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ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Knowledge on Breastfeeding Legislation and Its Impact on Breastfeeding Duration

Elizabeth Furey*, Lauren Landfried, Patrick Kelly and Lori Jones
Saint Louis University, Nutrition and Dietetics, United States
Corresponding Author : Elizabeth Furey
Masters Student/Dietetic Intern, Saint Louis University
Nutrition and Dietetics, United States
Tel: (813) 597-6023
E-mail: [email protected]
Received: August 13, 2015; Accepted: September 27, 2015; Published: October 05, 2015
Citation: Furey E, Landfried L, Kelly P, Jones L (2015) Knowledge on Breastfeeding Legislation and Its Impact on Breastfeeding Duration. J Preg Child Health 2:194. doi:10.4172/2376-127X.1000194
Copyright: © 2015 Furey E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

An estimated $13 billion in health care costs could be saved each year due to the many health benefits of breastfeeding if 90% of mothers met the current recommendations for breastfeeding. These health benefits include, but are not limited to, improved nutrition status, stronger immune system profile, and more stable psychological and financial well-being. Recognizing this, government at the state and federal level has made marginal efforts the past few years to protect these mothers and infants with legislation and initiatives. A survey tool was prepared using the most up to date legislative information and was validated for this study by an expert panel of International Board Certified Lactation Consultants (IBCLCs) and Certified Lactation Counselors (CLCs). This survey was distributed at WIC clinics throughout St. Louis, Missouri to all qualifying postpartum mothers. Using a survey, this study evaluated the relationship between the knowledge and the awareness mothers have of these laws in comparison to breastfeeding duration to assess if a positive relationship exists between the two measures. Using a one-way ANOVA there was no statistical significance comparing the mean legislative knowledge between the three groups. This research explores the need of educating prenatal mothers of their legal rights in regards to breastfeeding in an effort to increase this country’s rate of initiation and duration to 6 months.

Keywords
Breastfeeding; Legislation; Awareness; Knowledge; Support
Introduction
Growing research shows that prenatal education on the maternal and infant health benefits of breastfeeding positively influences longer duration and delayed introduction to formula by 2 months [1]. Breastfed infants have fewer occurrences and less severity of otitis media, gastroenteritis, respiratory infections, asthma, childhood obesity and sudden infant death syndrome (SIDS) [2]. It is well-documented that babies who aren’t breastfed visit healthcare providers more often for sick visits, receive more prescription medications, and are hospitalized more often [2]. Women who breastfeed have been shown to be at decreased risk for breast cancer, osteoporosis, and cardiovascular disease [2]. Therefore, women who become familiar with the health benefits through prenatal education may feel there is more of an incentive to initiate breastfeeding.
A women’s belief that she understands the health benefits and has the skill set to nurse her infant has made a large impact on the United States’ current duration rates [3]. By providing mothers an additional piece of information during prenatal care about her legal right to breastfeed in public or private places as well as work site pumping policies, we could see a further increase in the current breastfeeding rates.
Currently 76.9% of women initiate breastfeeding upon delivery in the U.S., and 47.2% are only partially breastfeeding at 6 months. These numbers fall short of the Healthy People 2020 goals of 81.9% initiation, 60.6% at 6 months, and 34% at one year [2].
In an effort to improve initiation and duration of breastfeeding, more emphasis has been placed on educating women nationwide during the prenatal and postnatal periods. More specifically, in 2011 the Surgeon General’s Call to Action ignited several federal activities. These actions included a call for hospitals to become accredited as “Baby-Friendly Hospitals,” increased incentives for Special Supplemental Nutrition programs for Women, Infants, and Children (WIC) participants who are exclusively breastfeeding, and a segment of the Patient Protection and Affordable Care Act that uses legislation to support breastfeeding in more places and protects working mothers who pump [4].
Many hospitals have also implemented an initiative called “The Ten Steps to Successful Breastfeeding” with a heavy focus on educating new mothers before delivery to increase breastfeeding rates [5]. Currently there are only 286 hospitals and birthing facilities designated as Baby- Friendly hospitals across 47 states [6]. Of those 286 Baby-Friendly facilities in the country, only 4 exist in the state of Missouri, none of which exist in the region of Saint Louis.
