Infant Feeding Core Indicator

Proportion of women who intend to exclusively breastfeed per the number of women who give birth
Proportion of infants fed breast milk only / combination breast milk and substitute / breast milk substitute at hospital or Midwifery Practice Group (MPG) per the number of live births

Report an Issue Appendices

Method of Calculation

Intention to Exclusively Breastfeed

Number of women with intention to exclusively breastfeed

100

Total number of women who gave birth (live or still)

100

Infant Feeding at Entry to Public Health Service

Number of infants being fed breast milk proportion* in hospital or MPG

100

Number of live births

* Breast milk proportions = {breast milk only; combination breast milk and substitute;
breast milk substitute (formula and other)}

100

Recommended Subset Analysis Categories

Geographic Areas of Patient Residence

Ontario
Public Health Unit
Dissemination Area

Data Sources

Numerator & Denominator	Alternative Data Sources
BORN Information System Original Source: Better Outcomes Registry Network (BORN) Ontario Distributed by: Better Outcomes Registry Network (BORN) Ontario Suggested Citation: BORN Information System [years], Date Extracted: [date].	None

Data Elements in the BORN Information System (BIS)

Name and Description	Categories	Encounter	BORN ID
Intention to Breastfeed Identifies whether the mother intends to breasfeed her infant. Self-reported during pregnancy or at time of birth.	Yes, intends to exclusively breastfeed Yes, intends to combination feed (use breast milk and breast milk substitute) No, does not intend to breastfeed Mother Unsure Unknown, intent not collected	Birth (Mother) Labour Antenatal General	M0047
Newborn Feeding from Birth to Discharge from Hospital or Birth Centre The type of feeding given to the newborn at time of discharge from hospital.	Breast milk only Combination of breast milk and breast milk substitute Breast milk substitute - Formula only Breast milk substitute - Other None Unknown	Postpartum (Child)	N0044

QUESTION FOR THE SUBGROUP: Should this second table be listed under "Recommended Subset Analysis Categories" instead of here???

Dimension	Categories
Maternal Age Group	<20 20-24 25-29 30-34 35-39 40-44 >=45
Parity	1 2 3-4 >=5 Missing Data
Newborn DOB Calendar	2013 2014 etc.

Analysis Checklist

If Using the Public Health Standard Reports

Please follow the general analysis checklist for the BORN Information System data source.
In the Public Health Standard Reports, comparator data for Ontario or Peer Group is only available for six months prior to the date of extraction. Public Health Units are categorized into Peer Groups as per the 2011 classifications.
For Intention to Exclusively Breastfeed:

Select the PHU-Pregnancy report under Clinical Reports
the dates/years of analysis
Go to the link for 'Distribution of intention to breastfeed, by public health unit and province'
Calculate the percentages from the standard report or export the table to Excel

For Infant Feeding at Entry to Public Health Service:

Select the PHU-Newborn report under Clinical Reports
Specify the dates/years of analysis
Go to the link for ‘Distribution of infant feeding from birth to discharge from hospital or birth centre'
Calculate the percentages from the standard report or export the table to Excel

If Using the Public Health Cube

Please follow the general analysis checklist for the BORN Information System data source.
For Intention to Exclusively Breastfeed:

Select Dimension > Pregnancy > Feeding > Intention to Breastfeed
Select Measures > Pregnancy > # of Pregnancies – Women Who Gave Birth
Add filters to the tables and specify by right clicking on each of the following dimensions and selecting the following categories:
Maternal Age Group (found under Pregnancy > Maternal Characteristics) = <20, 20-24, 25-29, 30-34, 35-39, 40-44, ≥45
Newborn DOB Calendar (found under Newborn DOB > Newborn DOB Calendar) = Deselect 2012 (and others as appropriate for your analysis)
Parity (found under Dimensions > Pregnancy > Pregnancy History > Parity) = Parity 1, Parity 2, Parity 3-4, Parity ≥ 5
Calculate percentages within the Cube or export to Excel

