Breastfeeding & Public Health 2012

Objectives

Students will be able to:• Identify advantages to increasing breastfeeding

rates in the population• List 2020 Healthy People goals for breastfeeding• Access population-based breastfeeding data

and describe patterns of breastfeeding in the US• Use knowledge about the physiology of

breastfeeding to advocate for policies that support breastfeeding

Benefits of Breastfeeding

• Health outcomes– Infant – short term– Infant – long term– Maternal

• Economic

• Environmental

Breastfeeding and Maternal and Infant

Health Outcomes in Developed Countries

(Agency for Healthcare Research and Quality, 2007)

• Systematic reviews/meta-analyses, randomized and non-randomized comparative trials, prospective cohort, and case-control studies on the effects of breastfeeding

• English language• Studies must have a comparative arm of formula

feeding or different durations of breastfeeding. Only studies conducted in developed countries were included in the updates of previous systematic reviews.

• Studies graded for methodological quality.

Limitations of Breastfeeding Outcome Studies

• Definitions of breastfeeding; misclassification

• Lack of randomization; confounding & residual confounding

• “Wide range in quality of evidence”

AHRQ: Positive Findings for Infants% less in BF

Acute otitis media (exclusive BF 3-6 mos.) 50%

GI infection (infants breastfeeding) 64%

Lower respiratory tract diseases 72%Atopic dermatitis (exclusive BF 3 mos.) 42%

Asthma (in young children) – no family hx, family hx 27%, 40%

Type I diabetes 19, 27%

Type 2 diabetes 39%

Childhood leukemia 15, 19%

Sudden Infant Death Syndrome 36%

Necrotizing enterocolitis 4-82%

Obesity 4, 7, 24%

Breastfeeding and Obesity: Reviews & Meta-analysis

• Owen et al. Pediatrics. 2005– 61 studies– Odds ratio = 0.87 (95% CI 0.85-0.89) for reduced

risk of later obesity associated with breastfeeding compared to formula

• Arenz et al. Int J obes relat metab disord. 2004– 9 studies met criteria– Odds Ratio = 0.78, 95% CI (0.71, 0.85) protective

effect of breastfeeding for obesity– Found dose response

• Harder et al. Am J Epidemiol. 2005

Breastfeeding and risk of obesity

Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007

Harder et al. Am J Epidemiol. 2005 (17 studies)

Length of Breastfeeding

Odds Ratio for Risk of Obesity

95% CI

< 1 1.00 0.65, 1.55

1-3 0.81 0.74, 0.88

4-6 0.76 0.67, 0.86

7-9 0.67 0.55, 0.82

9 0.68 0.50, 0.91

AHRQ: Equivocal or insignificant infant outcomes

• Cognitive development in term or preterm infants

• CVD

• Infant mortality in developed countries

AHRQ: Positive Maternal Outcomes

% less in BF

Maternal Type II Diabetes (reduction in risk per year of lactation)

4, 12%

Postpartum depression association

Breast cancer (reduction per year of lactation)

4.3, 28%

Ovarian cancer 21%

AHRQ: Equivocal or insignificant maternal outcomes

• Effect of breastfeeding in mothers on return-to-pre-pregnancy weight was negligible

• Effect of breastfeeding on postpartum weight loss was unclear

• Little or no evidence for association with osteoporosis

Long-Term Protective Maternal Effects?

• Wicklund et al, Pub Health Nutr, 2011: Finland; 16-20 years post partum, women who bf < 6 mos. had higher body fat mass, fat mass% and android region fat than women who bf > 6 mos.

• Bobrow et al, Int J Obesity, 2012: UK Million Women Study (postmenopausal); Mean BMI lower among women who had breastfed, showing dose response 1% lower for every 6 months of breastfeeding; controlled for SES, smoking, PA.

