.97 — 0.63* 0.64*
1.07 — 0.87 0.87
0.95 — 0.81 0.86
1.45 — 0.66* 0.42*
1.52 — 0.59* 0.32*
0.96 — 1.19 1.20
1.85* 1.01 —
1.69* 1.16 —
1.80* 1.18 —
2.63* 1.38* —
2.05* 1.59* —
1.09 1.12 —
0.92 1.24 —
1.57* 1.01 —
0.88 —
1.15 —
0.99 —
1.01 —
1.06 —
0.91 —
0.63* —
0.69* —
0.81 —
— 0.88
— 0.71*
— 0.66*
— 0.67*
— 0.71*
— 0.67*
— 0.77
— 1.05
— 1.13 (continued)
Factor III Breastfeeding in Public
0.81 1.57* 1.07 0.65 0.97 0.94 0.81 1.57 — 0.87 0.78 0.47* 0.42* 0.54* 0.37* 0.59* 0.74 — 0.69 0.59 0.42 0.41 0.54 0.33 0.57* 0.96 — 1.46 1.37 1.18 1.15 1.03 1.48 0.76 1.07 — 1.03 1.20 0.98 0.86 0.72 0.76 0.58 0.77 — 0.82 1.04 0.75 0.65 0.77 0.76 0.79 0.70 —
1.53* — 1.34* 1.30 — 0.88 1.35* — 0.91 1.34 — 1.18 1.64* — 1.24 1.28 — 1.03
●
0.80 1.16 0.86 0.63 0.91 0.78 0.59 0.69 — 0.86 0.97 0.63* 0.52* 0.79 0.87 0.57* 0.73 —
a Reference level. *95% confidence interval does not include one.
1.76* — 1.25 1.61 — 1.26
1.07 1.15 1.00 0.92 0.87 1.01 0.86 0.97 —
— 1.49*
Employed Yesa No Population density Rural Suburbana Urban Region New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacifica
— 1.39*
1.35 — 1.22
— 0.95 — 1.26 — 1.04 — 1.10
●
— 1.37*
●
— 1.48*
— 1.11
CONCLUSIONS Although our results show that public support for breastfeeding policies varies, a large proportion of the general public would support the policies surveyed in this study. Establishing workplace breastfeeding policies and lactation rooms in public places are the most acceptable breastfeeding policies surveyed, especially among African Americans and low-income populations. The overall population appears to approve of breastfeeding in public, but less educated or older persons (aged ⱖ45 years ) are less likely to do so. In general, there is relatively less public support for breastfeeding education in high schools. Based on the findings of this study, we have several recommendations. In recent years, employers have been encouraged to establish breastfeeding policies and to provide appropriate facilities for pumping breastmilk. The public support for these policies at work should ease the way toward implementation of such policies. Public support is essential for implementing any changes in the social environment. The support of people for establishing lactation rooms in the public places confirms the need of such change and encourages implementation of this policy. To establish and implement breastfeeding policies successfully, future studies that provide direct evidence on how these policies influence a woman’s breastfeeding behavior are warranted and cost-benefit analyses of interventions are also needed.
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11. Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Other Multivariable Methods. Belmont, CA: PWS-KENT Publishing Co; 1988. 12. Fein SB, Roe B. The effect of work status on initiation and duration of breastfeeding. Am J Public Health. 1998;88:1042-1046. 13. Roe B, Whittington LA, Fein SB, Teisl MF. Is there competition between breastfeeding and maternal employment? Demography. 1999;36:157-171. 14. Baldwin E, Friedman K. A current summary of breastfeeding legislation in the US. Available at: http://www.lalecheleaque.org. Accessed February 18, 2003. 15. Galtry J. The impact on breastfeeding of labour market policy and practice in Ireland, Sweden, and the USA. Soc Sci Med. 2003;57:167-177. 16. McIntyre E, Turnbull D, Hiller JE. Breastfeeding in public places. J Hum Lact. 1999;15:131-135. 17. Li R, Fridinger F, Grummer-Strawn L. Public perceptions on breastfeeding constraints. J Hum Lact. 2002; 18:227-235. 18. Sheeshka J, Potter B, Norrie E, Valaitis R, Adams G, Kuczynski L. Women’s experiences breastfeeding in public places. J Hum Lact. 2001;17:31-38. 19. US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: US Government Printing Office; 2000. 20. Centers for Disease Control and Prevention. National and state-specific pregnancy rates among adolescents—United States, 1995-1997. Morbid Mortal Wkly Rep. 2000;49:605-611. 21. Ventura SJ, Curtin SC, Mathews TJ. Variations in teenage birth rates, 1991-1998: National and state trends. Natl Vital Stat Rep. 2000;48:1-13. 22. Ryan AS, Wenjun Z, Acosta A. Breastfeeding continues to increase into the new millennium. Pediatrics. 2002;110:1103-1109.
