What the Numbers Say: Birth, Breastfeeding, and Family in America

By Tiffaney Isaacson
Issue 111, March/April 2002

Note: All data are for the US , unless otherwise specified.

Health Insurance/Expenditures

National health expenditures(1)
1998: $1,149.1 billion
1992: $ 838.5 billion

Percent of Gross National Product (GNP) spent on health care
1998: 13.4
1992: 12
1965: 6

Percent of GNP spent on health care by other countries, 1998
Germany: 10.6
Japan: 7.6
UK: 6.7

Total expenditure on health, per capita(2)
$4,178

Country with next closest spending on health, per capita
Switzerland, $2,749

Amount by which 1998 US healthcare expenditures per capita exceeded those of
Germany: 42%
Japan: 56%
UK: 65%

Percent of women without health insurance in 1999(3)
14.6 (20.5 million women)

Percent of children without health insurance in 1999
13.9 (10 million children)

State with the highest percent of uninsured people in 1999
Texas (23.3%)

State with the lowest percent of uninsured people in 1999
Minnesota (8%)

Chance that an uninsured newborn will suffer an adverse hospital outcome, compared to privately insured newborns(4)
130%

Infant mortality rate (deaths per 1,000 live births)(5)
7.2 (1998)

Infant mortality ranking internationally(6)
26

Disability Adjusted Life Expectancy (DALE) (years expected to be lived in “full health”)(7)
US citizens
overall: 70 years
women: 72.6 years
US ranking: 24
Top three ranked countries:
Japan (overall 74.5 years)
Australia (overall 73.2 years)
France (overall 73.1 years)

Prenatal Care

Reduction in preterm births among high-risk patients who participated in a prenatal care program, including education, more frequent visits, and greater provider attention(8)
19%

Among high-risk patients in the same prenatal care program, compared to nonparticipants
preterm birthrate: 7.4 vs. 9.1%
rate of LBW (low birthweight) babies born: 5.8 vs. 6.4%
preterm labor episodes successfully stopped: 11.4 vs. 6.6%
average preterm labor inpatient cost: $435 vs. $566
average newborn inpatient cost for infants: $3,146 vs. $5,342
Net savings per high-risk prenatal care patient in this program: $1,768

Result of a mother not receiving prenatal care:(9)
increased likelihood of a LBW delivery: 400%
increased likelihood of a preterm delivery: 700%
increased cost of long-term postnatal care for one neonate: $3,247
Cost of prenatal care for one mother: $702
For every dollar cut from prenatal care, amount of increase in the cost of long-term postnatal care: $4.63

*Total healthcare cost savings obtainable by providing prenatal care to all high-risk patients
$62 million per year

Low Birthweight
Number of LBW babies born annually(10)
298,208 (7.5%)
Proportion of infants who did not survive the first year who were: (1997 statistics)(11)
very LBW (1500 grams or less): 51%
moderately LBW (1,500 to 2,499 grams): 14%

Number of infant deaths (under 1 year) attributed to disorders relating to short gestation and unspecified low birthweight(12)
4,101 (14.5% of total deaths, number two cause of death among this age group)
Number of neonatal deaths (under 28 days) attributed to disorders relating to short gestation and unspecified low birthweight
4,050 (21.4% of total deaths, number two cause of death among this age group)

Average cost of first year of medical care for a surviving infant, by birthweight(13)
under 750 grams: $273,900
750-999 grams: $138,800
1000-1249 grams: $75,100
1250-1499 grams: $58,000

Cost savings available in the first year of care from increasing birthweight of a LBW infant
by 250 grams: $12-$16,000
by 500 grams: $28,000

Cost savings for an infant of normal rather than LBW
$59,700 over the first year of care

Percent of women who have(14)
intensive prenatal care: 31
adequate prenatal care: 43.3
intermediate prenatal care: 13.8
inadequate prenatal care: 11.9

