Maternal and Infant Health Hospital Practices and Breastfeeding

Maternal and Infant Health Assessment Survey, 2022

Breast milk is recognized as the optimal source of nutrition for infants, and breastfeeding provides benefits for both the infant and birthing individual, including facilitating bonding, and improved health outcomes across the life course.^1-4 For example, those who breastfeed have lower risks of ovarian and breast cancer, high blood pressure, and type 2 diabetes, and those who are breastfed have reduced risks of ear infections, sudden infant death syndrome, childhood obesity and type 2 diabetes.The early postpartum period is especially important for establishing successful breastfeeding, and hospital practices during this time influence breastfeeding initiation, exclusivity and duration.^5-9 California legislation requires that hospitals implement these practices using the Baby-Friendly Hospital Initiative (BFHI) Ten Steps to Successful Breastfeeding^10,11 or an alternate process that includes evidence-based policies and practices or the Model Hospital Policy Recommendations¹² developed by the California Department of Public Health.¹³ The 2022 California Maternal and Infant Health Assessment (MIHA) survey measured birthing peoples' experiences of hospital practices supportive of breastfeeding, including experiencing immediate and uninterrupted skin-to-skin contact, initiating breastfeeding early, rooming-in for at least 23 hours a day, receiving lactation support, receiving no formula samples, feeding only breastmilk, and receiving a contact for post-discharge support.

Hospital practices experienced by birthing people:

• Rooming-in, 96.6%
  
• Contact for post-discharge support, 91%
  
• Lactaction support, 86.6%
  
• Early breastfeeding initiation, 83.2%
  
• Fed only breast milk, 65.7%
  
• Skin-to-skin contact, 65%
  
• No formula samples, 57.5%
  

Only 29% experienced all 7 practices

Asian, Black and Hispanic birthing people were less likely to experience all seven hospital practices than were White birthing people:

• White, 39.5%
  
• American Indiean or Alaska Native, 39.5%
  
• Black, 30.6%
  
• Hispanic, 24.6%
  
• Asian, 22.6%

Other characteristics of birthing people who were less likely to experience all seven hospital practices:

• Birthing people who spoke primarily Spanish, Spanish and English equally or an Asian language at home compared to those who spoke English.
• Birthing people with a cesarean delivery compared to those with a vaginal delivery.
• Birthing people who had Medi-Cal for prenatal care compared to those who had private insurance.

Any and exclusive breastfeeding rates at three months postpartum were higher among birthing people who experienced more hospital practices.

• Any breastfeeding
  • 58.6% experienced 0–2 hospital practices
    
  • 67% experienced 3–4 hospital practices
  • 75.9% experienced 5–6 hospital practices
  • 90.5% experienced 7 hospital practices
    
• Exclusive breastfeeding
  • 7.8% experienced 3–4 hospital practices
  • 31.2% experienced 5–6 hospital practices
  • 60.1% experienced 7 hospital practices

-- Estimate for exclusive breastfeeding among those who experienced 0-2 steps is not shown because the RSE is greater than 50% or fewer than 5 birthing individuals reported.

Resources

Resources and Technical Assistance for Evidence-Based Maternity Care

• Policies and Tools to Support Breastfeeding in Hospitals 
• California Model Hospital Policy Recommendations (PDF): a comprehensive, evidence-based framework that outlines actionable steps to help hospitals implement best practices that promote, protect, and support breastfeeding and ensure compliance with state legislation.
  
• Baby Friendly Hospital Initiative, USA (BFUSA): national authority for the Baby-Friendly Hospital Initiative (BFHI) in the United States and accrediting body for the Baby-Friendly Hospital Initiative’s Baby-Friendly® designation.
  
• California Breastfeeding Coalition - Breastfeeding and Lactation Support in Hospitals: information about breastfeeding and lactation support in hospitals and resources for healthcare providers.
  
• Carolina Global Breastfeeding Institute (CGBI) – Maternity Care Handouts for Staff: supplemental educational handouts on hot topics in the Ten Steps to Successful Breastfeeding.
  
• Regional Perinatal Programs of California (RPPC): resource to support birthing hospitals in implementing evidence-based maternity care services.
  
