Changes in public attitudes toward breastfeeding in the United States; 1999-2003

Nutrition Research Newsletter, Feb, 2007

The significant benefits of breastfeeding for children, mothers, and society are widely recognized. Human milk not only contains a balance of nutrients that closely matches infant requirement for growth and development, but also an abundance of immunological agents that protect infants against infectious diseases. Health professionals in the United States recommend that infants be exclusively breastfed for the first 6 months of life and then breastfed in combination with complementary foods for at least the first year. Children who are not breastfed are at increased risk of respiratory tract infection, otitis media, diarrhea, necrotizing enterocolitis, undemutrition, delayed cognitive development, and childhood overweight. Despite the many benefits of breastfeeding, breastfeeding rates in the United States are lower than in most nations; the rates also vary by sociodemographic factors. The 2004 National Immunization Survey indicated that 71% of children had never been breastfed. At 6 months, 14% of infants were exclusively breastfed and 36% were breastfed to some extent. At 12 months, the rate of receiving some breastmilk dropped to 18%. Non-Hispanic African Americans and socioeconomically disadvantaged groups had even lower breastfeeding rates. Thus, the rate of exclusively breastfeeding is low in the United States and the rates of breastfeeding continuation are still considerably below the national goals of 50% at 6 months and 25% at 12 months. Among many factors that affect a mother's breastfeeding practice are social support and social influence. Public beliefs also affect women's choice on breastfeeding. If mothers are told by their family and friends that their baby should be fed solid foods during the first few months, they will find it difficult to avoid feeding their babies solids until 6 months of age, despite their pediatrician's recommendation to exclusively breastfeed. Because social and cultural norms help guide women's decisions on breastfeeding, it is important to address what these norms are in developing strategies for promoting and supporting breastfeeding. To understand changes in public attitudes toward breastfeeding in the United States, the researchers examined data from the 1999 and 2003 HealthStyles surveys.

HealthStyles is a national mail survey of men and women aged 18 years and older. It has been administered every year since 1995 by Porter Novelli, a public relations firm, as a follow-up survey to a consumer mail panel survey (for example, Lifestyles in 1999 and ConsumerStyles in 2003). The consumer mail panel of the market research firm, Synovate (previously Market Facts), consists of 500,000 households throughout the United States that have agreed to answer mail questionnaires concerning media, products, and lifestyles. The consumer mail panel survey is sent to a stratified random sample drawn from the panel with each household receiving one such survey. The HealthStyles survey is sent to the same people who complete the preceding consumer mail panel survey. To compensate for low response rates with certain subgroups, low-income and minority groups are oversampled. To create a nationally representative sample, the data are poststratified and weighted to the US Census Current Population Survey on five demographic variables (that is, sex, age, income, race/ ethnicity, and household size). Responses to HealthStyles questions on adult health behaviors have been shown to he compatible to similar questions from the Behavioral Risk Factor Surveillance System survey, which uses a conventional probability sampling technique to track health risks in the United States.

Since 1999, about 10 breastfeeding questions each year have been added to the HealthStyles questionnaire. The dataset in this analysis consists of responses to four statements about breastfeeding that appeared in both 1999 and 2003 HealthStyles, including, "Mothers who breastfeed should do so in private places only," "I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, etc.," "Feeding a baby formula instead of breastmilk increases the chances the baby will get sick," and, "Infant formula is as good as breastmilk." For these four items, respondents were asked to rate their agreement on a five-point Likert scale from "strongly disagree" to "strongly agree."

The response rates for the 1999 Lifestyles and the 2003 ConsumerStyles survey was 67% (3636/5420) and 59% (5873/ 10,000), respectively. In 1999 and 2003, the HealthStyles surveys were mailed to 3554 and 5845 participants, respectively, who completed the preceding 1999 Lifestyles or 2003 ConsumerStyles survey. The final sample size was 2636 in 1999 (74% response rate) and 4035 in 2003 (69% response rate).

The sociodemographic distributions of the 1999 and 2003 HealthStyles samples were similar. The weighted analysis of the 2003 HealthStyles indicates that 71.6% of the samples were white, 11.5% were African American, and 11.7% were Hispanic. About 52% of respondents are women and 31% reported the highest education level of the household head as less than or equal to high school degree. Among the four breastfeeding items examined in this study, two are related to public attitudes toward breastfeeding in public and two are related to public attitudes toward differences between infant formula and breastmilk. Total changes in public attitudes toward breastfeeding in public were not significant, but generally were in the direction of reduced acceptability of such breastfeeding. The proportion of respondents in agreement with the statement, "Mothers who breastfeed should do so in private places only," significantly increased among whites (3.7%), low-income households (4.7%), and respondents with a high school degree or less (4.9%). In addition, a significant decrease occurred in agreement with the statement, "I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, etc.," among non-Hispanic African Americans ("7.6%), women ("3.8%), low-income households ("5.0%), unemployed respondents ("4.9%), and those living in urban areas ("4.6%). Modern American society pays great attention to the sexual and aesthetic function of women's breasts, which may make some people perceive that breastfeeding should be hidden from the public. To promote breastfeeding, it is important to engage the community to accept breastfeeding as a normal, desirable, and achievable activity for women of all cultures and socioeconomic levels.