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 J Hum Lact OnlineFirst, published on May 19, 2010 as doi:10.1177/0890334410362222

Maternal Hospital Experiences Associated With Breastfeeding

at 6 Months in a Northern California County
Haydee A. Dabritz, PhD, Bette G. Hinton, MD, and Jan Babb, MSN

Abstract
A retrospective cohort study of infant-feeding practices at 6 months of age was conducted for
382 breastfed infants in a semirural northern California county. The authors hypothesized that
almost exclusive breastfeeding at 6 months would be related to maternal experiences in the
hospital. Multiple logistic regression analysis, controlling for maternal age and education,
found that almost exclusive breastfeeding at 6 months was positively associated with receiving
a telephone number for breastfeeding help from the hospital (odds ratio, 6.45; 95% confidence
interval, 1.23-33.9), use of a breast pump in the first 6 months (odds ratio, 2.19; 95% confi-
dence interval, 1.01-4.76), and gestational age (odds ratio, 2.26; 95% confidence interval,
1.08-4.71 for a 4-week age difference), whereas formula supplementation at the hospital had
a negative association (odds ratio, 0.27; 95% confidence interval, 0.13-0.56). Making postpar-
tum breastfeeding support easily accessible and offering breast pumps at low or no cost may
help to increase exclusive breastfeeding rates in this county. J Hum Lact. XX(X):xx-xx.
Keywords: artificial infant milk, breast pumping, exclusive breastfeeding, hospital practices,
Baby-Friendly Hospital Initiative (BFHI)

Supplementation with artificial milk (formula feeding)
shortly after birth and weaning from the breast within
a few weeks or months has been a culturally accept-
able practice for American mothers for many decades,
with prevalence of any breastfeeding at 6-months-
old reaching an all-time low in 1971.1,2 Over the past
Accepted for publication December 12, 2009.
No reported competing interests.
Haydee A. Dabritz, PhD, obtained her PhD in epidemiology from the
University of California Davis and is currently employed as a research
epidemiologist with the California Department of Public Health, Infant
Botulism Treatment and Prevention Program, in Richmond. Bette G.
Hinton, MD, received her MD from the University of Louisville in 1973,
completed her MPH and preventive medicine residency at Johns Hopkins
University in 1975, and received board certification from the American
Board of Preventive Medicine in 1977, after completing a public health
residency at the State of Maryland, Department of Health and Mental
Hygiene. She served in California as the health officer in Sacramento
County for 11 years and Yolo County for 9 years until her retirement in
December 2008. Jan Babb, MSN, is a public health nurse and pediatric
nurse practitioner. She received her bachelor of science in nursing from the
University of California San Francisco in 1981 and her master of science in
nursing from California State University in 1990. She has served as the
MCAH director for the Yolo County Health Department since 2006 and is
the cochair of the Community Breastfeeding Coalition of Yolo County.
Address correspondence to Jan Babb, MSN, Yolo County Health Department,
MCAH Program, 137 N. Cottonwood Street, Ste. 2450, Woodland, CA
95695; e-mail: jan.babb@yolocounty.org.
J Hum Lact XX(X), XXXX
DOI: 10.1177/0890334410362222
© Copyright 2010 International Lactation Consultant Association
35 years, gains have been made, but the increases in
breastfeeding prevalence and duration fall far short of
the Healthy People 2010 objectives for some groups in
the population, including teenagers, mothers in low-
income households, mothers with less formal educa-
tion, and those belonging to certain ethnic minorities.3-6
A strong public health community response to this
problem is critical to increase the prevalence and dura-
tion of breastfeeding and to reshape our cultural view
of infant feeding.7 The American Academy of Pediatrics
(AAP) recommends exclusive breastfeeding for the
first 6 months of life; thereafter adding complementary
foods and continuing to breastfeed up to the age of 1
year, longer if mother and infant mutually desire.8
Infants receiving exclusively breast milk in the first 6
months do not need supplemental fluids, such as water
and juice, even in hot climates like California.8
Exclusive breastfeeding provides optimal infant nutri-
tion and protects infants against intestinal and respira-
tory infections.9-11 It also confers a number of long-term
health benefits7,12-16 and reduces the likelihood of sud-
den infant death syndrome (SIDS).17,18
In 1989, in an effort to promote breastfeeding for
infants around the globe, the United Nations Inter-
national Children’s Emergency Fund (UNICEF) and
the World Health Organization (WHO) established the
Baby-Friendly Hospital Initiative (BFHI) and the Ten
Steps to Successful Breastfeeding.19 Many hospitals

