A Review of Extant Data and Data Sources Related to Breastfeeding in New Mexico and Recommendations to Improve Breastfeeding Data in the State

A Report Issued by the RWJF Center for Health Policy at the University of New Mexico

Angelina L. Gonzalez-Aller, MA [email protected]

Samuel Howarth, PhD [email protected]

NOTES AND DISCLAIMER

This report and overview was compiled in preparation for the W.K. Kellogg Foundation.

This publication is a product of the RWJF Center for Health Policy and was commissioned by the W.K. Kellogg Foundation. The views expressed in this report are those of the authors and do not necessarily represent those of the RWJF Center for Health Policy, the University of New Mexico, collaborating organizations, or funders.

Editor In-Chief: Gabriel R. Sanchez, PhD. Location: 1909 Las Lomas Road, Albuquerque, NM 87131 Phone: 505.277.0130 Email: [email protected]

TABLE OF CONTENTS Executive Summary , Overview of Recommendations and Acknowledgements 3

Abbreviations 6

Tables and Figures 7

Part One: A Review of Extant Data and Data Sources Related to Breastfeeding Surveillance in New Mexico 8

Part Two: Leveraging Data to Improve Breastfeeding in New Mexico 46

Part Three: Recommendations for Improving Breastfeeding Data Surveillance, Data Availability and data Analyses in New Mexico 53

References 58

Appendix A: Healthy People 2020 Survey Instrument 65

Appendix B: Ross Mothers Survey Instrument 2010 67

Appendix C: National Immunization Survey 2002-2012 72

Appendix D: mPINC Dimensions of Care 73

Appendix E: mPINC 2013 Report Card: New Mexico 74

Appendix F: New Mexico Baby Friendly Certified Hospitals 76

Appendix G: National Survey of Children’s Health Breastfeeding Indicators 77

Appendix H: PNSS Breastfeeding Initiation 2011 78

Appendix I: HealthStyles Breastfeeding Attitudes and Opinions 79

Appendix J: New Mexico Baby Friendly Hospital Map Prototype 80

EXECUTIVE SUMMARY, OVERVIEW OF RECOMMENDATIONS AND ACKNOWLEDGEMNENTS

Executive Summary The health and economic benefits of breastfeeding are well recognized across the globe. Breastfeeding has been shown to provide both mothers and children with health benefits. Women who breastfeed are at lower risk of breast and ovarian cancer, while breastfed infants have lower rates of respiratory infections and lower incidence of sudden infant death syndrome. The U.S. Surgeon General, the U.S. Department of Health and Human Services, the American Academy of Pediatrics, and the World Health Organization all encourage exclusive breastfeeding for the first six months of an infant’s life, with breastfeeding continuation until one year of age. Despite the widespread recognition of the benefits of breastfeeding, New Mexico lags behind other states on several breastfeeding indicators. According to results reported in the CDC’s 2014 Breastfeeding Report Card, New Mexico ranks 36th out of 50 states and the District of Columbia on breastfeeding initiation and 33rd out of 51 for exclusive breastfeeding at 6 months. Additionally, research has demonstrated pervasive disparities in breastfeeding rates in New Mexico when examined by race, ethnicity, acculturation, and geography. Because thorough and accurate data enable successful public health interventions and the development of effective policies at the state and federal level, the objectives of this study are as follows:

1. Identify and evaluate sources of breastfeeding data and determine if these sources are sufficiently robust to assess the status of breastfeeding rates and behavior throughout the state of New Mexico 2. Identify data gaps and areas where additional data collection would improve the ability to understand breastfeeding rates and trends in the state 3. Make recommendations on how to fill these data gaps

In order to accomplish these objectives, our analysis is presented in three corresponding parts. In Part One, we conduct a systemic and comprehensive review of national, state, regional, and local data systems that collect breastfeeding data. In Part Two, we present results from an online questionnaire designed and implemented by the RWJF Center for Health Policy that assessed data needs among public health professionals and breastfeeding advocates. In Part Three, and based on information and findings in Parts One and Two, we offer concrete recommendations for improving or expanding available data related to breastfeeding in New Mexico.

Recommendations The analysis conducted and the findings made in this report support the following recommendations towards improving breastfeeding data and data analyses in New Mexico:

 Expand the sample size of respondents to the PRAMS  Add questions to the PRAMS survey that ask mothers about breastfeeding exclusivity  Support the PRAMS Toddler Survey such that it is administered every year and administered to a large enough sample of mothers  Support current efforts to administer a Native American-specific version of a PRAMS-like survey and support collaboration between the partners involved in this effort  Create and support a “Kellogg Foundation PRAMS Fellow”  Work with the New Mexico Department of Health to support the creation of a file that contains PRAMS data geocoded to birth records  Support the creation and administration of a new survey that would provide important information on public attitudes towards breastfeeding

Acknowledgements This report was conducted by the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico and funded by the W. K. Kellogg Foundation. The report is a product of a collaborative effort between researchers, data experts, and breastfeeding advocates. As such, we would like to acknowledge the following individuals and organizations that provided insightful feedback and shared their expertise:

 Jessica Coloma, Program Officer, W. K. Kellogg Foundation  Heidi Fredine, Evaluation Director, New Mexico Breastfeeding Taskforce  Eirian Coronado, Maternal Child Health Epidemiology Program Manager/PRAMS PI, NM Department of Health  Sharon Giles-Pullen, New Mexico WIC Program Breastfeeding Manager, NM Department of Health  Erin Marshall, Project Director, Baby-Friendly Hospital Initiative, New Mexico Breastfeeding Taskforce  Members of the New Mexico Breastfeeding Taskforce  The New Mexico Department of Health  Envision New Mexico

We would also like to thank Envision New Mexico and the New Mexico Breastfeeding Taskforce for inviting us to participate in their meetings and for their many contributions to this report.

ABBREVIATIONS AAP- American Academy of Pediatrics BF- breastfeeding BFHI- Baby-Friendly Hospital Initiative CDC- Centers for Disease Control and Prevention CLC- Certified Lactation Consultant ECLS-B- Early Childhood Longitudinal Study Birth Cohort FDA- Food and Drug Administration HHS- U.S. Department of Health and Human Services IBCLC- International Board Certified Lactation Consultants IFPS II- Infant Feeding Practices Study II mPINC- Maternity Practices in Infant Nutrition & Care NCIRD- National Center for Immunizations and Respiratory Diseases NCHS- National Center for Health Statistics NHANES- National Health and Nutrition Examination Survey NIH- National Institutes of Health NIS- National Immunization Survey NMBTF- New Mexico Breastfeeding Task Force NMDOH- New Mexico Department of Health NSCH- National Survey of Children's Health PedNSS- Pediatric Nutrition Surveillance System PNSS- Pregnancy Nutrition Surveillance System PP- Post-partum PRAMS- Pregnancy Risk Assessment and Monitoring System RMS- Ross Mothers Survey RWJF- Robert Wood Johnson Foundation UNICEF- The United Nations Children’s Fund WHO- World Health Organization WIC- Special Supplemental Nutrition Program for Women Infants and Children WPPC- WIC Participant and Program Characteristics Y6FU- Year Six Follow Up of IFPS II

TABLES AND FIGURES Table 1 National Immunization Survey: Results for 2011 Births Table 2 National Immunization Survey: Sample Sizes 2009-2012 Table 3 New Mexico mPINC Scores: 2007-2013 Table 4 CDC New Mexico Report Card Summary: 2014 Table 5 Pregnancy Nutrition Surveillance System: Ever Breastfed 2011 Table 6 National Survey of Family Growth: Breastfeeding Indicators Table 7 HealthStyles Selected Reponses: 2015 Table 8 IFPS Breastfeeding Indicators and Questions Table 9 IFPS Any Breastfeeding Table 10 New Mexico Vital Statistics Breastfeeding Initiation: 2013 Table 11 WIC Breastfeeding Initiation: October 2014-2015 Table 12 WIC Reasons for Not Initiation Breastfeeding: October 2014-2015 Table 13 Summary of Data Availability Table 14 Summary of Datasets Assessing Breastfeeding in New Mexico Figure 1 2013 CDC Report Card: Lactation Consultants and Counselors by State Figure 2 National Survey of Children’s Health: Breastfeeding Indicators 2011-2012 Figure 3 Breastfeeding Initiation: WIC Mothers FFY2014

PART ONE: A REVIEW OF EXTANT DATA AND DATA SOURCES RELATED TO BREASTFEEDING IN NEW MEXICO

OVERVIEW National, state, and regional datasets were reviewed to evaluate various breastfeeding data and determine the status of breastfeeding surveillance throughout the state of New Mexico. Overall, breastfeeding initiation is the most commonly collected breastfeeding indicator, though there is significant variation in how initiation is measured, including differences in when data is collected, how questions are worded, and whether breastfeeding initiation is exclusive. In addition to initiation, a number of data sources include variables on breastfeeding duration, breastfeeding exclusivity, breastfeeding barriers, workplace policies, breastfeeding resources, hospital policies, and support services. While the variety of available data and data sources provides an opportunity for cross-validation and comparison, a number of data sources are hindered by small sample sizes, or, in the case of national data sources, do not include a sample representative of New Mexico’s state population. A brief summary of available data sources follows, with a discussion of the status of extant data

INTRODUCTION Worldwide, breastfeeding is recognized as beneficial for both infants and mothers. The American Academy of Pediatrics recommends that infants be exclusively breastfed for six months, with continuation of breastfeeding for 1 year or longer as complementary foods are introduced (Pediatrics, 2012). Increasing exclusive breastfeeding and the duration of breastfeeding is a major goal of the U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) as outlined in the Healthy People 2020 report.1 This report includes objectives for increasing the proportion of infants who are breastfed, increasing the proportion of employers that have worksite lactation support programs, reducing the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life, and increasing the proportion of live births that occur in facilities that provide care for lactating mothers and their babies.2 In order to accomplish these goals,

1 Healthy People is a national health promotion and disease prevention initiative which provides specific objectives in an effort to address major public health issues. Healthy People 2020 was released by the Department of Health and Human Services in 2010. 2 There are four objectives and five sub-objectives related to breastfeeding. Detailed objectives are provided in Appendix A.

8 breastfeeding monitoring and surveillance is needed. As outlined by Chapman and Pérez-Escamilla (2009), “national surveillance and monitoring of breastfeeding behavior are essential for the planning, implementation, and evaluation of public health interventions.” Breastfeeding data collection serves many public health purposes, from determining best practices, to identifying breastfeeding trends and monitoring progress towards goals and objectives (Heinig, 2010b). Quantitative and qualitative data may also be used to identify and clarify common challenges to breastfeeding, thereby enabling alternative solutions to emerge and informing the development of programs, policies, and initiatives to reduce barriers and increase the incidence and duration of breastfeeding. For example, more detailed statistics could be used to raise stakeholder awareness of the value of breastfeeding as a key preventative health measure (Heinig, 2010b). In order to assess the capacity of current breastfeeding data sets specific to New Mexico, we evaluated the availability of data and the quality of federal, state, and regional monitoring systems and the data collected through these systems. To identify these data sources we contacted data experts in the state, including staff at the New Mexico Department of Health and the New Mexico Breastfeeding Task Force. At the federal level we spoke with experts at the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). The datasets examined here are those that collect or analyze data on breastfeeding within the state of New Mexico. Such data sources include periodic surveys, one time studies and/or surveys, and evaluation systems for federally funded programs. When available, eligible surveys and datasets were downloaded from their respective websites. Each surveillance system was evaluated based on the breastfeeding-related data collected, the overall study sample, the New Mexico specific sample size, and whether the data is suitable for analysis at the state level.3 When available, results for breastfeeding indicators are reported. For the purpose of this study, we have identified four classifications of data sources:

 Data Type 1: National Data Sources that Sample New Mexico  Data Type 2: National Data Sources that do not Sample in New Mexico  Data Type 3: New Mexico Statewide Data  Data Type 4: New Mexico Site or Region Specific Data  Data Type 5: Forthcoming Resources

3 This study was not subject to Institutional Review Board approval because no private, identifiable information was obtained from individuals for the analyses presented in this report.

DATA TYPE 1: NATIONAL DATA SOURCES WITH NEW MEXICO SUBPOPULATIONS There are 11 federally funded datasets that include data on breastfeeding practices and behaviors (Chapman & Pérez-Escamilla, 2009). In their review of these 11 datasets, Chapman and Perez-Escamilla found that while multiple surveys and datasets collect breastfeeding data, extant data on breastfeeding is suboptimal for the evaluation of breastfeeding statistics. Out of these 11 datasets, six are nationally representative and three pertain to subpopulations of WIC participants. Ultimately, Chapman and Pérez- Escamilla (2009) conclude that differences in sampling procedures, recall bias, inconsistent wording on breastfeeding questions, and limited racial/ethnic category choices constrain the extent to which results can be generalized or compared. In addition to these 11 datasets, there are a number of additional monitoring systems, including private data sources, independent research studies, and other types of surveillance that provide information on breastfeeding behaviors, trends, opinions, and policies. A brief description of each system follows.

