This document discusses collecting breastfeeding data on US birth certificates. It finds that while most states now collect or will soon collect this data, the questions used are not standardized. It recommends that future revisions to the standard birth certificate assess breastfeeding exclusivity. Revisions should include feedback from health professionals, pretesting, and training to improve data quality.

1. Breastfeeding Status on US Birth Certificates: Where Do We Go From Here?
Donna J. Chapman, Anne Merewood, Robert Ackatia Armah and Rafael
Pérez-Escamilla
Pediatrics 2008;122;e1159-e1163
DOI: 10.1542/peds.2008-1662
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/122/6/e1159
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2. ARTICLE
Breastfeeding Status on US Birth Certificates: Where
Do We Go From Here?
Donna J. Chapman, PhD, RDa, Anne Merewood, MPH, IBCLCb, Robert Ackatia Armah, BSc, MPhilb, Rafael Perez-Escamilla, PhDa
´
aDepartment of Nutritional Sciences, Center for Eliminating Health Disparities Among Latinos, University of Connecticut, Storrs, Connecticut; bDivision of General
Pediatrics, Boston Medical Center, Boston, Massachusetts
The authors have indicated they have no financial relationships relevant to this article to disclose.
What’s Known on This Subject What This Study Adds
In 2003, the US SCLB was revised and for the first time included a question on breast- In May 2008, 79% of US states reported that breastfeeding data were currently collected
feeding; however, states are required neither to use the SCLB nor to adopt the exact on the birth certificate or would be collected within the next 2 years. The wording of the
wording of SCLB questions. breastfeeding question is not standardized. Suggestions are provided for revision.
ABSTRACT
OBJECTIVES. The objectives of this study were to assess the extent to which states
collected breastfeeding data on the birth certificate, to verify the wording of the
breastfeeding questions used, and to develop recommendations for future revisions www.pediatrics.org/cgi/doi/10.1542/
peds.2008-1662
of the breastfeeding question asked on the US Standard Certificate of Live Birth.
doi:10.1542/peds.2008-1662
METHODS. Registrars of vital statistics in US states and territories were contacted via Key Words
telephone with e-mail follow-up between April 2006 and May 2008 to determine breastfeeding, Standard Certificate of Live
whether their state/territory collected breastfeeding data on its birth certificate. Birth, birth certificate, US birth certificate,
exclusive breastfeeding
Responses were categorized as follows: (1) breastfeeding data currently collected; (2)
Abbreviations
breastfeeding data not currently collected but implementation date set; or (3) breast-
SCLB—Standard Certificate of Live Birth
feeding data not currently collected and no implementation plans. PRAMS—Pregnancy Risk Assessment
Monitoring System
RESULTS. In May 2008, 56.6% (30 of 53) of US states and territories were collecting data
Accepted for publication Aug 15, 2008
on breastfeeding status at hospital discharge on their birth certificate. The questions
Address correspondence to Donna
used to collect breastfeeding data, however, had not been standardized. Approxi- J. Chapman, PhD, RD, University of
mately one quarter (12 of 53) reported that they were not yet collecting breastfeed- Connecticut, Department of Nutritional
Sciences, 3624 Horsebarn Rd Extension, Storrs,
ing data on their birth certificate but that an implementation date had been set. CT 06269-4017. E-mail: donna.chapman@
Approximately one fifth (11 of 53) indicated that their state birth certificate did not uconn.edu
plan to collect breastfeeding data by January 2010. PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2008 by the
CONCLUSIONS. A total of 79% of the registrars reported that breastfeeding data were American Academy of Pediatrics
collected on the birth certificate or that the process would begin within the next
2 years. Future revisions to the Standard Certificate of Live Birth breastfeeding question should assess breast-
feeding exclusivity. The revision process should include feedback from health professionals who collect these
data, pretesting of the revised question for feasibility, and extensive training before data collection. Pediatrics
2008;122:e1159–e1163
E LEVEN FEDERALLY FUNDED US surveys/data sets collect data on breastfeeding practices; however, issues such as
sampling procedures, recall bias, inconsistent wording of the breastfeeding questions, and limited racial/ethnic
category choices constrain the extent to which these data can be generalized.1 In 2003, the US Standard Certificate
of Live Birth (SCLB) was revised and for the first time included a question on breastfeeding. The SCLB is a model or
template birth certificate that can be adopted or modified by individual states. In the “newborn” section of this
document, breastfeeding status is assessed by using the question, “Is the infant breastfed at discharge?” with the
responses listed as “yes” and “no.”2
This question is designed to capture breastfeeding status at hospital discharge, and because SCLB breastfeeding
data should be collected for all newborns in participating states, these data should be representative at the state level.