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23. Li R, Ogden C, Ballew C, Gillespie C, GrummerStrawn L. Prevalence of exclusive breastfeeding among US infants: The Third National Health and Nutrition Examination Survey (Phase II, 1991-1994). Am J Public Health. 2002;92:1107-1110. 24. Hannon PR, Willis SK, Bishop-Townsend V, Martinez IM, Scrimshaw SC. African-American and Latina adolescent mothers’ infant feeding decisions and breastfeeding practices: A qualitative study. J Adolesc Health. 2000;26:399-407. 25. Neifert M, Gray J, Gary N, Camp B. Factors influencing breast-feeding among adolescents. J Adolesc Health Care. 1988;9:470-473. 26. Wiemann CM, DuBois JC, Berenson AB. Racial/ethnic differences in the decision to breastfeed among adolescent mothers. Pediatrics. 1998;101:E11. 27. Baisch MJ, Fox RA, Goldberg BD. Breastfeeding attitudes and practices among adolescents. J Adolesc Health Care. 1989;10:41-45. 28. Cusson RM. Attitudes toward breast-feeding among female high-school students. Pediatr Nurs. 1985;11: 189-191. 29. Ineichen B, Pierce M, Lawrenson R. Teenage mothers as breastfeeders: attitudes and behavior. J Adolesc. 1997;20:505-509. 30. Taylor JS, Cabral HJ. Are women with an unintended pregnancy less likely to breastfeed? J Fam Pract. 2002;51:431-436. 31. Peterson CE, Da Vanzo J. Why are teenagers in the United States less likely to breast-feed than older women? Demography. 1992;29:431-450. 32. Purtell M. Teenage girls’ attitudes to breastfeeding. Health Visit. 1994;67:156-157. 33. Ellis DJ. Secondary school students’ attitudes and beliefs about breastfeeding. J School Health. 1983;53: 600-604.
Public Beliefs about Breastfeeding Policies in Various Settings RUOWEI LI, MD, PhD; JASON HSIA, PhD; FRED FRIDINGER, DrPH; ABEDA HUSSAIN; SANDRA BENTON-DAVIS, RD; LAURENCE GRUMMER-STRAWN, PhD
ABSTRACT To understand the public beliefs about breastfeeding policies in various settings and to examine the associations of these beliefs with sociodemographic characteristics, we analyze the data from the 2001 Healthstyles survey, which is an annual national mail survey to US adults. We found that establishing workplace breastfeeding policies and lactation rooms in public places are the most acceptable breastfeeding policies surveyed, especially among African Americans and low-income populations. The overall population appears to approve of breastfeeding in public, but less-educated or older people (aged ⱖ45 years) are less likely to do so. In general, there is relatively less public support for breastfeeding education in high schools. The results indicate that many Americans, especially African Americans and those with low household income, believe that women who breastfeed need extra support both at work and in public places. A variety of policy strategies would be appropriate to create a favorable environment for breastfeeding. J Am Diet Assoc. 2004;104:1162-1168.
