Call to Action to Support Breast Feeding

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Te Surgeon Generals Call to Actionto Support Breastfeeding2011

U.S. Department of Health and Human Services


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The Surgeon Generals Call to Actionto Support Breastfeeding


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U.S. DEPARMEN OF HEALH AND HUMAN SERVICESU.S. Public Health ServiceOce o the Surgeon General

Suggested Citation

U.S. Department o Health and Human Services. Te Surgeon Generals Call to Action to SupportBreasteeding. Washington, DC: U.S. Department o Health and Human Services, Oce o theSurgeon General; 2011.

Tis publication is available at http://www.surgeongeneral.gov.
http://www.surgeongeneral.gov/http://www.surgeongeneral.gov/


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Table of Contents

Message rom the Secretary, U.S. Department o Health and Human Services ...........................iii

Action 3. Strengthen programs that provide mother-to-mother support

Action 4. Use community-based organizations to promote and

Foreword rom the Surgeon General, U.S. Department o Health and Human Services ............. v

Te Importance o Breasteeding...................................................................................................1Health Eects .............................................................................................................................1

Psychosocial Eects.....................................................................................................................3

Economic Eects ........................................................................................................................3

Environmental Eects.................................................................................................................4

Endorsement o Breasteeding as the Best Nutrition or Inants .................................................. 4

Federal Policy on Breasteeding...................................................................................................5

Rates o Breasteeding....................................................................................................................6

Disparities in Breasteeding Practices ..........................................................................................7

Barriers to Breasteeding in the United States .............................................................................10

Lack o Knowledge ...................................................................................................................10

Social Norms ............................................................................................................................11

Poor Family and Social Support................................................................................................12

Embarrassment .........................................................................................................................13

Lactation Problems ...................................................................................................................13

Employment and Child Care....................................................................................................14

Barriers Related to Health Services............................................................................................15

Breasteeding rom the Public Health Perspective.......................................................................16Mothers and Teir Families ......................................................................................................16

Communities............................................................................................................................18

Health Care ..............................................................................................................................24

Employment.............................................................................................................................29

Research and Surveillance ......................................................................................................... 32

Public Health Inrastructure .....................................................................................................35

A Call to Action ............................................................................................................................37

Mothers and Teir Families.....................................................................................................38

Action 1. Give mothers the support they need to breasteed their babies........................... 38

Action 2. Develop programs to educate athers and grandmothers about breasteeding.....39

Communities...........................................................................................................................40

and peer counseling...........................................................................................40

support breasteeding ........................................................................................41

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Action 5. Create a national campaign to promote breasteeding........................................ 42Action 6. Ensure that the marketing o inant ormula is conducted in a way that

Action 7. Ensure that maternity care practices throughout the United States are ully

Action 8. Develop systems to guarantee continuity o skilled support or lactation

Action 9. Provide education and training in breasteeding or all health

Action 10. Include basic support or breasteeding as a standard o care or midwives,

Action 11. Ensure access to services provided by International Board Certied

Action 12. Identiy and address obstacles to greater availability o sae banked donor

minimizes its negative impacts on exclusive breasteeding..................................43

Health Care.............................................................................................................................44

supportive o breasteeding................................................................................44

between hospitals and health care settings in the community ............................45

proessionals who care or women and children.................................................46

obstetricians, amily physicians, nurse practitioners, and pediatricians...............47

Lactation Consultants .......................................................................................48

milk or ragile inants.......................................................................................49Employment.............................................................................................................................50

Action 13. Work toward establishing paid maternity leave or all employed mothers ..........50

Action 14. Ensure that employers establish and maintain comprehensive, high-quality lactation support programs or their employees .............................51

Action 15. Expand the use o programs in the workplace that allow lactating

Action 16. Ensure that all child care providers accommodate the needs o

mothers to have direct access to their babies ......................................................52

breasteeding mothers and inants .....................................................................53

Research and Surveillance.......................................................................................................54

Action 17. Increase unding o high-quality research on breasteeding ................................ 54Action 18. Strengthen existing capacity and develop uture capacity or

conducting research on breasteeding ................................................................55

Action 19. Develop a national monitoring system to improve the tracking o breasteeding rates as well as the policies and environmental

Action 20. Improve national leadership on the promotion and support

actors that aect breasteeding..........................................................................56

Public Health Infrastructure..................................................................................................57

o breasteeding................................................................................................. 57

Reerences .....................................................................................................................................59

Acknowledgments .........................................................................................................................69

Appendix 1. Actions to Improve Breasteeding...........................................................................71

Appendix 2. Excess Health Risks Associated with Not Breasteeding.........................................79

Appendix 3. Development o the Call to Action..........................................................................81

Appendix 4. Abbreviations and Acronyms...................................................................................87

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Message from the Secretary,U.S. Department of Health and Human ServicesAs one o the most universal and natural acets o motherhood, the ability to breasteed is a great

git. Breasteeding helps mothers and babies bond, and it is vitally important to mothers andinants health.