According to the Surgeon General in 2011, the most commonly reported causes of poor initiation included healthcare professionals’ lack of education, an absence of community support, current hospital practices preventing a successful start with breastfeeding, and limited accommodations at the workplace to pump/breastfeed [7]. The Surgeons General’s Call to Action has identified many barriers that this country faces when it comes to educating and protecting mothers and their rights to breastfeed their babies. As a result, current federal legislation allows a woman to breastfeed her infant at any public or private location where she is authorized to be. Additionally, the Fair Labor Standard Act in the Affordable Care Act states that “employers must provide reasonable break time and an appropriate space for employee’s breastfeeding or expressing breastmilk by pump to an infant under 1 year” [7]. Some states have taken their commitment to protect mothers and infants to a further extent than the federal laws. Prior to the 2010 Affordable Care Act provisions, 24 states already had legislation in place protecting mothers and infants [8]. Many states have created laws exempting breastfeeding from public indecency laws, exempting mothers temporarily from serving civic responsibilities such as jury duty, and placing laws prohibiting discrimination on any facility or individual denying a breastfeeding mother services [9]. Great emphasis has been placed on these state laws using specific language that provides more protection to this vulnerable population when compared to the federal laws.
With these recent changes, little research currently evaluates the strength and influence of these measures on the country’s breastfeeding rates. There is a great need to evaluate the impact of these laws, find concrete ways of enforcing them, and improve the education of all mothers as to their rights to breastfeed in order to meet expected goals [2]. Thus, the purpose of this study was to investigate whether a relationship exists between knowledge of breastfeeding laws and the duration of breastfeeding. The hypothesis is mothers who are more informed of their rights and of breastfeeding legislation will have an increased duration of breastfeeding.
Methods
Participants
Participants were recruited from Women, Infants, and Children (WIC) clinics in a midwestern city. WIC clinics provided an ideal population for this study since WIC promotes breastfeeding and serves postpartum clients, some of whom are continuing to breastfeed. The inclusion criteria specified that WIC clients needed to be mothers who were asked about their breastfeeding practices and choices with their most recently delivered infant. All mothers, including those who never initiated breastfeeding were included in the research to investigate if lack of knowledge regarding their rights had any relationship with initiation and duration of breastfeeding. Participants could be of any ethnicity, but had to be at least 18 years of age. WIC income guidelines are based on 185% of poverty level, therfore all participants were of lower socioeconomic status [10]. To achieve 80% power, this study needed to enroll 75 particpants, 25 exclusively breastfeeding, 25 partially breastfeeding, and 25 who opted not to breastfeed.
Survey
The survey was designed to assess the knowledge mothers have about recent breastfeeding legislation and their breastfeeding duration. It was developed based on the most current breastfeeding research and legislation, and validated by an expert panel of four International Board Certified Lactation Consultants (IBCLCs) or Certified Lactation Counselors (CLCs). This expert panel was chosen based on their expertise in working with WIC participants; they were tasked to review the survey and provide input for any additional changes. The final survey included question on participants’ demographics, their knowledge of policy, and their breastfeeding duration. The questions pertaining to demographics included, age, ethnicity/race, education, employment status, household income and marital status. The questions pertaining to legislative knowledge looked at breastfeeding policies at the federal level and the Missouri state level. Their answers were recorded as ‘Is a law’, ‘Not sure but should be a law’, ‘Not a law’, or ‘Not sure but should not be a law’. Respondents were also asked which facilities and/or healthcare providers were required by law to provide mothers consultation or information on breastfeeding benefits and local support groups. The legislative questions also addressed breastfeeding in public/ private locations, exemptions from jury duty, and the state level work place pumping policy. A likert scale was used to measure confidence in their answer to each legislative question.
The last section looked at actual duration, frequency of feedings per day, length of time respondents planned to breastfeed for, and use of formula supplementation. Skip logic was used if a mother identified as never initiating breastfeeding; she was then asked to identify why she chose not to initiate this form of infant feeding. For the purpose of this study, exclusively breastfed infants were not currently receiving any formula, and partially breastfed infants were given breastmilk at least once a day in conjunction with formula.
