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Perception and Attitudes: Breastfeeding in Public in New York City Candace Mulready-Ward and Martine Hackett J Hum Lact 2014 30: 195 originally published online 10 March 2014 DOI: 10.1177/0890334414524988 The online version of this article can be found at: http://jhl.sagepub.com/content/30/2/195
Published by: http://www.sagepublications.com
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research-article2014
JHLXXX10.1177/0890334414524988Journal of Human LactationMulready-Ward and Hackett
Original Research
Perception and Attitudes: Breastfeeding in Public in New York City
Journal of Human Lactation 2014, Vol. 30(2) 195–200 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334414524988 jhl.sagepub.com
Candace Mulready-Ward, MPH1 and Martine Hackett, PhD, MPH2
Abstract Background: In the United States, 76.9% of women initiate breastfeeding but only 36.0% breastfeed exclusively for 3 months. Lack of support for public breastfeeding may prevent women from breastfeeding in public, which could contribute to low rates of breastfeeding exclusivity and continuation, despite high rates of breastfeeding initiation. Objective: This study aimed to determine whether residents of New York City, New York, were supportive of and comfortable with public breastfeeding. Methods: A population-based public opinion telephone survey of non-institutionalized New York City residents 18 years and older was conducted by the New York City Department of Health and Mental Hygiene. Results: Overall, 50.4% of respondents were not supportive of public breastfeeding. In the multivariable analysis, there was significant variation in support by race/ethnicity, age, and education. There were no significant differences in support by sex, receipt of food stamps, nativity, or the presence of children younger than 12 years in the home. One-third (33.2%) of respondents were uncomfortable with women breastfeeding near them in public. There was significant variation by education in the multivariable analysis. Lack of comfort was highest among those with a high school education or less (39.9%) and some college (33.8%). Conclusion: New York City residents are conflicted about whether breastfeeding is a private act or one that can be done in public. For women who want to continue with their intention to breastfeed exclusively, the negative opinion of other residents may cause them to breastfeed only in private, thereby limiting the opportunity to breastfeed for the recommended time. Keywords breastfeeding, breastfeeding attitudes, public opinion, public places, social norms
Well Established The most recent national data suggest that there is regional variation in support for breastfeeding in public and that at least onethird of Americans believe that women should breastfeed only in private.
Newly Expressed Half of New York City residents believe that women should breastfeed only in private. However, support for breastfeeding in public is higher among younger residents and those with a college education.
United States: social norms that are unsupportive of mothers breastfeeding their children in public. New York State was the first state to enact a law to protect a mother’s right to breastfeed in public nearly 2 decades ago.3 More recently, in 2011, the City of Seattle, Washington, elevated breastfeeding to a civil right, and it is now illegal for others to ask mothers not to nurse in public or any other location.4 Even with these and other laws across the country that protect the right of women to breastfeed in public,5 the attitudes of members of 1
New York City Department of Health and Mental Hygiene, Bureau of Maternal, Infant and Reproductive Health, Long Island City, NY, USA 2 Hofstra University, Hempstead, NY, USA
Background
Date submitted: August 14, 2013; Date accepted: January 16, 2014.
Recent protests over women being told by authorities to stop breastfeeding in public places like retail stores and restaurants and even on social media sites like Facebook1,2 have highlighted a key area for breastfeeding promotion in the
Corresponding Author: Candace Mulready-Ward, MPH, New York City Department of Health and Mental Hygiene, Bureau of Maternal, Infant and Reproductive Health, 42-09 28th Street, 10th Floor, Long Island City, NY 11101, USA. Email: [email protected]
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the public can serve as a barrier for women who wish to breastfeed their children without restriction. Despite dramatic increases in breastfeeding initiation in New York City, New York (NYC) over the past 30 years, from 33% in 19806 to 89% in 2011 (NYC Department of Health and Mental Hygiene [DOHMH], Pregnancy Risk Assessment Monitoring System, unpublished data, 2011), most women do not breastfeed exclusively for 6 months, as recommended by the American Academy of Pediatrics.7 Although NYC exceeds the Healthy People 2020 goal of 81.9% for breastfeeding initiation,8 early supplementation and early cessation of breastfeeding are the norm. Only 35% of NYC women are exclusively breastfeeding at 1 week postpartum, defined as the infant being fed only breast milk and no other solids or liquids, including water (NYC DOHMH, Pregnancy Risk Assessment Monitoring System, unpublished data, 2011). By 2 months postpartum, only 26% of NYC women are exclusively breastfeeding, and only 13.3% by 6 months postpartum,9 well below the Healthy People 2020 goals that 46.2% of infants be exclusively breastfed for at least 3 months and 25.5% for 6 months.8 In addition, among all women who initiate breastfeeding in NYC, 23% stop breastfeeding altogether within 2 months (NYC DOHMH, Pregnancy Risk Assessment Monitoring System, unpublished data, 2011). There are many reasons that breastfeeding women feed their infants formula or discontinue breastfeeding. Common reasons cited by breastfeeding mothers include difficulties with breastfeeding,10-12 concerns about the infant not gaining enough weight or being satisfied by breast milk alone,10,11 the influence of family members,12 and a desire to ensure that their infants receive the perceived benefits of formula.12 Perceived social norms surrounding breastfeeding in public are also associated with women’s breastfeeding behaviors.10,13-15 Nationally, 12% of US women report not wanting to breastfeed in public as a reason for stopping breastfeeding.10 In NYC, interviews with breastfeeding women in a low-income neighborhood in Brooklyn found that breastfeeding in public was unthinkable.14 In another study of pregnant women in NYC, 72% reported that they would be uncomfortable breastfeeding in public.11 In this same study, women who were comfortable with breastfeeding in social settings were more likely to intend to exclusively breastfeed,13 and intention is a strong predictor of breastfeeding behavior.16 The high breastfeeding initiation rate in NYC suggests that most women have positive beliefs about breastfeeding. We hypothesize that 1 reason for the rapid drop off in exclusive breastfeeding in the first few months postpartum is that social norms are not supportive of breastfeeding in public. New York City residents are constantly interacting with each other in public due to population density, widely available public transportation, and living in multiple unit dwellings. This makes socially accepted behavior about breastfeeding in public particularly important for women in NYC.