For much o the last century, Americas mothers were given poor advice and were discouragedrom breasteeding, to the point that breasteeding became an unusual choice in this country.However, in recent decades, as mothers, their amilies, and health proessionals have realizedthe importance o breasteeding, the desire o mothers to breasteed has soared. More and moremothers are breasteeding every year. In act, three-quarters o all newborns in America now begintheir lives breasteeding, and breasteeding has regained its rightul place in our nation as thenormthe way most mothers eed their newborns.

Each mothers decision about how she eeds her baby is a personal one. Because o theramications o her decision on her babys health as well as her own, every mother in our nationdeserves inormation, guidance, and support with this decision rom her amily and riends, thecommunity where she lives, the health proessionals on whom she relies, and her employer.

Tat is why this Surgeon Generals Call to Action is so important.

Tis Call to Action describes specic steps people can take to participate in a society-wideapproach to support mothers and babies who are breasteeding. Tis approach will increase thepublic health impact o everyones eorts, reduce inequities in the quality o health care thatmothers and babies receive, and improve the support that amilies receive in employment andcommunity settings.

I recall my own cherished memories o breasteeding, and I am grateul or the help and support Ireceived, especially when I went back to work as a young mother. I am also aware that many othermothers are not able to benet rom the support I had. As Secretary o the Department o Healthand Human Services, I urge all Americans to be supportive o breasteeding mothers and amiliesin their communities and to extend their support so that these mothers get the health care, thehelp, and the encouragement they deserve.

Kathleen SebeliusSecretaryU.S. Department o Health and Human Services

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Foreword from the Surgeon General,U.S. Department of Health and Human ServicesFor nearly all inants, breasteeding is the best source o inant nutrition and immunologicprotection, and it provides remarkable health benets to mothers as well. Babies who are breastedare less likely to become overweight and obese. Many mothers in the United States want tobreasteed, and most try. And yet within only three months ater giving birth, more than two-thirds o breasteeding mothers have already begun using ormula. By six months postpartum,more than hal o mothers have given up on breasteeding, and mothers who breasteed one-yearolds or toddlers are a rarity in our society.

October 2010 marked the 10th anniversary o the release o the HHS Blueprint or Action onBreasteeding, in which ormer Surgeon General David Satcher, M.D., Ph.D., reiterated thecommitment o previous Surgeons General to support breasteeding as a public health goal. Tiswas the rst comprehensive ramework or national action on breasteeding. It was created through

collaboration among representatives rom medical, business, womens health, and advocacy groups aswell as academic communities. Te Blueprintprovided specic action steps or the health care system,researchers, employers, and communities to better protect, promote, and support breasteeding.

I have issued this Call to Action because the time has come to set orth the important roles andresponsibilities o clinicians, employers, communities, researchers, and government leadersand to urge us all to take on a commitment to enable mothers to meet their personal goals orbreasteeding. Mothers are acutely aware o and devoted to their responsibilities when it comesto eeding their children, but the responsibilities o others must be identied so that all motherscan obtain the inormation, help, and support they deserve when they breasteed their inants.Identiying the support systems that are needed to help mothers meet their personal breasteeding

goals will allow them to stop eeling guilty and alone when problems with breasteeding arise.All too oten, mothers who wish to breasteed encounter daunting challenges in moving throughthe health care system. Furthermore, there is oten an incompatibility between employment andbreasteeding, but with help this is not impossible to overcome. Even so, because the barriers canseem insurmountable at times, many mothers stop breasteeding. In addition, amilies are otenunable to nd the support they need in their communities to make breasteeding work or them.From a societal perspective, many research questions related to breasteeding remain unanswered,and or too long, breasteeding has received insucient national attention as a public health issue.

Tis Call to Action describes in detail how dierent people and organizations can contribute to thehealth o mothers and their children. Rarely are we given the chance to make such a proound and

lasting dierence in the lives o so many. I am condent that this Call to Actionwill spark countlessimaginative, eective, and mutually supportive endeavors that improve support or breasteedingmothers and children in our nation.