R. Li is a medical epidemiologist, S. Benton-Davis is a public health nutritionist, and L. Grummer-Strawn is the branch chief, Division of Nutrition and Physical Activity, and J. Hsia is a statistician, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. F. Fridinger is an associate professor, Department of Social and Behavioral Science, School of Public Health, University of North Texas Health Science Center at Fort Worth. A. Hussain is a public health nutritionist, Southside Medical Center, Atlanta, GA; at the time of the study, she was an undergraduate student, Department of Nutrition, College of Health and Human Sciences, Georgia State University, Atlanta. Address for correspondence: Ruowei Li, MD, PhD, Centers for Disease Control and Prevention, Mailstop K-25, 4770 Buford Highway, NE, Atlanta, GA 303413717. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10407-0010$30.00/0 doi: 10.1016/j.jada.2004.04.028
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espite a wide range of benefits of breastfeeding for children and their mothers (1-3), rates of breastfeeding in the United States are low, especially when measured by duration (4). Many states have established legislation that supports breastfeeding (www. ncsl.org), and many corporations have implemented lactation support programs (5-7). Before enacting these laws and policies across the country, policymakers need to know if they will be acceptable to the citizenry. Unfortunately, to date there are no national data to indicate how much the general public would support various breastfeeding policies. The purpose of this study is to describe public beliefs about breastfeeding policies in various settings and to examine the associations of these beliefs with certain sociodemographic characteristics. METHODS We used data from the 2001 Healthstyles survey, a national mail survey of 5,065 US adults who completed that year’s DDB Needham Lifestyle survey. Three thousand seven hundred nineteen persons returned the survey instrument, yielding a 73% response rate. The study population of the Lifestyle survey was generated by quota sampling from a consumer mail panel of some half million adults and the data are weighted on seven demographic variables (age, sex, marital status, race/ethnicity, income, region, and household size) to reflect opinions of US adults aged 18 years and older. It has been demonstrated that the sample distribution of the Healthstyles survey matches that of the US census data and the survey sample reflects the general adult population in the United States (8). Details of the study design and methods are described elsewhere (9). The nine breastfeeding items surveyed are shown in the column headings of Tables 1 and 2. For each statement, respondents were asked to rate their agreement on a scale of 1 to 5, where 1⫽strongly disagree, 2⫽moderately disagree, 3⫽neither disagree nor agree, 4⫽moderately agree, or 5⫽strongly agree. For this analysis, we treated responses of 1 and 2 as indicating disagreement; 4 and 5, agreement; and 3, no opinion. We estimated the percentage of agreement with each breastfeeding statement and compared the weighted proportions of agreement within each stratum using Quantum (10). We applied multiple logistic regression to determine whether each agreement was related to a series of sociodemographic characteristics. Except for the significance test for the weighted proportional difference, all the analyses were conducted using SAS (version 8.0. 1999, SAS Institute, Inc, Cary, NC).
© 2004 by the American Dietetic Association
RESULTS AND DISCUSSION Among all the breastfeeding items surveyed (Table 1), the statement that shopping malls should provide private places to help women breastfeed had the highest percentage agreement (52%), with rates significantly higher among women, African Americans (vs whites), low-income households (⬍$20,000/year) vs households with income ⱖ$50,000/year, and the Mid-Atlantic and East South Central regions (vs West South Central). The items with the lowest level of agreement were No. 4 (tax incentives for employers, 27%) and No. 8 (showing women breastfeeding on television programs, 27.9%). Although the percentage of agreement varied widely, about one third of the population had no opinion across all breastfeeding items (data not shown). To reduce the responses to the nine breastfeeding items surveyed to a set of underlying constructs, we applied exploratory factor analysis with Varimax rotation (11). Because exploratory factor analysis identified four distinct constructs among all the responses with each construct representing a different dimension of data, we present and discuss the results by the following four factors: Factor I (Workplace Breastfeeding Policies), workplaces should have policies to support breastfeeding; Factor II (Lactation Rooms in Public Places), there should be lactation rooms in public buildings or