Breastfeeding prevalence and distribution in the USA and Appalachia by rural and urban setting

Introduction: Breastfeeding provides health benefits to infants and mothers, yet many women decide against breastfeeding. This study examined differences in the prevalence of breastfeeding among national, urban, rural, and Appalachian regions of the USA. Methods: Secondary data analysis of the US 2007 National Survey of Children’s Health (n=27 388) data were completed for prevalence, insurance coverage, and medical home (a source of comprehensive primary care) determinations according to rural or urban location. Results: The weighted US and Appalachian prevalences of breastfeeding were 0.755 (CI 0.743-0.767) and 0.683 (CI 0.6720.694). National and Appalachian urban prevalences were 0.770 (CI 0.757-0.784) and 0.715 (CI 0.702-0.728). Rural areas had a significantly lower prevalence of breastfeeding of 0.687 (CI 0.661-0.713). Appalachia was significantly lower than the national rural level at 0.576 (CI 0.554-0.598). Women with Medicaid/State Children's Health Insurance Program (SCHIP) had an odds ratio of 1.79 of not breastfeeding compared with privately insured women. Nationally, 26.6% (CI 24.5-28.7) of children of women who did not breastfeed did not have a medical home. Conclusions: Anticipatory guidance about breastfeeding with culturally sensitive awareness programs and interventions directed at rural populations, especially in high risk geographic areas such as Appalachia, may be needed. Healthcare professionals have a unique opportunity to provide anticipatory guidance to pregnant women by discussing the benefits of breastfeeding during visits. High school health educational programs should address the benefits of breastfeeding with rural females.


Benefits of breastfeeding
There are many known infant health benefits related to exclusive breastfeeding, including nutritional, developmental, psychological, neurological, social, environmental, and immunological benefits 1 .Exclusive breastfeeding has been shown to decrease the incidence or severity of bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otits media, urinary tract infection, late-onset sepsis in preterm babies, lymphoma, leukemia, Hodgkin disease, hypercholesterolemia, asthma, as well as reduce postneonatal infant mortality 1 .Exclusive breastfeeding has also been reported to be protective against obesity (odds ratio [OR] 0.75) [1][2][3] .Breastfeeding has been associated with higher cognitive development of the child 1 and higher Weschler scores in adulthood 4 .Similarly, breastfeeding mothers benefit by having decreased postpartum bleeding, an earlier return to their pre-pregnancy weight, and a decreased risk of breast and ovarian cancer 1 .Although the American Academy of Pediatrics and WHO recommend exclusive breastfeeding for 1 year, there are benefits to the infant of breastfeeding during the first few days of life in which antibody-rich colostrum is provided, and intimate bonding occurs with the mother.

Goals in 'Healthy People 2020'
Although there are recognized health benefits for infants and mothers through breastfeeding, many women choose not to breastfeed their infants.The US Government 'Healthy People 2020' agenda has a target of a breastfeeding prevalence of 0.819, which corresponds to an 8% improvement over the 2006 baseline of 0.739 5 .Intervention strategies to promote breastfeeding have been successful in many settings 6 .However, culturally sensitive awareness programs and interventions directed at the populations of specific geographic areas may be needed to improve the prevalence of breastfeeding 7 .

Rural Appalachia breastfeeding prevalence
The Appalachian Region is a 329916 km  9 .The rural area has rolling hills, and rapidly rising ridges to over 1220 m (4000 feet) with remote valleys 10 .There are isolated, secluded communities in the hills and hollows, and this isolation has forged family and community cohesiveness 10 .Some communities have been able to thrive, grow and develop; while for others, the isolation has resulted in the continued absence of basic infrastructure (roads, water, sewage) and access to health care and support 8 .
Support and aid during the initiation of breastfeeding have been identified as important factors for mothers to decide to breastfeed 11,12 ; however, in rural Appalachia there are few resources to offer this.Socioeconomic factors, such as the need to return to work and limited maternity have also been related to breastfeeding decisions 13 .Additionally, and specific to rural Appalachia, pregnant women with a low socioeconomic level also have a high prevalence of smoking morbidity 14 .There is a negative association of maternal smoking with breastfeeding intention, initiation, and duration 13 .For Appalachian women, access to health professionals, socioeconomics and rural living may impact breastfeeding decisions.Therefore, it is important to know if the rates of breastfeeding are higher or lower in Appalachia, as a preliminary to assessing needs for health services or behavioral intervention.
Previous studies have indicated a low breastfeeding prevalence in the southern region of the USA 11 .Direct comparisons between urban and rural women and their differences in breastfeeding initiation have been infrequently explored 12 .A more refined analysis for the Appalachian Region was needed.The purpose of this study was to examine for differences in the national and Appalachian prevalences of breastfeeding in rural and urban settings, and to identify health care and socioeconomic factors that may impact on this.