Percent of birth-related neurologic handicaps associated with preterm birth(15)
50
Percent of handicapping conditions associated with preterm birth
30

Medical costs of birth defects in the US(16)
$2,104,419,000

Average differences in standardized cognitive score for LBW compared with middle birthweight(17)
at age 8: .25 points lower
at age 11: .21 points lower
at age 15: .24 points lower

*Healthcare cost savings obtainable from reducing LBW deliveries by providing prenatal care
$167 million per year

Midwifery

Percent of US births attended principally by midwives(18)
1998: 7.4
1992: 4

Percent of New Zealand births attended principally by midwives
2000: 70

Cesarean section rate for certified nurse-midwives (CNM) who attended hospital births(19)
11.6%
Overall US cesarean rate for the same period
23.3%
Vaginal Birth after Cesarean (VBAC) rate with CNMs
68.9%
Overall US VBAC rate for the same period
24.9%
Percent of states in which the practice of nurse-midwifery is expressly permitted by legislation
100
Percent of CNM practices that have excess capacity and could increase the number of midwife-attended births without adding new staff
63
Percent of CNM practices reporting that their practice of nurse-midwifery was restricted in some way
64
Services offered during labor to CNM patients vs. non-CNM patients
oral fluids: 94.5 vs. 55.8%
room to ambulate: 97.8 vs. 76.4%
friends, in addition to partner, in attendance: 98.8 vs. 85.6%
use of shower, bath, or hot tub: 93.5 vs. 53.9%
encouragement of alternative delivery positions: 96.9 vs. 27.9%
use of intermittent, rather than continuous, fetal monitoring: 94.4 vs. 34.9%
breastfeeding on demand 99.5 vs. 92.2%

When using a CNM, chances of experiencing(20)
infant death: 19% lower
neonatal mortality: 33% lower
low birthweight infant: 31% lower

Percent of female obstetricians who would choose an elective cesarean section rather than any other mode of delivery (for an uncomplicated, singleton pregnancy with a cephalic presentation and no obstetric problems)(21)
31
Percent of female midwives who would choose an elective cesarean section rather than any other mode of delivery (under the same circumstances)
5

Median duration of labor for women who received active management of labor with one-to-one care by a CNM(22)
6.2 hours
Duration for those who did not
8.9 hours
Median rate of maternal fever for women who received active management of labor with one-to-one care by a CNM
7%
Rate for those who did not
11%

For patients who received continuous support from a doula, compared to patients who did not, difference in(23)
duration of labor: 1.64 hours less
need for any analgesia: 36% less
need for any oxytocin: 71% less
need for the use of forceps: 57% less
need for cesarean section: 51% less

Among patients under the continuous care of a midwife (compared to intermittent care of both a midwife and a physician), difference in(24)
likelihood of being admitted antenatally to a hospital
21% lower
likelihood of attending antenatal education programs
42% greater
likelihood of infant requiring resuscitation
44% lower
likelihood of receiving an episiotomy
25% lower

Difference in cost of a midwife-attended delivery(25)
12.2% lower

*Healthcare cost savings obtainable by utilizing midwifery care for 75% of pregnancies in the US
$85 billion per year

Electronic Fetal Monitoring

Most prevalent obstetric procedure was electronic fetal monitoring reported for nearly 3.3 million births, or 84% of all live births(26)

Association found between highest or lowest fetal heart rate recorded and risk of cerebral palsy(27)
None

False positive rate for multiple late decelerations in fetal heartbeat (indicating risk of cerebral palsy and often resulting in an emergency cesarean section)
99.8%

Percent of children who did not have abnormalities on fetal monitoring and were diagnosed with cerebral palsy
73

Percent of children with abnormalities on fetal monitoring who were delivered via cesarean section and were still diagnosed with cerebral palsy
48

Percent of children with abnormalities on fetal monitoring, who were delivered via cesarean section, and were not diagnosed with cerebral palsy
36