shopping malls; Factor III (Breastfeeding in Public), breastfeeding in public is appropriate; and Factor IV (Breastfeeding Education in High School), high schools should offer education on breastfeeding. These four factors account for 78.6% of the total variance of all the data (data not shown). With regard to Factor I (Workplace Breastfeeding Policies), at least 43% of the population surveyed believes employers should provide flexible work schedules, extended maternity leave, and a private room for pumping breastmilk, but only 27% support providing tax incentives to employers who make special accommodations (Table 1). Women with infants and children are the fastest-growing segment of the US labor force. Studies in the United States suggest that employment may have little influence on breastfeeding initiation, but the timing of return to paid employment is a key factor influencing breastfeeding duration (12,13). Even though the federal legislation provides up to 12 weeks of job-protected, unpaid maternity leave (14), many exceptions to this law exist, including employees in small companies or businesses (⬍50 employees), those working less than an average of 24 hours per week, and employees with less than 1 year of continuous service. Low-income populations, among whom African Americans and Hispanics are overrepresented, may be particularly affected by lack of paid maternity leave and return to paid work soon after childbirth (15). This may partially explain why we found African Americans about three times as likely and Hispanics two times as likely as whites to believe employers should provide extended maternity leave to make it easier for mothers to breastfeed (Table 2). Thus, more favorable treatment of mothers, such as paid leave and allowance for flexible time, might be critical to reaching higher levels of continued breastfeeding, particularly among women whose jobs offer low pay or little status, or both. The analysis of Factor II (Lactation Rooms in Public
Places) indicates substantial support in the US adult population for having public buildings or shopping malls provide lactation rooms to help women breastfeed, with agreement levels of 41% and 52%, respectively (Table 1). For this factor, we found greater support among African Americans than whites and among those with low household incomes than those whose household made $50,000 or more (Table 2). Breastfeeding in public places is often seen as embarrassing and unacceptable in modern societies (16). Our previous study indicates that more than one third of US adults find it embarrassing for a mother to breastfeed in front of others (17). Women often feel vulnerable and nervous and generally sense that people are reluctant to approach them while they are nursing their babies in public places (18). To make women feel at ease about breastfeeding in public places, societal norms need to evolve so breastfeeding is considered a normal occurrence. In the meantime, women need to be prepared with strategies to better cope with the difficulties they encounter. There are mothers who prefer to breastfeed with some privacy when outside the home and this option should be available to them. Establishing lactation rooms in shopping malls or public buildings could help remove some of the barriers to breastfeeding in public places. For Factor III (Breastfeeding in Public), although we found good support (43% agreement) for women’s right to breastfeed in public places, only 28% of persons surveyed think it is appropriate to show a woman breastfeeding on television (Table 1). Men are more likely than women to support breastfeeding in public, whereas people who are ⱖ45 years old or less educated are less likely to support these items than their younger or more educated counterparts (Table 2). Modern American society pays great attention to the sexual and aesthetic functions of women’s breasts, which may make people perceive that breastfeeding should be hidden from the media. Therefore, it is important to encourage the media to portray breastfeeding as a normal, desirable, and achievable activity for women of all cultures and socioeconomic levels as stated in the Department of Health and Human Services’ Blueprint for Action on Breastfeeding (19). Factor IV includes only one item, Breastfeeding Education in High School. Each year in the United States, 800,000 to 900,000 adolescents become pregnant, resulting in about a half million live births (20,21). Unfortunately, young mothers are less likely than older women to breastfeed (22,23). Teenagers not only share the barriers faced by adults, but also face additional barriers. These barriers include lack of support, going back to school, being unmarried, being African American, having an unwanted pregnancy, and belonging to a low socioeconomic group (24-32). Although there is relatively less support for breastfeeding education in high school among the population surveyed, school-based interventions that integrate breastfeeding information into school health education programs can be effective (33). Because education, support, and exposure come from multiple sources and interact with each other, a successful teenage breastfeeding promotion program would probably be a multifaceted intervention involving school, home, and clinical settings.