This study explores public attitudes toward breastfeeding in NYC based on responses to questions on a public opinion telephone survey.
Methods In 2011, a population-based public opinion telephone survey of NYC residents (n = 2075) was conducted by the NYC DOHMH. The survey was limited to non-institutionalized adults 18 and older. Respondents were identified by random digit dialing sampling of landlines (50% of sample, n = 1035) and cell phones (50% of sample, n = 1040). The data were weighted using the 2006-2008 American Community Survey estimates of the population of non-institutionalized adults age 18 and older living in NYC’s 5 boroughs. The response rate was 32% and the cooperation rate was 94%. The primary purpose of the survey was to gather baseline data on perceptions of obesity and consumption of sugarsweetened beverages and was funded through the Centers for Disease Control and Prevention’s Communities Putting Prevention to Work program. Two items on breastfeeding were included: (1) Mothers who breastfeed should do so in private places only, and (2) I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, and so on. Respondents stated their level of agreement on a 4-point Likert-type scale. The response options were strongly agree, somewhat agree, somewhat disagree, and strongly disagree. The questions were originally developed by the Centers for Disease Control and Prevention and were part of a series of questions on breastfeeding intended to provide baseline data for a national breastfeeding campaign.17 For the purpose of this analysis, responses were recoded to create 2 dichotomous outcome variables: support for public breastfeeding and comfort with public breastfeeding. Respondents with missing or don’t know responses on either breastfeeding question (n = 96) were excluded from this analysis, resulting in a final sample size of 1979 respondents. Analyses were conducted using Statistical Analysis Software (SAS version 9.2). Differences in each outcome, by demographic characteristics of respondents, were tested by chi-square statistic. Predictors of each outcome were tested using multivariable logistic regression analysis. The outcomes were lack of support for public breastfeeding and lack of comfort with public breastfeeding. The models were adjusted for demographic variables that were significant at the P < .05 level in the bivariate analyses. All numbers reported are based on unweighted data, and percentages, standard errors, adjusted odds ratios (AORs), and 95% confidence intervals (CIs) are based on weighted data. This study was approved by the NYC DOHMH Institutional Review Board, and all procedures followed were in accord with the ethical standards of the DOHMH Institutional Review Board.
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Mulready-Ward and Hackett Table 1. Demographic Characteristics of Sample (n = 1979), New York City, 2011.a Characteristic
No.
Sex Male 918 Female 1060 Children younger than 12 living in respondent’s home Yes 650 No 1326 Age, y 18-44 1049 45-64 614 65+ 296 Race/ethnicity Black non-Hispanic 447 White non-Hispanic 742 Asian non-Hispanic 171 Puerto Rican 173 Other Hispanic 344 Other race/mixed/unknown 101 Education High school or less 911 Some college 440 College graduate 611 Received food stamps past 12 months Yes 446 No 1509 Nativity Born in the US/Puerto Rico 1210 Born outside US 758
% 46.4 53.6 32.9 67.1 53.5 31.4 15.1 22.6 37.5 8.6 8.8 17.4 5.1 46.4 22.4 31.2 22.8 77.2 61.5 38.5
a
Number is based on unweighted data and percentage is based on weighted data. Totals for each characteristic may not equal overall sample size due to missing data.
Results More than half of the sample (53.6%) were women, and 53.5% were 18 to 44 years old. The race/ethnic distribution was 37.5% white non-Hispanic, 22.6% black non-Hispanic, 8.8% Puerto Rican, 17.4% other Hispanic, 8.6% Asian nonHispanic, and 5.1% of other, mixed, or unknown race. Less than half (46.4%) of the sample had a high school education or less. All demographic characteristics of the study population can be found in Table 1.
Support for Public Breastfeeding Overall, 50.4% of respondents were not supportive of public breastfeeding, agreeing with the statement that women should breastfeed in private only (Table 2). In bivariate analyses, there was significant variation in support for public breastfeeding by race/ethnicity, age, education, and the presence of children younger than 12 in the home. Lack of support was highest among respondents 65 years and older (63.8%), Asians (61.8%), and those with a high school education or
less (58.3%). There were no differences in support for public breastfeeding by sex, receipt of food stamps, or nativity. In the multivariable analysis, compared to white non-Hispanic respondents, Asians were significantly more likely (AOR = 1.63; 95% CI, 1.15-2.31) to be unsupportive of public breastfeeding, whereas both other Hispanics (AOR = 0.52; 95% CI, 0.39-0.70) and black non-Hispanics (AOR = 0.67; 95% CI, 0.52-0.86) were significantly less likely to be unsupportive of public breastfeeding (Table 3a). There was an inverse relationship between education and lack of support such that respondents with a high school education or less (AOR = 2.91; 95% CI, 2.30-3.68) and those with some college (AOR = 1.95; 95% CI, 1.50-2.52) were more likely to be unsupportive of public breastfeeding compared to college graduates. Adults age 65 and older were significantly more likely to be unsupportive of public breastfeeding (AOR = 1.55; 95% CI, 1.15-2.08) compared to 18- to 44-year-olds.