Ross Mothers Survey For several decades the Ross Mothers Survey (RMS) was the only source for breastfeeding statistics at both the state and federal level.4 The Ross Mothers Survey is an annual survey conducted by the Ross Products Division of Abbott Laboratories, one of the major infant formula manufacturers. The RMS is usually conducted 4 times a year by mailing questionnaires to a large sample of mothers when their infants reach six months of age. The study was first conducted in 1954 and was still active as of 2010 (Abbott, 2002; J. Edwards, 2011). In 2000 the Ross Mothers Survey was selected as the baseline monitoring and surveillance method for the Healthy People 2010 report. Because the RMS is administered by a private organization and RMS data is published on an ad hoc basis, the legitimacy of its results have been challenged throughout the relevant literature (CDC, 2007; Grummer-Strawn & Li, 2000; Grummer-Strawn & Shealy, 2009; Li, Zhao, Mokdad, Barker, & Grummer-Strawn, 2003; Alan S. Ryan, 2004, 2005; A. S. Ryan et al., 1991; Alan S. Ryan, Wenjun, & Acosta, 2002). In 2007 the Healthy People 2010 objectives were updated to include two new objectives for exclusive breastfeeding. As a result of these changes, the importance of the RMS began to decline, and in 2010 the National Immunization Survey was established as the official monitoring system for Healthy People 2020 objectives. While the Ross Mothers Survey is still administered, the last publicly available RMS was published in 2002 (NMBTF, 2014). According to 2001 survey responses, breastfeeding initiation was 69.5% nationwide and continuation to 6 months of age was 32.5% (Alan S.

4 The Ross Mothers Survey is also known as the Ross Laboratories Mothers Survey, the Infant Food Survey, and the National Institute of Infant Nutrition Survey.

Ryan et al., 2002). While Abbott Laboratories declined to provide any additional information on their sampling methodology or estimated New Mexico sample size, the rise in federally funded studies and surveys seems to have left the RMS to focus on its consumer market research purposes (J. Edwards, 2011; McCormack, 2011).5 Nonetheless, the RMS survey remains one of the few information resources for breastfeeding data throughout the 1950s-1990s before CDC data became more available.

National Immunization Survey Each year, the CDC’s National Center for Immunizations and Respiratory Diseases (NCIRD), in partnership with the National Center for Health Statistics, conducts the National Immunization Survey (NIS). In 2010 NIS became the official surveillance instrument for the Healthy People 2020 breastfeeding objectives. The National Immunization Survey is a random digit dialed telephone survey of households with children ages 19-24 months (CDC, 2007). As the name of the survey indicates, its primary purpose is to collect data on the immunization and health status of children. Following completion of the telephone survey, additional data is collected through a mail survey to the eligible child’s vaccination providers to validate vaccination information. Analyses of NIS data are limited to the children whose vaccination histories are confirmed by vaccination providers. While the sample size varies from year to year, the number of respondents in New Mexico tends to hover around the 300 mark. Breastfeeding surveillance was first incorporated into rotating modules of the NIS in 2001. This decision was a result of a November 1999, CDC sponsored, United States Breastfeeding Committee meeting on surveillance systems for monitoring breastfeeding behavior. Attendees recommended using existing surveillance systems to improve data collection and, as a result, three questions on breastfeeding initiation, duration, and exclusivity were added to the CDC’s National Immunization Study (CDC, 2007; Grummer-Strawn & Li, 2000; Li et al., 2003). The person or caregiver who is most knowledgeable about the child’s immunization status completes the survey and provides information on breastfeeding (CDC, 2015f).

5 Through an online parenting blog we were able to obtain a copy of the 2010 Institute of Infant Nutrition Survey, which is provided in Appendix B.

NIS Breastfeeding Questions 2006-present Was [child] ever breastfed or fed breast milk? How old was [child's name] when [child's name] completely stopped breastfeeding or being fed breast milk? How old was [child's name] when (he/she) was first fed formula? This next question is about the first thing that [child] was given other than breast milk or formula. Please include juice, cow's milk, sugar water, baby food, or anything else that [child] may have been given, even water. How old was [child's name] when (he/she) was first fed anything other than breast milk or formula?

Because children are between 19-35 months of age at the time of data collection, each survey year collects data on children born over a three-year period.6 In order to generate information by year of childbirth, data are combined across all relevant survey years.

Table 1. NIS Results for 2011 Births Ever BF BF at 6 BF at 12 Exclusive BF Exclusive BF Months months at 3 months at 6 months National 79.2 49.4 26.7 40.7 18.8 New Mexico 76.9 45.9 28.3 43.1 16.1

NIS data is representative at both the state and national level, thereby allowing interstate comparisons and the ability to track individual state progress as compared to nationwide results.

Table 2. National Immunization Survey Sample Sizes 2012 2011 2010 2009 United States 15,141 14,456 15,912 23,542 New Mexico 262 247 272 381

Between 2010 and 2012 the New Mexico sample has hovered around 260. With the exception of Texas and Pennsylvania, which have above average sample sizes, New Mexico’s sample size is on par with the NIS average of 269 respondents per state. In 2009 (excluding Texas and Pennsylvania) the state average was 417 to New Mexico’s reported 381 (CDC, 2015c).

6 Results on NIS breastfeeding indicators are reported in Appendix C.

Maternity Practices in Infant Nutrition & Care In an effort to monitor labor and delivery service facilities in the U.S. and to evaluate maternity care practices, the CDC began the Maternity Care Practices Survey in 2007 (mPINC) (CDC, 2015d; R. A. Edwards & Philipp, 2010). The mPINC survey was designed to serve as a census of facilities that routinely provide maternity care. Questions were developed by an advisory panel to evaluate practices known to affect successful breastfeeding (R. A. Edwards & Philipp, 2010). All hospitals with maternity services, all free-standing birth centers, and any facility that routinely provides maternity care services in the United States are invited to participate in the mPINC survey every two years (CDC, 2014b). The survey is completed by an experienced staff member on behalf of his or her institution. While all maternity care facilities are invited to participate, participation in the survey is voluntary. Data from each participating institution is aggregated and compiled into a state report. Although data is collected by hospitals and birthing centers and reported to the CDC, no site- or facility-specific data is released; only aggregated state level information is reported. State reports summarize each state’s facilities’ strengths in breastfeeding support and identifies areas in need of improvement. These reports provide parameters for states to better protect, promote, and support breastfeeding mothers and infants. Since reports are issued every two years, mPINC reports are important tools for tracking trends over time. According to the most recent report, New Mexico has 32 eligible facilities and a response rate of 91% (CDC, 2014b). The mPINC survey contains 52 questions: 33 of these focus on hospital/birth center practices; 13 focus on staff training and policy; and 5 relate to characteristics of the hospital birth center (R. A. Edwards & Philipp, 2010). Questions from each of these sections are then organized into 7 scoring groups:

1. Labor and Delivery Care 2. Breastfeeding Assistance 3. Contact Between Mother and Infant 4. Feeding of Breastfed Infants 5. Facility Discharge Care 6. Staff Training 7. Structural and Organizational Aspects of Care Delivery7

The highest score possible for the mPINC survey is 100. To determine final scores the mean of each of the 7 scoring groups is averaged again to obtain a final score.8

7 A copy of the mPINC dimensions of care is provided in Appendix D. 8 Greater detail on the mPINC scoring algorithm is available from: http://www.cdc.gov/breastfeeding/pdf/scoring_algorithm_mpinc09-508_tagged.pdf

Table 3. New Mexico mPINC Results Year Score Rank (out of) Response Rate Facilities (n) 2013 77 21 (53) 91% 32 2011 69 26 (53) 84% 31 2009 64 24 (52) 67% 30 2007 64 20 (52) 67% 30

In 2013 New Mexico received an mPINC score of 77 and ranked 21 out of 53 states and territories.9 In general, New Mexico scores higher on labor and delivery and postpartum care such as the feeding of breastfed infants, breastfeeding assistance, and contact between mother and infant; New Mexico scores lower on discharge care, staff training, and structural and organizational aspects of care. New Mexico’s mPINC score has gradually improved since the survey was initiated in 2007; however, the rate of improvement has not changed New Mexico’s comparative ranking against other states and territories. For the most part, New Mexico has remained in the bottom 50% of state performances. While the response rate to mPINC has improved from 67% in 2007 to 91% in 2013, it is important to remember that mPINC is both voluntary and self- reported.

CDC Breastfeeding Report Card Breastfeeding Report Cards are issued by the National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity for the CDC. Utilizing data from various sources, they compile a “report card,” or an assessment, for each state in the U.S. documenting their respective performance across several breastfeeding initiative dimensions or “indicators.” These indicators are established by the Centers for Disease Control and Prevention’s National Immunization Survey (NIS) and the Maternity Practices in Infant Nutrition and Care Survey (mPINC), among others. The Report Cards focus on two primary areas: breastfeeding rates and breastfeeding support indicators, including birth facility support, mother-to-mother support, and professional support. State-by-state NIS data is used to track breastfeeding initiation, exclusivity, and duration using five indicators that correspond to goals in the Healthy People 2020 report:

1. Ever Breastfed 2. Breastfeeding at 6 months 3. Breastfeeding at 12 months

9 The 2013 New Mexico mPINC Report Card is available in Appendix E.

4. Exclusive Breastfeeding at 3 months 5. Exclusive Breastfeeding at 6 months

The Report Card also briefly addresses breastfeeding support indicators. These indicators range from assessing support from birth facilities and health professionals to childcare settings. Since 2008, results from the mPINC survey have been included to measure breastfeeding-related maternity care practices at maternity care facilities across the U.S. and to compare the extent to which these practices vary by state. Two of these indicators are new to the 2013 report and originate from the 2011 CDC mPINC survey:

1. The percent of hospitals and birth centers where at least 90% of mothers and newborn infants have skin-skin contact for at least 30 minutes within an hour of an uncomplicated vaginal birth. 2. The percent of hospitals and birth centers where at least 90% of healthy full-term infants are rooming with their mother for at least 23 hours per day (CDC, 2011a).

The above indicators are based on recommendations from the Baby-Friendly Hospital Initiative (BFHI), a global program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to both encourage and recognize hospitals and birthing facilities that offer an optimal level of care for lactation.10 The BFHI program is based on the WHO/UNICEF Ten Steps to Successful Breastfeeding for Hospitals (Baby-Friendly-USA, 2013). The other two breastfeeding indicators are:

3. The percent of live births occurring at hospitals or birth centers designated as “Baby-Friendly.”11 4. The percentage of breastfed infants receiving formula before 2 days of age.

In addition to the outcome and breastfeeding support indicators, the Report Card includes a mother-to-mother support indicator, which is the number of La Leche League Leaders per 1,000 live births, and a professional support indicator, which is measured by the number of International Board Certified Lactation Consultants (IBCLCs) per 1,000 live births. The report also provides information on the number of IBCLCs and Certified Lactation Counselors (CLCs) in each state.

10 BFHI was launched in 1991 in an effort to address international concerns about common marketing and medical practices that interfered with successful breastfeeding. Since the implementation of BFHI, research has indicated that baby friendly hospital policies result in increased breastfeeding rates. For a concise summary see (Heinig, 2010a). 11 As of 2016, there are 7 Baby Friendly Hospitals in New Mexico. The list of BFHI approved facilities is available in Appendix F.

Figure 1. Lactation Consultants and Counselors by State 2013

Lastly, a support in childcare settings indicator is included, which consists of a state’s childcare regulation of onsite breastfeeding support (CDC, 2015f).

Table 4. 2014 Report Card Summary12 Average % of live % of BF Number of Number of Number of Childcare mPINC births at infants La Leche CLCs* IBCLCs* laws Score baby receiving League support friendly formula leaders* onsite BF facilities before 2 days of age United 75 7.79 19.4 0.90 3.84 3.48 7** States New 77 3.77 15,5 0.87 1.75 3.3 No Mexico *per 1,000 live births ** Arizona, California, Delaware, Mississippi, North Carolina, Texas, Vermont

It is important to note that while the Report Cards do not collect any original data, they provide a concise summary of NIS and mPINC results and provide a useful platform for tracking state level changes over time or making state-to-state comparisons. From 2007-2014 the CDC issued yearly Report Cards. Beginning in 2014, Report Cards will be issued every other year; it is anticipated that the next Report Card will be released in 2016.

12 CDC. (2014). Breastfeeding Report Card. Atlanta: CDC Retrieved from http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf.

National Survey of Children’s Health The National Survey of Children’s Health (NSCH) is sponsored by the Maternal and Child Health Bureau of the Health Resources and Services Administration. The survey examines the physical and emotional health of children ages 0-17 years of age (CDC, 2013a). The NSCH provides a broad range of information about children’s health and well-being sampled in a manner which permits comparisons among states as well as nationally. For the 2011-2012 survey, a total of 95,677 NSCH interviews were completed, approximately 1,876 in each state and the District of Columbia, ranging from a minimum of 1,811 in South Dakota to a maximum of 2,200 in Texas (childhealthdata.org, 2013). Survey results are adjusted and weighted to reflect the demographic composition of non-institutionalized children and youth age 0–17 in each state. Questionnaire topics include demographics, health and functional status, health insurance coverage, health care access and utilization, medical home, early childhood (0–5 years) issues, issues specific to middle childhood and adolescence (6–17 years), family functioning, parental health status, and neighborhood and community characteristics. The NSCH is a cross sectional telephone survey of U.S. households with at least one resident age 0-17 at the time of the survey. NSCH follows the sampling method of the NIS, operating from a random digit dialed sample of landline telephone numbers supplemented with an independent sample of cellphone numbers (CDC, 2013a). The survey was conducted in 2003, 2007, and 2011/2012. The 2011/2012 survey includes two indicators on breastfeeding that are asked about children ages 0-5: whether children were ever breastfed; and whether or not they were exclusively breastfed through 6 months. To produce these two indicators, four questions are asked: whether a child was ever breastfed or fed breast milk; the age at which breastfeeding stopped; the age at which formula was introduced; and the age at which anything other than breast milk was introduced (childhealthdata.org, 2013). Data for the breastfeeding indicators are included in the early childhood health section, which is asked about children ages 0-5. As a result, breastfeeding questions have a smaller sample size. While there were approximately 1,870 NSCH respondents in New Mexico, approximately 500 survey respondents participated in questions relating to breastfeeding.