Wicklund et al, Pub Health Nutr, 2011:

Wicklund et al, Pub Health Nutr, 2011:

Economic Costs of Formula Feeding(US Breastfeeding Committee)

• Families: ~$2,000 for the first year• Employers: loss of productivity, increased

absence, more health claims• Health care: 3.6 billion a year to treat

infant illnesses, $331-475 per child for one HMO

• Food assistance: costs to support breastfeeding mothers in WIC are 55% the cost for providing formula

Environmental Benefits of Breastfeeding

(ADA Position Paper, 2005)

• Human milk is a renewable natural resource.• Produced and delivered to the consumer directly• Formula requires manufacturing, packaging,

shipping, disposing of containers– 550 million formula cans in landfills each year*– 110 billion BTUs of energy to process and transport*

• Breastfeeding delays return of menses, increases birth spacing, limits population growth

• Note ADA position statement 2009 – environmental benefits not included…..

*USBC

Barriers to Breastfeeding (ADA Position Paper 2005)

• Individual: Inadequate knowledge, embarrassment, social reticence, negative perceptions

• Interpersonal: Lack of support from partner and family, perceived threat to father-child bond

• Institutional: Return to work or school, lack of workplace facilities, unsupportive health care environments

• Community: discomfort about nursing in public• Policy: aggressive marketing by formula

companies

2007 Health Styles Survey

Question AgreeNeither

Agree/Disagree

Disagree

Mothers who breastfeed should do so in private places only.

35.8% 26.0% 38.2%

I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, etc.

44.1% 24.6% 31.3%

I believe women should have the right to breastfeed in public places.

52.0% 23.8% 24.2%

Infant formula is as good as breast milk.

- 2011 answers to this question

20.2%

18.1%

27.2%

24.5%

52.6%

57.3%

Healthy People Goals and Breastfeeding Data

National Immunization Survey

• Random-digit--dialed telephone survey conducted annually by CDC

• Nationally representative data

• Breastfeeding questions first added in 2001

• Data organized by birth cohort, not year of data gathering

• 2004 data from 17,654 infants

Healthy People 2010: Increase the proportion of mothers who breastfeed their

babiesGoal US

Base-line

WA

2004

WA 2005 WA 2006 WA 2007

Early post-partum

75% 64% 88% 90% 86% 88%

At 6 months

50% 25% 57% 57% 58% 60%

At one year

25% 16% 32% 33% 35% 33%

New 2010 Breastfeeding Objectives added in 2007

• To increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60%

• To increase the proportion of mothers who exclusively breastfeed their infants through age 6 months to 25%

Exclusive breastfeeding: definition

• Exclusive breastfeeding is defined as an infant receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines

Optimal Duration of Exclusive Breastfeeding: Cochrane, August 2012

• 23 studies (11 from developing countries): Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are partially breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea.

Exclusive BreastfeedingUS

2004

US

2005

US 2006

US 2007

WA

2004

WA 2005

WA 2006

WA 2007

Through 3 months

31 36 33 33 50 45 49 44

Through 6 months

11 12 14 13 23 21 25 21

Healthy People 2020; & Report Card

2008 Births 2009 Births

Goal National WA State

National WA State

Ever Breastfed 82 75 89 77 89

At 6 months 61 44 60 47 55

At 12 months 34 24 35 26 34

Exclusive at 3 months

46 35 49 36 44

Exclusive at 6 months

26 15 23 16 20

Percent of Children Ever Breastfed by State among Children Born

2004

2007

2000

National prevalence of breastfeeding initiation and duration to 6 months and 12 months,* by selected sociodemographic characteristics --- National Immunization Survey (NIS), United States, 2004--2008

Initiation 6 months 12 monthsCharacteristic % % %

Total 73.4 41.7 21.0Race/Ethnicity (child)Hispanic 80.4 45.1 24.0White, non-Hispanic 74.3 43.2 21.4Black, non-Hispanic 54.4 26.6 11.7American Indian/Alaska Native 69.8 37.1 19.4

Asian or Pacific Islander 80.9 52.4 29.7Recipient of WIC¶Yes 66.1 32.7 16.5No (but eligible) 76.5 50.4 30.1No (not eligible) 82.2 51.7 25.5)Mother's educationLess than high school diploma or GED** 66.2 35.9 19.9High school diploma or GED 65.2 31.7 15.7Some college 74.8 40.5 19.7 College graduate 85.4 56.5 28.6Mother's age (yrs)<20 53.0 19.3 8.120--29 69.0 33.8 16.2≥30 77.5 48.5 25.4

Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State --- National Immunization Survey, United States, 2004—2008. WeeklyMarch 26, 2010 / 59(11);327-334

FIGURE. Prevalence of initiating breastfeeding* among Hispanics, non-Hispanic whites, and non-Hispanic blacks --- National Immunization Survey, United States, 2004--2008†

Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State --- National Immunization Survey, United States, 2004—2008. WeeklyMarch 26, 2010 / 59(11);327-334

Percent of Children Breastfed at 6 Months of Age by State

2004

2006

2007

2000

Percent of Children Breastfed at 12 Months of Age by State2004

2006

2007

Percent of Children Exclusively Breastfed Through 3 Months of Age among Children born

National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

20052007

Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)

Maternal Education %

Less than high school 24

High school 23

Some college 33

College graduate 42

Income/poverty ratio

< 100 24

100 - 184 29

185 - 340 34

>350 39

Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)

Education %

Hispanic 31

White, non-Hispanic 33

Black, non-Hispanic 20

Asian, non-Hispanic 31

Other

Mother’s age at birth of child

< 20 17

20-29 26

> 30 35

Percentage of children <six months old exclusively breastfed (2000-2006)

http://www.unicef.org/nutrition/index_24824.html

Percentage of infants under the age of six months who are exclusively breastfed, 1995–2010

http://www.childinfo.org/breastfeeding_progress.html

State of the World’s Mothers Report, 2012: Save the Children

Assurance:What Works to Support

Breastfeeding?

Structures, Policies, SystemsLocal, state, federal policies and laws to

regulate/support healthy actions

InstitutionsRules, regulations, policies &

informal structures

CommunitySocial Networks, Norms, Standards

InterpersonalFamily, peers, social networks,

associations

IndividualKnowledge, attitudes,

beliefs

Levels of Influence in the Social-Ecological Model

The CDC Guide to Breastfeeding Interventions, 2005

Six evidence-based interventions• Individual:

– Educating mothers– Professional support

• Intrapersonal:– Peer support/counseling programs

• Institutional – Maternity care practices

• Media and social marketing

Breastfeeding Policy Documents1984   U.S. Surgeon General’s Workshop

1990   Innocenti Declaration, WHO and UNICEF

2000   HHS Blueprint for Action on Breastfeeding

2001 US Breastfeeding Committee Strategic Plan

2003 WHO: Global Strategy for Infant and Young Child Feeding

2010 Breastfeeding A Vision for the Future (USBC & others)

2011 Surgeon General’s “Call to Action to Support Breastfeeding”

Supporting Breastfeeding

Mothers & FamiliesWorksites & Childcare

HealthcareLegislation

Mothers & Families

Support for healthy breastfeeding mothers with healthy term babies. Cochrane, May 2012

• “All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available.”

The Surgeon General’s Call to Action to Support Breastfeeding

Actions for Mothers and Their Families: 1. Give mothers the support they need to breastfeed their babies.

2. Develop programs to educate fathers and grandmothers about breastfeeding.

Actions for Communities: 3. Strengthen programs that provide mother-to-mother support and peer counseling.

4. Use community-based organizations to promote and support breastfeeding.

5. Create a national campaign to promote breastfeeding.

6. Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding

Worksites & Child Care

The Surgeon General’s Call to Action to Support Breastfeeding

Actions for Employment: 13. Work toward establishing paid maternity leave for all employed mothers.

14. Ensure that employers establish and maintain comprehensive, high-quality lactation support programs for their employees.

15. Expand the use of programs in the workplace that allow lactating mothers to have direct access to their babies.

16. Ensure that all child care providers accommodate the needs of breastfeeding mothers and infants.

HHS Blueprint: Worksites

“Facilitate breastfeeding or breastmilk expression at the workplace by providing private rooms, commercial grade breastpumps, milk storage arrangements, adequate breaks during the day, flexible work schedules and onsite childcare facilities.”