Regina M. Benjamin, M.D., M.B.A.Vice Admiral, U.S. Public Health ServiceSurgeon General

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The Importance of Breastfeeding

Health Eects

Te health eects o breasteeding are well recognized and apply to mothers and children indeveloped nations such as the United States as well as to those in developing countries. Breastmilk is uniquely suited to the human inants nutritional needs and is a live substance withunparalleled immunological and anti-inammatory properties that protect against a host oillnesses and diseases or both mothers and children.1

In 2007, the Agency or Healthcare Research and Quality (AHRQ) published a summary osystematic reviews and meta-analyses on breasteeding and maternal and inant health outcomesin developed countries.2 Te AHRQ report rearmed the health risks associated with ormula*eeding and early weaning rom breasteeding. With regard to short-term risks, ormula eeding is

associated with increases in common childhood inections, such as diarrhea3 and ear inections.2

Te risk o acute ear inection, also called acute otitis media, is 100 percent higher amongexclusively ormula-ed inants than in those who are exclusively breasted during the rst sixmonths (see able 1).2

Te risk associated with some relatively rare but serious inections and diseases, such as severelower respiratory inections2,4 and leukemia2,5 are also higher or ormula-ed inants. Te risk ohospitalization or lower respiratory tract disease in the rst year o lie is more than 250 percenthigher among babies who are ormula ed than in those who are exclusively breasted at least ourmonths.4 Furthermore, the risk o sudden inant death syndrome is 56 percent higher among

inants who are never breasted.

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For vulnerable premature inants, ormula eeding is associatedwith higher rates o necrotizing enterocolitis (NEC).2 Te AHRQ report also concludes thatormula eeding is associated with higher risks or major chronic diseases and conditions, such astype 2 diabetes,6 asthma,2 and childhood obesity,7 all three o which have increased among U.S.children over time.

As shown in able 1, compared with mothers who breasteed, those who do not breasteed alsoexperience increased risks or certain poor health outcomes. For example, several studies haveound the risk o breast cancer to be higher or women who have never breasted.2,8,9 Similarly,the risk o ovarian cancer was ound to be 27 percent higher or women who had never breastedthan or those who had breasted or some period o time.2 In general, exclusive breasteeding and

longer durations o breasteeding are associated with better maternal health outcomes.

* Te term ormula is used here to include the broad class o human milk substitutes that inants receive, including commercialinant ormula.

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Te AHRQ report cautioned that, although a history o breasteeding is associated with a reducedrisk o many diseases in inants and mothers, almost all the data in the AHRQ review weregathered rom observational studies. Tereore, the associations described in the report do notnecessarily represent causality. Another limitation o the systematic review was the wide variation

in quality among the body o evidence across health outcomes.

As stated by the U.S. Preventive Services ask Force (USPSF) evidence review,10 human milkis the natural source o nutrition or all inants. Te value o breasteeding and human milk orinant nutrition and growth has been long recognized, and the health outcomes o nutrition andgrowth were not covered by the AHRQ review.

Table 1. Excess Health Risks Associated with Not Breastfeeding

Outcome Excess Risk* (%)

Among full-term infantsAcute ear inection (otitis media)2 100

Eczema (atopic dermatitis)11 47

Diarrhea and vomiting (gastrointestinal inection)3 178

Hospitalization or lower respiratory tract diseasesin the rst year4

257

Asthma, with amily history2 67

Asthma, no amily history2 35

Childhood obesity7 32

ype 2 diabetes mellitus6 64

Acute lymphocytic leukemia2 23

Acute myelogenous leukemia5 18

Sudden inant death syndrome2 56

Among preterm infants

Necrotizing enterocolitis2 138

Among mothers

Breast cancer8 4

Ovarian cancer2 27

* Te excess risk is approximated by using the odds ratios reported in the reerenced studies. Further details are provided in Appendix 2.