JHL362222.indd 1 14/04/2010 11:25:43 AM

 2 Dabritz et al
worldwide strove to implement their recommendations
and become BFHI certified. The 2 hospitals deliver-
ing the majority of infants in this study did not meet
BFHI guidelines in 2006. Since the study, 1 of these
hospitals has received Baby-Friendly designation. No
data about long-term breastfeeding rates or factors
associated with breastfeeding duration in the local
health jurisdiction had been collected, other than
Internet-accessible in-hospital breastfeeding rates (by
hospital and race/ethnicity) from the California
Department of Public Health (CDPH) Newborn
Screening Test Form20 and breastfeeding questions on
the Centers for Disease Control and Prevention
National Immunization Survey, conducted annually
since 2003.5 However, the CDPH newborn screening
does not track breastfeeding rates at later time points,
and the National Immunization Survey does not pro-
vide county-level estimates of breastfeeding duration.
Therefore, a study to determine breastfeeding rates for
infants at various time points in the first 6 months of
life was initiated in this semirural county. One of its
objectives, the focus of this article, was to evaluate the
effects of the hospital experience on breastfeeding at 6
months of age, accounting for well-recognized predic-
tors of breastfeeding duration.
Methods
Subject Selection Criteria
All mothers were recruited postnatally. Mothers were
eligible to be in the study if they were residents of Yolo
County (regardless of delivery hospital) at the time of
delivery, they gave birth to a live infant, the infant lived
in the mother’s home, and the infant was between 0 and
8 months old at the time the mother signed up to
participate in the study. They could participate in the
study regardless of infant-feeding status, even if they
had never breastfed. They were told that the study was
to assess infant-feeding practices, rather than specifically
about breastfeeding behavior and outcomes, so as not to
discourage recruitment of mothers who had not breastfed
or planned to do so for only a short time. Interviews
were conducted between May 2006 and April 2007,
when the infant had reached 6 months of age. Mothers
of twins were interviewed about the hospital experience
and infant-feeding practices for each infant separately. A
human subjects protocol for the study was reviewed and
approved by the Institutional Review Board at the
University of California, Davis.
JHL362222.indd 2
J Hum Lact XX(X), XXXX
Recruitment of Participants
Mothers were recruited through outreach by staff at
community health centers; family health care practices;
pediatricians’ offices; a retail store selling baby products;
a migrant camp; the county’s Special Supplemental
Nutrition Program for Women, Infants, and Children
(WIC); and a breastfeeding support program at a university
campus. Participants also found out about the study
through word of mouth from public health nurses and
health ca re provider staff. Mothers interested in
participating in the study completed a form with their
contact information and infant birth date. One of 2
interviewers (fluent in English and Spanish) contacted
the mother when her infant had reached 6 months old.
Up to 10 attempts were made to reach mothers who
returned the signup form. Study participants received a
$30 gift card to a local retail store after completing the
30-minute telephone interview.
Questionnaire Design and Scope
The 67-question survey was developed by an advi-
sory group of experts in the field of breastfeeding and
maternal and child health. The group included repre-
sentatives from the 2 hospitals, nurse practitioners from
local medical practices, physicians, university faculty,
international board-certified lactation consultants, and
epidemiologists from the local health jurisdiction. The
survey contained questions in 7 areas: predelivery breast-
feeding intentions, information, and encouragement;
hospital experiences; feeding practices (milk feeding
[designated as 100% breast milk, mixed breast milk
and formula, or 100% formula] at 2 days, 2 weeks,
2 months, and 6 months); breast pump usage; support
in the work or school environment; support in the child
care environment; and demographic characteristics. A
copy of the questionnaire is available from the corre-
sponding author on request.
Definition of Variables
Variables relating to the hospital experience (yes,
no) were cesarean section (but not whether this was
preplanned or emergency), presence of a maternal
medical problem at delivery (“any problems with your
health at birth that made it hard for you to care for the
baby”), receiving breastfeeding information from the
hospital staff, infant rooming-in with the mother for
the entire hospital stay, any breastfeeding in the hospi-
tal, breastfeeding at <1 hour of birth, staff teaching the
mother how to breastfeed, feeding the infant breast
14/04/2010 11:25:43 AM
 J Hum Lact XX(X), XXXX Maternal Hospital Experiences
milk exclusively (ie, no dextrose or liquids other than
breast milk; could include breast milk fed by bottle),
feeding the infant formula, feeding the infant breast or
formula milk by bottle, use of a breast pump by the
mother at the hospital, receiving instructions from staff
to feed the infant on demand, getting a discharge gift
pack containing formula, receipt of a phone number
for breastfeeding help, use of a pacifier by the infant at
the hospital, and the mother expressing a desire for
additional breastfeeding support from hospital staff.
Hospital of birth was defined as occurring at location
A, B, C, or D. Designations A and B were smaller
delivery hospitals, C was a large managed-care hospital
system, and D represented all other delivery hospitals
(because deliveries occurred at 26 other hospitals).
Results from the bivariate analyses pertaining to indi-
vidual hospitals or hospital groups are presented anon-
ymously. Breastfeeding variables included intention
(definitely/probably planning to breastfeed, did not
know/no plans), presence of breastfeeding family mem-
bers, prior experience breastfeeding, feeding breast
milk exclusively in the first 3 months of life, use of a
breast pump in the first 6 months, the mother experi-
encing “barriers or difficulties in breastfeeding” in the
first 6 months (open-ended question), and the mother
needing additional breastfeeding support in the first 6
months. Infant variables included gender, weeks gesta-
tion (continuous), birth weight (continuous), presence
of a neonatal problem (defined as “problems with the
baby’s health at birth”), admission to the neonatal
intensive care unit (NICU), and attendance at day care.
The maternal variables were being a recipient of WIC
benefits (yes, no), maternal ethnicity (Hispanic, white,
all other), family composition (living with spouse/part-
ner, family/friends, or single), parity (1 or > 1 child),
maternal age (continuous), maternal education (high
school or less, some college/technical school, and col-
lege degree or higher), annual household income (<
$40K, ≥ $40K, unknown/declined), and maternal birth
country (United States, Mexico, all other foreign coun-
tries). Annual household income was initially collected
as < $15K, $15 to < $25K, $25K to < $40K, $40K to <
$75K, ≥ $75K, and declined/unknown. Because descrip-
tive analyses of breastfeeding rates at the 4 time points
for the 3 lowest income categories did not differ, income
categories were collapsed into those defined above.
The 3 outcomes at the 6-month time point were des-
ignated as almost exclusive breastfeeding (AEBF) for
infants receiving breast milk as the only milk source
and included some infants who were infrequently fed
JHL362222.indd 3