For Infant Feeding at Entry to Public Health Service:

Select Dimension > Newborn > Feeding > Feeding at Hospital or MPG
Select Measures > Birth > # of Births – Live Births
Add filters to the tables and specify by right clicking on each of the following dimensions and selecting the following categories:
Maternal Age Group (found under Pregnancy > Maternal Characteristics) = <20, 20-24, 25-29, 30-34, 35-39, 40-44, ≥45
Newborn DOB Calendar (found under Newborn DOB > Newborn DOB Calendar) = Deselect 2012 (and others as appropriate for your analysis)
Parity (found under Dimensions > Pregnancy > Pregnancy History > Parity) = Parity 1, Parity 2, Parity 3-4, Parity ≥ 5
Calculate percentages within the Cube or export to Excel

Indicator Comments

Influencing Factors and Benefits of Breastfeeding

Breastfeeding has a number of well-documented short and long-term health benefits for both babies and mothers1,2. It is known to reduce the risk of sudden infant death syndrome and gastrointestinal, ear and respiratory infections throughout childhood1. Breastfeeding infants is also associated with lower levels of diabetes and obesity later in life3.
Exclusive breastfeeding of infants until 6 months of age is recommended by the World Health Organization (WHO)4. Exclusive breastfeeding is defined as no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive oral rehydration solution, drops and syrups (vitamins, minerals and medicines).
In recent years, there has been increased public health attention directed towards increasing rates of exclusive breastfeeding as part of the WHO Baby-Friendly Initiative5. As such, public health practitioners have a unique and important role in promoting and supporting breastfeeding.
There are many factors known to influence breastfeeding rates including: age, income, education, living with a partner, previous pregnancies, home delivery, attitudes and comfort with breastfeeding, hospital practices, social network and return to work / school6. Data on these factors are also available in the BORN database, although there may be high rates of missing information.

Dimension Choices

The 'Infant Feeding at Entry to Public Health Service' indicator is measured using the dimension 'Feeding at hospital or MPG'. The ‘Feeding at hospital or MPG’ dimension was chosen as opposed to 'Feeding at discharge' due to inconsistencies in time of discharge between hospitals and Midwifery Practice Groups (MPGs). In hospitals, discharge can be within a few days after birth but in MPGs it is measured when the MPG discharges the infant from their care, which is usually 6 weeks after birth. This results in high levels of missing information for the 'Feeding at discharge' dimension among infants born in MPGs. As such, the use of the 'Feeding at hospital or MPG' approximates infant feeding at entry to public health service in the best possible current method, given the data quality issues of the variable 'Feeding at discharge'.
The 'Infant Feeding at Entry to Public Health Service' indicator uses the '# of births – Live' measure for the denominator data (as opposed to '# of births - discharged home or home births') to ensure consistency between populations drawn for the numerator and denominator. More specifically, infants who are discharged to the neonatal intensive care unit or to another hospital would be captured in the 'Feeding at hospital or MPG' but excluded from the '# of births - discharged home or home births'. However, the LDCP Infant Feeding Surveillance Pilot Study (7) and the BORN Standard Report available through the BIS use the '# of births - discharged home or home births' as the denominator for their infant feeding indicator. As of 2016, BORN is currently addressing this issue and changes may be made in future data collection.

Data Changes over Time

Data are available from April 1st, 2012 to present. BORN in their reports use a waiting period of 6 months to give hospitals and MPGs the opportunity to verify data before reporting. A recent report by Public Health Ontario found that the time to 99% completeness for BORN data ranges by public health unit and can be up to 15 months8. For more information on the lag time by public health unit, please refer to Table 4 (page 20-21).
Prior to April 2014, the indicator for 'intention to exclusively breastfeed' did not distinguish between intention to exclusively breastfeed and intention to breastfeed in combination with breast milk substitute. If data from before April 2014 is being used, the indicator can be adapted to 'intention to breastfeed (exclusively or in combination)' by combining mothers who intended to exclusively or combination-feed in the more recent data.
As of Fall 2014, there were three level 3 NICUs that had not yet started submitting data to BORN (i.e. Mount Sinai, London Health Sciences, and Sunnybrook). As such, for some public health units, there are large proportion of missing information. This error is currently being worked on and data from January 2016 onwards are expected to be more complete.