Procedure
Participants were recruited in the waiting room before or after their WIC appointment. They were first asked to provide their consent to complete a paper survey. The survey was completed without any identifiers, thus keeping the confidentiality of the participants. The process was reviewed and approved by WIC and the appropriate Institutional Review Board.
Analysis
Data were analyzed using Statistical Analysis Software (SAS), version 9.3 (2013). Statistical analyses included descriptive statistics, one-way ANOVAs, and independent sample t-test. All of the data were aggregated, analyzed collectively, and then compared between the three groups. Each survey had 12 pieces of legislation, and respondents were assigned a score of 1 if they identified the law correctly or responded “Not sure but should be a law” and a 0 if identified incorrectly or “Not sure but should not be a law”. A score was calculated for each participant based on the number correct out of 12, which was then averaged between the three groups. To understand the mean difference on correct scores between groups and breastfeeding duration between the two breastfeeding groups, one-way ANOVAs and t-tests were performed using the data collected.
Results
A total of 39 women were approached to participate in this research study. Of those 39 approached, 36 participants enrolled in the study. Of the 36 participants, 11 were exclusively breastfeeding, 12 were partially breastfeeding in conjunction with formula, and 13 mothers did not initiate breastfeeding with their most recent delivery. Due to the modest sample size (n=36) this study achieved limited statistical power. Using the final sample size collected a Post Hoc power analysis revealed a 23% power was achieved with an alpha set 0.05. The demographic breakdown of all participants can be found in Table 1.
The mean correct score of legislative knowledge between the three groups with differing durations was compared using a oneway ANOVA with no statistical significance (p=0.167). While no statistical significance, the exclusively breastfeeding group (EBF) had the highest mean score of 11.27 correct out of 12, followed by partially breastfeeding (PBF) with 10.5 correct out of 12, and finally the never initiated breastfeeding group (NBF) with the lowest mean score of 9.62 correct out of 12. Results from this analysis can be found in Table 2.
Mean duration of breastfeeding was compared between exclusively breastfeeding and partially breastfeeding mothers with an independent samples t-test and was found that exclusively breastfeeding mothers were breastfeeding on average 2.5 months longer compared to the partially breastfeeding group. (t=4.58, p<0.001).
When comparing frequency of responses of why women discontinued exclusively breastfeeding and introduced formula, the highest responses included low milk production (46.1%), difficulty latching (30.7%), and anticipating a quick return to work (23.1%). Comparing frequencies of responses when asked why mothers who opted not to initiate breastfeeding made their decision, the most frequent responses included returning to work soon after delivery (23.1%) followed by discomfort nursing in public (15.4%).
Discussion
The main purpose of this study was to determine whether scores on knowledge of rights and laws related to breastfeeding influenced breastfeeding duration. The hypothesis is mothers who are more informed of their rights and of breastfeeding legislation will have an increased duration of breastfeeding. This study was designed to provide further insight on the relationship between knowledge and breastfeeding duration. Federal laws concerning breastfeeding have been passed since 2011 and little research currently exists evaluating whether they’ve had an impact on initiation and duration. This research aims to contribute to the hole in research looking at the relationship between legislative knowledge and duration.
The one way ANOVA comparing the correct mean score of legislative knowledge between the three groups of mothers was not statistically significant, thus disproving the proposed hypothesis that increased knowledge of legislation influences longer duration times. Results from this test failed to support previous studies and literature that have shown a positive association between breastfeeding knowledge and longer duration. This could be due to the number of participants needed for a power analysis of 80% not being achieved. However, while no significant difference was found between the groups, the mean correct scores of legislative knowledge among the exclusively breastfeeding group was the highest followed by the partially breastfeeding with the lowest score belonging to the group that decided to not initiate breastfeeding. The trend in the results support previous studies and research with greater power analysis looking at the factors that influence a healthy behavior being adopted. Demonstrating an increase in overall knowledge increases the prevalance of a prefered behavior being implemented.