3
water, juice, or solid food21; partial breastfeeding (PBF)
for infants receiving mixed feedings of breast and for-
mula milk; and no breastfeeding for infants receiving
exclusively formula. Liquids (water or juice) and solid
foods being fed at the 6-month time point, if any, were
also recorded. Breastfeeding status at 6 months was
verified by comparing responses to the specific ques-
tion about milk feeding at the 6-month time point with
answers to the open-ended question, “How old was
your baby when you stopped breastfeeding or feeding
pumped breast milk to him/her?” Mothers could pro-
vide their answers in units of days, weeks, or months,
as well as responding that they were still breastfeeding
at the time of interview.
Statistical Analysis
Sample size calculations with 95% confidence and
80% power indicated that 133 to 186 infants would be
needed in each group to detect statistically significant
differences of 15% in the prevalence of a risk factor.
Fewer infants (< 100/group) would be needed if risk
factors differed by larger proportions. A target sample
size of 399 infants, assuming approximately one third
would be exclusively breastfeeding at 6 months of age,
was selected in consideration of funding and resources.
Descriptive statistics were computed in Epi Info, ver-
sion 3.3.2 (Centers for Disease Control and Prevention,
Atlanta, Georgia), and logistic regression, c2, Fisher
exact, and t tests were performed in SAS, version 9.1
(SAS Institute Inc, Cary, North Carolina). Chi-square
or Fisher exact tests (if expected cell counts ≤ 5 in 2 ×
2 contingency tables) and t tests (for continuous vari-
ables) were used to compare characteristics of 2006
births in the county to infants enrolled in the study and
any or exclusive breastfeeding prevalence by hospital
from the CDPH Newborn Screening Test to maternal
report at 2 days of age for the hospital locations in the
study with ≥ 20 study infants. It should be noted that
breastfeeding reported on the Newborn Screening Test
and that at 2 days old in the study are not strictly com-
parable because the former occurs at some time in the
first days of life, whereas the study asked about breast-
feeding at a specific time point.
Infants were included in the logistic regression if
they were ever breastfed, even once. Factors associated
with AEBF versus no breastfeeding and PBF versus
no breastfeeding were assessed in 2 separate multivari-
ate models. Potential predictors with P < .20 in bivari-
ate analyses were selected as candidates for the multiple
logistic regression model. Participants who did not
14/04/2010 11:25:43 AM
 4 Dabritz et al
remember or declined to respond to questions about
what happened in the hospital were coded as missing
data and were omitted from analyses. Continuous pre-
dictors associated with AEBF or PBF in bivariate analy-
ses were checked for linearity by plotting the estimated
log odds against the midpoints of the group (quartile or
5 categories for maternal age). Variables with P < .05
were considered statistically significant in the multi-
variate model. Multivariate models were built using
forward and backward stepwise regression to verify
that the selected model contained the same variables.
Models were compared with the likelihood ratio test,
and Aikaike’s information criterion was used to com-
pare nonnested models.22 The model with the smallest
Aikaike’s information criterion was then selected as
the most appropriate model. Fit of the final model
was assessed with the Hosmer-Lemeshow goodness-
of-fit test.23
Results
Demographic Data and Comparison to 2006 Births
in the County and In-hospital Newborn Screening
A total of 438 contact forms (47%) were returned
out of the 932 distributed to health care providers and
community partners. The 2 interviewers were able to
reach 93% of mothers completing contact forms,
resulting in 399 interviews representing 405 infants
(6 mothers with twins). The mean age of the infant on
the date of interview was 28.6 ± 0.3 weeks (range, 21-42
weeks). One infant aged 21 weeks on the date of inter-
view, whose mother was accidentally contacted early,
was retained in the analysis because the infant had
stopped breastfeeding prior to the interview date. One
third of infants (n = 132) were born at out-of-county
hospitals, and 3 were born at home. Mean gestational
age was 39.3 ± 0.2 weeks (range, 26-44 weeks), and
mean birth weight was 3.45 ± 0.06 kg (range, 0.86-
4.94 kg). Birth weights of study infants were distrib-
uted similarly to the birth weights of all infants born to
county residents in 2006. Twenty-three percent of
births were by cesarean section (vs 25% for all 2006
births in the county). Compared to the 2643 live births
in the county in 2006, participants did not differ sig-
nificantly in their level of education (P = .20) but were
significantly different for city of residence (P < .001),
age (P < .001), ethnicity (P = .002), health insurance
coverage (P < .001), and hospital of birth (P = .043).
Residents from 1 city, teen mothers, Hispanic mothers,
Medi-Cal recipients or families without insurance, and
JHL362222.indd 4
J Hum Lact XX(X), XXXX
births at hospital A were somewhat overrepresented
(data not shown). Sixty-eight percent (n = 272) of par-
ticipants were receiving WIC benefits, and 50% (n =
201) had annual household incomes of < $25K. In
large part, the high proportion of low-income house-
holds in the survey reflects the success of recruitment
efforts at the county WIC locations. The WIC recipients
differed significantly from all other mothers for sev-
eral demographic variables (data not shown). They
were younger in age, had less education, lived in lower
income households, and were predominantly Hispanic.
Breastfeeding was initiated at least once for 382
(94% of 405) infants. Compared to any breastfeeding
reported on the in-hospital CDPH Newborn Screening
Test Form in 2006, prevalence of any breastfeeding
(ie, our definition of PBF) at 2 days old was similar for
all hospitals except hospital B (2006 prevalence of
98% vs 94% for study infants, P = .01). The preva-
lence of in-hospital exclusive breastfeeding on the
CDPH Newborn Screening Test Form differed for
study infants at 3 hospitals: Hospital A (2006 preva-
lence 51% vs 64% for study infants, P = .01), hospital
B (2006 prevalence 90% vs 78% for study infants, P <
.001), and hospital C (2006 prevalence 73% vs 50%
for study infants, P < .001).
Bivariate Analyses
Factors relating to the hospital experience that had
strong negative associations (P < .05) with AEBF ver-
sus not breastfeeding at 6 months included birth in
hospital A versus all other, formula or bottle-feeding at
the hospital, the mother receiving a gift pack with for-
mula samples at discharge, and use of a pacifier (Table
1). Mothers who gave birth at hospital A (n = 104)
came from households with lower socioeconomic sta-
tus: 84% were receiving WIC benefits, and 55% lived
in households with annual incomes < $25K. Feeding
the infant exclusively breast milk in the hospital was
positively associated with AEBF at 6 months. Experi-
ences at the delivery hospital associated with a greater
likelihood of PBF versus not breastfeeding at 6 months
of age were being fed breast milk exclusively, not
being fed formula, not using a pacifier, and having a
mother who did not use a breast pump at the hospital
(Table 1).
Breastfeeding-related factors that had positive asso-
ciations with AEBF at 6 months of age included having
a mother with definite or probable plans to breastfeed,
use of a breast pump by the mother in the first 6
months, having a mother who experienced barriers to
14/04/2010 11:25:43 AM
 J Hum Lact XX(X), XXXX Maternal Hospital Experiences 5