Figure 2. NSCH 2011-2012 Breastfeeding Indicators

Results from the 2011/2012 NSCH report that approximately 19.3 % (n=83) of New Mexico children were never breastfed of given breast milk, while 19.1% (n=90) were exclusively breastfed for 6 months and 61% (n=302) were breastfed but not exclusively breasted for the first 6 months (NSCH, 2013).13

Early Childhood Longitudinal Program-Birth Cohort The Early Childhood Longitudinal Study Birth Cohort (ECLS-B) was designed to provide policy makers, researchers, educators, and parents with detailed information about the development of children in the United States (West). The program is administered by the Institute of Education Sciences and focuses on children’s health, development, care, and education during the years from birth to kindergarten entry. ECLS-B is a one-time longitudinal study which follows a sample of 14,000 children born

13 NSCH. (2013). NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative. Retrieved from http://childhealthdata.org/browse/survey/results?q=2461&r=33 Detailed comparisons of New Mexico indicators results are available in Appendix G.

18 in 2001 until the time at which they enter kindergarten (Belfield & Kelly, 2010). The ECLS-B consists of two cohorts: a birth cohort, and a kindergarten cohort. In combination these two cohorts provide a long range of data describing children’s health, early learning, home life, development, and educational experiences (West). Information is collected at 9 months, 2 years, and 4 years of age (IES, 2015). The survey is completed through a series of in-home interviews with primary caregivers, including a videotaping of parent-child interaction. The birth cohort focuses on characteristics of children and their families, including health care and in-home and out-of-home experiences (West). Breastfeeding questions are asked in the 9-month survey and include questions related to breastfeeding initiation, duration, and the age at which child is first given formula or other foods. The longitudinal component of the ECLS-B provides an opportunity to evaluate the effects of breastfeeding both at the 9-month time point and as an independent variable on a variety of health, educational, and well-being factors later in life. Due to the ECLS-B’s restricted-use data guidelines, we are only able to provide an estimate of the sample size for New Mexico. In the base year of the ECLS-B (i.e., the 9- month data collection) approximately 100 children in New Mexico participated in the ECLS-B.14

Pediatric Nutrition Surveillance System The Pediatric Nutrition Surveillance System (PedNSS) monitors health behavior of low-income children in federally funded maternal and child health programs (CDC, 2009; B. E. Dalenius K, Smith B., Polhamus B., Grummer Strawn L, 2012). Data for breastfeeding and other health factors are collected for children who are provided care at public health clinics. Data are generally collected at the clinic level, aggregated at the state level, and then submitted to the CDC for analysis (Grummer-Strawn & Li, 2000; Polhamus B, 2011). Since 2004, PedNSS has monitored exclusive breastfeeding and breastfeeding initiation. Breastfeeding duration is measured up to one year; however, the sample of this data only includes those children turning one year of age who received public health services during the reporting period (B. E. Dalenius K, Smith B., Polhamus B., Grummer Strawn L, 2012). Breastfeeding initiation is determined by “ever breastfed” while duration is determined by “breastfed at least 6 months” and “breastfed at least 12 months” (CDC, 2009). New Mexico participated in PedNSS from 2000-2002 and again from 2004-2010. Along with the Pregnancy Nutrition Surveillance System (PNSS), the CDC discontinued PedNSS in 2012. The last year for which data is available

14 Sample estimate is rounded to the nearest 50. As such, there were more than 75 children and less than 125 included in the ECLS-B. As with most national studies, the ECLS-B was designed to be representative at the national, but not state or local level.

19 is 2011. Due to data restrictions, we are unable to provide further information on breastfeeding rates or sample size.15

Pregnancy Nutrition Surveillance System The Pregnancy Nutrition Surveillance System (PNSS) began in 1973 with yearly data collection until the study (along with PedNSS) was discontinued in 2012. The most recent year PNSS was conducted was 2011. PNSS was designed to monitor the prevalence of nutrition-related problems and behavioral risk factors for infant health. The target population of PNSS participants were low-income, high-risk pregnant women who participated in publicly funded health, nutrition, and food assistance programs (Kim, 1995). PNSS focused on dietary choices and behavioral risk factors such as smoking and alcohol consumption before and during pregnancy. Data collected about infants included date of birth, birth weight, and breastfeeding status (B. P. Dalenius K, Smith B, Reinold C, Grummer-Strawn L., 2012). Because PNSS focuses on pregnancy, breastfeeding duration was not collected. Much like PedNSS, the Pregnancy Nutrition Surveillance system (PNSS) is a program-based surveillance system that includes data collected from federally funded public health programs serving low- income pregnant women (CDC, 2010). Participation in PNSS is voluntary, and not all women receiving public health program services participate. As a result, PNSS is not representative of all low-income pregnant women or pregnant women in the general population (CDC, 2010; B. P. Dalenius K, Smith B, Reinold C, Grummer-Strawn L., 2012). New Mexico contributed data to PNSS in 2009, 2010, and 2011, before data collection was discontinued in 2012.

Table 5. PNSS Breastfeeding Initiation: 2011 Percent Ever BF N New Mexico 66.6 5,846 United States 70.1 765,791

In 2011, 5,846 New Mexico infants were included in PNSS, of whom 66.6% were “ever breastfed” (CDC, 2011b).16 New Mexico’s rate falls below the average of the 30 states/territories who reported data to PNSS (70.1%). When comparing breastfeeding indicators to PNSS results, it is important to remember that the PNSS sample population is based on a non-representative sample of women who participate in public health programs.

15 Data requests may be submitted to the Centers for Disease Control and Prevention. 16 The full table of state comparisons is available in Appendix H.

DATA TYPE 2: NATIONAL DATA SOURCES WITHOUT REPORTED NEW MEXICO SUBPOPULATIONS In addition to the studies listed above, there are a number of national surveys that do not routinely collect data in New Mexico or collect limited data in New Mexico. These surveillance systems provide useful platforms from which to compare data sources and also demonstrate potential data gaps. A brief discussion of each system follows. When available, summary findings are reported.

National Survey of Family Growth The National Survey of Family Growth, or NSFG, was designed to be the national fertility survey of the United States. As a result, the survey’s primary focus is on factors that help to explain trends and group differences in birth rates such as contraception, infertility, sexual activity, and marriage (CDC, 2015a). The NSFG is administered by the CDC’s National Center for Health Statistics (NCHS) with the support and assistance of a number of other organizations and individuals. The NSFG is conducted in five-year cycles, with data made available approximated every six years (Chandra, Martinez, Mosher, Adbma, & Jones, 2005; Grummer-Strawn & Li, 2000). The cycles thus far are as follows:

 Cycle 1, started 1973  Cycle 2, started 1976  Cycle 3, started 1982  Cycle 4, started 1988  Cycle 5, started 1995  Cycle 6, started 2002  2006-2010 NSFG  2011-2015 NSFG

The first NSFF surveys were conducted as periodic cycles in 1973, 1976, 1982, 1988, and 1995. During this period, the survey sampled women exclusively; however, the survey was expanded in Cycle 6 to include men (NCHS, 2012). In 2006 the NSFG shifted from a periodic (cycle based) survey to continuous interviewing. Interviews were conducted 48 weeks of every year for four years from June 2006 to June 2010 (CDC, 2015a). NSFG continues to interview men and women ages 15-44 living in households in the United States (CDC, 2015a). The most recent available data is the 2011-2013 NSFG, which interviewed a national sample of 10,416 men and women 15-44 years of age (CDC, 2015a). The NSFG is designed to be nationally representative based on a representative multistage area probability drawn from 120 geographic areas across the nation (Chandra et al., 2005).

Table 6. National Survey of Family Growth Breastfeeding Indicators Singleton babies Singleton babies Singleton babies United States born in 1997-2000* born in 2001-2005** born in 2006-2009** Percent Ever 66.8% 68.1% 72.6% Breastfed Percent breastfed 3 48.0% 49.8% 50.1% months or more Percent breastfed 6 34.9% 37.3% 36.5% months or more Percent breastfed 12 17.3% 17.0% 20.0% months or more *(Chandra et al., 2005) ** Tabulation from NCHS available at: http://www.cdc.gov/nchs/nsfg/key_statistics/b.htm#breastfeeding

Breastfeeding questions are asked of mothers reporting births in the 5 years preceding the survey, including questions related to breastfeeding initiation and duration (McDowell, Wang, & Kennedy-Stephenson, 2008). The National Center for Health Statistics declined to provide estimates of state sample sizes, indicating that any samples within New Mexico would be small and not representative of the state.

National Health and Nutrition Examination Survey The National Health and Nutrition Examination Survey (NHANES) is a series of point-in-time surveys designed to assess the health and nutritional status of children and adults throughout the United States (CDC, 2013b; Grummer-Strawn & Li, 2000; McDowell et al., 2008). NHANES began in the early 1960s and became a continuous program in 1999. The survey examines a nationally representative sample of about 5,000 people each year in an effort to understand the prevalence of chronic conditions in the population and associated risk factors (CDC, 2013b). The study is unique in that data are collected from a combination of home interviews and physical laboratory examinations (CDC, 2013b). Breastfeeding data are usually collected at the home interview from parents (CDC, 2015d; Grummer-Strawn & Li, 2000). In the reproductive health questionnaire, women who have had one or more live born children are asked about whether they breastfed their children. Following a positive response, participants are asked whether they breastfed their child at least a month. Following a negative response, women are asked the reasons for not breastfeeding. Responses are grouped according to a birth cohort based on the date of birth of the child for whom breastfeeding questions are asked (McDowell et al., 2008). The NHANES sample is selected to represent the U.S. population of all ages. In an effort to produce reliable data, NHANES oversamples persons 60 and older, African Americans, Asians, and Hispanics (CDC, 2013b). It is

22 important to note that NHANES data is not obtained through random sampling methods. NHANES data is collected via a complex, multistage probability sampling design that selects a sample that is representative of the civilian household population of the United States (Zipf, Chiappa, Porter, & al., 2013).17 Though it is collected, the geographic variable “state of residence” is not made available for analysis.

HealthStyles Survey The HealthStyles Survey is a national mail survey of men and women aged 18 years and older. The survey is conducted in two parts: the first focuses on general media habits, product use, interests, and lifestyle. The second part focuses on health orientations and practices. The survey has been administered annually since 1995, with the CDC beginning to include questions related to breastfeeding in 1996 (CDC, 2015d). These breastfeeding related questions focus on public beliefs, perceptions, opinions, and attitudes about breastfeeding policies (CDC, 2015e).18 From 1995 to 2001, the HealthStyles survey was a part of the DDB Needham LifeStyles consumer survey administered by Porter Novelli, a public relations firm that conducted the survey in consultation with health professionals and experts from health related organizations. The HealthStyles survey is mailed to persons who have completed the DDB Needham Lifestyle Survey, which is conducted annually in April. The HealthStyles follow up survey is usually conducted around June of the same year (Hannan, Li, Benton-Davis, & Grummer-Strawn, 2005). The respondent list is drawn from a consumer mail panel which consists of 500,000 households throughout the United States that have agreed to answer mail questionnaires about their lifestyles and media and product use (Li, Rock, & Grummer-Strawn, 2007). Since 2002, the survey has been administered by Porter Novelli in conjunction with their Consumer Styles, or SpringStyles survey (CDC, 2015e). Since 1999, about ten breastfeeding questions have been included in the HealthSytles questionnaire (Li et al., 2007).

17 Approximately 12,000 people are asked to participate in the NHANES study every two years. Of these 12,000 about 10,000 complete the interview and examination (Zipf et al., 2013). 18 2015 HealthStyles Question Responses are reported in Appendix I.

Table 7. HealthStyles 2015 Selected Questions Neither N Agree Disagree Agree/Disagree I am comfortable when mothers breastfeed their babies near me in a public place, such as a 4,121 57.75% 23.13% 19.12% shopping center, bus station, etc. I believe women should have the right to 4,117 63.74% 23.03% 13.24% breastfeed in public places. Women should be encouraged to breastfeed. 4,117 62.91% 32.55% 4.54% Public buildings need to have a room where women could breastfeed and pump milk for their 4,120 57.31% 28.88% 13.81% babies. A mother needs lots of support to breastfeed her 4,116 49.17% 35.06% 15.77% baby. I believe employers should provide extended maternity leave to make it easier for mothers to 4,120 46.67% 33.30% 20.02% breastfeed. I would support financial incentives for employers who make special accommodations to make it 4,115 41.07% 37.84% 21.09% easier for mothers to breastfeed. There should be paid maternity leave to workers. 4,122 69.72% 20.45% 9.83% *All items are coded on the likert scale of 1 to 5 from strongly disagree, moderately disagree, neither disagree nor agree, moderately agree, or strongly agree (CDC, 2015e).

HealthStyles data is widely utilized in publications focusing on breastfeeding perceptions and public beliefs, changes in attitudes, and regional or demographic variation in breastfeeding public opinion (Hannan et al., 2005; Li, Fridinger, & Grummer-Strawn, 2002, 2004; Li, Hsia, et al., 2004; Li et al., 2007). In recent years total participation in the study has hovered at around 4,000 respondents. The sample is drawn to be representative of all U.S. adults, with an oversample to compensate for low response rates among low-income individuals and minorities. Because the data are products of both the CDC and a private organization, sample details are not provided. A CDC representative, however, did indicate that any sample within New Mexico would not be representative and would be unsuitable for analysis.