All WIC particpants during prenatal enrollment are offered an optional ‘infant feeding class’ which reviews infant feeding frequency, breastmilk supply and demand, and maintiaining breastmilk production. This class goes over one piece of federal legislation pertaining to every mothers right to breastfeed in any public and private location. Mothers who had intentions to breastfeeding while pregnant may have taken this optional class and aquired this legislative knowledge ending up with a higher mean score compared to mothers who may not have had intentions to breastfeed during pregnancy and did not take the class. These optional classes may have influenced the slight trend in knowledge seen across the three groups in this study, however, whether particpants enrolled in this study took part in the classes was not documented.
When looking at results from the independent samples t-test comparing mean duration between the two breastfeeding groups it is expected to see mothers who are breastfeeding exclusively to be nursing for longer durations compared to those who are partially breastfeeding. This introduction to formula greatly reduces a mothers’ breastmilk supply and as a result decreases her duration of nursing [11]. It is impoartant to identify why exclusively breastfeeding mothers begin to offer formula to their infants during this on average 2.5 month time frame. Helping mothers to overcome perceived barriers during this 2.5 month time can be crucial in helping more infants reach the benchmarks of exclusively breastfeeding at 6 months and optimally a year.
It is also important to note that the top three reasons mothers discontinue or stop breastfeeding include the following in order: low milk supply, difficultly latching, and return to work soon after delivery. While the top two responses are common breastfeeding issues not related to legislation, they can be prevented when mothers deliver at Baby-Friendly hospitals and have access to breastfeeding experts. The fact that only 4 hospitals in the state of Missouri are accredited as Baby-Friendly, none of which exist in the region of Saint Louis, where this study was conducted could have influenced this study’s results. These experts can reduce these common complications that lead to formula reliance. The third highest reason for discountinuing breastfeding can greatly be reduced by having work-place pumping policies promoted during pregnancy and uniformly enforced. About 50% of women of childbearing age are expected to return to work at a time when exclusively breastfeeding is optimal [12]. Prenatal education that encourages mothers to ask employeers about work-place pumping policies before delivery can help break this barrier many women perceive when retruning to work [12]. Educating mothers on this statewide policy can make the transition back to work more manageable for those deciding to breastfeed.
A similar argument could be made for common reasons mothers choose to not initiate breastfeeding. They may be discouraged from initiating because they feel their quick return to work will be more difficult compared to the alternative of only offering formula from the beginning. Educating our communities, as well as our mothers on their right to breastfeed in public places will provide more mothers with support and encouragement. Promoting these recent legislative changes that protect breastfeeding mothers could possibly increase the number of mothers who initiate breastfeeding. Also by increasing the number of Baby-Friendly hospitals and enforcing “The Ten Steps to Successful Breastfeeding” as standard hospital policy, we could provide mothers the initial support they need to have a successful start with breastfeeding. Increasing the number of these facilities in Missouri and in St. Louis could have a great impact on initiation and duration.
Failure in this study to support findings from previous studies with evidence of increased knowledge increasing duration can be explained by a number of factors. Limited power due to a small enrollment of 36 partipcants, enrolling only WIC participants, and only having access to two clinic locations could have contributed to the lack of evidence found in other studies supporting the influence knowledge has on duration. Lack of prior research looking at the impact on recent legislative influence on this health promoting practice is also a hindrance. Many studies have been conducted assessing knowledge prenatal mothers have of health benefits compared to initiation and duration but there is a great need for research similar to this study to assess whether legislative knowledge influences either initiation or duration in this country.
Conclusion
While no statistical significance was found, this study will aid future research measuring which laws mothers are more knowledgeable of and where improvement still needs to be made in order to increase breastfeeding initiation and duration rates. Although this study is not generalizable based on being based on a particular state, it provides a model that can be adapted by other states. As indicated by the literature review, confidence and knowledge are great predictors of a mother choosing to breastfeed her infant. This study recognizes the need to inform mothers of their legal rights related to breastfeeding during prenatal education in order to improve initiation and duration rates. The slight trend found in knowledge among the groups calls for future research to look at what exposure and education these mothers have had to positively influence longer duration.
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