It has limitations, however, because it does not directly assess breastfeeding initiation and does not measure
breastfeeding exclusivity. Given the limitations of the federally funded surveys in assessing US breastfeeding
outcomes, the inclusion of a carefully constructed breastfeeding question on the SCLB has the potential to make a
valuable contribution to our knowledge on breastfeeding practices during the early postpartum period. The SCLB
contains a wealth of information on relevant confounders that may affect breastfeeding rates, including maternal and
paternal variables (age, education, birthplace, and race/ethnicity), maternal variables (height; prepregnancy weight;
marital status; smoking status; participation in Special Supplemental Nutrition Program for Women, Infants, and
PEDIATRICS Volume 122, Number 6, December 2008 e1159
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3. FIGURE 1
US map indicating status of breastfeeding data collection on birth certificates.
Children; parity; pregnancy risk factors; delivery method; text of their question to the research assistant. New York
and insurance status), and infant variables (birth weight, City was included as a separate entity from the state of
Apgar scores, and gestational age). Thus, the SCLB data New York in our analyses. This was done because, as
could be analyzed for determinants of breastfeeding out- reported in other analyses of birth certificate data,8,9 New
comes. York City and New York State use different birth certif-
Breastfeeding data derived from birth certificates icates.
have been used to evaluate factors that affect breastfeed- Follow-up e-mail surveys were sent approximately
ing initiation3–7; however, states are required neither to every 4 months to recontact registrars who had not
use the SCLB nor to adopt the exact wording of SCLB responded. Registrars who did not respond by July 1,
questions. The objectives of this study were to assess the 2007, were recontacted by telephone to verify their in-
extent to which US states and territories collected breast- formation. States that were categorized as not collecting
feeding data on the birth certificates, to verify the word- breastfeeding data (with or without implementation
ing of the breastfeeding questions used, and to develop dates) were recontacted by telephone and e-mail every 3
recommendations for future revisions of the SCLB months between December 2007 and May 2008 to de-
breastfeeding question. termine whether their status had changed. Data were
tabulated in Microsoft Excel (Redmond, WA). This study
METHODS was not subject to institutional review board approval
To assess the extent to which breastfeeding data were because no private, identifiable information was ob-
collected on birth certificates, the registrar of vital statis- tained.
tics in each of the 50 states plus New York City, Wash-
ington, DC, and 4 US territories (Puerto Rico, Guam, US RESULTS
Virgin Islands, and American Samoa) were contacted via Responses were received from 100% of the state vital
telephone by a research assistant in Spring 2006, with statistics registrars (including Washington, DC, and New
e-mail follow-up beginning in August 2006. During York City) and from 1 of the 4 registrars in a US territory
these contacts, registrars were asked whether their state (Puerto Rico). Among those who responded, 56.6% (30
was collecting breastfeeding data on their birth certifi- of 53) were collecting data on breastfeeding status on
cate. Responses were recorded as follows: (1) breastfeed- their state birth certificate (Fig 1). Approximately one
ing data currently collected; (2) breastfeeding data not quarter of the registrars (12 of 53) reported that they
currently collected but a planned implementation date were not yet collecting breastfeeding data on their birth
set; or (3) breastfeeding data not currently collected and certificate but that they had a scheduled date to begin
no planned implementation date. Registrars who re- implementation of a revised birth certificate that would
sponded that breastfeeding data were collected were collect breastfeeding data. Approximately one fifth (11
requested to verify the wording of their breastfeeding of 53) indicated that their state birth certificate did not
question, either by sending an electronic template of the plan to collect breastfeeding data by January 2010. In
birth certificate worksheet or by providing the verbatim total, 79% (42 of 53) of the registrars reported that their
e1160 CHAPMAN et al
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4. TABLE 1 Summary of the Questions Used to Assess Breastfeeding Status on State Birth Certificates