Infant Feeding Practices Study II and Year Six Follow Up The Infant Feeding Practices Study II (IFPS II) was conducted by the CDC and the Food and Drug Administration (FDA) from 2005-2007. Developed to provide greater understanding of mothers’ breastfeeding practices, the IFPS II is a longitudinal study that assesses the diets and behaviors of women from late pregnancy through their infants’ first year of life (CDC, 2015d; DHHS, 2011). The study evaluates infant feeding behavior, including breastfeeding, formula feeding, solid food intake, and the feeding

24 of other complementary foods and liquids. IFPS II was conducted using a monthly hard copy mailed questionnaire. On average, members of the study group had higher levels of education, were older, more likely to be white, had a middle level income, and were more likely to be employed than the overall U.S. female population (DHHS, 2011). In 2012 the FDA and CDC conducted a follow-up study of mothers and children who participated in the IFPS II to evaluate the health, development, and dietary patterns of the children at six years of age (CDC, 2014a, 2015d).

Table 8. IFPS Breastfeeding Indicators and Questions Questions addressed by the Infant Feeding Practices Study II Use of Consumer Products  What types of formulas do infants consume and how?  What are consumers' experiences with breast pumps?  When and why do women express or pump milk?

Maternal Dietary Intake During Pregnancy and at Four Months Postpartum  What are the dietary practices of pregnant women and lactating and non-lactating postpartum women?  What dietary supplements do women take during pregnancy and lactation?  How are these practices different from non-pregnant women?

Characteristics of Infant Feeding Patterns  When and how are complementary foods introduced?  How is breastfeeding practiced among U.S. infants?  Do U.S. infants consume teas or herbal preparations?  Are feeding patterns of infants with a family history of allergy different from infants without this family history? Determinants and Benefits of Breastfeeding  Do birth hospitals in the U.S. adhere to the Ten Steps to Successful Breastfeeding?  Where do mothers receive information regarding infant feeding?  What are the reasons for women do not initiate breastfeeding or stop breastfeeding?  Is breastfeeding intention related to a woman's perception of social support?  Does maternity care practice affect exclusivity of breastfeeding?  Does postnatal depression affect exclusivity of breastfeeding?  Is workplace or childcare breastfeeding support important for women to continue breastfeeding?  Is the use of breast pumps related to breastfeeding duration?  Do mothers who share a bed with their infants breastfeed longer?  Are pre-pregnant weight and gestational weight gain related to breastfeeding patterns?  Does breastfeeding reduce maternal weight retention following birth? Recommendations and Evaluation  How effective was the National Breastfeeding Awareness Campaign?  Are the AAP recommendations for vitamin D supplementation for breastfeeding infants being followed?  How have infant feeding practices changed from a decade ago?

(CDC, 2014a)

The IFPS II is unique in that it is one of the only longitudinal studies that collects breastfeeding data. Questionnaires were mailed to mothers at 2, 3, 4, 5, 6, 7, 8, 10.5, and 12 months after their child’s birth. All participants in the study were mothers of infants born between May 2005 and March 2006 (Ruowei Li, 2008). In addition to questions about breastfeeding initiation and duration, the study includes a comprehensive series of questions related to reasons for discontinuing breastfeeding (Ruowei Li, 2008). IFPS includes a robust series of questions and indicators ranging from the use of consumer products like infant formula and breast pumps to maternal diet during pregnancy and postpartum. Moreover, a series of indicators are included in an effort to address breastfeeding determinants such as the effectiveness of support services, the role of workplace policies, and co-sleeping on the initiation and duration of breastfeeding.

Table 9. Infant Feeding Practices Study II Any Breastfeeding Percent of babies fed any breast milk in the past 7 days19 Infant age in months Neonatal 2 3 4 5 6 7 9 10 12 ALL(n) 3,002 2,546 2,381 2,232 2,178 2,092 2,017 1,942 1,804 1,802 (%) 72.4 63.8 60.4 56.9 53.7 49.8 45.6 41.6 37.1 25.2

The IFPS utilizes a convenience sample that is not nationally representative. The sample is drawn from a U.S. consumer opinion panel of approximated 500,000 households. Approximately 4,900 pregnant women above the age of 18 participated in the IFPS II prenatal survey, and, of these, approximately 2,000 received one neonatal and nine postnatal questionnaires. As a result, the study only includes 27 mothers sampled from New Mexico.

DATA TYPE 3: NEW MEXICO STATEWIDE DATA Currently, there are a number of federal data collection programs that evaluate breastfeeding throughout the state, including Vital Statistics, WIC participant data, and the Pregnancy Risk Assessment and Monitoring System (PRAMS). These programs have the benefit of collecting data in New Mexico as independent data sources available to state health officials. Unlike federal studies, which include New Mexico in their samples but are only representative at the national level, state level data collection programs are designed specifically to provide data representative of New Mexico’s own population. A summary of state level data sources follows.

19 Tabulation by the Centers for Disease Control and Prevention Report on the Infant Feeding Practices Study II (CDC, 2015h)

Vital Statistics: Standard Certificate of Live Birth In 2003 the U.S. Standard Certificate of Live Birth (SCLB) was revised to include a question on breastfeeding (Chapman, Merewood, Armah, & Pérez-Escamilla, 2008). The SCLB is a template birth certificate that may be edited and adjusted by individual states. By May of 2008, over thirty states had updated their certificate of live birth to include a question on breastfeeding (Navidi, Chaudhuri, & Merewood, 2009). New Mexico is one of several states that collect breastfeeding status with the question “Is the infant breastfed at discharge?” with the available responses of “yes” and “no” listed. Since a SCLB is issued for every live birth in the state, SCLB data reflects the total population and is the only data source that is not based on a sub-sample of births. However, it does not directly assess breastfeeding initiation, does not specify whether breastfeeding is exclusive, and, since it is collected at discharge, reflects only very early postpartum behavior.

Table 10. Vital Statistics 2013 Breastfeeding Initiation New Mexico N Percent Yes 20,308 77.39 No 4,033 15.37 Unknown 1,901 7.24 Total 26,242 100

In addition to breastfeeding initiation, the SCLB contains information on paternal variables such as age, education, birthplace, race/ethnicity, and other relevant maternal variables such as delivery method, height, pre-pregnancy weight, WIC participation, and infant variables such as gestational age and birth weight (Chapman et al., 2008). As a result, breastfeeding data derived from New Mexico birth certificates presents a unique opportunity to analyze breastfeeding initiation with a sample of the complete New Mexico birth population. While the SCLB only collects breastfeeding initiation shortly following birth and does not specify whether breastfeeding is exclusive, vital statistics data present a particularly useful comparison source for other data sources that are collected on a population sample.

Newborn Screening Newborn Screening is a state administered public health program which uses blood sample testing to screen newborn infants for certain diseases. Each year, millions of babies in the U.S. are routinely screened, using a few drops of blood from the newborn's heel, for certain genetic, endocrine, and metabolic disorders (CDC, 2016). The State of New Mexico mandates that two Newborn Genetic Screens be collected on every newborn born in New Mexico. The newborn screen blood sample is obtained by a

27 health care provider, typically a hospital nurse. In addition to capturing a blood sample, the screening also collects information on the breastfeeding status of the infant.20

Breastfeeding Data Collected Through Newborn Screening Total number of births per calendar year Infants feeding method at the time the screen is obtained  Exclusive breastfeeding is defined as ONLY breast milk – no other liquids.  Any breastfeeding is defined as a combination of breast milk and any other infant feeding method.

Since the primary purpose of newborn screening is diagnostic, the data collected is not usually made publicly available. Access to newborn screening data may be requested through the New Mexico Department of Health.

Pregnancy Risk Assessment Monitoring System for New Mexico The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, multi-year, state-based population survey used to identify and monitor selected maternal behaviors and experiences occurring before, during, and after pregnancy. The goal of the PRAMS is to improve the health of mothers and infants by reducing unfavorable outcomes such as low birth weight, infant mortality and morbidity, and maternal morbidity. The PRAMS was piloted by the CDC in 1989 and consists of three parts: a series of core questions that all states use, a bank of standardized optional questions that states may select from, and state-developed questions that are usually used only by the state that developed them (CDC, 2015b). The core portion of the questionnaire includes questions about the following:

 Attitudes and feelings about the most recent pregnancy  Content and source of prenatal care  Maternal alcohol and tobacco consumption  Physical abuse before and during pregnancy  Pregnancy-related morbidity  Infant health care  Contraceptive use  Mother’s knowledge of pregnancy-related health issues, such as adverse effects of tobacco and alcohol, the benefits of folic acid, and the risks of HIV(CDC, 2015g)

20 Thanks to Heidi Fredine of the New Mexico Breastfeeding Taskforce who provided this information.

Currently 40 states and the District of Columbia participate in the PRAMS. In 1998 a collaboration between the NM Department of Health and the Centers for Disease Control and Prevention brought the first installment of the PRAMS to New Mexico.21 Using a sampling frame from resident in-state birth records with a monthly sample of around 1 out of every 12 live births, the PRAMS provides ongoing surveillance of public health issues throughout New Mexico. PRAMS samples are stratified by maternal race and/or ethnicity, including non-Hispanic white, Hispanic native born, American Indian, and all other reported race-ethnicities. The data are collected through hard copy questionnaire mailings with incentives, phone follow-up, and hand delivery for non- responders, with a $10 gift card for completion. The surveys are administered approximately 2–6 months after women give birth.

PRAMS Breastfeeding Behavior Questions  Did you ever breastfeed or pump breast milk to feed your new baby after delivery, even for a short period of time?  Are you currently breastfeeding or feeding pumped milk to your new baby?  How many weeks or months did you breastfeed or pump milk to feed your baby?  How old was your new baby first time he or she drank liquids other than breast milk (such as formula, water, juice, tea, or cow’s milk?)

(NMDOH, 2012)

Because mothers receive the survey between 60 and 120 days postpartum, breastfeeding duration estimates are limited to nine weeks (Weng, Coronado, & Nadler, 2005).22 In addition to questions on breastfeeding behavior, PRAMS also asks questions about breastfeeding services in hospitals, including whether staff provided information about breastfeeding, assisted in breastfeeding or provided a breast pump, and reasons for discontinuing breastfeeding.

21 NM PRAMS started with July 1997 births. 22 Indirect estimates are available for longer durations.

Breastfeeding Discontinuation Question What were your reasons for stopping breastfeeding? Check all that apply:  My baby had difficulty latching or nursing  Breast milk alone did not satisfy my baby  I thought my baby was not gaining enough weight  My nipples were sore, cracked, or bleeding  It was too hard, painful, or too time consuming  I thought I was not producing enough milk  I had too many other household duties  I felt it was the right time to stop breastfeeding  I got sick and was not able to breastfeed  I went back to work or school  My baby was jaundiced  Other, Please tell us

(NMDOH, 2012)

In addition to the aforementioned measures profiled, the 2008-2012 NM PRAMS also responded to the increase in goals for breastfeeding in Healthy People 2020 as well as to an amendment to NM law NMSA 1978 which supports breastfeeding in the workplace. In response the PRAMS system added additional components to the survey to evaluate the status of workplace breastfeeding policies.

Workplace Policy Question New Mexico state law requires that all employers provide a clean, private location for mothers to breastfeed or pump milk for their infants. What happens when a mother wants to breastfeed or pump milk for her baby at your current or most recent workplace?  She can breastfeed or pump milk at anytime  She can breastfeed her baby during break times only  She has flexible break times to breastfeed or pump milk  She has a clean private place that is not a bathroom, where she can breastfeed or pump milk  She is not allowed to breastfeed or pump milk at work  I don’t know (NMDOH, 2012)

The PRAMS provides a series of useful breastfeeding questions ranging from breastfeeding behavior from initiation, reasons for termination, workplace policies, and support services. The study population is all New Mexican resident mothers with a registered live birth for the sampling year. About 1 in 12 mothers are selected for the survey sample (NMDOH, 2012). In recent years the sample size for the New Mexico PRAMS has ranged from a maximum of 1,615 in 2000 to a minimum of 977 in 2012.23

23 2012 is the most recent year for which we have available data. With Kellogg funding, 2012-2015 PRAMS included a significant oversample.

Despite the fact that PRAMS has a large New Mexico sample size, the sample is still relatively small, hovering at around the 1,400 mark, which requires combinations of sample years in order to be able to disaggregate by demographic indicators such as race or ethnicity, county or region, or education or income. Moreover, breastfeeding duration is limited to 6 months with subsamples of duration responses, as surveys are mailed to mothers when their infant is 2-6 months of age.

Women, Infants and Children program for New Mexico The Women, Infants and Children Program (WIC) is the federal Special Supplemental Food Program for women, infants, and children administered by the United States Department of Agriculture (USDA), Food and Nutrition Service and the New Mexico Department of Health, Public Health Division. WIC services are also available through select Indian Tribal Organizations. WIC provides supplemental food to program participants along with nutrition education, information on breastfeeding, and referrals to health and social programs. In order to quality for WIC, one must live in New Mexico and be a pregnant, breastfeeding, or postpartum mother to an infant under one year of age or a child of less than 5 years of age. Additionally, WIC eligibility requires mothers to meet the income requirement of an income at or below 185% of the federal poverty income level.24 Lastly, participants must be at nutritional risk as determined by an initial health and diet screening at a WIC clinic.