Handling Missing Values and Small Cell Counts

For any indicator, if missing is less than 5%, individuals with missing values should be excluded. If missing is 5-30%, individuals with missing values should be included as their own category. If missing is more than 30%, the indicator should not be reported
Some cells may have very small counts, especially when obtaining data by dissemination area. Data can be rolled up into neighbourhood level or multiple years can be combined to address small cell counts that threaten confidentiality.

References

Cited References

Horta, B.L. et al. (2007) Evidence on the long-term effects of breastfeeding. Geneva: World Health Organization.
Office of the Surgeon General, Centers for Disease Control and Prevention & Office on Women's Health (2011). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US). Available from: http://www.ncbi.nlm.nih.gov/books/NBK52687/.
Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2006). Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. The American Journal of Clinical Nutrition, 84(5), 1043-1054.
WHO. (2016). The WHO's infant feeding recommendation. The World Health Organization. Retrieved 26 January 2016, from http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/.
Pound, C. M., Unger, S. L., Section, H. P., & Nutrition and Gastroenterology Committee. (2012). The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding. Paediatrics & Child Health, 17(6), 317.

Ontario Public Health Association (2007). Breastfeeding Position Paper. Ontario: OPHA Breastfeeding Workgroup.
Haile R., Procter TD., Alton GD. et al. on behalf of LDCP Breastfeeding Surveillance Project Team. (2015). Infant Feeding Surveillance Pilot Study: Final Report and Recommendations. Woodstock, Ontario: LDCP Breastfeeding Surveillance Project Team.
Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2016). BORN Information System: Data quality assessment for public health monitoring. Toronto: Queen's Printer for Ontario.

Acknowledgements

Lead Authors

Kandace Ryckman, Toronto Public Health

Core Indicators Reviewers

Sarah Collier, Toronto Public Health

Sandy Dupuis, Niagara Region Public Heath

Denis Heng, York Region Public Health

Andrew Lam, Peel Public Health

Adam Stevens, Brant County Health Unit

Jordan Robson, Algoma Public Health

Fangli Xie, Durham Public Health

Contributing Authors

Amira Ali, Ottawa Public Health

Reproductive Health Sub-Group

External Reviewers

Paula Morrison, BORN

Revision History

This Core Indicator Product webpage is maintained by the Reproductive Health Subgroup.

Date	Review Type	Author	Changes	PDF
June 2016	New Indicator	Reproductive Health Sub-Group	New Indicator
December 2016	Ad-hoc Review	Kandace Ryckman	Incorporating reviewer comments Updating format
September 14, 2019	Website Update: No Content Review	Caitlyn Paget, on behalf of the CIWG	No changes made to indicator definitions. Migrated to new website structure and format, including: Reorganized content to provide high-level information at a glance, and move in-depth analytic information into dedicated sections for users to access when needed. Renamed "Basic Categories" section to "Recommended Subset Analysis Categories"; "Definitions" renamed to "Glossary". Replaced both "Cross-References to Other Indicators" and "OPHS" sections with "Related OPHS Topics" to crosslink with relevant Core Indicators webpages including OPHS program standard(s) and associated indicator(s). Added descriptive sub-headings to the Analysis Checklist and Indicator Comments sections. Removed "Corresponding Health Indicator(s) from Statistics Canada and CIHI" and "from Other Sources" sections. Updated Revision History table, and added PDF copy of previous version for reference.

APHEO's Core Indicators Project has been developed through collaboration across the field of public health in Ontario,

to provide standardized methodology for population health assessment, to measure complex concepts of individual and community health.

Please contact core.indicators@apheo.ca for further information.

Infant Feeding (DRAFT)