Wording of Questiona No. of Specific States
States
1. Is the infant being breastfed at discharge?
(Yes/no) 5 Delaware, Iowa, Montana, Vermont, Wyoming
(Yes/no/unknown) 6 Indiana, Kansas, New Hampshire, New Mexico,
Ohio, Oregon
(Yes/no/infant transferred, status unknown) 1 Texas
2. Is infant being breastfed at time of discharge?
(Yes/no) 1 South Dakota
(Yes/no/unknown) 1 North Dakota
3. Is infant being breastfed? (Yes/no) 8 Florida, Idaho, Kentucky, Nebraska, Pennsylvania,
South Carolina, Tennessee, Washington
4. Is infant being breastfed, even partially? (no, unknown, yes) 1 Georgia
5. Is the infant receiving breast milk at discharge? (yes/no) 1 Colorado
6. Are you breastfeeding or do you intend to breastfeed? 1 Massachusetts
(yes/no)
7. Breast feeding initiated, planned or not planned?
(Initiated, planned, not planned, unknown) 1 Michigan
8. Feeding at discharge (check one)
(Breast feeding, formula, combination, other) 1 New Jersey
9. How is infant being fed at discharge? (select one)
Breast milk only, formula only, both breast milk and 1 New York State
formula, other, do not know
10. How is infant being fed (check one): breast milk only, 1 New York City
formula only, both, neither (ie, infant may be on
intravenous fluids)
11. Method of feeding: (bottle, breast, or both) 1 Washington, DC
a Slight variations in wording are grouped together.
state was already collecting breastfeeding data on the are being used to collect breastfeeding data are not
birth certificate or had a planned implementation date to standardized. Only 5 states use the exact wording of
do so. the breastfeeding question and responses specified by
The questions that were used to assess early breast- the SCLB. Six states plus New York City and Wash-
feeding practices varied by state (Table 1). Among the 30 ington, DC, have developed their own questions. The
localities (29 states and New York City) that collected wide variation in the wording of the breastfeeding
breastfeeding data, 40% (12 of 30) used the wording of question adopted for use on individual state birth
the breastfeeding question on the SCLB (“Is the infant certificates suggests dissatisfaction with the breast-
being breastfed at discharge?”). Five of these states used feeding question originally specified in the US SCLB.
the responses specified on the SCLB (“yes/no”), whereas Because the SCLB is periodically revised, we offer
7 added the option to respond “unknown.” Two addi- some suggestions for the future modifications of the
tional states used a nearly identical question (“Is the breastfeeding question.