Table 1. Bivariate Analyses of the Association of Hospital Experiences With AEBF Versus Not Breastfeeding and PBF Versus Not
Breastfeeding for 6-Month-Old Infants Born to Mothers Residing in Yolo County, Californiaa

AEBF PBF
No. Not
No. Odds Ratio No. Odds Ratio Breastfeeding
Risk Factor Category (% of 121) (95% CI) (% of 108) (95% CI) (% of 153)

Hospital of birth D 29 (24) 1.0 18 (17) 1.0 33 (22)

A 17 (14) 0.3 (0.2-0.7)b 27 (25) 0.8 (0.4-1.7) 60 (39)
B 55 (45) 1.3 (0.7-2.4) 51 (47) 1.9 (0.9-3.8)c 49 (32)
C 20 (17) 2.1 (0.9-5.0)c 12 (11) 2.0 (0.7-5.4) 11 (7)
Mother had a medical problem at delivery No 112 (93) 1.0 104 (96) 1.0 145 (95)
Yes 8 (7) 1.5 (0.5-4.2) 4 (4) 1.5 (0.5-4.2) 7 (5)
Missing 1 (1) 0 (0) 1 (0.7)
Mother had a cesarean No 94 (78) 1.0 84 (78) 1.0 113 (74)
Yes 26 (21) 0.8 (0.4-1.4) 24 (22) 0.8 (0.5-1.4) 40 (26)
Missing 1 (1) 0 (0) 0 (0)
Mother received breastfeeding information from the hospital No 9 (7) 1.0 6 (6) 1.0 5 (3)
Yes 107 (88) 0.4 (0.1-1.2)c 102 (94) 0.6 (0.2-2.0) 147 (96)
Missing 5 (4) 0 (0) 1 (0.7)
Infant roomed with mother for entire hospital stay No 17 (14) 1.0 18 (17) 1.0 24 (16)
Yes 101 (83) 1.1 (0.6-2.2) 89 (82) 0.9 (0.5-1.8) 129 (84)
Missing 3 (2) 1 (1) 0 (0)
Infant breastfed in the hospital No 2 (2) 1.0 6 (6) 1.0 11 (7)
Yes 115 (95) 4.5 (1.0-20.1)c 102 (94) 1.3 (0.5-3.7) 142 (93)
Missing 4 (3) 0 (0) 0 (0)
Infant breastfed < 1 hour of birth No 20 (17) 1.0 29 (27) 1.0 40 (26)
Yes 97 (80) 1.8 (1.0-3.2)c 75 (69) 0.9 (0.5-1.6) 111 (73)
Missing 4 (3) 4 (4) 2 (1)
Hospital staff taught mother how to breastfeed No 15 (12) 1.0 17 (16) 1.0 23 (15)
Yes 103 (85) 1.2 (0.6-2.5) 91 (84) 1.0 (0.5-1.9) 128 (84)
Missing 3 (2) 2 (1)
Infant fed breast milk exclusively at the hospital No 29 (24) 1.0 37 (34) 1.0 74 (48)
   (including by bottle)
Yes 89 (74) 2.9 (1.7-4.9)b 71 (66) 1.8 (1.1-3.0)b 79 (52)
Missing 3 (2) 0 (0) 0 (0)
Infant fed formula at the hospital No 90 (74) 1.0 66 (61) 1.0 71 (46)
Yes 28 (23) 0.3 (0.2-0.5)b 42 (39) 0.6 (0.3-0.9)b 80 (52)
Missing 3 (2) 0 (0) 2 (1)
Infant fed by bottle (breast or formula milk) at the hospital No 93 (77) 1.0 59 (55) 1.0 83 (54)
Yes 24 (20) 0.3 (0.2-0.5)b 49 (45) 1.0 (0.6-1.6) 69 (45)
Missing 4 (3) 0 (0) 1 (0.7)
Mother used a breast pump at the hospital No 93 (77) 1.0 90 (83) 1.0 105 (69)
Yes 25 (21) 0.6 (0.3-1.0)c 18 (17) 0.4 (0.2-0.8)b 48 (31)
Missing 3 (2) 0 (0) 0 (0)
Mother was told to feed infant on demand No 14 (12) 1.0 11 (10) 1.0 27 (18)
Yes 102 (84) 1.6 (0.8-3.3)c 95 (88) 1.9 (0.9-4.1)c 121 (79)
Missing 5 (4) 2 (2) 5 (3)
Mother received a gift pack with formula from the hospital No 56 (46) 1.0 33 (31) 1.0 42 (27)
Yes 55 (45) 0.4 (0.2-0.6)b 74 (68) 0.9 (0.5-1.5) 110 (72)
Missing 10 (8) 1 (1) 1 (0.7)
Hospital staff provided a telephone number for No 5 (4) 1.0 11 (10) 1.0 17 (11)
   breastfeeding help
Yes 107 (88) 2.7 (1.0-7.5)c 93 (86) 1.1 (0.5-2.4) 135 (88)
Missing 9 (7) 4 (4) 1 (0.7)
Infant used a pacifier at the hospital No 87 (72) 1.0 73 (68) 1.0 76 (50)
Yes 29 (24) 0.3 (0.2-0.6)b 33 (31) 0.5 (0.3-0.8)b 76 (50)
Missing 5 (4) 2 (2) 1 (0.7)
Mother wanted additional support from the hospital No 101 (83) 1.0 91 (84) 1.0 130 (85)
Yes 18 (15) 1.0 (0.5-2.0) 17 (16) 1.1 (0.5-2.1) 23 (15)
Missing 2 (2) 0 (0) 0 (0)
a
AEBF, almost exclusive breastfeeding; CI, confidence interval; PBF, partial breastfeeding.
b
Statistically significant at P < .05.
c
.05 < P < .20, selected as a potential covariate for the multiple logistic regression model.

JHL362222.indd 5 14/04/2010 11:25:43 AM

 6 Dabritz et al J Hum Lact XX(X), XXXX

Table 2. Bivariate Analyses of the Association of Breastfeeding Variables With AEBF Versus Not Breastfeeding and PBF Versus Not
Breastfeeding for 6-Month-Old Infants Born to Mothers Residing in Yolo County, Californiaa

AEBF PBF

No. Odds Ratio No. Odds Ratio No. Not Breastfeeding

Risk Factor Category (% of 121) (95% CI) (% of 108) (95% CI) (% of 153)

Breastfeeding intention Unsure/no plans 6 (5) 1.0 8 (7) 1.0 17 (11)