Significant differences observed in one-minute apgar (evaluation of an infant’s physical condition, on a 0 to 10 scale) scores below 4 among infants who received continuous electronic fetal monitoring(28)
none

Increase in risk of cesarean sections associated with the use of electronic fetal monitoring
41%

Cesarean Sections
Rate of cesarean delivery(29)
1998: 21.2%
1992: 25%
1965: 5%

VBAC rate
1998: 26.3%
1992: 91%

Cesarean rates by state
highest: Mississippi, 27%
lowest: Alaska, 14.7%

Cesarean rate recommended by WHO
12%

Number of cesarean sections performed annually(30)
835,609 (1998)

Risk of rehospitalization (within 60 days of delivery) among women who delivered by cesarean section for(31)
uterine infection: 100%
gallbladder disease: 50%
genitourinary tract conditions: 50%
cardiopulmonary and conditions: 140%
thromboembolic conditions: 150%
appendicitis: 80%

Overall postpartum rehospitalization risk among women with cesarean delivery
80%

Cesarean section rate(32)
patients in a clinic staffed by CNMs
13.1%
patients of private-practice obstetricians in the same community
26.4%

Percent of women delivered by emergency cesarean section who viewed their delivery as a traumatic event(33)
76

Percent of women delivered by emergency cesarean section who had various forms of posttraumatic stress reactions one to two months postpartum
52

Among women who had delivered previously by cesarean section(34) risk of ectopic pregnancy
28% greater
risk of an abruptio placentae (in multiparous patients)
320.5% greater
risk of placenta previa
356% greater

Percent of women found to have “white coat hypertension” (presence of hyptertension in a doctor’s office and lower 24-hour, daytime, and nighttime blood pressure)(35)
29.2

Proportion of women diagnosed with white coat hypertension who delivered by cesarean section, compared to women in the normal group
45.2 vs. 12.4%
who received drug treatment for their condition
66%
who received nifedipine for their condition (which may depress uterine ability to contract)
38%
who received nifedipine for their condition and underwent cesarean sections because of unproductive labor due to uterine inertia
37.5%

Difference in cost for cesarean compared to a vaginal delivery(36)
$1,549 more

*Healthcare cost savings obtainable by reducing US cesarean rate to WHO recommended rate
$561 million per year

Breastfeeding

Average age of weaning worldwide in 1992 (see “Mothering Perinatal Healthcare Index,” Mothering no. 68, Fall 1993)
4.2 years

WHO recommendation for age of weaning
2 years

Percent of breastfed infants in US(37)
at birth: 67
at 6 months: 31
at 12 months: 17
at 2 years: less than 5

Number of acute ear infections (under age 5)(38)
11 million (1996)

Among breastfed infants compared to formula-fed infants, incidence of(39)
otitis media: 19% lower
prolonged episodes of otitis media (more than ten days): 80% lower
diarrheal illness: 50% lower
duration of episodes of otitis media: 5.9 vs. 8.8 days

Rate of recurrent otitis media in infants exclusively breastfed(40)
for 6 months or more: 10%
for less than 4 months: 20.5%

Number of Americans under 45 with asthma(41)
10.5 million (1996)

Number of deaths from asthma in 1998
5,438

Increase in risk of asthma diagnosed by a doctor at age 6 when a child is introduced to milk other than breastmilk before 4 months of age(42)
25%

Increase in risk of allergies at age 6 when a child is introduced to milk other than breastmilk before 4 months of age
30%

Number of infant deaths (under 1 year) attributed to pneumonia and influenza(43)
441 (1.6% of total deaths, number ten cause of death in this age group)

Number of postneonatal deaths (28 days-one year) attributed to pneumonia and influenza
352 (3.7% of total deaths, number four cause of death in this age group)

Number of pneumonia cases annually (under age 5)(44)
783,000 (1996)

Number of influenza cases annually (under age 5)
10.8 million (1996)

