Assessment of obstetrical maternity care practices in Mississippi Health Districts

Breastfeeding objectives listed in Healthy People 2010 address the disparities in the breastfeeding rates in the United States, especially among racial and ethnic groups. Mississippi has a large population of African Americans who have been targeted as one of the groups that are at-risk of not breastfeeding. Obstetricians in Mississippi play an important role in breastfeeding education and support of pregnant women, which research suggests does positively influence the decision to breastfeed.

The prenatal period is a critical time in the decision to choose breastfeeding as the method of infant feeding. Breastfeeding education, which is included during the prenatal visits, has positively impacted intention to breastfeed as well as initiation of breastfeeding. A national survey conducted by the CDC reports that the initiation rate in the United States reached 73.8% in 2004, and the initiation rate in Mississippi was only 50.2%. Both the national and Mississippi rate of mothers who initiated breastfeeding are lower than the recommendations in Healthy People 2010, which set an initiation rate of 75% at hospital discharge as a goal to improve the health of mothers and infants.

Numerous studies indicate the relationship of higher rates in breastfeeding initiation with medical facilities and birth centers that have implemented the Ten Steps to Successful Breastfeeding and have earned the recognition of baby-friendly. Several surveys have been conducted in the United States and internationally on the knowledge of and compliance with the Ten Steps by health care professionals.

In a national survey on public opinion of breastfeeding, Mississippi was part of the East South Central region. This region had the lowest scores for 5 out of 8 questions; including the lowest score of 13.7% (baby formula increases the chance the baby will get sick). Another question with the lowest score (21.2%) stated that cereal and baby food can begin by 3 months which is contrary to the recommendation of exclusive breastfeeding for the first six months by major national and international health organizations.

For this assessment, a survey instrument, based on the Ten Steps, was developed with a panel of experts and pilot tested in Baton Rouge, Louisiana. A three-wave mailing was used to conduct this survey, which was approved by the Mississippi State University Institutional Review Board. The practicing obstetricians who are members of the Mississippi State Medical Association were surveyed in three areas: agreement with statements on the Ten Steps, awareness of the local breastfeeding support network and policies of medical facilities, and maternity care practices related to breastfeeding education and support. The data collected from the obstetricians were grouped by the nine health districts in Mississippi. This assessment of the obstetricians practicing in the health districts gives an understanding about the types of breastfeeding education and support that pregnant women receive in specific localities in Mississippi. Districts I, III, V, and VII include counties in west MS. Districts II, IV, VI, VIII, and IX include the counties in east MS. Districts I and II include the northern counties, and District IX includes the coastal counties.

The data from 116 obstetricians (59.2%) revealed that District III has no female obstetricians; only Districts II, III, V, and IX have solo practices; only District V has the academic practice; and Districts III, IV, VI, and VIII lack obstetricians with five or less years of practice. With the majority of the obstetricians caucasian (85.3%), District V is the one health district that has seven non-white obstetricians. Six other districts have only one non-white obstetrician, and Districts IV and VI have only caucasian obstetricians. Districts IV and VI, located on the eastern part of the state, and District IX, the coastal area, had less than 55% participation.

Thirteen of the 18 statements on the Ten Steps were agreed with by 80% of the obstetricians. Obstetricians in District VI agreed with six of the statements, including an obstetrician's discussions on breastfeeding are influential and breastfeeding within one hour after birth should be encouraged. District IV agreed with five statements, including a written breastfeeding policy ensures breastfeeding support and rooming-in establishes breastfeeding. District III agreed with four statements, including in-service training maintains breastfeeding support and rooming-in establishes breastfeeding. Districts II and V agreed with only one of the statements on the Ten Steps. Four statements related to exclusive breastfeeding received low agreement by the obstetricians in all nine health districts: feeding on baby's cues, no need for water supplements or solid foods for infants less than six month old, and the interference of pacifiers with the establishment of breastfeeding.

Most of the obstetricians in Mississippi who participated in this study were unaware of the Ten Steps. Fifteen obstetricians reported awareness, but four health districts (I, III, VI, and VII) had none. Their awareness of the breastfeeding support networks was 34% to 80% for lactation consultants (IBCLCs), 50% to 86% for La Leche League (LLL), and 79% to 93% for Women, Infants, and Children (WIC) peer counseling program. District VIII reported the highest percentage of awareness for LLL and WIC. Eighty percent of the obstetricians in districts III and IV reported awareness of IBCLCs.

Obstetricians in District IX reported five maternity care practices as common practices during prenatal visits: obstetricians discuss infant feeding; infant feeding choice is discussed; breastfeeding is encouraged; breastfeeding classes are encouraged; and breastfeeding literature is distributed. Three other districts reported that infant feeding choice is discussed and breastfeeding is encouraged as common practices during prenatal visits. Formula is still distributed during prenatal visits in all nine health districts.

Chi-square tests revealed significant differences between health districts in eight areas: agreement that working mothers can exclusively breastfeed (p=.001); awareness of hospital breastfeeding policy (p=.002); awareness of breastfeeding classes conducted by their medical facility (p=.012); agreement that an obstetrician's discussions on breastfeeding with the practice of encouraging breastfeeding in District VI (p=.007) and District IX (p=.002); agreement that breast milk should be the main source of nourishment for the first year with the practice of distributing coupons for formula packs to prenatal patients in District V (p=.035); awareness of the WIC breastfeeding peer counseling program with their referrals to WIC peer counselors in District VII (p=.008); and awareness of LLL with their awareness of breastfeeding classes conducted by LLL in District IV (p=.018). Also, the maternity care practice of obstetricians discussing infant feeding with their prenatal patients differed among the health districts (p=.055).

The findings identified variety in breastfeeding education and support during prenatal visits that need to be investigated further. Healthy People 2010 is a federal document that challenges all members of the health care team to endorse in order to improve the health of women, infants, and children and that would decrease the disparities in the service of health care. The Ten Steps to Successful Breastfeeding has been recognized as an integral strategy to increase breastfeeding, especially in groups with low rates of breastfeeding intention and initiation. Pregnancy is the critical time to educate future mothers about breastfeeding to ensure the optimal health for both mothers and their infants. Obstetricians are in the unique position to offer prenatal education and to refer pregnant women to local breastfeeding support groups. With this type of breastfeeding education and support during pregnancy, more women will become comfortable with breastfeeding as the first choice for infant feeding. Improvements in the health status of women, infants, and children in Mississippi are possible if all the professionals of the health team promote, encourage, and support breastfeeding in their maternity care practices.