Table 11. WIC Breast Feeding Initiation: New Mexico Infants Born October 2014- 201525 Yes No No Answer Total Initiated 12,949 3,107 52 16,108 Breastfeeding 80.4% 19.3% 0.3% 100%

Following the passage of the Child Nutrition and WIC Reauthorization Act of 1989, WIC strengthened its breastfeeding promotion efforts for pregnant and postpartum participants (Johnson et al., 2013). As a result of this legislation, WIC programs expanded to include a range of strategies aimed at increasing breastfeeding initiation and duration. These programs included new data collection efforts, individual and group education programs, breastfeeding peer counselor programs and support groups, staff education and training, breast-pump loan programs, and community partnerships (Johnson et al., 2013). In 1994 federal legislation passed requiring the

24 According to a 2015 memo from the USDA, in 2013 there were 14,420 infants (<12 months of age) who were at or below 185% of the federal poverty line. 25 Data was provided by the NM WIC Program. For additional information, please contact Sharon.Giles- [email protected]

USDA to report breastfeeding incidence and duration rates of WIC participants (Johnson et al., 2013). Consequently, WIC is the largest public breastfeeding promotion program in the nation (nwica.org, 2015).

Table 12. Reasons for not Initiating Breastfeeding New Mexico Infants Born October 2014-2015 N Percent Embarrassment 108 3.5% Family or friend’s influence 70 2.3% Lack of confidence 1,627 52.4% Lack of hospital support 221 7.1% Lack of professional support postpartum 54 1.7% Lack of professional support prenatally 12 0.4% Lifestyle restrictions 328 10.6% Other 230 7.4% Valid Medical Contraindications 123 4.0% Work or School 21 0.7% No Response 313 10.1% Total 3,107 100%

Breastfeeding data is collected from WIC participants by WIC staff after a mother has delivered her baby and usually when the mother visits a WIC clinic to be recertified as a breastfeeding or postpartum (non-breastfeeding) client. Mothers are asked if they have ever breastfed, how long they breastfed, their use of a breast pump and whether they participated in the breastfeeding peer counselor program, and their reason(s) for discontinuing breastfeeding. Demographic data is also collected and reported. For example, in 2014, breastfeeding initiation for WIC infants was reported at 80.9%. However, breastfeeding initiation rates were considerably higher in central and western New Mexico than eastern New Mexico (NMDOH, 2015).

Figure 3. Breastfeeding Initiation: WIC Mothers Who Gave Birth in FFY2014

While the data provided by the WIC report are informative, comprehensive, and specific across several dimensions, it is important to note that the instrument itself was designed for and administered to mothers enrolled in WIC benefits in New Mexico only. Thus, the data reflect a specific subpopulation of mothers in the state. Moreover, while duration and discontinuation data is collected, a data management complication in the MIS data management system does not permit reports to be issued for these indicators. Although WIC staff is able to view the data for individual clients, they cannot aggregate responses for statewide analysis. As result, currently WIC data only provides information on breastfeeding initiation and reasons for not initiating breastfeeding.

Data Type 4: Site or Regional Surveillance and Data In addition to the large federal and state surveillance systems previously discussed, there are other, independent efforts to improve breastfeeding rates in New Mexico. These efforts range from community meetings to studies conducted by the University of New Mexico and other research institutes. Although these efforts usually produce data and information on a smaller scale than large federal and state surveys,

33 they provide valuable insights into a variety of information areas related to breastfeeding. For example, many healthcare facilities within the state have their own internal data systems, and research efforts by the University of New Mexico and the New Mexico Breastfeeding Task Force have produced a number of reports that provide useful details on breastfeeding behaviors, barriers, and opinions.

New Mexico Breastfeeding Task Force: BBER Economic Benefits of Breastfeeding Study In 2013 the New Mexico Breastfeeding Task Force (NMBTF) commissioned the University of New Mexico’s Bureau of Business and Economic Research (BBER) to complete a study on cost savings attained by increasing statewide breastfeeding rates (Bhandari & Nepal, 2014). The report, “Cost-Benefit Analysis of Increasing Breastfeeding Rate in New Mexico,” was issued in July of 2014 and was modeled after the seminal 2010 study by Melissa Bartick.26 As part of the cost-benefit analysis, BBER conducted a survey of New Mexico businesses regarding the cost and availability of nursing rooms, maternity leave flex-time, awareness of laws pertaining to breastfeeding and breast milk pumping in the workplace, and business performance. BBER sent the survey to over 17,000 New Mexico businesses and received 274 usable responses. BBER concluded that New Mexico could save upwards of $32.5 million per year by increasing statewide breastfeeding rates.

New Mexico Breastfeeding Task Force: Lake Research Partners Report In 2013 the NMBTF commissioned a survey report from Lake Research Partners to evaluate public opinion on breastfeeding throughout the state. Lake Research designed and administered a telephone survey of 500 New Mexico residents, including an oversample of 100 Latino residents. The goals of the study were to gauge public opinion and knowledge on breastfeeding, gain an understanding of how breastfeeding is promoted in certain demographic groups, and determine which breastfeeding support messages and phrases New Mexicans find most convincing. Overall, findings of the study suggest that New Mexicans feel positively toward breastfeeding and are comfortable around women who breastfeed.27 The Lake Research report is one of the few information sources on breastfeeding attitudes and opinions in New Mexico.

Envision New Mexico: Systems of Support for Breastfeeding Report In late 2015 Envision New Mexico released a report titled “Systems of Support for Breastfeeding in Select New Mexico Communities” (McGrath et al., 2015). Utilizing

26 (Bartick & Reinhold, 2010) 27 Thanks to Heidi Fredine and Lissa Knudsen from the New Mexico Breastfeeding Taskforce who provided us with access to the Lake Report.

34 a mixed methods approach, the analysis consists of three parts: a focused community assessment compromised of eight focus groups and six key informant interviews; a statewide hospital readiness survey designed to ascertain barriers and facilitators to Baby Friendly Designation status among maternity care hospitals in New Mexico; and an analysis of NM PRAMS data from 2008-2012. Findings from the report suggest that statewide efforts are needed to improve breastfeeding support systems. The Envision report identifies approaches for improving breastfeeding rates, including addressing hospital settings, normalizing public breastfeeding, and increasing knowledge of breastfeeding resources and support services. The study also found evidence that breastfeeding disparities exist in New Mexico by race, ethnicity, acculturation, and geography (McGrath et al., 2015). The study was released in December 2015 by Envision New Mexico and funded by the W. K. Kellogg Foundation.

New Mexico Breastfeeding Taskforce Hospital Report Cards While the mPINC survey collects hospital-based information on breastfeeding, results are only reported at the state level, and no individual facility-based data is released. In an effort to inform hospitals of their current breastfeeding status and provide areas for targeted improvements, the New Mexico Breastfeeding Taskforce has prepared and released Hospital Report Cards. Hospital Report Cards were sent to 29 of the 30 New Mexico maternity hospitals in October of 2015.28 Using results from Newborn Genetic Screening data, Report Cards report breastfeeding initiation or “any breastfeeding rate” as well as exclusive breastfeeding rate and number of births at the facility. Report Cards also rank hospitals’ breastfeeding performance against facilities of the same size and all facilities in the state.29 Due to data restrictions on the use of Newborn Screening data, Report Cards are issued directly to facilities and are not made publicly available.

UNM Early Childhood Survey In 2015, with support from the Robert Wood Johnson Foundation and the Kellogg Foundation, the University of New Mexico completed a study aimed at better understanding the ways in which some New Mexico families interface with the early care and education and health systems. Towards this end, The Robert Wood Johnson Center for Health Policy, the Center for Education Policy Research, and the Center for Community Behavioral Health designed a survey that was administered to families

28One IHS Hospital was not identifiable in the Newborn Screening data set. 29 It is worth noting that several hospitals reported back to the NMBTF that the number of births listed on their Report Card was inaccurate—affecting the denominator and overall breastfeeding rates and rankings. This means there is likely a problem with accurate reporting on the part of the hospitals or recording/data-collecting within the NM DOH Newborn Screening Program.

35 with a child four years old or younger. Questions related to breastfeeding fit into two broad categories:

1. Questions related to breastfeeding behaviors such as breastfeeding initiation and duration 2. Questions related to breastfeeding support services

The survey was administered in September of 2015 and is specific to families living in rural New Mexico and the South Valley of Albuquerque. The survey was administered both in person and over the phone or web.

UNM Early Childhood Survey: Breastfeeding Behavior Questions Did you (or anyone in the household) ever breastfeed for pump breast milk to feed the child? When did breastfeeding for this child begin? How long was the child breastfed or fed pumped breast milk? Is the child still being breastfed or fed breastmilk?

126 families living in the South Valley completed the survey in person, and 656 families from rural New Mexico and the South completed the survey by phone or through the web (total n of 782). The survey was conducted in both Spanish and English, depending on the respondent’s preference.

UNM Early Childhood Survey: Breastfeeding Support Questions When your child was being breastfed, did you (or the person in the household breastfeeding) receive support from any of the following?  A hospital or clinic  Your employer  A breastfeeding counselor, midwife, or doula  Family members or friends  Other healthcare providers like nurses, doctors, or promatoras

Some hospitals are trying to provide extra supports to help mothers be able to breastfeed their babies. How helpful would these supports be to you or someone in the household?  Not at all helpful  Not very helpful  Somewhat helpful  Very helpful

Survey response data is in the process of being cleaned, coded, and merged. It is anticipated that analyses of survey responses, including breastfeeding indicators included here, will be published in 2016.

Community Conversations, Focus Groups, and Breastfeeding Support Efforts A number of organizations, including, but not limited to, the New Mexico Breastfeeding Task Force, WIC, the Navajo Nation Breastfeeding Coalition, La Leche League New Mexico, UNM’s Women’s Resource Center, Tewa Women United, as well as health care based programs, offer breastfeeding support services which provide insights into attitudes, practices, and obstacles to successful breastfeeding.30 Many of these organizations facilitate community meetings, focus groups, and support groups aimed at increasing and extending breastfeeding rates. While public data is not made available, these organizations likely have some of the richest qualitative information on the subject.

Data Type 5: Forthcoming Resources

Baby Friendly Hospital Map The New Mexico Breastfeeding Taskforce is currently developing an interactive Baby-Friendly Hospital Map to provide statewide information on breastfeeding rates and the status of hospital and birth facility progress towards the WHO’s Baby Friendly Hospital Initiative. The map will be made available on the New Mexico Breastfeeding Taskforce website and will allow users to identify birth facilities that are BFHI approved, on the pathway to BFHI approval, or not on the pathway. The map also presents geographic information on PRAMS breastfeeding rates at 9 weeks, allowing for comparison between New Mexico counties.31

WIC Duration Data The New Mexico Department of Health and the states of Texas and Louisiana are currently developing a completely new data collection system that will remedy the issues in the current MIS data management system. The new system is expected to begin running in 2017, after which point WIC duration and other longitudinal information should become available.

PRAMS Toddler Survey The New Mexico Department of Health is currently developing a follow up survey to the annual PRAMS surveillance of mothers and children 6 months of age and

30 For example, Presbyterian Health Services offers a breastfeeding hotline as well as classes and support groups. Mountain View Regional and Dar A Luz Birth Center in Las Cruces offer a breastfeeding support group every Wednesday. 31 Thanks to Heidi Fredine from the NMBTF who generously provided this information. A prototype of the map is provided in Appendix J.

37 younger. This new survey will collect new health data on the population of two-year old children. A number of states have already implemented a PRAMS follow up survey, including Oklahoma’s Toddler Survey (TOTS), Alaska’s Childhood Understanding Behaviors Survey (CUBS), and Oregon’s PRAMS-2. New Mexico’s statewide survey is being designed to monitor and answer key questions on a wide variety of health outcomes, including the presence of certain health conditions, health care access and utilization, developmental screening, family stressors, and items specific to maternal experiences. Key focus measures include: presence of certain health conditions, health care utilization and access (including barriers to care), routine well-child checks, presence of health insurance, child care, immunizations, nutrition and physical activity, child safety, breastfeeding, and developmental delay. While the survey is currently still in development, it is expected to address a number of breastfeeding indicators, including breastfeeding initiation, duration, exclusivity, reasons for discontinuing breastfeeding, and support services used during breastfeeding.

PRAMS Toddler Survey: Proposed Breastfeeding Measures Was your two-year-old ever breastfed or fed (pumped/expressed) breast milk?  Yes  No If No, what were your reasons for never breastfeeding? Check all that apply.  I thought I would not produce milk.  My baby didn’t latch on.  I had too many other demands.  I was taking medication I didn’t want to expose my child to.  My health provider or pediatrician advised me not to breastfeed.  I didn’t want to breastfeed.  Husband or partner said no  I had too many other demands.  I had no help or support.  I didn’t breastfeed my other children.  Other (please tell us) How long did you breastfeed or pump breast milk to feed your child?  less than one week of age/birth  _____ weeks or _____ months  I am still breastfeeding or feeding pumped breast milk to my child. How old was your two-year-old when (he/she) was first fed formula, water or juice?  less than one week  _____ weeks or _____ months  Don’t Know What were your reasons for deciding to stop breastfeeding your child? Check all that apply.  I achieved the goal I set for nursing.  My baby was not gaining weight.  Breast milk supply was not adequate  My baby lost interest.