Comfort with Public Breastfeeding Only 33.2% of respondents were uncomfortable with women breastfeeding near them in public (Table 2). Lack of comfort was highest among respondents with a high school education or less (39.9%) and those age 65 and older (39.5%). There were no differences by race/ethnicity, sex, receipt of food stamps, nativity, or the presence of children younger than 12 years old in the home, in the bivariate analyses. In the multivariable analysis, only education was associated with being uncomfortable with public breastfeeding (Table 3b). Respondents with a high school education or less (AOR = 2.24; 95% CI, 1.78-2.83) and those with some college (AOR = 1.76; 95% CI, 1.34-2.31) were significantly more likely to be uncomfortable with public breastfeeding than were those with a college degree or more.
Discussion This study found that NYC residents are conflicted about whether breastfeeding is a private act or one that can be done in a public space. A majority of NYC residents felt comfortable when mothers breastfed near them in a public place. However, NYC residents were evenly divided over whether or not women who breastfeed should do so in private only. This lack of consistency between support for the idea of breastfeeding in public and an individual’s level of comfort with women breastfeeding near them has also been found in similar studies.18-21 National data from the 2007 HealthStyles Survey from which the NYC questions were taken also found that more respondents felt that women should breastfeed only in private (36%) than reported that they were uncomfortable with women breastfeeding near them in a public setting (31%).22 The difference between the 2 responses was greater in our study, and more respondents thought that women should breastfeed only in private in our study compared to nationally (50% vs 36%, respectively).22
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Table 2. Support and Comfort with Breastfeeding by Demographic Characteristics, New York City, 2011.a Not Supportive of Breastfeeding in Public
Not Comfortable with Women Breastfeeding in Public
% (SE)
% (SE)
50.4 (±1.11)
33.2 (±1.05)
50.6 (±1.63) 50.2 (±1.52)
34.0 (±1.55) 32.6 (±1.42)
46.3 (±1.95) 52.4 (±1.35)
31.8 (±1.81) 34.0 (±1.29)
48.2 (±1.53) 48.0 (±1.99) 63.8 (±2.75)
33.4 (±1.45) 30.3 (±1.83) 39.5 (±2.81)
47.5 (±2.35) 51.1 (±1.82) 61.8 (±3.64) 55.7 (±3.75) 43.3 (±2.65) 53.2 (±4.78)
33.3 (±2.21) 32.7 (±1.70) 39.3 (±3.71) 33.7 (±3.60) 30.5 (±2.47) 34.3 (±4.62)
58.3 (±1.61) 50.8 (±2.37) 38.1 (±1.95)
39.9 (±1.61) 33.8 (±2.23) 22.7 (±1.68)
53.2 (±2.34) 49.5 (±1.27)
35.7 (±2.24) 32.6 (±1.19)
51.8 (±1.43) 48.1 (±1.79)
33.4 (±1.34) 33.0 (±1.70)
Characteristic Overall Sex Male Female Children younger than 12 living in respondent’s homeb Yes No Age, yb,c 18-44 45-64 65+ Race/ethnicityb Black non-Hispanic White non-Hispanic Asian non-Hispanic Puerto Rican Other Hispanic Other race/mixed/unknown Educationb,c High school or less Some college College graduate Received food stamps past 12 months Yes No Nativity Born in the US/Puerto Rico Born outside US
Abbreviation: SE, standard error. a Percentages and standard errors are based on weighted data. b Differences in support for breastfeeding in public are significant at P < .05 level. c Differences in comfort with women breastfeeding in public are significant at P < .05 level.
This study also provides baseline data for NYC on public attitudes toward breastfeeding. Its strengths are that it adds to the existing literature on social acceptability of public breastfeeding by identifying groups least likely to be supportive of breastfeeding in NYC, including adults older than 65, individuals without a college education, and Asians. The limitations of this study include not directly testing the association between women’s beliefs about the acceptability of breastfeeding in public and how likely women were to breastfeed in public, controlling for public opinion about breastfeeding in public. Therefore, it could not answer the question of whether lack of consensus on whether breastfeeding in public is acceptable contributes to the high discontinuation rates for individual women. It also did not explore the reasons that people disapprove of breastfeeding in public. Greater overall support for breastfeeding in public among younger cohorts than among those 65 and older suggests that
the norms may have changed over the course of several generations and that public spaces where younger people gather, such as parks and playgrounds, could provide more supportive environments for breastfeeding mothers. Efforts to increase support for breastfeeding in public should focus on individuals older than 65, in addition to Asians, and those without a college degree. One way to change norms about breastfeeding in public is to enact laws that protect a woman’s right to breastfeed in public. New York City residents have that right under New York State law. However, as in other locations, incidents arise that challenge these rights and illustrate that laws alone are not enough. For example, in 2004, a NYC mother was harassed by police and given a ticket to appear in court for a misdemeanor for breastfeeding her infant on a public commuter train, referred to in NYC as the subway. In response, the NYC Breastfeeding Promotion Leadership Committee, a
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Mulready-Ward and Hackett Table 3a. Logistic Regression Model Predicting Lack of Support for Public Breastfeeding among New York City Residents, 2011. Characteristic
AOR
Race/ethnicity Other Hispanic 0.52 Asian, non-Hispanic 1.63 Puerto Rican 0.80 Black non-Hispanic 0.67 Other/mixed/unknown race 1.01 White non-Hispanic (referent) 1.00 Education High school or less 2.91 Some college 1.95 College graduate or more (referent) 1.00 Children younger than 12 living in respondent’s home No 1.20 Yes (referent) 1.00 Age, y 18-44 (referent) 1.00 45-64 0.94 65+ 1.55
95% CI 0.39-0.70 1.15-2.31 0.56-1.15 0.52-0.86 0.65-1.57 2.30-3.68 1.50-2.52 0.97-1.48 0.76-1.17 1.15-2.08