Methods
The   with no breastfeeding were equivalent to or had more women who did not breastfed than nationally.There were significantly more women who did not breastfeed and were at 0-99% FPL in WV, KY, SC, AL, and MS, compared with the national level.There were significantly more women who did not breastfeed and were at 100-199% FPL in WV, and MS.There were significantly more women who did not breastfeed and were at 200-399% FPL in WV, KY, and SC.There were significantly more women who did not breastfeed and were at 400% and over FPL in AL (Table 2).Nationally, 26.6% (CI 24.5-28.7) of the children of women who did not breastfeed also did not meet all criteria for having a medical home.In Appalachia, with sample sizes above 50 women, WV, KY, TN, OH, SC, AL, and MS had significantly higher percentages of children of women who did not breastfeed who also did not meet the criteria for having a medical home, compared with the national percentage.In PA, GA, and NC, the percentage was higher, but within the confidence level of the national percentage; and in NY the percentage was lower, but within the confidence level of the national prevalence (Table 3).
The prevalence of not breastfeeding in the uninsured or privately insured women was (0.207 CI 0.165-0.245)for uninsured and 0.191(CI 0.178-0.204)for privately insured; whereas, the women who had Medicaid/State Children's Health Insurance Program (SCHIP) had a prevalence of not breastfeeding of 0.341 (CI 0.316-0.366).Women who had Medicaid/SCHIP had an OR of 1.65 of not breastfeeding, compared with uninsured women; and an OR of 1.79 compared with privately insured women.Of the Appalachian states with sample sizes greater than 50 women, the prevalence of women who had Medicaid/SCHIP and did not breastfeed was higher than the national level for WV, KY, TN, AL and MS.The prevalence of not breastfeeding among women with Medicaid/SCHIP was within the confidence levels of the national prevalence for all of the other Appalachian states.The women who had private insurance and did not breastfeed in WV, KY, SC, AL, and MS had a significantly higher prevalence of not breastfeeding than the national level.The prevalence of not breastfeeding among women who had private insurance was within the confidence levels of the national prevalence for the other Appalachian states.There were too few women who were uninsured who were sampled in the Appalachian states to compare with the national statistic on prevalence of uninsured and not breastfeeding (Table 4).†Sample < 50, use caution in interpreting results.*Significantly fewer did not breastfeed than the national 0-99% FPL; **significantly more did not breastfeed than national categories 200% FPL and above; ***significantly fewer did not breastfeed than national categories 100-199% FPL and 200-399% FPL; ****significantly more did not breastfeed than all national categories; *****significantly more did not breastfeed than national categories 100% FPL and above; *******significantly more did not breastfeed than national category 400%+ FPL.