 Too hard to pump at work or school  I had too many other demands/time consuming  No support, help or resources available  I was tired of pumping.  It was painful to breastfeed or pump.  I was taking a medication and I didn’t want to expose my child.  Family or friends suggested that I stop breastfeeding.  My health provider or pediatrician advised me to not breastfeed.  I am still breastfeeding or feeding pumped breast milk to my child.  Other (please tell us) During the time you breastfed or if you still breastfeed, which of the following supported you to continue?  Support from my partner/spouse  Support from family or friends  Support from my employer  Support from a health care provider  Support from WIC staff  Support from a WIC Breastfeeding Peer Counselor  Home visitor Which of the following helped you to keep breastfeeding? Check all that apply.  Convenience to me  Cost savings  Benefits to my child  Benefits for myself  My own commitment to breastfeed  My baby was not ready to stop breastfeeding

The New Mexico Toddler Study (NMTS) is intended to provide a continuous public health surveillance system that can be used for descriptive, inferential, and methodologic data. The longitudinal aspect of the NMTS will include measures specific to maternal and parental experience such as: social/emotional support, contraceptive use, pregnancy history, maternal smoking status, family stressors, employment history, household income, parental education levels, and marital status with family size. The survey is anticipated to launch in June with a sample size of approximately 1,000 respondents per year. Like PRAMS, data will be available approximately 11 months after collected, and data sharing agreements will permit researchers and organizations access to data that has not been available previously.32

FINDINGS AND DISCUSSION A variety of large and small surveillance systems collect data related to breastfeeding in New Mexico. Table 13 provides a summary of data availability, and

32 Thanks to Eirian Coronado and Christopher Whiteside of the NMDOH who generously provided this information.

Table 14 summarizes relevant background information of each data source. In recent years breastfeeding statistics for the state of New Mexico have become both more comprehensive and more available. Until new surveys and studies were launched in the late 1990s, the primary source for statistical information on breastfeeding rates for the United States was the Ross Mothers Survey administered by Ross Laboratories. With the exception of the Pediatric Nutrition Surveillance System, Pregnancy Nutrition Surveillance System, and Infant Feeding Practices Survey, which are already retired, all the other surveillances presented here are still ongoing either annually or periodically.

Table 13: Data Availability Duration Duration Duration Race or Survey Initiation Exclusivity Notes < 3 mo. <6 mo. <12 mo. Ethnicity ECLS-B Exclusivity determined by asking when infant was first given formula       or food other than breast milk. NM sample size is small (~100) and not representative IFPS II       NHANES NHANES I & II: initiation and      duration. NHANES III and later: initiation, duration, and exclusivity. NIS       NSCH     NSFG Exclusivity rates are often not       reported; NM sample size is negligible. PedNSS Breastfeeding duration is measured up to one year; however, the sample of this data is contingent on children       who turn one year of age who receive public health services during the reporting period. PNSS Incidence, duration up to 2 months, introduction of formula. Sample   consists of low-income populations only. PRAMS Breastfeeding duration estimates are limited to nine weeks; indirect     estimates are available for longer durations. SCLB     WIC Sample represents women and       children in nutrition assistance program.

The overwhelming majority of data pertains to indicators of breastfeeding behavior such as breastfeeding initiation and duration. The mPINC survey provides limited data on facility practices and services to support breastfeeding while the PRAMS survey includes a few questions that address breastfeeding barriers. As a result, our discussion here is focused on variations and issues related to breastfeeding indicators. A comprehensive discussion of data voids, such as facility and attitudes data, is available in part two of this analysis.

Summary Findings: Sample Size and Demographic Factors While a number of nationally representative studies include New Mexico samples, these studies, such as the ECLS-B or NSCH, are designed to be representative at the national, but not state or local, level. Consequently, while these studies provide some information related to breastfeeding behavior within the state, the data are generally not representative of the New Mexico population and therefore are not appropriate for analysis at the state level. Moreover, national level studies, which use convenience samples such as HealthStyles and the IFPS, are not representative and generally have very small sample sizes. As such, these data sources are also not appropriate for state level assessments. Surveillance systems that are representative at the state level include the National Survey of Children’s Health (n~500), The National Immunization Survey (n~260), Vital Statistics (total birth population), and PRAMS (n~1,400). Improving breastfeeding rates in New Mexico requires a comprehensive and targeted approach that includes identifying low success rate regions and focused efforts to improve breastfeeding across the state. The ability to disaggregate data by region, race or ethnicity, income, or education is critically important to these efforts. While most studies collect pertinent demographic indicators, small sample sizes make disaggregation difficult and often require the use of “rolling averages” or combined sample years. For example, while PRAMS is conducted annually, most surveillance reports are based on multiple birth years. Similarly, while NIS data is representative of the state population, the small sample size does not permit reliable disaggregation by race or ethnicity at the state level, and breastfeeding rates for racial and ethnic groups are only reported at the national level. Although WIC data is not representative at the state level, the large scale of participation in the WIC program permits analysis at varying degrees of specificity, including race or ethnicity, region, and socio-economic status.

Summary Findings: Initiation Across all surveys that collect breastfeeding data in New Mexico, the most common measure is breastfeeding initiation, or “ever breastfed.” As illustrated in Table 13, breastfeeding initiation is the most frequently and reliably collected breastfeeding indicator. While there is variation in when and how this data is collected, we believe there are sufficient data for accurate breastfeeding initiation comparisons between and across data sources.33

33 When comparing breastfeeding initiation, it is important to evaluate comparable data years. For example, NIS data are aggregated by birth year, while the 2011/2012 NSCH survey reports data for children under the age of 6, and while the PRAMS survey is conducted annually, most surveillance reports are based on combined birth years.

Summary Findings: Duration and Exclusivity As compared to initiation, breastfeeding duration data are substantially more limited in New Mexico. The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months of age and breastfeeding continuation with the introduction of complementary foods until one year of age. It is worth nothing that definitions of “exclusivity” vary, with some definitions requiring the infant be given nothing other than breast milk, with other definitions permitting the child to have breast milk and water. Both definitions are included as measures of exclusivity in this study. Table 13 illustrates the availability of breastfeeding duration and exclusivity measures. Only the NIS and NSCH surveys provide state representative samples and collect both duration and exclusivity measures. As such, options for assessing breastfeeding duration and exclusivity at the state level are limited, as the samples for NSCH and NIS are 500 and 260, respectively. Moreover, while a number of studies include some measure to determine duration, there is tremendous variation on when and how breastfeeding duration data are collected. Research indicates that most women accurately recall breastfeeding duration when the recall period is less than three years (Li, Scanlon, & Serdula, 2005). With the exception of the NSFG, which has a maximum recall time of 18 years, and the NHANES, which has a maximum recall of 6 years, the studies included here all have a recall period of less than 3 months. Additionally, due to variation in when data are collected, there are major limitations to the reliability and availability of duration measures. For example, while the maximum recall period for PRAMS is six months, surveys are conducted and completed when infants are between 2-6 months of age. As a result, PRAMS breastfeeding duration estimates are limited to 9 weeks, with smaller samples reported for longer durations. Similarly, the PedNSS survey provides duration data up to one year of age, but the sample is contingent on data collected during visits to public health clinics. The most rigorous duration data are collected on the IFPS II survey, though its usefulness for evaluating breastfeeding duration in New Mexico is null due to the use of a non-representative consumer opinion panel convenience sample and an exceptionally small sample (n=27) in New Mexico.

Table 14: Summary of Datasets Assessing Breastfeeding Variables in New Mexico

Survey Methods Format Timing of Data Languages Year Last Frequency Nationally NM Collection Conducted Conducted Representative Sample ECLS-B Longitudinal In person BF questions English, Spanish 2010-2011 Not previously Yes ~100* study with interviews and included on the 9 (Birth cohort) conducted, cross- self-administered month survey likely a one sectional questionnaires time study assessment of BF status

IFPS II Longitudinal One telephone Data collected English 2007 Previously No, convenience 27* interview, multiple prenatally, conducted in sample of mailed postpartum, 3 1993/1994 consumer opinion questionnaires weeks pp and 2, panel 3, 4, 5, 6,7, 9, 10, 12 months

NHANES Cross- In-person Varies, BF asked English, Spanish, Ongoing Biennial Yes Not sectional interviews and for each 6 year other languages if Available* physical exam old child required

NIS Cross- Telephone 19-35 months PP English, Spanish Ongoing Annual Yes 262* sectional interview other languages (2012) via AT&T language line NSCH Cross- Telephone BF questions English, Spanish 2012 Every four Yes ~500 (2012) sectional interview asked of children other languages years ages <6 via AT&T language line

NSFG Cross- In-person home BF question English and 2010 Every six years Yes Not sectional interviews asked of women Spanish (data is Available* reporting a birth collected over within the past 5 five-year years. cycles)

Table 14 Continued: Summary of Datasets Assessing Breastfeeding Variables in New Mexico

Survey Methods Format Timing of Data Languages Year Last Frequency Nationally NM Sample Collection Conducted Conducted Representative PedNSS Program Predominantly Varies, BF English, Spanish, 2012 Annual, No, reflects Not based WIC data assessed through other languages discontinued in participants in Available surveillance 24 months of age spoken in WIC 2012 public health offices programs

PNSS Program Predominantly 2-5 months PP English, Spanish, 2012 Annual, No, reflects 5,846* based WIC data other languages discontinued in participants in (2012) surveillance spoken in WIC 2012 public health offices programs PRAMS Cross- Predominantly Survey mailed English and Ongoing Annual Representative of ~1,400 sectional mail, telephone approximated 2- Spanish state populations, follow up with 6 months PP 40 states currently non-responders participating RMS Cross- Mailed Mailed when English Ongoing Annual Yes, data is private Not sectional questionnaire infant reaches 6 and shared at the Available months of age discretion of Abott Laboratories WIC Cross- Utilizes WIC Varies English, Spanish, Ongoing Annual No, reflects WIC Varies by sectional program data other languages population only participation spoken in WIC ~16,500/yr* offices SCLB Cross- Questionnaire Post-partum, English, Spanish, Ongoing Annual No, statewide data Total birth sectional usually at other languages population discharge of spoken by hospital providers

* Sample is not representative at the state level

CONCLUSION Improving breastfeeding initiation and duration in New Mexico requires the development of timely, culturally sensitive, and well-developed interventions. Surveillance and monitoring of breastfeeding behavior is essential to the planning, implementation, and evaluation of these interventions.34 Throughout the state there are several organizations and agencies that work to promote healthy breastfeeding behaviors. Most of these organizations rely on the data sources discussed here. Namely, the New Mexico PRAMS and CDC Report Card on breastfeeding by state are the only two data sources relied upon by the following agencies to conduct research: the March of Dimes, NM Public Health, New Mexico WIC, Breastfeeding New Mexico, New Mexico’s Indicator Based Information System, the New Mexico Breastfeeding Taskforce, and the La Leche League. While these data are informative and assist in researching and better understanding breastfeeding initiatives, they serve as virtually the sole data sources for various organizations and agencies and do not provide information beyond the scope of their respective instruments. Thus, these organizations and agencies are not able to provide new additional information but rather rely on echoing the information released from NM PRAMS or the CDC. Across the surveillance systems presented here only Vital Statistics, PRAMS, NSCH, and NIS are representative of the state population. However, the sample sizes of these surveys are too small to permit disaggregation by demographic indicators, or, in the case of Vital Statistics, have only limited breastfeeding information (duration only). NIS and PRAMS are collected annually, while NSCH is conducted every four years. PRAMS is also the only representative survey to assess breastfeeding services, barriers, and reasons for discontinuing breastfeeding. While the mPINC survey provides useful data on hospital services and care, the inability to assess services at the site or regional level presents complications in improving breastfeeding services across the state. In general, site- or region-specific data is substantially limited across all surveillance systems. In regards to breastfeeding behaviors, initiation data appears to be quite abundant while duration and exclusivity have substantial limitations. In an effort to better assess data needs and gaps we have implemented an online survey interview with breastfeeding experts and advocates in order to refine the findings presented here. Part two presents findings from that survey and further discusses the status of breastfeeding data and surveillance in the state of New Mexico.

34 For such a discussion see Chapman and Pérez-Escamilla (2009).

PART TWO: LEVERAGING DATA TO IMPROVE BREASTFEEDING RATES IN NEW MEXICO

OVERVIEW Across the globe, exclusive breastfeeding is considered the best choice for infant nutrition and immunologic protection (DHHS, 2011; Komodiki et al., 2014; Pediatrics, 2012). Despite the well-known public health benefits of breastfeeding, the rate and duration of breastfeeding in the United States are low (HHS, 2010; Li et al., 2004). This is especially true for New Mexico, which lags behind national averages for breastfeeding initiation and duration (CDC, 2014). As demonstrated in part one, a number of surveillance systems monitor breastfeeding behavior in the state. These data play an important role in state and federal public health, providing platforms for epidemiologic assessments such as identification of target populations and providing important insights for program development and evaluation. In order to assess specific data needs in the state of New Mexico, the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico developed and conducted an online questionnaire to gather information on existing and potential breastfeeding data collection and use. The questionnaire was administered from January to April of 2016. Breastfeeding professionals, stakeholders, and advocates were invited to participate through email. Initial participants were recruited from the New Mexico Breastfeeding Taskforce and subsequent participants were included through snowball sampling as participants were asked to recommend other contacts. Eighty individuals were contacted yielding 51 complete or partial responses. Participation in the questionnaire was voluntary and no incentives were provided.