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
Table 3b. Logistic Regression Model Predicting Lack of Comfort with Public Breastfeeding among New York City Residents, 2011. Characteristic Education High school or less Some college College graduate or more (referent) Age, y 18-44 (referent) 45-64 65+
AOR
95% CI
2.24 1.76 1.00
1.78-2.83 1.34-2.31
1.00 0.87 1.24
0.70-1.08 0.95-1.62
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
group of public and private breastfeeding advocates, organized an annual Subway Caravan in which mothers and breastfeeding advocates travel by subway together throughout NYC while breastfeeding their infants to increase awareness about their rights.23 The NYC Subway Caravan and other grassroots efforts such as public gatherings of breastfeeding mothers may increase acceptability of breastfeeding in public by increasing awareness of this issue. One way to target groups that are unsupportive of public breastfeeding is through public awareness campaigns. In 2012, the DOHMH ran a small public awareness campaign that included posters on the subway and in hospitals that showed the benefits of breast milk. The campaign was part of the larger Latch on NYC initiative, a voluntary hospital-based initiative to increase support for breastfeeding at maternity hospitals by asking hospitals to discontinue formula supplementation
of breastfed infants unless medically necessary or requested by the mother, and to limit the promotion of infant formula in the hospital. Results from an evaluation of the public awareness campaign showed that 33% of individuals who saw the public awareness campaign felt more supportive of public breastfeeding after seeing the campaign (Global Strategy Group, unpublished data, 2012). Despite high rates of breastfeeding initiation in NYC, which suggest that mothers view breast milk as the preferred food for infants, meeting the recommended duration for breastfeeding is a challenge for many new mothers. For women who want to continue exclusive breastfeeding, the negative opinion of their fellow NYC residents may influence their decisions to breastfeed only in private, thereby limiting the opportunity to continue with breastfeeding for the recommended time. Improving the acceptance of breastfeeding in public may help to support women’s breastfeeding intentions and behaviors. Furthermore, providing women with the skills and abilities to combat negative attitudes toward breastfeeding in public may strengthen their intention to increase duration in spite of ambivalent public opinion.
Conclusion This study identified the attitudes of NYC residents about mothers breastfeeding their children in public places. Nationally, attitudes are moving toward more support of public breastfeeding, and this study found that young NYC residents were more likely to support public breastfeeding than were older residents. However, we also identified that half of NYC residents were not supportive of public breastfeeding. In an urban area like NYC, with great diversity by immigration status, education, and income, there is a potential for increased acceptance of breastfeeding in public over time as approval from younger residents becomes more influential. Changing local laws to establish breastfeeding in public as a civil right for all may help to establish breastfeeding as the norm in other locations. Future research is needed to address the reasons for discomfort and disapproval, as well as to address the relationship between perceived public support and actual breastfeeding and exclusive breastfeeding duration. In addition, more in-depth research is needed on how to improve public attitudes about breastfeeding in public and create a national strategy to improve the rate of exclusive breastfeeding. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported in part by a cooperative agreement from the Centers for Disease Control and Prevention’s Communities Putting
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Prevention to Work program (1U58DP002418-01 & 3U58DP002418-01S1). The findings and conclusions are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
References 1. Rochman B. The nurse-in: Why breast-feeding mothers are mad at Target. Time. December 27, 2011. http://healthland. time.com/2011/12/27/the-nurse-in-why-breast-feeding-momsare-mad-at-target/. Accessed February 10, 2014. 2. Shaw A. Moms’ ‘nurse in’ protests breastfeeding cover-up order at Colo. water park. ABC News website. http://abcnews.go.com/US/colo-mom-stages-nurse-city-owned-waterpark/story?id=16773575. Published July 13, 2012. Accessed February 4, 2013. 3. New York Statewide Breastfeeding Coalition. Laws and Legislation. http://www.nysbreastfeeding.org/laws-and-legislation/. Accessed February 24, 2014. 4. Office of the City Clerk, City of Seattle, Washington. An ordinance relating to unfair public accommodation practices. http://clerk.seattle.gov/~archives/Ordinances/Ord_123863. pdf. Accessed February 4, 2013. 5. National Conference of State Legislatures. Breastfeeding laws. www.ncsl.org/issues-research/health/breastfeeding-state-laws. aspx. Updated May 2011. Accessed February 6, 2013. 6. Rosenberg KD, McMurtrie C, Kerker BD, Na Y, Graham EH. Breast-feeding initiation in New York City, 1979 to 1996. Am J Public Health. 1998;88(12):1850-1852. 7. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506. 8. US Department of Health and Human Services. Healthy People 2020 breastfeeding objectives. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist. aspx?topicid=26. Accessed January 21, 2013. 9. National Immunization Survey. Provisional geographic-specific exclusive breastfeeding rates among children born in 2007. Centers for Disease Control and Prevention website. http://www.cdc.gov/breastfeeding/data/NIS_data/2007/state. htm. Accessed November 22, 2013. 10. Li R, Fein SB, Chen J, Grummer-Strawn LM. Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics. 2008;122(suppl 2): S69-S76.
11. Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System. Pediatrics. 2005;116(6):1408-1412. 12. Bunik M, Clark L, Zimmer LM, et al. Early infant feeding decisions in low-income Latinas. Breastfeed Med. 2006;1(4): 225-235. 13. Stuebe AM, Bonuck K. What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and beliefs in a diverse urban population. Breastfeed Med. 2011;6(6):413-420. 14. Kaufman L, Deenadayalan S, Karpati A. Breastfeeding ambivalence among low-income African American and Puerto Rican women in north and central Brooklyn. Matern Child Health J. 2010;14(5):696-704. 15. Holmes AV, Chin NP, Kaczorowski J, Howard CR. A barrier to exclusive breastfeeding for WIC enrollees: limited use of exclusive breastfeeding food package for mothers. Breastfeed Med. 2009;4(1):25-30. 16. Bai Y, Middlestadt SE, Peng CY, Fly AD. Predictors of continuation of exclusive breastfeeding for the first six months of life. J Hum Lact. 2010;26(1):26-34. 17. Centers for Disease Control and Prevention. HealthStyles survey—breastfeeding practices: 2003. http://www.cdc.gov/ breastfeeding/data/healthstyles_survey/survey_2003.htm. Accessed November 22, 2013. 18. Hannan A, Li R, Benton-Davis S, Grummer-Strawn L. Regional variation in public opinion about breastfeeding in the United States. J Hum Lact. 2005;21(3):284-288. 19. Centers for Disease Control and Prevention. HealthStyles survey—breastfeeding practices: 2007. http://www.cdc.gov/ breastfeeding/data/healthstyles_survey/survey_2007.htm#2007. Accessed January 28, 2013. 20. Li R, Rock VJ, Grummer-Strawn L. Changes in public attitudes toward breastfeeding in the United States, 1999-2003. J Am Diet Assoc. 2007;107(1):122-127. 21. Li R, Hsia J, Fridinger F, Hussain A, Benton-Davis S, GrummerStrawn L. Public beliefs about breastfeeding policies in various settings. J Am Diet Assoc. 2004;104(7):1162-1168. 22. Guttman N, Zimmerman DR. Low-income mothers’ views on breastfeeding. Soc Sci Med. 2000;50(10):1457-1473. 23. New York State Senate. NYC breastfeeding promotion leadership committee holds annual Breastfeeding Mothers’ Subway Caravan. http://www.nysenate.gov/news/nyc-breastfeeding-promotionleadership-committee-holds-annual-breastfeeding-mothers-subway-cara. Published July 30, 2008. Accessed January 13, 2014.
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Perception and Attitudes: Breastfeeding in Public in New York City Candace Mulready-Ward and Martine Hackett J Hum Lact 2014 30: 195 originally published online 10 March 2014 DOI: 10.1177/0890334414524988 The online version of this article can be found at: http://jhl.sagepub.com/content/30/2/195
Published by: http://www.sagepublications.com
Additional services and information for Journal of Human Lactation can be found at: Email Alerts: http://jhl.sagepub.com/cgi/alerts Subscriptions: http://jhl.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Apr 15, 2014 OnlineFirst Version of Record - Mar 10, 2014 What is This?
Downloaded from jhl.sagepub.com at University of North Carolina at Chapel Hill on November 7, 2014
524988
research-article2014
JHLXXX10.1177/0890334414524988Journal of Human LactationMulready-Ward and Hackett
Original Research
Perception and Attitudes: Breastfeeding in Public in New York City
Journal of Human Lactation 2014, Vol. 30(2) 195–200 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334414524988 jhl.sagepub.com
Candace Mulready-Ward, MPH1 and Martine Hackett, PhD, MPH2
Abstract Background: In the United States, 76.9% of women initiate breastfeeding but only 36.0% breastfeed exclusively for 3 months. Lack of support for public breastfeeding may prevent women from breastfeeding in public, which could contribute to low rates of breastfeeding exclusivity and continuation, despite high rates of breastfeeding initiation. Objective: This study aimed to determine whether residents of New York City, New York, were supportive of and comfortable with public breastfeeding. Methods: A population-based public opinion telephone survey of non-institutionalized New York City residents 18 years and older was conducted by the New York City Department of Health and Mental Hygiene. Results: Overall, 50.4% of respondents were not supportive of public breastfeeding. In the multivariable analysis, there was significant variation in support by race/ethnicity, age, and education. There were no significant differences in support by sex, receipt of food stamps, nativity, or the presence of children younger than 12 years in the home. One-third (33.2%) of respondents were uncomfortable with women breastfeeding near them in public. There was significant variation by education in the multivariable analysis. Lack of comfort was highest among those with a high school education or less (39.9%) and some college (33.8%). Conclusion: New York City residents are conflicted about whether breastfeeding is a private act or one that can be done in public. For women who want to continue with their intention to breastfeed exclusively, the negative opinion of other residents may cause them to breastfeed only in private, thereby limiting the opportunity to breastfeed for the recommended time. Keywords breastfeeding, breastfeeding attitudes, public opinion, public places, social norms
Well Established The most recent national data suggest that there is regional variation in support for breastfeeding in public and that at least onethird of Americans believe that women should breastfeed only in private.
Newly Expressed Half of New York City residents believe that women should breastfeed only in private. However, support for breastfeeding in public is higher among younger residents and those with a college education.
United States: social norms that are unsupportive of mothers breastfeeding their children in public. New York State was the first state to enact a law to protect a mother’s right to breastfeed in public nearly 2 decades ago.3 More recently, in 2011, the City of Seattle, Washington, elevated breastfeeding to a civil right, and it is now illegal for others to ask mothers not to nurse in public or any other location.4 Even with these and other laws across the country that protect the right of women to breastfeed in public,5 the attitudes of members of 1
New York City Department of Health and Mental Hygiene, Bureau of Maternal, Infant and Reproductive Health, Long Island City, NY, USA 2 Hofstra University, Hempstead, NY, USA
Background
Date submitted: August 14, 2013; Date accepted: January 16, 2014.