CDC Healthstyle Survey (Nationally

representative postal survey N~5000)

Agree 2006

Agree 2009

Agree 2011

I believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers

51 56 64

I believe employers should provide extended maternity leave to make it easier for mothers to breastfeed.

49 47

Healthstyle Survey, cont.

Agree 2006

Agree 2009

Agree 2011

I believe employers should provide a private room for breastfeeding mothers to pump their milk at work.

47 46 56

I would support tax incentives for employers who make special accommodations to make it easier for mothers to breastfeed.

30 25

WA Healthy Worksite Survey• Content: Measures policies, & environments to support

healthy nutrition, physical activity, breastfeeding and to discourage tobacco use.

• Population: WA businesses with 50+ employees, selected from WA Department of Employment Security.

• Sampling: Representative geographic sample across WA. 900 contacted, 540 responded.

• Administration: Fall 2005. 15 minute phone survey of HR managers, conducted by Gilmore. Repeat in 2007.

• Background: DOH STEPS/CDNPA/Tobacco collaboration

Of the 400 Businesses with Female Employees < age of 50:

• 11% had a specific policy to support breastfeeding

• 82% provided flexible scheduling to allow employees adequate break time to breastfeed or pump/express breast milk

• 31% had a designated room or location (not counting bathroom stalls) for mothers to breastfeed or pump/express breast milk

Amenities Located in Breastfeeding Rooms

0% 20% 40% 60% 80% 100%

Locking door for privacy

Electrical outlet

Handwashing sink

Refrigerator to storepumped/expressed milk

Characteristics of Breastfeeding Rooms

Interventions in the workplace to support breastfeeding for women in

employment. Cochrane, 2012

• “No trials have evaluated the effectiveness of workplace interventions in promoting breastfeeding among women returning to paid work after the birth of their child.”

Childcare: HHS Blueprint for Action

•Safe storage•Follow mothers’ instructions•Provide quiet and comfortable place for mothers

Health Care

The Surgeon General’s Call to Action to Support Breastfeeding

Actions for Health Care: 7. Ensure that maternity care practices around the United States are fully supportive of breastfeeding.

8. Develop systems to guarantee continuity of skilled support for lactation between hospitals and health care settings in the community.

9. Provide education and training in breastfeeding for all health professionals who care for women and children.

10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.

11. Ensure access to services provided by International Board Certified Lactation Consultants.

12. Identify and address obstacles to greater availability of safe banked donor milk for fragile infants.

Code of Marketing of Breastmilk Substitutes WHO (1981)

• “No facility of a health care system should be used for the purpose of promoting infant formula or other products…”

HHS Blueprint: Health Care System

1. Train health care providers who provide maternal and child care on the basics of lactation, breastfeeding counseling and lactation management during coursework, clinical and in-service training and continuing education.”

2. Ensure that breastfeeding mothers have access to comprehensive, up-to-date, and culturally tailored lactation services provided by trained physicians, nurses, lactation consultants and nutritionists/dietitians.

National Survey of Maternity Care Practices in Infant Nutrition and Care (mPINC)

• 2,546 hospitals, 121 birth centers in the 50 states, DC, Puerto Rico

• 35 questions; 7 categories – labor and delivery, – breastfeeding assistance, – mother-newborn contact, – newborn feeding practices, – breastfeeding support after discharge, – nurse/birth attendant breastfeeding training and

education, – structural and organizational factors related to

breastfeeding MMWR. June 13, 2008 / 57(23);621-625

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5723a1.htm#fig

FIGURE. Percentage of hospitals that implemented recommended maternity care practices related to breastfeeding* --- Maternity Practices in Infant Nutrition and Care Survey (mPINC), United States, 2007 and 2009

Recommended maternity care practices are indicators of the Ten Steps to Successful Breastfeeding

MMWR, August 5, 2011 / 60(30);1020-1025

mPINC Indicator 2007 (%)

2009 (%)

1. Model breastfeeding policy: hospital has a written breastfeeding policy that includes 10 model policy elements§

11.7 14.4

2. Staff competency assessment: nurses/birth attendants are assessed for competency in basic breastfeeding management and support at least once per year

44.6 49.7

3. Prenatal breastfeeding education: breastfeeding education is included as a routine element of prenatal classes

92.5 92.8

4. Early initiation of breastfeeding: ≥90% of healthy full-term breastfed infants initiate breastfeeding within one hour of uncomplicated vaginal birth

43.5 50.9

5. Teach breastfeeding techniques: ≥90% of mothers who are breastfeeding or intend to breastfeed are taught breastfeeding techniques (e.g., positioning, how to express milk, etc.)