RWJF Breastfeeding Data Questionnaire Objectives Identify information sources collecting data on breastfeeding in New Mexico Understand which data sources are frequently used by breastfeeding advocates and professionals Solicit suggestions for improving available data and collecting new data to improve breastfeeding rates

The survey was completed by medical professionals, such as pediatricians, midwives, nurses, healthcare providers, doulas and lactation consultants, as well as public health researchers, policy advocates, home visitors, and breastfeeding peer counselors. Below we present results from the questionnaire. It is important to remember that the goal of the questionnaire was to gather a snapshot on data use and

46 data needs. The questionnaire is based on a convenience sample, and findings should be considered as guidelines in conjunction with the assessment from part one.

RWJF BREASTFEEDING QUESTIONNAIRE RESULTS A majority of respondents use the CDC Breastfeeding Report Card, mPINC, PRAMS, and WIC data. Figure 1 illustrates data sources used by respondents of the questionnaire. Six respondents cited using data other than the sources listed.35

Figure 1. Data Use Among Respondents

As discussed in part one, the CDC Breastfeeding Report Card does not collect any original data but instead reports summary findings from the mPINC and NIS surveys. As a result, we believe the popularity of the CDC Report Card is due to the way in which information presented and its accessibility. The Breastfeeding Report Card and mPINC survey provide direct, easy to use information in a concise format. While surveys such as the NIS and PRAMS have equally rich data, these data are more difficult to access and require an individual to find reports or publications that report breastfeeding data from the survey. Moreover, the popularity of the CDC Report Card and mPINC survey is likely due to the number of healthcare providers completing the

35 “Other” sources included research articles, the New Mexico Breastfeeding Taskforce, the WHO, the UNM BBER study, the Baby-friendly hospital map, and facility specific data.

47 questionnaire.36 PRAMS data is popular with researchers and policy advocates.

Data Needs Assessment Questions What New Mexico specific breastfeeding data would you like to have that is currently not available? What would you use these data for? How would you suggest that the data that you would like to have be gathered?

To assess data needs by breastfeeding professionals and advocates, we also provided respondents an opportunity to tell us what data they would like to have that is currently not available. We also asked respondents to provide suggestions on how data could be collected. Table 1 provides a summary of questionnaire findings, and a brief discussion of each data request follows.

Table 1. Data Questionnaire: Summary Findings Suggested Data Request Purpose and Goals Method Demographic and regional PRAMS -Identify which counties need breastfeeding support data: BF initiation and Toddler, -Develop & evaluate interventions and programs duration by race/ethnicity, PRAMS, NIS -Reduce breastfeeding disparities region and income PRAMS -Identify which counties need breastfeeding support Exclusivity 3, 6, 12 months Toddler, -Develop & evaluate interventions and programs PRAMS, NIS -Reduce breastfeeding disparities

PRAMS -Identify which counties need breastfeeding support Duration 3, 6, 12 months Toddler, -Develop & evaluate interventions and programs PRAMS, NIS -Reduce breastfeeding disparities Breastfeeding barriers, PRAMS, Home -Develop & evaluate interventions and programs reasons mother are not visitation -Reduce breastfeeding disparities breastfeeding programs Newborn -Hospital reform: tracking and improving hospital Breastfeeding Initiation Screening, Vital breastfeeding rates by Birth Facility Statistics, BFHI -Encourage collaboration between facilities Breastfeeding knowledge and opinions by region -Normalizing breastfeeding among key populations Other large (rural vs urban) and -Development and evaluation of interventions and survey race/ethnicity including programs tribal areas.

36 The CDC Report Card and the mPINC survey report data pertinent to healthcare providers such as state rankings on labor and delivery care, staff training, the number of Certified Lactation Counselors, and the percent of infants receiving formula before 2 days of age.

Increase Detail of Demographic and Regional Indicators A frequent request is for greater specificity in the analysis of breastfeeding variables. Common requests include breaking breastfeeding behavior down by demographic and geographic variables such as race/ethnicity, region or county, age, and income. While these variables are available in a number of data sources, small sample sizes often limit the ability to disaggregate data by specific demographic or geographic indicators. For example, demographic variables are collected on the NIS, but the small sample size does not permit disaggregation by race or ethnicity at the state level. While the PRAMS survey has a sample size over five times larger than NIS, the sample size still requires combining survey years to achieve a reliable disaggregation by demographic indicators. For example, the most recent 2012 PRAMS surveillance report provides results from 2009-2010 while the 2010 surveillance report uses data averages from 2006-2008 (NMDOH, 2010, 2012). Reliable demographic data plays an important role in public health efforts. Improving breastfeeding rates requires targeting high-risk populations with low breastfeeding rates and creating corresponding interventions that work best in specific populations (Morrow & Lutter, 2012). Increasing the frequency and availability of demographic data on existing and additional breastfeeding indicators is an important step toward improving breastfeeding rates throughout the state.

Improve Exclusivity and Duration Measures As outlined in part one, New Mexico has limited information related to breastfeeding duration and exclusivity. The most frequent data request was to have reliable and timely breastfeeding duration and exclusivity data. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months, the introduction of complementary foods at six months, and breastfeeding continuation until one year (Pediatrics, 2012). The AAP recommendation is accepted around the globe as promoting health benefits for both mother and baby (Morrow & Lutter, 2012). However, reliable duration and exclusivity data is difficult to find in New Mexico and across the nation (DHHS, 2011; Flaherman, Chien, McCulloch, & Dudley, 2010; Greiner, 2014). Accurate measurement of the duration and exclusivity of breastfeeding is complicated by a number of factors, including variations in the definitions of “exclusivity,” the timing, duration of recall, methods of analysis, and sample biases (Greiner, 2014). Accurate measurements of breastfeeding initiation, duration, and exclusivity are necessary to assess progress towards public health goals (Flaherman et al., 2010). The primary source for duration and exclusivity data in New Mexico is the National Immunization Survey which tracks state progress towards Healthy People 2020 Breastfeeding Objectives. As discussed above, the small sample size of the NIS (n ~ 260)

49 only permits the analysis of breastfeeding rates at the aggregate state level. The PRAMS survey assesses breastfeeding duration up to nine weeks with indirect estimates up to 6 months. New data on breastfeeding duration and exclusivity will be produced by the PRAMS Toddler Survey, which is expected to launch in summer of 2016 and have data available the following year. Much like the existing PRAMS data, the PRAMS Toddler Survey has an anticipated sample size of 1,000, which will require combining survey years in order to disaggregate data by demographic indicators.

Report Breastfeeding Indicators by Birth Facility A frequent theme that emerged from questionnaire responses was the desire to have facility-specific data available. Strong evidence suggests that hospital maternity practices play a key role in breastfeeding initiation and exclusivity rates both in the hospital and duration after discharge (Hawke, Dennison, & Hisgen, 2013). Providing facility-specific data could also increase the collaboration between facilities to improve breastfeeding rates through prenatal and postpartum services. For example, one New Mexico hospital administrator points out that if facility-specific data were available they could “use it to compare breastfeeding rates and ask other hospitals for assistance if they are doing well, or provide assistance if we are doing better than them.” Another respondent pointed out, “we need breastfeeding duration for local areas and for hospitals! We have CDC data but it is based on small numbers and you can’t use it to evaluate your local area or hospital.” While the mPINC survey collects facility-specific data, only state-level aggregate results are reported. Facility-specific data is collected but not reported in New Mexico. For example, New Mexico’s standard certificate of live birth includes the question “is the infant being breastfed at discharge?” and the Newborn Screening program collects “any” and “exclusive” breastfeeding responses at the time the screen is obtained.37 Additionally, since the PRAMS sample is drawn from the Vital Statistics records, it may be possible to link PRAMS data to birth facility. However, a data expert at the New Mexico Department of Health has stated that publishing data at the birth facility level using data from either the standard certificate of live birth or Newborn Screening program would require permission from each birth facility center.38 In efforts to improve and track breastfeeding rates, a number of states publicly report breastfeeding initiation and/or exclusivity by birth facility.39 California utilizes Newborn Screening data to publish in-hospital “any breastfeeding” and “exclusive breastfeeding” by birth

37 New Mexico Vital Records stripped facility identification prior to 2008 and again in 2015. Vital statistics data from 2009-2014 should still include a facility ID. 38 As part of the Baby Friendly Hospital Initiative certification process, hospitals are required to collect information on breastfeeding rates. There are currently seven BFHI approved facilities and another 13 on the pathway to certification. 39 California and New York State report facility-specific data as required by state law (Hawke et al., 2013).

50 facility.40 Pennsylvania also utilizes data from certificates of live birth to publish breastfeeding initiation by hospital of delivery.41

Breastfeeding Barriers, Knowledge, and Attitudes A final theme in the responses to our questionnaire was that breastfeeding advocates want better information on public beliefs about breastfeeding. In particular, respondents expressed interest in having data on breastfeeding knowledge, opinions, attitudes, and perceived barriers to breastfeeding. At the federal level, the annual HealthStyles survey provides information on public attitudes towards breastfeeding.42 As discussed in part one, the HealthStyles survey is uses a convenience sample and does not include a sample suitable for analysis at the state level. In an effort to provide some background information on breastfeeding attitudes and knowledge, the New Mexico Breastfeeding Taskforce’s 2013 Lake Report provides a snapshot of point-in- time data on breastfeeding knowledge, attitudes, and opinions. The Lake Report is based on findings from a statewide telephone survey of 500 New Mexico residents with an oversample of 100 Latino residents. As such, while the Lake Report provides some insights into public opinion on breastfeeding, the study is limited in its ability to address variations in public opinion based on demographic and geographic variables. In addition to information on breastfeeding knowledge and opinions, several respondents indicated a desire to better understand breastfeeding barriers. One public health advocate responded that information was needed on “factors inhibiting exclusive breastfeeding during first 1-6 weeks postpartum” and another succinctly stated, “Reasons NM mothers are NOT breastfeeding.” Understanding breastfeeding barriers is a complicated endeavor. The Surgeon General’s 2011 Call to Action to Support Breastfeeding identifies seven breastfeeding barriers:

1. Lack of Knowledge 2. Social Norms 3. Poor Family and Social Support 4. Embarrassment 5. Lactation Problems 6. Employment and Child Care 7. Barriers Related to Health Services

40 https://www.cdph.ca.gov/data/statistics/Pages/InHospitalBreastfeedingInitiationData.aspx 41 http://www.health.pa.gov/My%20Health/Womens%20Health/Breastfeeding%20Awareness/Pages/Birth- Certificate.aspx#.VypIlT8WwhD 42 See for example (Hannan, Li, Benton-Davis, & Grummer-Strawn, 2005; Li et al., 2004; Li, Rock, & Grummer-Strawn, 2007)

Breastfeeding barriers have been shown to have a negative influence on breastfeeding initiation and duration (DHHS, 2011). Understanding the rates at which New Mexican mothers experience or encounter breastfeeding barriers is an important step in the process to reduce breastfeeding barriers and increase breastfeeding initiation and duration. Providing breastfeeding advocates with more in-depth information on breastfeeding attitudes, opinions, and the frequency at which mothers experience specific breastfeeding barriers could aide in the development of more effective breastfeeding interventions and programs. As outlined in Part One, the PRAMS survey includes two questions related to breastfeeding barriers; one asks about reasons for discontinuing breastfeeding and the other focuses on workplace policies. The forthcoming PRAMS Toddler survey will provide new data on breastfeeding support, reasons for discontinuing breastfeeding, and reasons for not initiating breastfeeding. Providing breastfeeding professionals and advocates with more complete information of statewide variation in breastfeeding knowledge, attitudes, opinions, and the barriers women face while breastfeeding could contribute to the development of more sophisticated and targeted interventions and programs.

Discussion In an effort to evaluate data priorities in the state of New Mexico, we contacted 50 breastfeeding professionals and/or advocates in order to improve our understanding of data needs among breastfeeding stakeholders. Our questionnaire sought information on data sources used and areas for improvement and expansion, yielding a number of helpful suggestions for improving breastfeeding data and surveillance. The results from the questionnaire parallel many of the findings presented in Part One of this analysis.43 The most commonly cited data request is to improve and expand duration and exclusivity measures. This request is consistent with our findings in Part One where we determined that measures of duration and exclusivity have substantial room for improvement. Respondents also cited the need to have greater information on breastfeeding rates according to geographic area. This also mirrors findings in Part One where we demonstrated that most breastfeeding data have small sample sizes, thereby limiting the ability to disaggregate by demographic and/or geographic indicators. Responses to the questionnaire also show that there is a high demand for data on breastfeeding rates by birth facility. Given the key role that hospital maternity practices play in breastfeeding initiation, providing data at the birth facility level could lead to

43 It is important to note that the results of the questionnaire are not intended to be decisive but rather informative. A large number of respondents to the questionnaire are medical professionals, and therefore the results are likely skewed to represent the specific data needs of the nurses, lactation consultants, and pediatricians who responded to the survey.

52 inter-facility collaboration to improve breastfeeding rates across the state. Lastly, New Mexico lacks a broader understanding of the experience of breastfeeding in the state; little information on public attitudes towards breastfeeding exists, and relatively little is known about regional or demographic variation in breastfeeding knowledge and opinions. Taken in sum, we believe the findings in Parts One and Two of this analysis point to a number of paths toward improving breastfeeding surveillance in the state. Moreover, we believe that the following, more specific recommendations for improving breastfeeding-related data collection and analyses could translate into improved understandings of breastfeeding in New Mexico which, in turn, could be used to support efforts to improve breastfeeding initiation, duration and exclusivity in the state.