Definitely/probably 115 (95) 2.4 (0.9-6.3)c 100 (93) 1.6 (0.7-3.8) 136 (89)
Presence of breastfeeding family members No 22 (18) 1.0 8 (7) 1.0 21 (14)
Yes 99 (82) 0.7 (0.4-1.4) 100 (93) 2.0 (0.9-4.7)c 132 (86)
Mother breastfed a previous child No 66 (55) 1.0 52 (48) 1.0 90 (59)
Yes 55 (45) 1.2 (0.7-1.9) 55 (51) 1.5 (0.9-2.5)c 63 (41)
Missing 0 (0) 1 (1) 0 (0)
Infant was exclusively breastfed for first No 34 (28) 1.0 55 (51) 1.0 93 (61)
   3 months of life
Yes 87 (72) 4.0 (2.4-6.6)b 53 (49) 1.5 (0.9-2.5)c 60 (39)
Mother used a breast pump in the first 6 months No 20 (17) 1.0 45 (42) 1.0 58 (38)
Yes 101 (83) 3.1 (1.7-5.5)b 63 (58) 0.9 (0.5-1.4) 95 (62)
Mother had barriers to breastfeeding No 51 (42) 1.0 66 (61) 1.0 88 (58)
   in the first 6 months
Yes 70 (58) 1.9 (1.2-3.0)b 42 (39) 0.9 (0.5-1.4) 65 (42)
Mother wanted additional breastfeeding No 102 (84) 1.0 91 (84) 1.0 122 (80)
   support in the first 6 months
Yes 19 (16) 0.7 (0.4-1.4) 17 (16) 0.7 (0.4-1.4) 31 (20)
a
AEBF, almost exclusive breastfeeding; CI, confidence interval; PBF, partial breastfeeding.
b
Statistically significant at P < .05.
c
.05 < P < .20, selected as a potential covariate for the multiple logistic regression model.

breastfeeding, and having a mother who wanted addi-
tional breastfeeding support in the first 6 months
(Table 2). However, for this group of variables, the
associations with PBF at 6 months were weaker or did
not exist (Table 2).
Infant and maternal demographic variables that
had significant positive associations (P < .05) with
AEBF versus not breastfeeding at 6 months of age
included mother’s employment status (notably; part-
time or at home vs full-time), older maternal age,
higher maternal education (a college or postgraduate
degree vs less than high school education), and
annual household income ≥ $40K (Table 3). Having
a mother on WIC, having a US- or foreign-born
Hispanic mother versus a US-born white mother, and
living with family/friends versus a spouse/partner
were negatively associated with AEBF at 6 months.
Similarly, PBF versus not breastfeeding at 6 months
of age had positive associations with maternal age
and education and negative associations for infants
with mothers on WIC and living with family/friends
but also for infants born to single mothers (Table 3).
In addition, infants were more likely to be PBF at 6
months if they had foreign-born Hispanic mothers
compared to US-born white mothers.
Logistic Regression Analysis: AEBF
Versus Not Breastfeeding at 6 Months of Age
Of the 121 infants who received breast milk as their
principal food source in the first 6 months of life,
87 (72%) were fed breast milk exclusively in the first
3 months of life. At 6 months of age, 80 (66%) were
receiving other liquids or foods. Sixty-eight (56%)
were given spoon or finger feedings of solids, 7 (6%)
were occasionally fed nonmilk fluids (juice or tea) by
bottle, and data on what liquids/solids were introduced
for 5 were unknown (4%). Of the 39 predictor variables
evaluated for their association with AEBF at the 6-month
time point, 26 had P < .20 and were candidates for the
multiple logistic regression model (Tables 1-3). In the
multiple logistic regression analysis (n = 15 infants with
incomplete data), 6 variables were associated with
AEBF at 6 months (Table 4). The Hosmer-Lemeshow
statistic indicated the model fit was adequate (P = .25).
Formula supplementation at the hospital was nega-
tively associated with AEBF at 6 months (odds ratio
[OR], 0.27), whereas receiving a telephone number for
breastfeeding help had a positive association (Table 4).
Infants whose mothers were given a breastfeeding help
line number had 6 times the odds of AEBF at the
6-month time point compared to infants whose mothers

JHL362222.indd 6 14/04/2010 11:25:43 AM

 J Hum Lact XX(X), XXXX Maternal Hospital Experiences 7

Table 3. Bivariate Analyses of the Association of Infant and Maternal Variables With AEBF Versus Not Breastfeeding and PBF Versus
Not Breastfeeding for 6-Month-Old Infants Born to Mothers Residing in Yolo County, Californiaa

AEBF PBF
No. Not
Odds Ratio Odds Ratio Breastfeeding
Risk Factor Category No. (% of 121) (95% CI) No. (% of 108) (95% CI) (% of 153)