Percent of children with pneumonia and gastroenteritis in a community(45)
before a breastfeeding program was put in place: 32.2
after a breastfeeding program was put in place: 14.6

Increased likelihood that an infant who was not breastfed will be admitted to the hospital for pneumonia(46)
1,700%

Among infants of mothers who did not participate in a breastfeeding intervention program compared to those who did(47)
risk of one or more gastrointestinal tract infections: 13.2 vs. 9.1%
risk of atopic eczema: 6.3 vs. 3.3%

Estimated probability of ever having respiratory illness in children(48)
who received breastmilk exclusively for at least 15 weeks: 17%
who received partial breastfeeding for at least 15 weeks: 31%
who were exclusively bottle-fed for at least 15 weeks: 32.2%

Incidence of obesity among children(49)
whose mothers exclusively breastfed for
2 months: 3.8%
3-5 months: 2.3%
6-12 months: 1.7%
12+ months: 0.8%
whose mothers never breastfed: 4.5%

Percent reduction in risk of breast cancer for women(50)
who have breastfed for at least two weeks: 13
who have breastfed for at least two years: 27
who began to breastfeed at age 20 or younger and continued for at least six months: 46

Percent reduction in breast cancer risk among parous (having borne one or more viable offspring) women who have never lactated(51)
61

Percent reduction in breast cancer risk among parous women who breastfed for 12-24 months
53

Cognitive function benefit when infants are breastfed(52)
3.16 points

Cognitive function benefit when low birthweight infants are breastfed
5.18 points

Increase in average school-leaving examination test scores among children who were breastfed for 8+ months(53)
.11 to .30 SD units higher than bottle-fed children

Increase in proportion of women breastfeeding exclusively for any period of time when a breastfeeding promotion program was put in place(54)
from 16.4 to 54.6%

For never-breastfed infants compared to infants breastfed for at least three months:(55)
additional office visits to healthcare provider (per 1,000 infants):
2,033 in the first year of life (for lower respiratory tract illness, otitis media, and gastrointestinal illness)
additional days of hospitalization: 212 in the first year of life (for the same ailments)
additional prescriptions: 609 in the first year of life (for the same ailments)

Average cost for one year of formula
$1,710

Cost to managed healthcare system per never-breastfed infant
$331 to $475 in the first year of life

Average six-month cost for formula-fed infants participating in the Women, Infants, and Children Program (WIC), compared to breastfed infants, for(56)
food: $715.81 vs. $339.65
Medicaid pharmacy payments: $37.56 vs. $16.83
average program costs (WIC and Medicaid): $956 vs. $795
Net six-month savings for breastfed infants: $161

Infant participants in WIC nationwide: 1.9 million (in 1995)

Medicaid participants under age 5: 8.5 million(57)

*Healthcare cost savings obtainable by encouraging government compliance with WHO infant feeding guidelines
$1.1 billion per year

*Total healthcare cost savings obtainable by providing prenatal care, developing midwifery care, and encouraging breastfeeding
$608,661,000,000 per year

*Healthcare Cost Savings Calculations

Healthcare cost savings obtainable by providing prenatal care to all high-risk patients
$62 million per year

This figure is based on the National Vital Statistics data showing 3,941,553 births in 1998. Approximately 30% of all patients might be considered “high risk” for preterm delivery, and approximately 11.9% of the population does not receive adequate prenatal care. The program in question (see Note 7) reduced preterm delivery by 19%. The differences in price when a preterm birth is prevented were $131 for labor costs and $2,196 for newborn inpatient costs, a total of $2,327.

3,941,553 X 11.9% = 469,045 population without adequate prenatal care
469,045 X 30% = 140,713 high-risk patients without prenatal care

140,713 X 19% = 26,735 reduction in preterm birthrate

26,735 X $2,327 = $62,212,345 savings from reducing preterm birthrate

A second figure can be used as an alternative, based on evidence cited in Note 8. Vital Statistics information indicates that 11.9% of women received only intermediate or inadequate prenatal care. The referenced study found a cost of $702 per mother for prenatal care, and an increase in long-term costs of $3,247 per neonate when prenatal care is absent. Taking these costs into account with the percent of mothers who receive inadequate prenatal care, we find a total long-term cost of $1,193,716,980 for the lack of prenatal care.