Discussion
This study shows that the national breastfeeding prevalence has increased from 2006 6 .Nevertheless, rural areas, and particularly rural areas in Appalachia, had more women who did not breastfeed.This supports previous research that suggested initiation of breastfeeding may be more frequent among urban women 11 .Rural children had an OR of 1.28 of not being breastfed , compared with the USA overall.The children in rural Appalachia had an OR of 1.73 of not being breastfed , compared with the USA overall, and 1.35 compared with children in other rural areas of the USA.
The major strengths of the study are its national populationbased design and large overall sample size.There were some limitations.The outcome variable, breastfeeding, was selfreported and thus there was a possibility of misclassification bias from a self-report error.Because the respondent selfreported a home address there was a possibility of misclassification bias relating to rural or urban location due to a self-report error.The study was cross-sectional, so inferences about risk should not be made; and in several analyses the sample sizes were small, therefore caution should be exercised with their interpretation.Participants had to have land-line telephones to be included in the study.As the number of people who are using cellular phones increase, the effectiveness of random digit dialing surveys becomes limited.This survey design attempted to weight participants who had interrupted phone service so as to adjust for those who did not have land-lines.The overall response rate was low, but adjusting for no answers, or busy signals after 6 or more attempts resulted in an alternate resolution rate of 89.9% 15 .This research indicates the significant impact of medical home, FPLs, insurance availability and living in rural Appalachia on breastfeeding rates.Other determinants also exist.Of the limited research that addresses factors that impact on a decision to breastfeed, partner influence has been shown to be an important factor in improving breastfeeding rates 16 .Some women report inflammation, soreness, tenderness, Candida infection, low milk supply, or the baby's colic as reasons to choose not to breastfeed 17 .Urban women who had support from the healthcare system 12 , and foreign-born women who emigrated to the USA were more likely to decide to breastfeed 18 .Women whose pregnancies were unplanned were more likely to decide against breastfeeding 19 .Urban women who developed postpartum depression were more likely to decide against breastfeeding 20 .Women who intended to work when their child was 2 months old, and women who participated in the US Federal Women, Infants, and Children program were more likely to decide against breastfeeding 12 .Qualitative research is needed to explore the other factors influencing the intention to breastfeed or not.
Little research is available about barriers that specifically dissuade rural women 12 , and women in Appalachia in particular, from breastfeeding.It has been reported that additional potential factors impacting the decision of rural women to breastfeed are geographic isolation, few economic resources, limited access to health care, and smoking, which may be similar or distinct from the factors influencing urban women in their decisions 12,14 .
There are also limited applications of behavioral science theories to breastfeeding research and frameworks from which to develop educational strategies that would modify factors involved in women deciding to initiate breastfeeding 12 .Before anticipatory guidance with culturally sensitive awareness programs and interventions can be effectively developed and disseminated, it is important to have a series of focus groups to qualitatively determine factors that may be culturally specific and influential for women in Appalachia.This would assist in formulating objectives to meet the needs of Appalachian women who decide to breastfeed.

Conclusions
Increasing the prevalence of breastfeeding is a national US objective.Rural areas, and rural Appalachia in particular, are lagging behind the rest of the nation in meeting the objective.The identification and removal of barriers are needed for this population.Future research should involve exploration and explanation of these barriers.
CI 0.661-0.713),and for Appalachia it was 0.576 (CI 0.554-0.598).None of the states in Appalachia had a prevalence of breastfeeding above the national rural prevalence or national urban prevalence.In the Appalachian states of WV, KY, AL, and MS, the prevalence of rural women who breastfed was significantly less than the national rural prevalence.In the states of TN, NC, SC, PA, NY, VA, OH, GA and MD, the prevalence was the same as the national rural prevalence.(Small sample sizes of <50 women sas.com) analysis to query the data base for prevalence data with CIs, and limited multivariate data analysis.No re-coding of variables was completed15.The database was queried with the SPSS (http://www.spss.com)ComplexSamplessoftware online query tool for breastfeeding prevalence, utilizing national and state data.Options were selected from the online query tool's menu for rural and urban status; Federal Poverty Level (FPL), medical home status, and insurance status.The Data obtained.The weighted US point prevalence of breastfeeding was 0.755 (CI 0.743-0.767);forAppalachia it was 0.683 (CI 0.672-0.694).Rural and urban prevalences were weighted to reflect population densities.The national urban areas had a prevalence of breastfeeding of 0.770 (CI 0.757-0.784);forAppalachia it was 0.715 (CI 0.702-0.728).Nationally, rural areas had a significantly lower prevalence of breastfeeding of 0.687 (were found in PA, NY, VA, OH, GA, and MD.Precision for population estimates is influenced by sample size, and if <50 women the 95% CI range may be too large for the standard of reliability 15 ).The prevalence of women who breastfed and lived in urban areas of Appalachia was significantly less than the national urban prevalence in the states of WV, KY, TN, PA, OH, SC, AL, and MS.The prevalence was the same as the national urban prevalence in NY, VA, NC, GA, and MD (Table1).

Table 1 : Prevalence of women who did not breastfeed (95% CI) 15
Significantly more did not breastfeed than national overall and national urban prevalence; **significantly more did not breastfeed than national overall, national urban, and national rural prevalence; ***significantly fewer did not breastfeed than national rural; ****significantly more did not breastfeed than national urban.

Table 3 : Prevalence of women who did not breastfeed and did not have all of the criteria of medical home met for children ages 0-5 (95%CI) 15
* Significantly more children did not have a medical home than nationally; **significantly fewer children did not have a medical home than in the Appalachian region; ***significantly more children did not have a medical home than in the Appalachian region.