Infant variables
   Infant gender Female 61 (50) 1.0 54 (50) 1.0 76 (50)
Male 60 (50) 1.0 (0.6-1.6) 54 (50) 1.0 (0.6-1.6) 77 (50)
   Gestational age Each week older 1.1 (1.0-1.3)c 1.1 (0.9-1.2)
   Infant birth weight Each additional 1 kg in weight 1.3 (0.9-2.1)c 1.3 (0.9-2.1)c
Weight unknown 1 (1) 0 (0) 1 (0.7)
   Infant had a neonatal problem No 106 (88) 1.0 91 (84) 1.0 132 (86)
Yes 15 (12) 0.9 (0.5-1.9) 17 (16) 1.2 (0.6-2.5) 20 (13)
Missing 0 (0) 0 (0) 1 (0.7)
   Infant admitted to NICU No 116 (96) 1.0 100 (93) 1.0 139 (91)
Yes 5 (4) 0.5 (0.2-1.3)c 8 (7) 0.9 (0.3-2.1) 13 (9)
Missing 0 (0) 0 (0) 1 (0.7)
   Birth order 1 64 (53) 1.0 53 (49) 1.0 82 (54)
>1 57 (47) 1.0 (0.6-1.6) 55 (51) 0.8 (0.5-1.4) 71 (46)
   Infant attended daycare No 78 (64) 1.0 76 (70) 1.0 100 (65)
Yes 42 (35) 1.0 (0.6-1.7) 32 (30) 0.8 (0.5-1.4) 53 (35)
Missing 1 (1) 0 (0) 0 (0)
Maternal variables
   Returned to work or school Stay at home 58 (48) 1.0 54 (50) 1.0 69 (45)
Work 47 (39) 1.0 (0.6-1.8) 35 (32) 0.8 (0.5-1.4) 54 (35)
School 7 (6) 0.4 (0.2-0.95)b 10 (9) 0.6 (0.3-1.3)c 22 (14)
Work and school 9 (7) 1.3 (0-3.7) 9 (8) 1.4 (0.5-4.0) 8 (5)
   Employment/student status Full-time 24 (20) 1.0 31 (29) 1.0 50 (33)
Part-time or seasonal 39 (32) 2.4 (1.2-4.7)b 23 (21) 1.1 (0.6-2.2) 34 (22)
Stay at home 58 (48) 1.8 (1.0-3.2)c 54 (50) 1.3 (0.7-2.2) 69 (45)
   Mother received WIC benefits No 74 (61) 1.0 29 (27) 1.0 20 (13)
Yes 47 (39) 0.1 (0.05-0.2)b 79 (73) 0.4 (0.2-0.8)b 133 (87)
   Ethnicity/birth country US-born white 66 (55) 1.0 18 (17) 1.0 36 (24)
US-born Hispanic 12 (10) 0.2 (0.1-0.3)b 8 (7) 0.4 (0.1-0.9)b 45 (29)
US-born other ethnicity 3 (2) 0.2 (0.1-0.7)c 7 (6) 1.6 (0.5-4.9) 9 (6)
Foreign-born Hispanic 21 (17) 0.2 (0.1-0.4)b 64 (59) 2.3 (1.2-4.5)b 56 (37)
Foreign-born other ethnicity 8 (7) 0.7 (0.2-2.3) 6 (6) 2.0 (0.6-7.1) 6 (4)
Foreign-born white 9 (7) 4.9 (0.6-40.3)c 4 (4) 8.0 (0.8-76.9)c 1 (0.6)
Declined 2 (2) 1 (1) 0 (0)
   Family composition Lives with partner/spouse 107 (88) 1.0 89 (82) 1.0 88 (58)
Lives with family/friend 6 (5) 0.1 (0.04-0.2)b 14 (13) 0.3 (0.1-0.5)b 50 (33)
Single parent 8 (7) 0.4 (0.2-1.1)c 5 (5) 0.3 (0.1-0.95)b 15 (10)
   Maternal age Each additional year older 1.2 (1.1-1.3)b 1.1 (1.06-1.2)b
   Maternal education Less than high school 7 (6) 1.0 19 (18) 1.0 34 (22)
High school graduate 23 (19) 1.4 (0.6-3.6) 45 (42) 1.0 (0.5-2.0) 79 (52)
Some college/technical school 14 (12) 2.4 (0.9-6.8)c 21 (19) 1.3 (0.6-3.0) 28 (18)
College/technical school graduate 33 (27) 17.8 (5.9-53.4)b 13 (12) 2.6 (0.9-7.2)c 9 (6)
Postgraduate 43 (36) 104 (20.4-535)b 10 (9) 9.0 (1.8-45.2)b 2 (1)
Declined 1 (1) 0 (0) 1 (0.7)
   Annual household income, $ < 40K 53 (44) 1.0 80 (74) 1.0 117 (76)
≥ 40K 58 (48) 7.5 (4.0-14.2)b 19 (18) 1.6 (0.8-3.3)c 17 (11)
Unknown/declined 10 (8) 1.2 (0.5-2.7) 9 (8) 0.7 (0.3-1.6) 19 (12)
a
AEBF, almost exclusive breastfeeding; CI, confidence interval; NICU, neonatal intensive care unit; PBF, partial breastfeeding; WIC, Special Supplemental
Program for Women, Infants, and Children.
b
Statistically significant at P < .05.
c
.05 < P < .20, selected as a potential covariate for the multiple logistic regression model.

were not. In addition, infants whose mothers used a Infant and maternal demographic risk factors
breast pump in the first 6 months were about twice as included in the model were gestational age, maternal
likely to be AEBF at 6 months of age as those whose age, and maternal education. Older gestational age was
mothers did not use one. positively associated with AEBF at 6 months of age.

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 8 Dabritz et al J Hum Lact XX(X), XXXX

Table 4. Significant Associations From Multivariate Logistic Regression for Infants AEBF Versus Not Breastfeeding at 6 Months of Agea

Risk Factor Coefficient SE Coefficient Adjusted Odds Ratio (95% CI) P

Intercept –14.1130 4.0778 .001

Infant was fed formula milk at the hospital (vs not) –1.2983 0.3683 0.27 (0.13-0.56) < .001b
Hospital staff provided a telephone number for breastfeeding help (vs not) 1.8641 0.8466 6.45 (1.23-33.9) .028b
Mother used a breast pump in the first 6 months (vs not) 0.7840 0.3959 2.19 (1.01-4.76) .048b
Infant’s gestational age (for each additional week older) 0.2036 0.0939 1.23 (1.02-1.47) .030b
Maternal age (for each year older) 0.1193 0.0310 1.13 (1.06-1.20) < .001b
Maternal education (vs high school or less) Referent 1.00
Some college/technical school 0.1945 0.4494 1.22 (0.50-2.93) .665
College/postgraduate degree 2.5642 0.4567 13.0 (5.31-31.8) < .001b
a
AEBF, almost exclusive breastfeeding; CI, confidence interval.
b
Predictors with statistically significant P values (< .05).

Table 5. Significant Associations From Multivariate Logistic Regression for Infants PBF Versus Not Breastfeeding at 6 Months of Agea

Risk Factor Coefficient SE Coefficient Adjusted Odds Ratio (95% CI) P

Intercept –3.2974 0.8005 < .001

Mother used a breast pump at the hospital (vs not) –1.4635 0.4481 0.23 (0.10-0.56) .001b
Infant had a medical problem at delivery (vs not) 1.2149 0.5177 3.37 (1.22-9.3) .019b
Maternal age (for 1-year difference) 0.0552 0.0260 1.06 (1.00-1.11) .034b
Maternal education (vs high school or less) Referent 1.00
Some college/technical school 1.5696 0.4792 4.80 (1.88-12.3) .001b
College/postgraduate degree 2.0619 0.5759 7.86 (2.54-24.3) < .001b
Maternal ethnicity/birth country (vs US-born white) Referent 1.00
US-born Hispanic –0.1566 0.5559 0.86 (0.29-2.54) .778
US-born other ethnicity 1.2943 0.6808 3.65 (0.96-13.9) .057
Foreign-born Hispanic 1.9968 0.5061 7.37 (2.73-19.9) < .001b
Foreign-born other ethnicity 0.4702 0.7535 1.60 (0.37-7.01) .533
Foreign-born white 2.3545 1.3084 10.53 (0.81-137) .072
a
CI, confidence interval; PBF, partial breastfeeding.
b
Predictors with statistically significant P values (< .05).