3,941,553 (births in 1998) X 11.9% = 469,044 deliveries to women without adequate prenatal care
469,044 X $702 = $329,268,888 = cost of providing prenatal care
469,044 X $3,247 = $1,522,985,868 = cost of not providing prenatal care
$1,522,985,868 minus $329,268,888 = $1,193,716,980 = savings obtainable from providing prenatal care

Healthcare cost savings obtainable from reducing low-birthweight deliveries by providing prenatal care
$ 167 million per year

The same study referenced in Note 7 found a 0.6% decrease in preterm births when prenatal care was provided. Information from the source in Note 8 found a cost of $702 per mother for prenatal care. The information referenced in Note 10 found a savings of $59,700 over the first year of care for a normal-birthweight child compared to a child with LBW. Applying these numbers to the birthrate quoted from Vital Statistics provides a savings of $166,020,372

3,941,553 X 11.9 % = 469,045 = population without adequate prenatal care
469,045 X 0.6% = 2,814 = number of preterm births due to lack of prenatal care
2,814 X $702 = $1,975,428 = cost of providing prenatal care to these mothers
2,814 X $59,700 = $167,995,800 = cost of not reducing LBW via prenatal care
$167,995,800 minus $1,975,428 =$166,020,372 = savings obtainable from reducing incidence of LBW

Healthcare cost savings obtainable by utilizing midwifery care for 75% of pregnancies in the US
$85 billion per year

According to the interview referenced in Note 29, the average cost for a vaginal, uncomplicated delivery was $2,617. Taking into account the 12.2% savings obtainable when a midwife is used (see Note 20) and the 75% rate of midwifery use in Europe , the savings obtainable by using midwives at the same rate in the US is $85,069,140,303.

3,941,553 X 67.6% = 2,664,489 = increase in deliveries required to meet European rate
$2,617 X 12.2% = $31,927 = average savings with midwife
$31,927 X 2,664,489 = $85,069,140,303 = savings obtainable by bringing US rate up to European rate

Healthcare cost savings obtainable by reducing US cesarean rate to WHO recommended rate
$561 million per year

The difference between the current US cesarean rate of 21.2% and the WHO recommended rate of 12% can be applied to the US birthrate. The average price difference between a cesarean section and a vaginal birth (see Note 19) can then be applied to the difference to produce a total savings of $561,701,478.

3,941,553 X 9.2% = 362,622 = number of unnecessary cesareans
362,622 X $1,549 = $561,701,478 = savings obtainable by reducing cesarean rate

Healthcare cost savings obtainable from government compliance with WHO infant feeding guidelines
$1.1 billion per year

The average health costs to managed care for the first year of life are $403 (see Note 45). The percentage of children on formula at age 1 (see Note 29) is 83%, and the number of WIC participants is 8.5 million. The healthcare cost savings obtainable by increasing that rate to 100% is $2,843,165.

8,500,000 X 83% = 7,055,000 = number of additional children breastfed
7,055,000 X $403 = $2,843,165 = savings from increasing rate to 100%

The food costs to WIC for one year for formula-fed infants (see Note 46) were $752.32 per child. There were 1.9 million infant participants in WIC, and applying that number to the savings per child yields a total of $1,186,408,640.

1,900,000 X 83% = 1,577,000 = number of additional children to be breastfed
1,577,000 X $752.32 = $1,186,408,640 = savings by increasing rate to 100%

Combining these two totals yields a savings of $1,189,251,805.
$2,843,165 + $1,186,408,640 = $1,189,251,805.