87.8 89.1

Maternity Practices in Infant Nutrition and Care (mPINC)

(2,690 hospital & birth facilities participated; 2,672 facilities participated in 2009; based on Ten Steps to Successful Breastfeeding; MMWR, August 5, 2011 / 60(30);1020-1025 )

mPINC Indicator 2007 (%)

2009 (%)

6. Limited use of breastfeeding supplements: <10% of healthy full-term breastfed infants are supplemented with formula, glucose water, or water

20.6 21.5

7. Rooming-in: ≥90% of healthy full-term infants, regardless of feeding method, remain with their mother for at least 23 hours per day during the hospital stay

30.8 33.2

8. Teach feeding cues: ≥90% of mothers are taught to recognize and respond to infant feeding cues instead of feeding on a set schedule

77.0 81.8

9. Limited use of pacifiers: <10% of healthy full-term breastfed infants are given pacifiers by maternity care staff members

25.3 30.1

10. Post-discharge support: hospital routinely provides three modes of post-discharge support to breastfeeding mothers: physical contact, active reaching out, and referrals¶

26.8 26.8

Data Source: Baby-Friendly facilities : www.babyfriendlyusa.org & Live Births: CDC NCHS Live Births by State.

CDC Breastfeeding Report Card Process Indicators

2009 2012

US WA US WA

Percent of live births occurring at facilities designated as Baby Friendly (BFHI)

2.9 6.9 6.2 9.2

Number of IBCLCs ** per 1000 live births

2.2 4.2 3.2 5.3

Number of state health dept. FTEs dedicated to breastfeeding

80 1.4 135 4.7

State Breastfeeding Legislation

• Breastfeeding in public: 23 states give the right to breastfeed in any place it is legal to be

• Jury duty: 7 states exempt breastfeeding mothers from jury duty

• Family law: three states require breastfeeding status to be considered in divorce or custody decisions.

WA Breastfeeding Legislation

1. Amendment to indecent exposure law– “A person is guilty of indecent exposure if he

or she intentionally makes any open and obscene exposure of his or her person or the person of another knowing that such conduce is likely to cause reasonable affront or alarm. The act of breastfeeding or expressing breast milk is not indecent exposure.”

WA breastfeeding legislation

• “Am employer may use the designation “ infant friendly” on its promotional materials if the employer has an approved workplace breastfeeding policy addressing at least the following:– Flexible work schedule, place to nurse/express with

handwashing facilities and refrigerator

• DOH to approve employers, but no funds to do this, so no worksites have been designated

HB 1596 - 2009

• An act relating to protecting a woman’s right to breastfeed in a place of public resort, accommodation, assemblage, or amusement; amending RCW 49.60.030 and 49.60.215.

• Adds breastfeeding to rights protecting discrimination because or race, creed, color, national origin, sex, honorably discharged veteran, sexual orientation or the presence of….disability..

1. Meet and exceed the Healthy People objectives to increase the proportion of mothers who breastfeed.

2. Implement maternity care practices that foster normal birth and breastfeeding in every facility that cares for childbearing women.

3. Ensure that health care providers provide evidence-based, culturally competent birth and breastfeeding care.

4. Create and foster work environments that support breastfeeding mothers.

5. Ensure that all federal, state, and local laws relating to child welfare and family law recognize the importance of breastfeeding and support its practice.

6. Implement curricula that teach students of all ages that breastfeeding is the normal and preferred method of feeding infants and young children.

7. Reduce the barriers to breastfeeding imposed by the marketing of human milk substitutes.

8. Protect a woman’s right to breastfeed in public.

9. Encourage greater social support for breastfeeding as a vital public health strategy.