Based on the selected model, the odds of AEBF at
6 months were calculated to be 1.50 (95% confidence
interval [CI], 1.04-2.17) for a 2-week difference in ges-
tational age and 2.26 (95% CI, 1.08-4.71) for a 4-week
difference. Maternal age and education, both well-
known predictors of breastfeeding duration, were also
significantly associated with AEBF at 6 months of age
(Table 4). For a 5-year maternal age difference, infants
were 1.8 times as likely to be AEBF at 6 months of age.
Logistic Regression Analysis: PBF Versus Not
Breastfeeding at 6 Months of Age
A total of 108 (28% of 382) infants who were ever
breastfed received mixed feedings of breast and for-
mula milk at the 6-month time point. These PBF
infants were fed a mean amount of 432 ± 67 mL
(range, 15-1776 mL) of formula milk per day. Sixteen
variables were potential predictors (P < .20) for PBF
at 6 months of age, and 4 were initially found to be
significant in a multivariate model. One infant was
omitted due to missing data. Because 1 of the selected
variables, breast pump use by the mother at the hospi-
tal, which had a negative association with PBF at 6
months, might be related to an infant with a medical
problem at delivery or admission to the NICU, we
investigated the association of breast pump with these
2 variables for the entire data set. Fifty-two infants
had a medical problem at delivery, and 25 (48%) of
these infants were admitted to the NICU. Excluding
the 3 home births and 1 infant whose mother declined
to respond, 67% of the 52 infants with medical prob-
lems and 92% of the 26 infants admitted to the NICU
had mothers who used a breast pump at the hospital.
This compares to breast pump use by the mother for
only 17% of 326 infants without medical problems
and 19% of 352 infants without a NICU admission