Notes

1.Organization for Economic Cooperation and Development, Health Data 2000.
2. Ibid.
3. “Health Insurance Coverage Report,” US Census Bureau, September 2000.
4. P. Braveman et al., “Adverse Outcomes and Lack of Health Insurance among Newborns in an Eight-County Area of California , 1982 to 1986,” New England Journal of Medicine 321 (1989): 508-513.
5. “National Vital Statistics Reports,” Final Death Data 1998 48, no. 11.
6. C. Hobel et al., ” West LA Preterm Birth Prevention Project,” American Journal of Obstetrics and Gynecology 170 (Jan 1994): 54-62.
7. Press release, WHO, June 4, 2000.
8. See Note 6.
9. M. Lu et al., “Elimination of Public Funding of Prenatal Care for Undocumented Immigrants in California : A Cost/Benefit Analysis,” American Journal of Obstetrics and Gynecology 182 (Jan 2000): 233-238.
10. “National Vital Statistics Reports,” Final Birth Data 1998 48, no. 3.
11. See Note 1.
12. See Note 5.
13. J. Rogowski, “Cost-Effectiveness of Care for Very Low Birthweight Infants,” Pediatrics 102, no. 1 (July 1998): 35-43.
14. Ibid.
15. “Low Birthweight in Minority and High-Risk Women,” in Patient Outcomes Research Team Final Report, University of Alabama , Birmingham , and Albert Einstein College of Medicine (Aug 1998): 5-6.
16. N. J. Waitzman et al., “Estimates of the Economic Costs of Birth Defects,” Inquiry 31 (1994): 188-205.
17. M. Richards et al., “Birthweight and Cognitive Function in the British 1946 Birth Cohort: Longitudinal Population Based Study,” British Medical Journal 322 (Jan 2001): 199-203.
18. See Note 9.
19. M. Gabay and S. M. Wolfe, “Encouraging the Use of Nurse-Midwives: A Report for Policymakers,” Public Citizen Health Research Group (Nov 1995): 13-29.
20. M. F. MacDorman and G. K. Singh, “Midwifery Care, Social and Medical Risk Factors, and Birth Outcomes in the USA ,” Journal of Epidemiology and Community Health 52 (1998): 310-317.
21. R. Al-Mufti et al., “Survey of Obstetricians’ Personal Preference and Discretionary Practice,” European Journal of Obstetrics and Gynaecology and Reproductive Biology 73 (1997): 1-4.
22. F. Frigoletto et al., “A Clinical Trial of Active Management of Labor,” New England Journal of Medicine 333, no. 12 (Sept 1995): 745-750.
23. K. Scott et al., “A Comparison of Intermittent and Continuous Support during Labor,” American Journal of Obstetrics and Gynecology 180 (May 1999): 1054-1059.
24. E. D. Hodnett, “Continuity of Caregivers for Care during Pregnancy and Childbirth,” Cochrane Review (April 2000), in The Cochrane Library ( Oxford : Update Software).
25. R. A. Rosenblatt et al., “Interspecialty Differences in Obstetric Care,” American Journal of Public Health 87 (1997): 344-351.
26. See Note 1.
27. K. B. Nelson et al., “Uncertain Value of Electronic Fetal Monitoring in Predicting Cerebral Palsy,” New England Journal of Medicine 334 (March 1996): 613-618.
28. S. B. Thacker and D. F. Stroup, “Continuous Electronic Heart Rate Monitoring for Fetal Assessment during Labor,” Cochrane Review (April 2000), in The Cochrane Library ( Oxford : Update Software).
29. See Note 12.
30. National Vital Statistics Reports 47, no 28 (1998).
31. M. Lydon-Rochelle et al., “Association Between Method of Delivery and Maternal Rehospitalization,” Journal of the American Medical Association 283 (2000): 2411-2416).