Recent protests over women being told by authorities to stop breastfeeding in public places like retail stores and restaurants and even on social media sites like Facebook1,2 have highlighted a key area for breastfeeding promotion in the
Corresponding Author: Candace Mulready-Ward, MPH, New York City Department of Health and Mental Hygiene, Bureau of Maternal, Infant and Reproductive Health, 42-09 28th Street, 10th Floor, Long Island City, NY 11101, USA. Email: [email protected]
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the public can serve as a barrier for women who wish to breastfeed their children without restriction. Despite dramatic increases in breastfeeding initiation in New York City, New York (NYC) over the past 30 years, from 33% in 19806 to 89% in 2011 (NYC Department of Health and Mental Hygiene [DOHMH], Pregnancy Risk Assessment Monitoring System, unpublished data, 2011), most women do not breastfeed exclusively for 6 months, as recommended by the American Academy of Pediatrics.7 Although NYC exceeds the Healthy People 2020 goal of 81.9% for breastfeeding initiation,8 early supplementation and early cessation of breastfeeding are the norm. Only 35% of NYC women are exclusively breastfeeding at 1 week postpartum, defined as the infant being fed only breast milk and no other solids or liquids, including water (NYC DOHMH, Pregnancy Risk Assessment Monitoring System, unpublished data, 2011). By 2 months postpartum, only 26% of NYC women are exclusively breastfeeding, and only 13.3% by 6 months postpartum,9 well below the Healthy People 2020 goals that 46.2% of infants be exclusively breastfed for at least 3 months and 25.5% for 6 months.8 In addition, among all women who initiate breastfeeding in NYC, 23% stop breastfeeding altogether within 2 months (NYC DOHMH, Pregnancy Risk Assessment Monitoring System, unpublished data, 2011). There are many reasons that breastfeeding women feed their infants formula or discontinue breastfeeding. Common reasons cited by breastfeeding mothers include difficulties with breastfeeding,10-12 concerns about the infant not gaining enough weight or being satisfied by breast milk alone,10,11 the influence of family members,12 and a desire to ensure that their infants receive the perceived benefits of formula.12 Perceived social norms surrounding breastfeeding in public are also associated with women’s breastfeeding behaviors.10,13-15 Nationally, 12% of US women report not wanting to breastfeed in public as a reason for stopping breastfeeding.10 In NYC, interviews with breastfeeding women in a low-income neighborhood in Brooklyn found that breastfeeding in public was unthinkable.14 In another study of pregnant women in NYC, 72% reported that they would be uncomfortable breastfeeding in public.11 In this same study, women who were comfortable with breastfeeding in social settings were more likely to intend to exclusively breastfeed,13 and intention is a strong predictor of breastfeeding behavior.16 The high breastfeeding initiation rate in NYC suggests that most women have positive beliefs about breastfeeding. We hypothesize that 1 reason for the rapid drop off in exclusive breastfeeding in the first few months postpartum is that social norms are not supportive of breastfeeding in public. New York City residents are constantly interacting with each other in public due to population density, widely available public transportation, and living in multiple unit dwellings. This makes socially accepted behavior about breastfeeding in public particularly important for women in NYC.
This study explores public attitudes toward breastfeeding in NYC based on responses to questions on a public opinion telephone survey.
Methods In 2011, a population-based public opinion telephone survey of NYC residents (n = 2075) was conducted by the NYC DOHMH. The survey was limited to non-institutionalized adults 18 and older. Respondents were identified by random digit dialing sampling of landlines (50% of sample, n = 1035) and cell phones (50% of sample, n = 1040). The data were weighted using the 2006-2008 American Community Survey estimates of the population of non-institutionalized adults age 18 and older living in NYC’s 5 boroughs. The response rate was 32% and the cooperation rate was 94%. The primary purpose of the survey was to gather baseline data on perceptions of obesity and consumption of sugarsweetened beverages and was funded through the Centers for Disease Control and Prevention’s Communities Putting Prevention to Work program. Two items on breastfeeding were included: (1) Mothers who breastfeed should do so in private places only, and (2) I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, and so on. Respondents stated their level of agreement on a 4-point Likert-type scale. The response options were strongly agree, somewhat agree, somewhat disagree, and strongly disagree. The questions were originally developed by the Centers for Disease Control and Prevention and were part of a series of questions on breastfeeding intended to provide baseline data for a national breastfeeding campaign.17 For the purpose of this analysis, responses were recoded to create 2 dichotomous outcome variables: support for public breastfeeding and comfort with public breastfeeding. Respondents with missing or don’t know responses on either breastfeeding question (n = 96) were excluded from this analysis, resulting in a final sample size of 1979 respondents. Analyses were conducted using Statistical Analysis Software (SAS version 9.2). Differences in each outcome, by demographic characteristics of respondents, were tested by chi-square statistic. Predictors of each outcome were tested using multivariable logistic regression analysis. The outcomes were lack of support for public breastfeeding and lack of comfort with public breastfeeding. The models were adjusted for demographic variables that were significant at the P < .05 level in the bivariate analyses. All numbers reported are based on unweighted data, and percentages, standard errors, adjusted odds ratios (AORs), and 95% confidence intervals (CIs) are based on weighted data. This study was approved by the NYC DOHMH Institutional Review Board, and all procedures followed were in accord with the ethical standards of the DOHMH Institutional Review Board.
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Mulready-Ward and Hackett Table 1. Demographic Characteristics of Sample (n = 1979), New York City, 2011.a Characteristic
No.
