In the majority of states, breastfeeding data are collected on the birth certificate, or this process will begin within the next 2 years; however, the questions being used to collect breastfeeding data are not standardized. Only 5 states use the exact wording of the breastfeeding question and responses specified by the SCLB. Six states plus New York City and Washington, DC have developed their own questions. The wide variation in the wording of the breastfeeding question adopted for use in individual state birth certificates implies dissatisfaction with the breastfeeding question originally specified in the US Standard Certificate of Live Birth (SCLB). Since the SCLB is periodically revised, we offer some suggestions for the future modifications of the breastfeeding question.
We strongly recommend that future revisions of the SCLB breastfeeding question assess breastfeeding exclusivity during hospitalization. Increasing exclusive breastfeeding is a national public health priority 10
, but unfortunately, a high percentage of breastfed infants start receiving formula during their hospitalization 11
. Data on in-hospital rates of exclusive breastfeeding would be useful at the state, county and hospital level to assess the adequacy of breastfeeding promotion efforts and monitor progress towards improvement in breastfeeding practices. It should be recognized that these exclusive breastfeeding data are likely to overestimate the true incidence of exclusive breastfeeding. Due to time constraints, the review of feeding practices may be limited to the last 24 hours of the hospital stay, as done in New Jersey 3
. Thus, infants who were supplemented with non-breastmilk substances early during their hospital stay, and then received only breastmilk for the remainder of their hospitalization would be misclassified as exclusively breastfed. Despite this limitation, these data are extremely useful, as they provide valuable insights regarding the adequacy of in-hospital lactation support, and allow benchmarking comparisons between hospitals, counties and states.
The exact wording of this question should be developed with guidance from experts in the areas of lactation and public health, and those currently involved in data collection. It would be essential to obtain feedback from Vital Records Registrars in New Jersey, New York State, New York City, and Washington, DC where data on breastfeeding exclusivity are currently collected on the birth certificate. Once developed, the breastfeeding question should be pilot tested for feasibility. Two states (Michigan and Massachusetts) ask about both breastfeeding intentions and initiation in a single question. This seems particularly confusing, as different responses may be obtained, depending on the timing of the question (prenatal vs. postpartum). Given that feeding intentions are not always predictive of infant feeding practices 12
, we recommend that breastfeeding intentions should not be documented on the birth certificate.
In addition to standardized wording, the administration of the birth certificate breastfeeding question should be standardized. The breastfeeding question typically appears on the Facility Worksheet, designed to be completed by health professionals. Process evaluation should be conducted to determine exactly how this question is currently answered, and by whom. For example, is the mother interviewed, or is the medical record/infant feeding record reviewed, or are the data entered from an electronic source? If mothers are interviewed, then accurate translation of the standardized question should be developed in multiple languages. The timing of the data collection should be consistent, in order to accurately capture the desired outcomes. If the phrase, “at discharge”, is included in future revisions, it will be necessary to specify the meaning of “at discharge”. For example, does “at discharge” refer to last 24 hours of hospitalization as are currently done in New Jersey3
? Alternatively, should only the last 2–4 documented in-hospital feedings be assessed, in order to capture feeding practices closest to discharge? We do not recommend the use of the last hospital feeding to answer this question, as this would misclassify mixed feeders as either breastfeeding or formula feeding. Thorough training of health professionals collecting birth certificate breastfeeding data is essential, in order to maximize the usefulness of these data for breastfeeding surveillance purposes.
Given all of the relevant demographic and biomedical data collected at birth, the birth certificate represents a very useful data source for breastfeeding researchers interested in examining breastfeeding outcomes from a health disparities perspective, and for policy makers wishing to improve hospital practice. Obviously, these data are only useful if they are made publicly available. To date, several peer-reviewed publications have resulted from analysis of birth certificate-derived breastfeeding data 3–7, 12
Ten states and Puerto Rico indicated that they do not have plans to collect breastfeeding data on their birth certificates. Some of these states are collecting breastfeeding data through alternate sources, such as the newborn screening programs. Other states reported collecting these data with PRAMS; however, given the smaller sample size and the longer recall period involved with the PRAMS survey, this does not represent an adequate substitute for collection of breastfeeding data on the birth certificate.