PART THREE: RECOMMENDATIONS FOR IMPROVING BRESTFEEDING DATA SURVEILLANCE, DATA AVAILABILITY, AND DATA ANALYSES IN NEW MEXICO

The more specific recommendations presented here are based on our review of the current data related to breastfeeding in New Mexico, our review of the types of data available elsewhere in the country, our identification of breastfeeding data gaps in New Mexico, and the input of many in the state’s breastfeeding community of practice who offered thoughtful input regarding the types of data and analyses they would find helpful. These recommendations are presented in no particular order.

Recommendation 1: Expand the sample size of respondents to the PRAMS The New Mexico Pregnancy Risk and Assessment Monitoring System (PRAMS) is the only regularly administered survey of a representative sample of new mothers in the state. As such, it is recommended that the PRAMS survey be expanded in two ways. First, the sample size participating in the survey each year should be expanded. Currently, approximately 1 in 12 new mothers respond to the survey each year. If a greater number of mothers were surveyed, the resulting data sets would then allow for more nuanced analyses of the data. For example, the data could then provide much better information about breastfeeding rates in smaller geographies (counties and/or regions) or, for example, the race/ethnicity, age, or income of the mothers. This increase to the sample size should be discussed with New Mexico Department of Health PRAMS administrators to determine the best ways to increase the sample size. For example, it probably does not make sense to simply increase the size of the representative sample in the state as this will do very little to increase the numbers of mothers responding in, for example, very rural, unpopulated counties; rather, it would make better sense to use a targeted approach through which certain

53 geographies, like moderately populated counties or border regions, or certain populations, such as Native Americans or African Americans, are oversampled such that the number of respondents from these geographies or groups are large enough to conduct more co-variate analyses. For example, if New Mexico needs more representation from medium-sized counties or sub-county geographies where there is a feasible number of births to analyze, New Mexico could increase the number of mothers surveyed in those areas to achieve more statistical power without having to aggregate so many years of birth data. It would also, for example, it may be optimal to increase the number of African-American births within those geographies, or across those boundaries where possible. Therefore, we recommend that conversations begin with New Mexico Department of Health officials overseeing the PRAMS to determine the best way to expand the sample to allow the for these additional and more nuanced analyses and support expansion of the sampling frame.

Recommendation 2: Add questions to the PRAMS survey that ask mothers about breastfeeding exclusivity The PRAMS survey is administered to mothers of children between the ages of two and six months. Due to the young age of the infants whose mothers are surveyed, a complete understanding of breastfeeding exclusivity cannot be determined using this survey alone (Many mothers breastfeed beyond 6 months and this survey would not, then, help us to understand the diets of infants beyond six months of age.). With this said, there is still value in understanding more about breastfeeding exclusivity amongst this population. As such, we recommend that questions related to the whole diet of these infants be included in the PRAMS to determine 1) if infants are breastfed exclusively and, if so, for how long, 2) if infants are also fed formula or other nutrients and, if so, what percentage of these infants’ diet is breast milk and what percentage is formula or other nutrients. This information would then allow for better analyses that would determine the rates of breastfeeding exclusivity in the state and subgeographies, and by other demographic characteristics of New Mexican mothers.

Recommendation 3: Support the PRAMS Toddler Survey such that it is administered every year and administered to a large enough sample of mothers The NM Department of Health is in the process of developing a PRAMS Toddler Survey that will be administered to mothers of two year olds. While this survey is designed to gather information on a wide verity of health outcomes, it will also include key questions related to breastfeeding initiation, duration and exclusivity. Asking such questions of mothers of two year olds will generate very rich information related

54 to these aspects of breastfeeding and will provide, perhaps, the best information on breastfeeding from a representative group of New Mexican mothers. As indicated in Recommendation 1, the sample size for the PRAMS survey and the PRAMS Toddler Survey should be large enough to allow for analyses of the data by small geographies (counties and regions) and other demographic factors such as race/ethnicity, age, or mothers’ income. It is our understanding that the current intent is to administer the PRAMS Toddler Survey to mothers who previously participated in the PRAMS survey two years prior. While this is an excellent start, and will allow for strong longitudinal analyses, there may be value in expanding the PRAMS Toddler Survey sample to include additional two year olds, perhaps to include a subpopulation of WIC and/or Medicaid recipients. As such, we would recommend that conversations with New Mexico Department of Health PRAMS administrators take place to determine how best to gather a representative sample of New Mexican mothers with two year olds and how best to oversample certain subgeographies and populations within the state. Further, it is our understanding that current W. K. Kellogg Foundation support for the Toddler survey will expire in 2019. The W. K. Kellogg Foundation (or another foundation or organization) may wish to consider funding this project for a longer period of time such that, for example, the New Mexico Department of Health (NMDOH) is able to gather at least five years of toddler data. Although the NMDOH is exploring other funding possibilities, and has limited funds from other sources, secure funding would help assure that this effort is maintained over a longer period of time (and not be susceptible to potential swings in state general fund or other support).

Recommendation 4: Support current efforts to administer a Native American-specific version of a PRAMS-like survey and support collaboration between the partners involved in this effort It is our understanding that a Native American-specific version of the PRAMS survey is in development and will be coordinated through the Navajo Nation Epidemiology Center and the Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC). Because the Department of Health is already in the process of building capacity and providing technical assistance to this effort, it is recommended that this work be supported, that it continue to be coordinated with the New Mexico Department of Health Maternal Child Health Epidemiology/ PRAMS Office and that data sharing agreements between the two be continued. It is important that all who are gathering and analyzing PRAMS (and other local breast feeding-related data) understand what each other are doing so as not to work at cross purposes or to duplicate efforts; similarly, it is important to leverage existing and to-be-gathered data to the maximum extent possible. Towards this end, we recommend that this effort be

55 supported by encouraging appropriate stakeholders with the Navajo Nation Epidemiology Center, the Albuquerque Area Southwest Tribal Epidemiology Center and the New Mexico Department of Health

Recommendation 5: Create and support a “ PRAMS Fellow” The W. K. Kellogg Foundation or another foundation or funding source may wish to fund a full time PRAMS Fellow to conduct analyses of existing and pending PRAMS, PRAMS Toddler Survey (and potentially WIC) data. While the NM Department of Health staff and others have been able to conduct many valuable analyses, this additional resource would allow for a significant number of new analyses using these rich data sources. This Fellow could potentially be housed at the New Mexico Department of Health, at a university or at a not-for-profit organization within the state. Funding, perhaps, could be provided for one year to determine the value of this additional resource.

Recommendation 6: Work with the New Mexico Department of Health to support the creation of a file that contains PRAMS data geocoded to birth records In order to have meaningful data that allows for a deeper examination of concentrated disadvantage, “lifecourse” metrics and other social determinants of health on an ecologic level there would be value in linking PRAMS data to census tract coded geographies. This currently does not occur. As such, we would recommend that conversations with the NM Department of Health also include discussion of this possibility. This ability to tie survey responses to census tract geographies would support efforts to better understand and evaluate improvements or risks in perinatal and health service outcomes over time.

Recommendation 7: Support the creation and administration of a new survey that would provide important information on public attitudes towards breastfeeding As mentioned in Parts One and Two of this report, surveys such as the HealthStyles survey or the New Mexico Breastfeeding Taskforce’s 2013 Lake Report gather and present information related to people’s breastfeeding knowledge, attitudes, and opinions. Currently, there is no formal mechanism to gather such information specific to New Mexico on a regular basis such that changes over time can be examined and better understood. (The New Mexico sample included in the HealthStyles survey is too small to generalize for the state.) As such, the we recommend that foundations and other organizations interested in improving breastfeeding rates in the state explore the possibility of developing and administering a New Mexico-specific survey designed to assess New Mexican’s breastfeeding knowledge, attitudes, and opinions overtime. This information could

56 then be used concretely to inform efforts to reduce barriers to breastfeeding in New Mexico.

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APPENDICES Appendix A Healthy People 2020 Breastfeeding Objectives Appendix B Ross Mothers Survey Instrument 2010 Appendix C National Immunization Survey 2002-2012 Appendix D mPINC Dimensions of Care Appendix E mPINC 2013 Report Card: New Mexico Appendix F New Mexico Baby Friendly Certified Facilities Appendix G National Survey of Children’s Health Breastfeeding Indicators Appendix H PNSS Breastfeeding Initiation 2011 Appendix I HealthStyles Breastfeeding Attitudes and Opinions Appendix J New Mexico Baby Friendly Hospital Map Prototype

APPENDIX A: Healthy People 2020 Breastfeeding Objectives

Healthy People 2020: Infant Care

MICH-21.1 Increase the proportion of infants who are ever breastfed Revised Baseline: 74.0 percent of infants born in 2006 were ever breastfed, as reported in 2007–09 Target: 81.9 percent Target-Setting Method: Projection/trend analysis Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.2 Increase the proportion of infants who are breastfed at 6 months Revised Baseline: 43.5 percent of infants born in 2006 were breastfed at 6 months, as reported in 2007–09 Target: 60.6 percent Target-Setting Method: Projection/trend analysis Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.3 Increase the proportion of infants who are breastfed at 1 year Revised Baseline: 22.7 percent of infants born in 2006 were breastfed at 1 year, as reported in 2007–09 Target: 34.1 percent Target-Setting Method: Projection/trend analysis Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.4 Increase the proportion of infants who are breastfed exclusively through 3 months Revised 33.6 percent of infants born in 2006 were breastfed exclusively through 3 months, as reported Baseline: in 2007–09 Target: 46.2 percent Target-Setting Projection/trend analysis Method: Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-21.5 Increase the proportion of infants who are breastfed exclusively through 6 months Revised 14.1 percent of infants born in 2006 were breastfed exclusively through 6 months, as reported Baseline: in 2007–09 Target: 25.5 percent Target-Setting Projection/trend analysis Method: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS Data Sources:

MICH-22 Increase the proportion of employers that have worksite lactation support programs Baseline: 25 percent of employers reported providing an onsite lactation/mother’s room in 2009 Target: 38 percent Target-Setting Method: Projection/trend analysis

Data Sources: Employee Benefits Survey, Society for Human Resource Management (SHRM)

MICH-23 Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life 24.2 percent of breastfed newborns born in 2006 received formula supplementation within the Baseline: first 2 days of life, as reported in 2007–09 Target: 14.2 percent Target-Setting Projection/trend analysis Method: Data Sources: National Immunization Survey (NIS), CDC/NCIRD and CDC/NCHS

MICH-24 Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies 2.9 percent of 2007 live births occurred in facilities that provide recommended care for lactating Baseline: mothers and their babies, as reported in 2009 Target: 8.1 percent Target-Setting Projection/trend analysis Method: Data Sources: Breastfeeding Report Card, CDC/NCCDPHP

APPENDIX B: Ross Mother’s Survey 2010

APPENDIX C: National Immunization Survey

APPENDIX D: mPINC Dimensions of Care

APPENDIX E: New Mexico 2013 mPINC Report Card

APPENDIX F: New Mexico Baby Friendly Hospitals

New Mexico BFHI Certified Birth Centers as of 2016 Gallup Indian Medical Center Gallup, NM 11/14

Gila Regional Medical Center Silver City, NM 07/15

Mountain View Regional Medical Center Las Cruces, NM 12/13

Northern Navajo Medical Center Shiprock, NM 10/14

Presbyterian Hospital Albuquerque, NM 04/15

University of New Mexico Health Sciences Center Albuquerque, NM 10/14

Zuni Comprehensive Health Center Zuni, NM 11/13

APPENDIX G: National Survey of Children’s Health

APPENDIX H: PNSS Breastfeeding Initiation 2011

Table 8D: 2011 Pregnancy Nutrition Surveillance Comparison of Infant Health Indicators by Contributor Ever Breastfed Contributor Number Included % Rank in Analysis Alabama 0 * * Arizona 45,387 68.3 (16) AZ I/Tribal Council 2,499 68.1 (17) Cheyenne River-SD 122 50.8 (29) Connecticut 10,318 74.6 (8) D.C. 4,203 58.3 (26) Florida 122,388 74.5 (9) Hawaii 9,061 88.2 (2) Idaho 9,859 86.1 (3) Illinois 62,252 69.2 (15) Indiana 42,656 67.6 (18) Iowa 14,010 62.0 (24) Kansas 18,328 74.2 (10) Massachusetts 0 * * Michigan 58,402 60.5 (25) Minnesota 24,650 73.5 (11) Montana 3,535 77.6 (5) Nebraska 9,261 75.6 (7) New Hampshire 4,315 73.0 (12) New Jersey 38,674 66.8 (19) New Mexico 5,846 66.6 (20) New York 119,782 76.9 (6) North Dakota 2,704 64.8 (21) Ohio 54,777 54.3 (28) Oregon 22,697 92.4 (1) Puerto Rico 0 * * Rhode Island 5,214 62.3 (23) Rosebud Sioux-SD 288 71.2 (14) Standing Rock-ND 112 57.1 (27) Vermont 2,972 79.6 (4) Virginia 29,328 63.9 (22) West Virginia 12,674 44.5 (30) Wisconsin 29,477 72.3 (13) Nation 765,791 70.1 (1) Reporting period is January 1 through December 31. (2) Excludes records with unknown data or errors. (3) Rank compares one contributor's rate to other contributors. Rank 1 = best rate. (4) <2500 g. (5) >4000 g. (6) <37 weeks gestation. (7) 37 or more weeks gestation and <2500 g. * Percentages are not calculated if <100 records are available for analysis after exclusions.

APPENDIX I: HealthStyles Breastfeeding Attitudes and Opinions

APPENDIX J: Baby Friendly Hospital Map Prototype