infant being breastfed at time of discharge?”), each with We strongly recommend that future revisions of the
a different set of potential responses. Eight states used a SCLB breastfeeding question assess breastfeeding exclu-
slightly abbreviated form of the SCLB breastfeeding sivity during hospitalization. Increasing exclusive breast-
question and asked “Is infant being breastfed? (yes/no).” feeding is a national public health priority,10 but, unfor-
Eight states or municipalities developed their own tunately, a high percentage of breastfed infants start
unique question. Half of these birth certificates (New receiving formula during their hospitalization.11 Data on
Jersey, New York State, New York City, and Washing- in-hospital rates of exclusive breastfeeding would be
ton, DC) included language that permitted analysis of useful at the state, county, and hospital levels to assess
the exclusivity of breastfeeding. Some of the states that the adequacy of breastfeeding promotion efforts and
reported not collecting breastfeeding data on their birth monitor progress toward improvement in breastfeeding
certificate indicated that these data were being collected practices. It should be recognized that these exclusive
by using other systems, such as a Newborn Screening breastfeeding data are likely to overestimate the true
Test form or via the Pregnancy Risk Assessment Moni- incidence of exclusive breastfeeding. Because of time
toring System (PRAMS) survey. constraints, the review of feeding practices may be lim-
ited to the last 24 hours of the hospital stay, as done in
DISCUSSION New Jersey.3 Thus, infants who were supplemented with
In the majority of states, breastfeeding data are col- non– breast milk substances early during their hospital
lected on the birth certificate, or this process will begin stay and then received only breast milk for the remain-
within the next 2 years; however, the questions that der of their hospitalization would be misclassified as
PEDIATRICS Volume 122, Number 6, December 2008 e1161
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5. exclusively breastfed. Despite this limitation, these data have resulted from analysis of birth certificate– derived
are extremely useful, because they provide valuable in- breastfeeding data.3–7,12
sights regarding the adequacy of in-hospital lactation Ten states and Puerto Rico indicated that they do not
support and allow benchmarking comparisons among have plans to collect breastfeeding data on their birth
hospitals, counties, and states. certificates. Some of these states are collecting breast-
The exact wording of this question should be devel- feeding data through alternative sources, such as the
oped with guidance from experts in the areas of lactation newborn screening programs. Other states reported col-
and public health and those currently involved in data lecting these data with PRAMS; however, given the
collection. It would be essential to obtain feedback from smaller sample size and the longer recall period involved
Vital Records Registrars in New Jersey, New York State, with the PRAMS survey, this does not represent an
New York City, and Washington, DC, where data on adequate substitute for collection of breastfeeding data
breastfeeding exclusivity are currently collected on the on the birth certificate.
birth certificate. Once developed, the breastfeeding
question should be pilot tested for feasibility. Two states CONCLUSIONS
(Michigan and Massachusetts) ask about both breast- Within the next 2 years, nearly 80% of US states are
feeding intentions and initiation in a single question. expected to be collecting breastfeeding data on their
This seems particularly confusing, because different re- birth certificate. This represents a significant contribu-
sponses may be obtained, depending on the timing of tion to our national breastfeeding surveillance efforts,
the question (prenatal versus postpartum). Given that because data should be collected for every newborn in
feeding intentions are not always predictive of infant every participating state, thereby avoiding the potential
feeding practices,12 we recommend that breastfeeding for sampling bias. Because birth certificates also collect
intentions should not be documented on the birth cer- data on several relevant variables that are known to
tificate. affect breastfeeding outcomes, the inclusion of a breast-
In addition to standardized wording, the adminis- feeding question on birth certificates has a strong poten-
tration of the birth certificate breastfeeding question tial to improve breastfeeding surveillance in the United
should be standardized. The breastfeeding question States. Consistent with the Healthy People 2010 guide-
typically appears on the Facility Worksheet, designed lines, we strongly encourage all states and US territories
to be completed by health professionals. Process eval- to collect exclusive breastfeeding data on their birth
uation should be conducted to determine exactly how certificates and to monitor this outcome closely. Standard-
this question is currently answered and by whom. For ization of the breastfeeding question that is used on state
example, is the mother interviewed, is the medical birth certificates should be a priority so that breastfeeding
chart/infant feeding record reviewed, or are the data outcomes can be compared across states. The revision of
entered from an electronic source? If mothers are this question should involve a process that includes feed-
interviewed, then accurate translation of the stan- back from health professionals who collect these data, pre-
dardized question should be developed in multiple testing of the revised question for feasibility, and training of
languages. The timing of the data collection should be professionals who collect these data.
consistent, to capture accurately the desired out-
comes. If the phrase “at discharge” is included in ACKNOWLEDGMENTS
future revisions, then it will be necessary to specify This research was supported by National Institutes of
the meaning of “at discharge.” For example, does “at Health NCMHD EXPORT grant P20 MD001765. We
discharge” refer to last 24 hours of hospitalization as is thank Lisa Phillips, Khara Leon and Ellen Meisterling for
currently the case in New Jersey3? Alternatively, their assistance.
