Health Disparities

HD: Effectiveness of Nutrition Intervention Methods (2010)


Cropley L, Herwehe JC. Evaluation of institutional support for breastfeeding among low-income women in the metropolitan New Orleans area. J Am Diet Assoc. 2002 Jan; 102(1): 94-96.

PubMed ID: 11794510
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To explore  institutional support for breastfeeding among low-income women in the metropolitan New Orleans area.

Inclusion Criteria:

Hospitals in the New Orleans area that provided obstetrical services.

Exclusion Criteria:

Hospitals in the New Orleans are that did not provide obstetrical services. 

Description of Study Protocol:


The ten hospitals that offered maternity services and care for newborns in the metropolitan New Orleans area were asked by phone to complete the study questionnaire. Key participants were lactation consultants of head nurses in obstetrics departments of the hospitals, who identified through the use of hospital directories and a list provided by the Louisiana Lactation Consultants Association. 


  • After verbal consent to participate in the study, the self-administered questionnaire was hand delivered  
  • Questionnaire adapted from the WHO/UNICEF Checklist for Evaluating the Adequacy of Support for Breast Feeding in Maternity Hospitals, Wards and Clinics. Information was collected on:
    • Breastfeeding policies
    • Staff training
    • Health education
    • Discharge procedures
    • Delivering mothers' demographics
    • It also allowed respondents to provide their views on breastfeeding barriers and key elements of successful promotion efforts.

Statistical Analysis

  • SPSS 9.0 for Windows, 1999, Chicago, IL was used for Spearman's correlation coefficients  and a partial correlation 
  • Because this study used aggregate hospital data, the researchers could not control for income or site of delivery to isolate specific effects of hospital policy.


Data Collection Summary:

Latent Variables

  • Breastfeeding policies
  • Staff training
  • Health education
  • Discharge procedures 
  • Delivering mother's demographics.
Description of Actual Data Sample:

Initial N

10 hospitals were asked to participate.

Attrition (Final N)

  • Nine hospitals participated
  • One hospital was excluded from the analysis because of missing data on patient ethnicity.


New Orleans, Louisiana.


Summary of Results:

General Information

  • Responding hospitals reported deliveries ranging between 400 to 2,000 births per year, with an average of 1,122 births per year
  • The percentage of low-income patients who were recipients of Medicaid or Special Supplemental Nutrition Program for Women, Infants and Children, or by income level, ranged from 6% to 90%, with an average of 47%. 

Breastfeeding Rates

  • The percentage of women who initiated breastfeeding after delivery ranged from 20% to 75%. Only one facility met the Healthy People 2010 objective of 75% of mothers who breastfeed their babies in the early post-partum period.
  • A negative correlation was found between breastfeeding rates and income level (P<0.01). The negative association maintained significance when a partial correlation between rates of breastfeeding and income level, controlling for African American ethnicity, was performed (P<0.05).
  • A negative correlation  was also found between African American ethnicity and breast feeding (P=0.08). 


  • The majority (N=6) of facilities had explicit policies for promoting and supporting breastfeeding
  • Almost all facilities (N=8) provided specialized training in lactation management to staff members
  • Most facilities (N=7) had at least one designated staff member, either lactation consultant or nurse with specialized training in lactation management, available full-time to advise mothers.


  • Eight facilities had policies allowing babies to stay in the rooms with their mothers. The respondent at the facility lacking such a policy reported, "Babies in room anyway."
  • Seven facilities allowed mothers to have their babies with them in their beds. One respondent from a facility where mothers were not allowed to have their babies with them reported, "They did it anyhow."
  • Eight facilities have policies to restrict an infant's feeding before the establishment of breastfeeding; staff interpretation of this policy at three different facilities resulted in food and drink being given to the newborns
  • Only five respondents reported that data are collected on the prevalence of breastfeeding initiation and breastfeeding at the time of discharge. Even fewer reported a system in place for assessing effectiveness of health care practices and educational materials specific to breastfeeding. 

Health and Education

  • All respondents reported that breastfeeding education covered lactation physiology, how to maintain lactation, prevention and management of common problems and sources of support for problems post-discharge
  • Eight respondents reported that expectant mothers were usually advised about nutritional requirements during pregnancy and lactation and on dangers associated with substance abuse and breastfeeding
  • All reported that support and counseling on initiation and maintenance of breastfeeding were routinely provided for women who experienced a cesarean or premature birth, delivered a low birth weight infant or had an infant in a special care unit
  • All reported that breastfeeding mothers were provided with printed educational materials. It was unknown if the education sessions or the print materials were relevant and appropriate to the target population.

Discharge Procedures 

  • Six facilities had a specific policy to give breastfeeding mothers special discharge packs 
  • Where facilities provided "discharge packs" containing formula, bottles, nipples and pacifiers, two respondents reported that anything unrelated to breastfeeding was removed and that packs were "not routinely" distributed to breastfeeding mothers
  • Six facilities provided breast pump rental on a sliding scale fee.
Author Conclusion:

Hospital facilities need to evaluate existing breastfeeding policies for consistency of interpretation and implementation. Furthermore, if no policy exists, one needs to be created.

Funding Source:
University/Hospital: University of New Orleans, La
Reviewer Comments:

I feel this would have been a stronger study if it was conducted as a chart review as opposed to a survey completed by one person representing the entire department.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? No
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? ???
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? N/A
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? Yes
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? N/A
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? No
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? No
  10.2. Was the study free from apparent conflict of interest? Yes