Nearly three-quarters of the hospitals in the sample were nonprofit with the remaining facilities being either government or private. Sixty-one percent of facilities were implementing 3–5 ideal practices, with another 29 percent implementing 6–8 ideal practices. The mean number of births per year was 1488 and 43 percent of births were covered by Medicaid (Table 2). The group with the highest median birth cost for all uncomplicated births was hospitals reporting 9–10 ideal practices ($3353) (Fig. 1); this finding was also true for vaginal ($2971) and cesarean section ($5722) births (Figs 2 and 3). However, the average birth cost at hospitals reporting 0–2 practices was not significantly different from hospitals reporting 9–10 practices, regardless of birth mode (p = 0.27–0.49).

Unadjusted linear regression analyses of uncomplicated births revealed a significant increase in the cost of cesarean section births ($98) with each additional practice in place, but no significant increase in the cost of all births or vaginal births ($44 and $35, respectively) (Table 3). After adjustment for state, percent of births paid for by Medicaid, hospital type, and annual number of births, costs associated with additional practices were reduced compared with the unadjusted model, and were nonsignificant for all birth groups (all births, $19; vaginal, $15; cesarean section, $39).

Concerns that improving maternity care practices may lead to higher birth costs are understandable as combined charges for birthing women and newborns totaled over $79 billion in 2005, and far exceeded total charges for any other condition (24). However, concerns that additional maternity care practices supportive of breastfeeding are associated with higher birth costs are not supported by our findings based on hospital records in 20 states, as we found no significant association between number of ideal practices reported and birth cost in the adjusted models. These findings are consistent with the findings of DelliFraine et al. Using two different methods to compare Baby-Friendly designated hospitals to non-Baby-Friendly hospitals their study found that costs were 1.6–5.0% ($35–$178) higher for Baby-Friendly hospitals, which was not a statistically significant difference (15). Similarly, we found a slightly higher but nonsignificant difference in birth costs associated with improved maternity care practices. Because non-Baby-Friendly hospitals may also have implemented some or even all of the Ten Steps to Successful Breastfeeding to improve maternity care practices, this study provides further evidence that improving hospital practices to support breastfeeding is not associated with significantly higher birth costs.

Our analysis is the first, to our knowledge, to examine the association between the incremental increase in number of ideal practices in place at a hospital and birth costs. In 2009, approximately half of all U.S. hospitals had 3–5 Baby-Friendly practices in place (19). Our data suggest that for these hospitals the cost of an uncomplicated birth would increase by approximately $95–$133 if they achieved all 10 practices; this analysis suggests the cost for uncomplicated vaginal and cesarean section births are not significantly higher for each additional ideal practice in place. Inherent in the process to become a Baby-Friendly hospital are expenses associated with designation fees, training, and purchasing infant formula (14). Neither the analysis by DelliFraine et al, nor our analysis was able to account for the costs associated with Baby-Friendly designation, or with implementing any particular practice. In fact very little data are available with respect to the cost of implementing the Ten Steps to Successful Breastfeeding and becoming Baby-Friendly. An article by Merewood and Philipp describes the experience of Boston Medical Center in becoming Baby-Friendly, including the cost of paying fair market value for infant formula (14). However, this article is now more than 10 years old, and is the experience of only one facility. Additional analyses, including longitudinal studies of change in cost as practices are implemented, are needed to better describe the costs associated with improving maternity care practices. In the meantime, this analysis suggests that whatever costs are assumed by a hospital in improving maternity care practices do not translate into increased birth costs at the facility.

Hospitals that follow the Ten Steps to Successful Breastfeeding increase breastfeeding initiation and in-hospital-exclusivity rates and improve patient care and quality (25,26). In April 2010, the Joint Commission, an organization that accredits and certifies health care organizations in the United States, added the rate of in-hospital exclusive breastmilk feeding as a perinatal care core measure that can be tracked as part of quality improvement (27); this measure is in-line with step 6, which indicates that breastfeeding infants should receive no food or drink other than breastmilk, unless medically indicated. Improving quality measures related to breastfeeding will help prepare hospitals seeking Baby-Friendly Hospital status, a designation a growing number of hospitals are obtaining (28).

This study has limitations. Birth costs were determined using overall, hospital-specific cost-to-charge ratios that only estimate birth costs and do not reflect the cost-to-charge ratio of specific units, such as labor and delivery. Besides, our sample of hospitals in 20 U.S. states is not nationally representative. Although the community hospitals included in this analysis included all uncomplicated births at the facility, hospitals without information for cost or ideal practices were excluded from analyses. However, the hospitals excluded did not differ from those included on important characteristics. Finally, mPINC is a self-reported survey filled out by a key informant at each hospital. Although a standard protocol is followed to identify the key informant, the responses may not accurately represent all practices.

In 2011, less than 50 percent of U.S. hospitals reported having more than five ideal practices in place (29). Hospitals may be helped in the adoption of these practices by better understanding the benefits and the barriers to adoption and how to overcome them.

This study did not find a significant increase in birth cost for each additional practice supportive of breast-feeding in place at a hospital. Breastfeeding is important for mothers, infants, and society and it is important that hospitals work to implement and improve maternity care practices that support breastfeeding and women who choose to breastfeed.