• Breastfeeding Support for Community Partners
• Breastfeeding Local Health Jurisdiction Coordinators by County: designated coordinators who facilitate communication between state and local government to increase local breastfeeding initiation and duration rates.
• Women, Infants and Children (WIC): WIC local offices offer breastfeeding support services such as peer-to-peer support, lactation professional visits, and breast pumps to income eligible families. WIC Regional Breastfeeding Liaisons establish partnerships with hospitals, health care providers, employers, and the breastfeeding support community to narrow breastfeeding support gaps.
• California Breastfeeding Coalition – Where to Get Support: resource to find peer, certified, and professional lactation support.
• Data
  
• Breastfeeding-Supportive Hospital Practices Data Dashboard: prevalence of hospital practices by selected indicators using MIHA data.
• In-Hospital Breastfeeding Data Dashboard: breastfeeding initiation rates using data collected by the California Newborn Screening Program.
• Breastfeeding Intention and Duration Data Dashboard: breastfeeding intention and duration rates by selected indicators using MIHA data.
• Maternity Practice in Infant Nutrition and Care (mPINC): national survey of maternity care feeding practices completed by hospitals.

About the Data

Methods

This fact sheet uses 2022 data from the Maternal and Infant Health Assessment (MIHA) survey, a statewide representative survey of individuals with a recent live birth in California, conducted annually since 1999 and linked to birth certificates. The survey collects self-reported information about maternal and infant experiences before, during and shortly after pregnancy.

MIHA is a stratified random sample of English- or Spanish-speaking individuals. MIHA data are weighted to be representative of California residents with a live birth, excluding those who were younger than 15 years old at delivery, had a multiple birth greater than triplets, or had a missing address on the birth certificate. The MIHA 2022 sample size was 5,893. MIHA data used in this brief exclude non-hospital births and birthing people who gave birth to multiples or those whose infants were premature, low birth weight, or placed in the neonatal intensive care unit. For more information on weighting and technical definitions, please see the MIHA Technical Notes.

MIHA is led by the Maternal, Child and Adolescent Health Division of the California Department of Public Health (CDPH), in collaboration with the CDPH Women, Infants and Children (WIC) Division and the Center for Health Equity at the University of California, San Francisco.

Definitions

Contact for post-discharge support: Prior to patient discharge, the hospital or birth center provided contact information for lactation or breastfeeding support services or a referral to the WIC program.

Early breastfeeding initiation: Breastfeeding was initiated within the first two hours after birth.

Fed only breastmilk: The baby received only breast milk and no formula while in the hospital or birth center.

Lactation support: A nurse, lactation consultant, or midwife helped with lactation or breastfeeding (e.g., with positioning or latching) at the hospital or birth center.

No formula samples: The hospital or birth center did not provide free samples of baby formula.

Rooming-in: The baby stayed in the same room as the birthing individual for at least 23 hours each day at the hospital or birth center.

Skin-to-skin contact: The baby was placed directly on the birthing individual's bare chest for at least one hour within the first two hours after birth.

For other definitions, please refer to the MIHA Methods narrative.

References

1. World Health Organization. Infant and Young Child Feeding Fact Sheet. December, 2023. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding Accessed June 3, 2025.

2. Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women's Health (US). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011. PMID: 21452448.

3. J Meek JY, Noble L, Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022 Jul 1;150(1):e2022057988.

4. ACOG Committee Opinion No. 756: Optimizing Support for Breastfeeding as Part of Obstetric Practice. Obstet Gynecol. 2018 Oct;132(4):e187-e196. doi: 10.1097/AOG.0000000000002890. PMID: 30247365.

5. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122(suppl 2):S43-S49.

6. Seoane Estruel L, Andreyeva T. Maternity Care Practices and Their Role in US Breastfeeding Disparities. Breastfeeding Medicine. 2025 Apr 21.

7. Perrine CG, Scanlon KS, Li R, Odom E Grummer-Strawn L. Baby-Friendly Hospital Practices and Meeting Exclusive Breastfeeding Intention. Pediatrics. 2012;130 (1):54-60. doi:10.1542/peds.2011-3633.

8. Jung S, Nobari TZ, & Whaley SE. Breastfeeding outcomes among WIC-participating infants and their relationships to baby-friendly hospital practices. Breastfeeding Medicine. 2019; 14(6), 424-431.

9. Moore ER, Bergman N, Anderson GC, Medley N. Early skin‐to‐skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub4.

10. The Ten Steps to Successful Breastfeeding, Baby-Friendly USA.https://www.babyfriendlyusa.org/for-facilities/practice-guidelines/10-steps-and-international-code/. Accessed May 13, 2025.

11. World Health Organization. Implementation Guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services-the revised Baby-friendly Hospital Initiative. Geneva, Switzerland; 2018. https://apps.who.int/iris/handle/10665/272943. Accessed May 13, 2025.

12. Arnold C, Rodriguez A, Spier P. Providing Breastfeeding Support: Model Hospital Policy Recommendations. 2021. California Department of Public Health, Sacramento, California. https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/Hospital-Policy-Recommendations.aspx. Accessed May 13, 2025.

13. California legislative information. California Health & Safety Code §123367. ://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=123367.&lawCode=HSC.. Accessed May 13, 2025.​