JHL362222.indd 8 14/04/2010 11:25:43 AM

 J Hum Lact XX(X), XXXX Maternal Hospital Experiences
(P < .001 for both comparisons). We therefore tested
these variables separately for PBF infants in the
model containing 4 predictors and found that having a
neonatal medical problem was significantly associ-
ated with the outcome (OR, 3.37; 95% CI, 1.22-9.30;
P = .019), although admission to the NICU was not
(Table 5). The Hosmer-Lemeshow statistic (P = .59)
indicated that this model was a good fit.
The remaining risk factors in the multivariate model
for PBF at 6 months were demographic. An infant born
to a 30-year-old mother compared to one born to a
25-year-old mother was 1.3 times more likely to be PBF
at 6 months of age, and infants whose mothers had some
college or possessed college or postgraduate degrees
were more likely to be PBF at 6 months of age than
were infants whose mothers had a high school or less
education (Table 5). Infants of foreign-born Hispanic
mothers and US-born mothers of other ethnicities were
also more likely to be PBF at 6 months of age than were
infants of US-born white mothers (Table 5).
Discussion
Despite the fact that California leads the nation in
breastfeeding duration,5,6,24 only 30% of the 405 Yolo
County infants recruited into the study were still breast-
feeding at 6 months of age. Some aspects of the hospi-
tal experience were significantly associated with infants
who were AEBF versus not breastfed at 6 months of
age, after adjustment for maternal age and education.
Infants whose mothers were given a number for breast-
feeding help by hospital staff and were not supple-
mented with formula at the hospital were more likely to
be AEBF at 6 months of age. The former may have
been an indicator for hospitals that were in better com-
pliance with the BFHI guidelines or hospitals that pro-
vided mothers with greater breastfeeding support
because we did not specifically ask participants if they
met with a lactation consultant or received additional
support from hospital staff in the days shortly after
discharge. It is also noteworthy that mothers who
reported encountering barriers to breastfeeding in the
first 6 months were twice as likely to AEBF their
infants at 6 months old as were mothers who did not
report such challenges (Table 2). This finding suggests
that mothers who told us about problems were more
motivated to resolve difficulties and that if mothers
have access to resources such as telephone help lines
when they encounter problems, they are able to over-
come barriers and continue breastfeeding.
JHL362222.indd 9
9
Formula supplementation at the hospital was nega-
tively associated with AEBF at 6 months of age in the
multivariate model. It has been associated with shorter
breastfeeding duration, insufficient milk supply, and a
reduction in the number of supplemental daily feeds in
other studies.25-32 Feeding only breast milk and no other
food or drink in the hospital, which would necessar-
ily exclude formula, is 1 of the 10 steps included in the
BFHI. Studies that evaluated hospital compliance with
the BFHI found that breastfeeding rates increased in
countries where BFHI guidelines were routinely imple-
mented.25,26,33-35 It should be noted, however, that
maternal requests may account for a large proportion
of supplemental feeds: 51% in 1 study29 and 39% in
another.36 In the former study,29 33% of infants were
supplemented for medical reasons; but Ekstrom et al37
and Tender et al36 found that fewer infants (25% and 13%
of supplemented infants, respectively) were supple-
mented for medical reasons.
Another challenge for hospitals is care of the pre-
term neonate. Infants of younger gestational age in our
study were less likely to be AEBF versus not breast-
feeding at 6 months of age. These infants can expect to
face a variety of medical complications and feeding
issues. They have underdeveloped sucking mecha-
nisms, may need physical assistance to latch properly,
and have difficulties transitioning from gavage feeding
to nursing at the breast.38 A recent study from Australia
also concluded that younger gestational age was asso-
ciated with lower odds of breastfeeding at 6 months of
age.39 Current recommendations indicate that breast
milk is the preferred food for both low birth weight (<
2500 g) and preterm infants, who accrue gastrointesti-
nal, immunological, developmental, and psychological
benefits from breastfeeding.40,41
There was also evidence from the multivariate model
of PBF versus not breastfeeding that infants who
received expressed breast milk had less successful
breastfeeding outcomes. (OR, 0.23; 95% CI, 0.10-
0.56). One common reason for receiving expressed
breast milk would be admission to the NICU; in fact,
infants admitted to the NICU were 5 times more likely
than were those without a NICU admission to have
received expressed breast milk. It was therefore sur-
prising to find NICU admission was not associated
with PBF at 6 months old in the multivariate model,
whereas having a neonatal medical problem at delivery
was (OR, 3.37; 95% CI, 1.22-9.3). One possible expla-
nation for this finding is that mothers of infants with
medical problems received more support, encouragement,
14/04/2010 11:25:43 AM
 10 Dabritz et al
and education about breastfeeding because their infants
were sick. Breastfeeding promotion programs in
NICUs have improved breastfeeding rates for NICU-
admitted infants.42,43 Colaizy and Morriss44 found that
NICU-admitted infants were 10% more likely to con-
tinue breastfeeding for at least 4 weeks than were infants
not admitted to the NICU. It appears that clinicians need
to be equally sensitive to the needs of mothers who
express breast milk with a breast pump in the hospital
for other reasons, which may be related to complica-
tions of delivery, delayed lactation onset, improper
latching, and discomfort related to engorgement.27,45 A
small study of primarily white married women with
some college education found that use of a breast pump
24 to 72 hours after cesarean delivery did not improve
milk transfer.46 This is not to say that use of a breast
pump necessarily results in poorer breastfeeding out-
comes. Breast pump use during the first 6 months (ie,
after breastfeeding has been successfully established)
was positively associated with AEBF at 6 months. A
breast pump is essential for maintenance of breastfeed-
ing if a mother is to provide her infant with breast milk
as the principal nutrition source after return to work or
school because the mother is typically unavailable to
nurse the infant for part or all of the day. Having access
to a pump, knowing how to use it, having a private place
where breast milk can be expressed, and having time
available to do so are all necessary components for a
mother who intends to continue breastfeeding after
return to work or school.
Of additional concern in the current study are socio-
economic factors associated with breastfeeding out-
comes. US-born Hispanic mothers with lower levels of
educational attainment were less likely to exclusively
breastfeed their infants for the recommended 6 months,
and US-born mothers of other ethnicities and foreign-
born Hispanic mothers were more likely to introduce
formula to a breastfeeding infant before 6 months of
age. Thus, in the multivariate model predicting PBF
at 6 months, infants of US-born mothers of other eth-
nicities and of foreign-born Hispanic mothers were
more likely to be PBF at 6 months old (Table 5). Other
studies and nationwide estimates also found higher
rates of breastfeeding among foreign-born Hispanic
women,4-6,20,47-50 as well as the tendency for foreign-
born Hispanic mothers to supplement breast milk with
formula due to perceived milk insufficiency or an infant
lacking chubbiness.51,52 Clinicians who counsel Hispanic
women about breastfeeding should teach them that
breast milk is produced in the quantity corresponding
JHL362222.indd 10
J Hum Lact XX(X), XXXX
to the demands of the infant and that it is healthiest
for the mother and infant to breastfeed exclusively up
to the age of 6 months.
Although the findings of this study have important
implications for hospitals in California, the study has
several limitations. Many participants were low-income,
Hispanic mothers receiving WIC benefits who have
different attitudes and approaches towards breastfeeding
that those from other ethnic groups, and the present
study does not represent the experience of California
as a whole. Therefore, this study cannot be generalized
to women with higher incomes, to other California
counties, or to other states in the United States. Asian,
black, and Native American mothers were not repre-
sented in sufficient numbers or in proportion to their
populations in other California counties to draw con-
clusions about breastfeeding outcomes of their infants,
which differ considerably from those of Hispanic and
white mothers.38,40
We also acknowledge that this study did not include
the strictest definition of breastfeeding exclusivity (ie,
no liquids or foods other than breast milk). We chose
to include mothers who infrequently fed water, teas, or
solid foods because it is recommended to begin intro-
ducing different foods to infants at 6 months of age
and because of the small sample size in what would
have been the exclusively breastfed group. The low
proportion of infants with medical problems or admit-
ted to the NICU (14% and 7%, respectively) also lim-
ited our ability to detect differences in breastfeeding
outcomes for these infants.
Maternal report of breastfeeding behavior and the
hospital experience may be subject to recall bias. Study
participants were interviewed 6 to 9 months after their
infants’ births and may not have reported their hospital
experiences, infant gestational age, or breastfeeding
duration correctly. For the questions relating to the hos-
pital experience, up to 8% of participants did not recall
what happened. The questionnaire was not validated, so
it is unclear how accurately maternal report reflected
the actual hospital experience. Recall of breastfeeding
duration, however, has been shown to be accurate
within a year after birth,51 but the duration of breast-
feeding reported by the mother may not have been
entirely accurate. Because mothers could answer the
question about how long they breastfed their infants in
units of days, weeks, or months, misclassification of
the outcome at 6 months could have occurred. For
example, a mother who stopped breastfeeding at 25
weeks but reported breastfeeding duration as 6 months
14/04/2010 11:25:43 AM
 J Hum Lact XX(X), XXXX Maternal Hospital Experiences
(26 weeks) would have been misclassified as still
breastfeeding at 6 months. It would also have been
desirable to conduct a follow-up call at 9 or 12 months
with mothers who were continuing to breastfeed at the
time of interview, to determine the date their infants
were weaned. This would have enabled us to conduct
survival analysis without a large number of right-
censored observations.
Despite its limitations, the present study does high-
light breastfeeding disparities and underline some hos-
pital practices related to the BFHI that could be
improved or changed in this rural county. In the present
study, 94% of infants began breastfeeding, but 40%
were weaned before 6 months of age. Hospital staff
should ensure that all mothers have a telephone number
to receive breastfeeding help when they leave the hos-
pital and that infants are not fed formula milk in the
first days of life, unless medically indicated. Infants of
younger gestational age, who are likely to be born early
and at lower birth weight, appear to be particularly
vulnerable to early breastfeeding cessation. Mothers of
these infants often need to use a breast pump in the
hospital to provide the infant with optimal nutrition but
have poorer breastfeeding outcomes at the 6-month
time point. Interventions to address the needs of these
mothers and infants should extend beyond the hospital
setting to include lactation consultants, breastfeeding
support groups, and community health educators. The
present study showed that better adherence to some of
the 10 steps in the BFHI guidelines in small county
hospitals could affect breastfeeding outcomes. Future
studies should measure in-hospital adherence to all 10
steps of the BFHI and conduct follow-up with mothers
recruited in birth hospitals to assess how implementa-
tion of the 10 steps affects long-term breastfeeding.
Implementation of all 10 steps is likely to have the most
impact on breastfeeding outcomes, provided that spe-
cial attention is directed towards low-income, Hispanic
mothers and mothers of infants born at younger gesta-
tional age.
Acknowledgment
The authors thank Josh Jorgenson, who assisted
with literature review and survey development, interns
Kelly Beaumont and Erica Gonzalez for survey imple-
mentation, and members of the Yolo County Breast-
feeding Coalition for their continued interest and
support of this project. Sources of support for this
study include the California Department of Public
JHL362222.indd 11
11
Health EIS Program, First 5 Yolo, Kaiser Permanente,
Woodland Healthcare Foundation, and the Yolo County
MCAH Program.
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