Breastfeeding rates in 1988 were very much lower than this at discharge from the birth site: 54% for white mothers, 32% for low-income mothers, 25% for black mothers, and 51% for Hispanic mothers.2 Rates for migrant Hispanic mothers appear to be lower than those for nonmigrants.3

When breastfeeding is not desired or not possible, modern infant formulas are an acceptable alternative if they are prepared and fed properly. The committee strongly endorses breastfeeding. It also believes that each woman should be able to make an informed decision about which feeding method will be most acceptable for her situation and to receive nutrition services appropriate to that choice. For example, the woman who decides to feed her baby formula may need to be taught how to reconstitute it. The committee supports a patient-centered plan of care to promote appropriate infant feeding.

Planning for the Support of the Breastfeeding Woman

Nutritional care of the breastfed infant mainly involves breastfeeding support for the mother. Most women make decisions about how to feed their infant before or during pregnancy.4,5 A small randomized study demonstrated that prenatal breastfeeding education was associated with higher rates of breastfeeding by low-income African-American women than by their counterparts in a control group.6 Thus, information to support the decision to breastfeed should be provided preconceptionally and prenatally, and methods to convey the information need to consider outside influences on decision making.7 Women may benefit from practical information about how to breastfeed offered during prenatal visits or classes as well as in the immediate postpartum period.

The logical times for health care providers to provide direct assistance to and support for the breastfeeding mother are when she first initiates feedings and when her milk ''comes in.'' Advice and support are also needed for mothers who encounter difficulties or have concerns in the following weeks or months. Hospitals should implement standard practices that facilitate the initiation of breastfeeding (such as those described by Strembel and colleagues,8 Winikoff and others,9 and the World Health Organization)10 , and primary care providers need to offer additional services after discharge. (See also Spisak and Gross.11)

During their hospitalization, women who deliver vaginally usually have only a short period to acquire breastfeeding skills and to ask questions. In 1990, the mean duration of hospitalization for these women, including time spent in labor, was 2.4 days (E. Graves, National Center for Health Statistics, personal communication, 1991); many women are discharged



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