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Table 1. Summary of the percentage agreement with each statement about breastfeedinga
Believe employers should provide extended maternity leave to make it easier for mothers to breastfeed
3,714
49.7
1,400 2,314
July 2004 Volume 104 Number 7
Sample sizeb
Believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers
Total agreement Sex Male Female Race/ethnicity White African American Hispanic Age (yrs) 18-29 30-44 45-64 65⫹ Household income ⬍$20,000 $20-49,900 $50,000⫹ Education ⱕHigh School ⬎High School Marital status Married Unmarried Employed Yes No Population density Rural Suburban Urban
Believe employers should provide a private room for breastfeeding mothers to pump their milk at work
Public buildings need to have a Would support room tax incentives where for employers women who make could special accommodations breastfeed and pump to make it milk for easier for their mothers to babies breastfeed
Shopping malls should provide private places to help women breastfeed their babies
Believe women should have the right to breastfeed in public places
Believe breastfeeding education It is appropriate should be available as to show a part of a woman breastfeeding high school health her baby education on TV curriculum programs
47.4
43.1
27.0
40.7
52.1
43.1
27.9
33.5
45.8 53.4c
42.5 51.8c
39.7 46.2c
25.5 28.5
37.7 43.5c
47.9 56.0c
45.2 41.3
30.7d 25.2
34.8 32.3
2,822 411 341
48.3 54.3 53.2
44.3 58.9e 54.5e
41.4 48.2e 44.8
25.4 34.0e 27.2
38.3 47.6e 45.7e
50.8 57.7e 49.5
43.1 38.8 46.4
27.2 27.5 33.1
33.6 33.5 31.9
268 1,563 1,347 536
62.1f 50.7g 43.7 43.6
58.5f 49.0g 40.2 43.4
43.8 45.0h 40.1 43.8
30.0 29.3h 22.8 26.5
45.9h 41.7h 36.9 39.1
55.7 53.2 49.3 50.8
52.4g 47.0g 39.1i 30.9
36.3g 31.8g 24.1i 15.7
32.4 32.6 33.6 36.5
704 1,296 1,714
54.2j 49.9 47.3
56.4k 47.0 43.1
47.6j 42.6 41.2
30.8j 27.5 24.8
49.9j 41.1j 35.6
57.4j 52.2 49.4
40.3 43.2 44.5
24.6 31.2l 26.7
37.0 31.6 33.4
1,271 2,387
48.6 49.8
49.5 46.3
45.0 43.3
27.9 26.8
43.8 40.0
53.5 51.7
36.1 46.8m
23.4 29.7m
32.3 34.1
2,648 1,057
49.5 49.9
47.4 47.4
44.9 40.6
27.8 25.7
41.3 39.4
53.9 49.4
45.5n 39.8
27.5 28.7
32.5 35.0
2,563 1,130
48.1 53.5o
45.4 51.9o
40.9 48.3o
25.3 31.3o
38.9 44.8o
50.8 55.0
43.8 41.9
30.4p 22.1
32.4 36.1
811 1,706 1,197
54.0q 45.8 52.1q
51.5q 44.6 48.6
44.0 42.2 43.7
27.4 27.0 26.9
44.3 39.0 40.7
53.9 50.9 52.6
45.5 43.9 40.8
28.8 28.5 26.6
35.7 31.8 34.3 (continued)
Region New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific a
171 552 616 288 666 278 397 252 494
53.1 49.2 47.9 49.6 49.2 50.2 47.2 54.0 52.8
44.3 45.6 47.2 44.8 47.9 51.0 43.6 52.6 49.9
41.5 43.3 41.5 40.5 44.8 49.4 41.0 46.3 41.8
23.6 28.4 26.0 23.6 28.3 26.6 27.8 23.0 29.9
40.2 44.0 42.3 38.9 38.3 43.6 36.0 41.8 41.4
54.9 55.6s 54.6 52.7 51.2 56.8s 46.1 50.4 49.1
44.2 40.6 37.7 41.3 41.1 37.2 43.2 58.8v 50.3x
35.9r 27.1 25.1 27.2 24.6 20.4 30.8u 36.1w 31.3
Values except for sample size represent the percent of agreement with each statement. Sample size may not add to total N because of missing values. c Significantly greater than males at P⫽.05 using special t statistics. d Significantly greater than women at P⫽.05 using special t statistics. e Significantly greater than whites at P⫽.05 using special t statistics. f Significantly greater than 30-44 years, 45-64 years, and ⬎65 years groups at P⫽.05 using special t statistics. g Significantly greater than 45-64 years and ⬎65 years groups at P⫽.05 using special t statistics. h Significantly greater than 45-64 years group at P⫽.05 using special t statistics. i Significantly greater than ⬎65 years group at P⫽.05 using special t statistics. j Significantly greater than ⬎$50,000 group at P⫽.05 using special t statistics. k Significantly greater than $20,000-$49,900 and ⬎$50,000 groups at P⫽.05 using special t statistics. l Significantly greater than ⬍$20,000 and ⬎$50,000 groups at P⫽.05 using special t statistics. m Significantly greater than ⱕHigh School at P⫽.05 using special t statistics. n Significantly greater than unmarried group at P⫽.05 using special t statistics. o Significantly greater than employed group at P⫽.05 using special t statistics. p Significantly greater than not employed group at P⫽.05 using special t statistics. q Significantly greater than Suburban group at P⫽.05 using special t statistics. r Significantly greater than East North Central, South Atlantic, and East South Central groups at P⫽.05 using special t statistics. s Significantly greater than West South Central group at P⫽.05 using special t statistics. t Significantly greater than West North Central group at P⫽.05 using special t statistics. u Significantly greater than East South Central group at P⫽.05 using special t statistics. v Significantly greater than New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, and West South Central groups at P⫽.05 using special t statistics. w Significantly greater than East North Central, South Atlantic, and East South Central groups at P⫽.05 using special t statistics. x Significantly greater than Middle Atlantic, East North Central, South Atlantic, and East South Central groups at P⫽.05 using special t statistics. b