should only the last 2 to 4 documented in-hospital
feedings be assessed, to capture feeding practices clos- REFERENCES
est to discharge? We do not recommend the use of the 1. Chapman D, Perez-Escamilla R. US national breastfeeding
´
last hospital feeding to answer this question, because monitoring and surveillance: current status and recommenda-
tions. J Hum Lact. In press
this would misclassify mixed feeders as either breast-
2. Kirby R, Salihu H. Back to the future? A critical commentary
feeding or formula feeding. Thorough training of on the 2003 US national Standard Certificate of Life Birth.
health professionals who collect birth certificate Birth. 2006;33(3):238 –244
breastfeeding data are essential, to maximize the use- 3. Kruse L, Denk C, Feldman-Winter L, Rotondo F. Comparing
fulness of these data for breastfeeding surveillance sociodemographic and hospital influences on breastfeeding ini-
purposes. tiation. Birth. 2005;32(2):81– 85
Given all of the relevant demographic and biomedical 4. Feldman-Winter L, Kruse L, Mulford C, Rotondo F. Breastfeed-
data collected at birth, the birth certificate represents a ing initiation rates derived from electronic birth certificate data
in New Jersey. J Hum Lact. 2002;18(4):373–378
very useful data source for breastfeeding researchers
5. Kruse L, Denk C, Feldman-Winter L, Rotondo F. Longitudinal
who are interested in examining breastfeeding outcomes patterns of breastfeeding initiation. Matern Child Health J. 2006;
from a health disparities perspective and for policy mak- 10(1):13–18
ers who wish to improve hospital practice. Obviously, 6. Merewood A, Brooks D, Bauchner H, MacAuley L, Mehta S.
these data are only useful if they are made publicly Maternal birthplace and breastfeeding initiation among term
available. To date, several peer-reviewed publications and preterm infants: a statewide assessment for Massachusetts.
e1162 CHAPMAN et al
Downloaded from www.pediatrics.org by on June 2, 2009

6. Pediatrics. 2006;118(4). Available at: www.pediatrics.org/cgi/ 10. Centers for Disease Control and Prevention. Healthy People 2010
content/full/118/4/e1048 operational definition. Available at: ftp://ftp.cdc.gov/pub/Health
7. Castrucci BC, Hoover KL, Lim S, Maus KC. A comparison of Statistics/NCHS/Datasets/DATA2010/Focusarea16/O1619a.pdf.
breastfeeding rates in an urban birth cohort among women Accessed April 29, 2008
delivering infants that employ and do not employ lactation 11. Anderson A, Damio G, Young S, Chapman D, Pe ´rez-Escamilla R.
consultants. J Public Health Manag Pract. 2006;12(6):578 –585 A randomized trial assessing the efficacy of peer counseling on
8. McLaughlin C, Baptiste M, Schymura M, Nasca P, Zdeb M. exclusive breastfeeding in a predominantly Latina low-income
Birth weight, maternal weight and childhood leukaemia. Br J community. Arch Pediatr Adolesc Med. 2005;159(9):836 – 841
Cancer. 2006;94(11):1738 –1744 12. Merewood A, Navidi T, Chaudhuri J. Accuracy of breast-
9. Menacker F, Martin JA. Expanded health data from the new feeding data on the Massachusetts birth certificate. J Hum
birth certificate, 2005. Natl Vital Stat Rep. 2008;56(13):1–24 Lact. In press
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7. Breastfeeding Status on US Birth Certificates: Where Do We Go From Here?
Donna J. Chapman, Anne Merewood, Robert Ackatia Armah and Rafael
Pérez-Escamilla
Pediatrics 2008;122;e1159-e1163
DOI: 10.1542/peds.2008-1662
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/122/6/e1159
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