Sex Male 918 Female 1060 Children younger than 12 living in respondent’s home Yes 650 No 1326 Age, y 18-44 1049 45-64 614 65+ 296 Race/ethnicity Black non-Hispanic 447 White non-Hispanic 742 Asian non-Hispanic 171 Puerto Rican 173 Other Hispanic 344 Other race/mixed/unknown 101 Education High school or less 911 Some college 440 College graduate 611 Received food stamps past 12 months Yes 446 No 1509 Nativity Born in the US/Puerto Rico 1210 Born outside US 758
% 46.4 53.6 32.9 67.1 53.5 31.4 15.1 22.6 37.5 8.6 8.8 17.4 5.1 46.4 22.4 31.2 22.8 77.2 61.5 38.5
a
Number is based on unweighted data and percentage is based on weighted data. Totals for each characteristic may not equal overall sample size due to missing data.
Results More than half of the sample (53.6%) were women, and 53.5% were 18 to 44 years old. The race/ethnic distribution was 37.5% white non-Hispanic, 22.6% black non-Hispanic, 8.8% Puerto Rican, 17.4% other Hispanic, 8.6% Asian nonHispanic, and 5.1% of other, mixed, or unknown race. Less than half (46.4%) of the sample had a high school education or less. All demographic characteristics of the study population can be found in Table 1.
Support for Public Breastfeeding Overall, 50.4% of respondents were not supportive of public breastfeeding, agreeing with the statement that women should breastfeed in private only (Table 2). In bivariate analyses, there was significant variation in support for public breastfeeding by race/ethnicity, age, education, and the presence of children younger than 12 in the home. Lack of support was highest among respondents 65 years and older (63.8%), Asians (61.8%), and those with a high school education or
less (58.3%). There were no differences in support for public breastfeeding by sex, receipt of food stamps, or nativity. In the multivariable analysis, compared to white non-Hispanic respondents, Asians were significantly more likely (AOR = 1.63; 95% CI, 1.15-2.31) to be unsupportive of public breastfeeding, whereas both other Hispanics (AOR = 0.52; 95% CI, 0.39-0.70) and black non-Hispanics (AOR = 0.67; 95% CI, 0.52-0.86) were significantly less likely to be unsupportive of public breastfeeding (Table 3a). There was an inverse relationship between education and lack of support such that respondents with a high school education or less (AOR = 2.91; 95% CI, 2.30-3.68) and those with some college (AOR = 1.95; 95% CI, 1.50-2.52) were more likely to be unsupportive of public breastfeeding compared to college graduates. Adults age 65 and older were significantly more likely to be unsupportive of public breastfeeding (AOR = 1.55; 95% CI, 1.15-2.08) compared to 18- to 44-year-olds.
Comfort with Public Breastfeeding Only 33.2% of respondents were uncomfortable with women breastfeeding near them in public (Table 2). Lack of comfort was highest among respondents with a high school education or less (39.9%) and those age 65 and older (39.5%). There were no differences by race/ethnicity, sex, receipt of food stamps, nativity, or the presence of children younger than 12 years old in the home, in the bivariate analyses. In the multivariable analysis, only education was associated with being uncomfortable with public breastfeeding (Table 3b). Respondents with a high school education or less (AOR = 2.24; 95% CI, 1.78-2.83) and those with some college (AOR = 1.76; 95% CI, 1.34-2.31) were significantly more likely to be uncomfortable with public breastfeeding than were those with a college degree or more.
Discussion This study found that NYC residents are conflicted about whether breastfeeding is a private act or one that can be done in a public space. A majority of NYC residents felt comfortable when mothers breastfed near them in a public place. However, NYC residents were evenly divided over whether or not women who breastfeed should do so in private only. This lack of consistency between support for the idea of breastfeeding in public and an individual’s level of comfort with women breastfeeding near them has also been found in similar studies.18-21 National data from the 2007 HealthStyles Survey from which the NYC questions were taken also found that more respondents felt that women should breastfeed only in private (36%) than reported that they were uncomfortable with women breastfeeding near them in a public setting (31%).22 The difference between the 2 responses was greater in our study, and more respondents thought that women should breastfeed only in private in our study compared to nationally (50% vs 36%, respectively).22
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Table 2. Support and Comfort with Breastfeeding by Demographic Characteristics, New York City, 2011.a Not Supportive of Breastfeeding in Public
Not Comfortable with Women Breastfeeding in Public
% (SE)
% (SE)
50.4 (±1.11)
33.2 (±1.05)
50.6 (±1.63) 50.2 (±1.52)
34.0 (±1.55) 32.6 (±1.42)
46.3 (±1.95) 52.4 (±1.35)
31.8 (±1.81) 34.0 (±1.29)
48.2 (±1.53) 48.0 (±1.99) 63.8 (±2.75)
33.4 (±1.45) 30.3 (±1.83) 39.5 (±2.81)
47.5 (±2.35) 51.1 (±1.82) 61.8 (±3.64) 55.7 (±3.75) 43.3 (±2.65) 53.2 (±4.78)
33.3 (±2.21) 32.7 (±1.70) 39.3 (±3.71) 33.7 (±3.60) 30.5 (±2.47) 34.3 (±4.62)
58.3 (±1.61) 50.8 (±2.37) 38.1 (±1.95)
39.9 (±1.61) 33.8 (±2.23) 22.7 (±1.68)
53.2 (±2.34) 49.5 (±1.27)
35.7 (±2.24) 32.6 (±1.19)
51.8 (±1.43) 48.1 (±1.79)
33.4 (±1.34) 33.0 (±1.70)
Characteristic Overall Sex Male Female Children younger than 12 living in respondent’s homeb Yes No Age, yb,c 18-44 45-64 65+ Race/ethnicityb Black non-Hispanic White non-Hispanic Asian non-Hispanic Puerto Rican Other Hispanic Other race/mixed/unknown Educationb,c High school or less Some college College graduate Received food stamps past 12 months Yes No Nativity Born in the US/Puerto Rico Born outside US
Abbreviation: SE, standard error. a Percentages and standard errors are based on weighted data. b Differences in support for breastfeeding in public are significant at P < .05 level. c Differences in comfort with women breastfeeding in public are significant at P < .05 level.