29.0 36.3t 35.9t 23.8 34.9t 32.7 31.1 40.9t 32.4
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Table 2. Adjusted odds of agreement with each breastfeeding statement using multiple logistic regression analysis
Factor I Workplace Breastfeeding Policies
Sex Female (Ref) Male Race/ethnicitya White (Ref) African-American Hispanic Age (yrs) 18-29 30-44a 45-64 65⫹ Household income ⬍$20,000 $20-49,900 $50,000⫹a Education ⱕHigh School ⬎High Schoola Marital status Marrieda Unmarried
Factor II Lactation Rooms in Public Places Public buildings need to have a Would support room tax incentives where for employers women who make could special accommodations breastfeed and pump to make it milk for easier for their mothers to babies breastfeed
Believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers
Believe employers should provide extended maternity leave to make it easier for mothers to breastfeed
Believe employers should provide a private room for breastfeeding mothers to pump their milk at work
— 0.82
— 0.70*
— 0.80
— 0.87
— 1.58* 1.07
— 3.42* 2.27*
— 1.69* 1.12
1.41 — 0.74* 0.55*
1.66 — 0.72* 0.61*
1.37 1.11 —
Factor IV Breastfeeding Education in High School
Shopping malls should provide private places to help women breastfeed their babies
Believe women should have the right to breastfeed in public places
It is appropriate to show a woman breastfeeding her baby on TV programs
Believe breastfeeding education should be available as part of a high school health education curriculum
— 0.88
— 0.77*
— 1.39*
— 1.49*
— 1.35*
— 2.04* 1.05
— 2.25* 1.46
— 1.84* 0.98
— 1.11 1.00
— 1.17 1.13
— 1.15 0.98
0.90 — 0.92 0.93
0.97 — 0.63* 0.64*
1.07 — 0.87 0.87
0.95 — 0.81 0.86
1.45 — 0.66* 0.42*
1.52 — 0.59* 0.32*
0.96 — 1.19 1.20
1.85* 1.01 —
1.69* 1.16 —
1.80* 1.18 —
2.63* 1.38* —
2.05* 1.59* —
1.09 1.12 —
0.92 1.24 —
1.57* 1.01 —
0.88 —
1.15 —
0.99 —
1.01 —
1.06 —
0.91 —
0.63* —
0.69* —
0.81 —
— 0.88
— 0.71*
— 0.66*
— 0.67*
— 0.71*
— 0.67*
— 0.77
— 1.05
— 1.13 (continued)
Factor III Breastfeeding in Public
0.81 1.57* 1.07 0.65 0.97 0.94 0.81 1.57 — 0.87 0.78 0.47* 0.42* 0.54* 0.37* 0.59* 0.74 — 0.69 0.59 0.42 0.41 0.54 0.33 0.57* 0.96 — 1.46 1.37 1.18 1.15 1.03 1.48 0.76 1.07 — 1.03 1.20 0.98 0.86 0.72 0.76 0.58 0.77 — 0.82 1.04 0.75 0.65 0.77 0.76 0.79 0.70 —
1.53* — 1.34* 1.30 — 0.88 1.35* — 0.91 1.34 — 1.18 1.64* — 1.24 1.28 — 1.03
●
0.80 1.16 0.86 0.63 0.91 0.78 0.59 0.69 — 0.86 0.97 0.63* 0.52* 0.79 0.87 0.57* 0.73 —
a Reference level. *95% confidence interval does not include one.
1.76* — 1.25 1.61 — 1.26
1.07 1.15 1.00 0.92 0.87 1.01 0.86 0.97 —
— 1.49*
Employed Yesa No Population density Rural Suburbana Urban Region New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacifica
— 1.39*
1.35 — 1.22
— 0.95 — 1.26 — 1.04 — 1.10
●
— 1.37*
●
— 1.48*
— 1.11
CONCLUSIONS Although our results show that public support for breastfeeding policies varies, a large proportion of the general public would support the policies surveyed in this study. Establishing workplace breastfeeding policies and lactation rooms in public places are the most acceptable breastfeeding policies surveyed, especially among African Americans and low-income populations. The overall population appears to approve of breastfeeding in public, but less educated or older persons (aged ⱖ45 years ) are less likely to do so. In general, there is relatively less public support for breastfeeding education in high schools. Based on the findings of this study, we have several recommendations. In recent years, employers have been encouraged to establish breastfeeding policies and to provide appropriate facilities for pumping breastmilk. The public support for these policies at work should ease the way toward implementation of such policies. Public support is essential for implementing any changes in the social environment. The support of people for establishing lactation rooms in the public places confirms the need of such change and encourages implementation of this policy. To establish and implement breastfeeding policies successfully, future studies that provide direct evidence on how these policies influence a woman’s breastfeeding behavior are warranted and cost-benefit analyses of interventions are also needed.
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