32. H. Blanchette, “Comparison of Obstetric Outcome of a Primary-Care Access Clinic Staffed by Certified Nurse-Midwives and a Private Practice Group of Obstetricians in the Same Community,” American Journal of Obstetrics and Gynecology 192 (June 1995): 1864-1871.
33. E. L. Ryding et al., “Experiences of Emergency Cesarean Section: A Phenomenal Study of 53 Women,” Birth 25 (Dec 1998): 246-251.
34. E. Hemminki and J. Merilainen, “Long-term Effects of Cesarean Sections: Ectopic Pregnancies and Placental Problems,” American Journal of Obstetrics and Gynecology 174 (May 1996): 1569-1574.
35. G. Bellomo et al., “Prognostic Value of 24-hour Blood Pressure in Pregnancy,” Journal of American Medical Association 282, no. 15 (Oct 1999): 1447-1452.
36. Interview with Connie Arcella of Admitting at Mesa Lutheran Hospital, Mesa, Arizona, March 7, 2001.
37. Annual Mother’s Survey, Ross Pediatrics Product Division of Abbott Laboratories, 1999.
38. See Note 1.
39. K. Dewey et al., “Differences in Morbidity between Breast-fed and Formula-fed Infants,” The Journal of Pediatrics 126, no. 1 (May 1995): 696-702.
40. B. Duncan, “Exclusive Breastfeeding for at Least Four Months Protects Against Otitis Media,” Pediatrics 91, no. 5 (May 1993): 867-872.
41. See Note 1.
42. W. Oddy et al., “Association between Breastfeeding and Asthma in 6-Year-Old Children: Findings of a Prospective Birth Cohort Study,” British Medical Journal 319 (Sept 1999): 815-819.
43. See Note 5.
44. Ibid.
45. A. L. Wright et al., “Increasing Breastfeeding Rates to Reduce Illness at the Community Level,” Pediatrics 101:5 (May 1998): 837-844.
46. J. A. Cesar et al., “Impact of Breastfeeding on Admission for Pneumonia during Postnatal Period in Brazil : Nested Case-Control Study,” British Medical Journal 318 (May 1999): 1316-1320.
47. M. Kramer et al., “Promotion of Breastfeeding Intervention Trial: A Randomized Trial in the Republic of Belarius ,” Journal of the American Medical Association 285 (2001): 413-420.
48. A. C. Wilson et al., “Relation of Infant Diet to Childhood Health: Seven Year Follow Up of Cohort of Children in Dundee Infant Feeding Study,” British Medical Journal 316 (Jan 1998): 21-25.
49. R. von Kries et al., “Breastfeeding and Obesity: Cross Sectional Study,” British Medical Journal 319 (July 1999): 147-150.
50. P. Newcomb et al., “Lactation in Relation to Postmenopausal Breast Cancer,” American Journal of Epidemiology 150, no. 2 (1999): 174-182.
51. I. Romieu et al., “Breast Cancer and Lactation History in Mexican Women,” American Journal Epidemiology 143 (1996): 543-552.
52. J. Anderson et al., “Breast-feeding and Cognitive Development: A Meta-Analysis” The American Journal of Clinical Nutrition 70, no. 4 (Oct 1999): 525-535.
53. L. John Horwood, “Breastfeeding and Later Cognitive and Academic Outcomes,” Pediatrics 101, no. 1 (Jan 1998): 9.
54. See Note 5.
55. T. Ball and A. L. Wright, “Health Care Costs of Formula-feeding in the First Year of Life,” Pediatrics 103, no. 4 (April 1999): 870-876.
56. D. L. Montgomery and P.L. Splett, “Economic Benefits of Breastfeeding Infants Enrolled in WIC,” Journal of the American Dietetic Association 97 (1997): 279-285.
57. “HCFA-2082 Report,” HCFA (Health Care Financing Administration), CMSO (Center for Medicaid and State Operations), 1998.

Tiffaney Isaacson lives in Gilbert , Arizona , and is the ever-so-proud mother of two children, Kyle (3) and Kayla (6 months). She is a writer specializing in women and children’s issues as well as parenting and family topics.