This study also provides baseline data for NYC on public attitudes toward breastfeeding. Its strengths are that it adds to the existing literature on social acceptability of public breastfeeding by identifying groups least likely to be supportive of breastfeeding in NYC, including adults older than 65, individuals without a college education, and Asians. The limitations of this study include not directly testing the association between women’s beliefs about the acceptability of breastfeeding in public and how likely women were to breastfeed in public, controlling for public opinion about breastfeeding in public. Therefore, it could not answer the question of whether lack of consensus on whether breastfeeding in public is acceptable contributes to the high discontinuation rates for individual women. It also did not explore the reasons that people disapprove of breastfeeding in public. Greater overall support for breastfeeding in public among younger cohorts than among those 65 and older suggests that
the norms may have changed over the course of several generations and that public spaces where younger people gather, such as parks and playgrounds, could provide more supportive environments for breastfeeding mothers. Efforts to increase support for breastfeeding in public should focus on individuals older than 65, in addition to Asians, and those without a college degree. One way to change norms about breastfeeding in public is to enact laws that protect a woman’s right to breastfeed in public. New York City residents have that right under New York State law. However, as in other locations, incidents arise that challenge these rights and illustrate that laws alone are not enough. For example, in 2004, a NYC mother was harassed by police and given a ticket to appear in court for a misdemeanor for breastfeeding her infant on a public commuter train, referred to in NYC as the subway. In response, the NYC Breastfeeding Promotion Leadership Committee, a
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Mulready-Ward and Hackett Table 3a. Logistic Regression Model Predicting Lack of Support for Public Breastfeeding among New York City Residents, 2011. Characteristic
AOR
Race/ethnicity Other Hispanic 0.52 Asian, non-Hispanic 1.63 Puerto Rican 0.80 Black non-Hispanic 0.67 Other/mixed/unknown race 1.01 White non-Hispanic (referent) 1.00 Education High school or less 2.91 Some college 1.95 College graduate or more (referent) 1.00 Children younger than 12 living in respondent’s home No 1.20 Yes (referent) 1.00 Age, y 18-44 (referent) 1.00 45-64 0.94 65+ 1.55
95% CI 0.39-0.70 1.15-2.31 0.56-1.15 0.52-0.86 0.65-1.57 2.30-3.68 1.50-2.52 0.97-1.48 0.76-1.17 1.15-2.08
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
Table 3b. Logistic Regression Model Predicting Lack of Comfort with Public Breastfeeding among New York City Residents, 2011. Characteristic Education High school or less Some college College graduate or more (referent) Age, y 18-44 (referent) 45-64 65+
AOR
95% CI
2.24 1.76 1.00
1.78-2.83 1.34-2.31
1.00 0.87 1.24
0.70-1.08 0.95-1.62
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.
group of public and private breastfeeding advocates, organized an annual Subway Caravan in which mothers and breastfeeding advocates travel by subway together throughout NYC while breastfeeding their infants to increase awareness about their rights.23 The NYC Subway Caravan and other grassroots efforts such as public gatherings of breastfeeding mothers may increase acceptability of breastfeeding in public by increasing awareness of this issue. One way to target groups that are unsupportive of public breastfeeding is through public awareness campaigns. In 2012, the DOHMH ran a small public awareness campaign that included posters on the subway and in hospitals that showed the benefits of breast milk. The campaign was part of the larger Latch on NYC initiative, a voluntary hospital-based initiative to increase support for breastfeeding at maternity hospitals by asking hospitals to discontinue formula supplementation
of breastfed infants unless medically necessary or requested by the mother, and to limit the promotion of infant formula in the hospital. Results from an evaluation of the public awareness campaign showed that 33% of individuals who saw the public awareness campaign felt more supportive of public breastfeeding after seeing the campaign (Global Strategy Group, unpublished data, 2012). Despite high rates of breastfeeding initiation in NYC, which suggest that mothers view breast milk as the preferred food for infants, meeting the recommended duration for breastfeeding is a challenge for many new mothers. For women who want to continue exclusive breastfeeding, the negative opinion of their fellow NYC residents may influence their decisions to breastfeed only in private, thereby limiting the opportunity to continue with breastfeeding for the recommended time. Improving the acceptance of breastfeeding in public may help to support women’s breastfeeding intentions and behaviors. Furthermore, providing women with the skills and abilities to combat negative attitudes toward breastfeeding in public may strengthen their intention to increase duration in spite of ambivalent public opinion.
Conclusion This study identified the attitudes of NYC residents about mothers breastfeeding their children in public places. Nationally, attitudes are moving toward more support of public breastfeeding, and this study found that young NYC residents were more likely to support public breastfeeding than were older residents. However, we also identified that half of NYC residents were not supportive of public breastfeeding. In an urban area like NYC, with great diversity by immigration status, education, and income, there is a potential for increased acceptance of breastfeeding in public over time as approval from younger residents becomes more influential. Changing local laws to establish breastfeeding in public as a civil right for all may help to establish breastfeeding as the norm in other locations. Future research is needed to address the reasons for discomfort and disapproval, as well as to address the relationship between perceived public support and actual breastfeeding and exclusive breastfeeding duration. In addition, more in-depth research is needed on how to improve public attitudes about breastfeeding in public and create a national strategy to improve the rate of exclusive breastfeeding. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported in part by a cooperative agreement from the Centers for Disease Control and Prevention’s Communities Putting
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Prevention to Work program (1U58DP002418-01 & 3U58DP002418-01S1). The findings and conclusions are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
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