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Psychosocial Eects

Although the typical woman may cite the health advantages or hersel and her child as majorreasons that she breasteeds, another important actor is the desire to experience a sense o

bonding or closeness with her newborn.1214

Indeed, some women indicate that the psychologicalbenet o breasteeding, including bonding more closely with their babies, is the most importantinuence on their decision to breasteed.12 Even women who exclusively ormula eed havereported eeling that breasteeding is more likely than ormula eeding to create a close bondbetween mother and child.13

In addition, although the literature is not conclusive on this matter, breasteeding may help tolower the risk o postpartum depression, a serious condition that almost 13 percent o mothersexperience. Tis disorder poses risks not only to the mothers health but also to the health o herchild, particularly when she is unable to ully care or her inant.15 Research ndings in this areaare mixed, but some studies have ound that women who have breasted and women with longer

durations o breasteeding have a lower risk o postpartum depression.1618 Whether postpartumdepression aects breasteeding or vice versa, however, is not well understood.19

Economic Eects

In addition to the health advantages o breasteeding or mothers and their children, there areeconomic benets associated with breasteeding that can be realized by amilies, employers,private and government insurers, and the nation as a whole. For example, a study conducted morethan a decade ago estimated that amilies who ollowed optimal breasteeding practices could savemore than $1,200$1,500 in expenditures or inant ormula in the rst year alone.20 In addition,better inant health means ewer health insurance claims, less employee time o to care or sickchildren, and higher productivity, all o which concern employers.21

Increasing rates o breasteeding can help reduce the prevalence o various illnesses and healthconditions, which in turn results in lower health care costs. A study conducted in 2001 on theeconomic impact o breasteeding or three illnessesotitis media, gastroenteritis, and NECoundthat increasing the proportion o children who were breasted in 2000 to the targets establishedin Healthy People 201022 would have saved an estimated $3.6 billion annually. Tese savings werebased on direct costs (e.g., costs or ormula as well as physician, hospital, clinic, laboratory, andprocedural ees) and indirect costs (e.g., wages parents lose while caring or an ill child), as well as theestimated cost o premature death.23 A more recent study that used costs adjusted to 2007 dollars

and evaluated costs associated with additional illnesses and diseases (sudden inant death syndrome,hospitalization or lower respiratory tract inection in inancy, atopic dermatitis, childhood leukemia,childhood obesity, childhood asthma, and type 1 diabetes mellitus) ound that i 90 percent o U.S.amilies ollowed guidelines to breasteed exclusively or six months, the United States would save$13 billion annually rom reduced direct medical and indirect costs and the cost o premature death.I 80 percent o U.S. amilies complied, $10.5 billion per year would be saved.24

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Environmental Eects

Breasteeding also coners global environmental benets; human milk is a natural, renewableood that acts as a complete source o babies nutrition or about the rst six months o lie.25

Furthermore, there are no packages involved, as opposed to inant ormulas and other substitutesor human milk that require packaging that ultimately may be deposited in landlls. For everyone million ormula-ed babies, 150 million containers o ormula are consumed;26 while some othose containers could be recycled, many end up in landlls. In addition, inant ormulas must betransported rom their place o manuacture to retail locations, such as grocery stores, so that theycan be purchased by amilies. Although breasteeding requires mothers to consume a small amounto additional calories, it generally requires no containers, no paper, no uel to prepare, and notransportation to deliver, and it reduces the carbon ootprint by saving precious global resourcesand energy.

Endorsement o Breasteeding as the Best Nutrition or InantsBecause breasteeding coners many important health and other benets, including psychosocial,economic, and environmental benets, it is not surprising that breasteeding has beenrecommended by several prominent organizations o health proessionals, among them theAmerican Academy o Pediatrics(AAP),25 American Academy o FamilyPhysicians,27 American College oObstetricians and Gynecologists,28

American College o Nurse-Midwives,29 American Dietetic

Association,30

and American PublicHealth Association,31 all o whichrecommend that most inants in theUnited States be breasted or at least12 months. Tese organizations alsorecommend that or about the rstsix months, inants be exclusivelybreasted, meaning they should not begiven any oods or liquids other thanbreast milk, not even water.

Regarding nutrient composition,the American Dietetic Associationstated, Human milk is uniquelytailored to meet the nutrition needs ohuman inants. It has the appropriatebalance o nutrients provided in easilydigestible and bioavailable orms.30

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Te AAP stated, Human milk is species-specic, and all substitute eeding preparationsdier markedly rom it, making human milk uniquely superior or inant eeding. Exclusivebreasteeding is the reerence or normative model against which all alternative eeding methodsmust be measured with regard to growth, health, development, and all other short- and long-term

outcomes.25

While breasteeding is recommended or most inants, it is also recognized that a small numbero women cannot or should not breasteed. For example, AAP states that breasteeding iscontraindicated or mothers with HIV, human -cell lymphotropic virus type 1 or type 2, activeuntreated tuberculosis, or herpes simplex lesions on the breast. Inants with galactosemia shouldnot be breasted. Additionally, the maternal use o certain drugs or treatments, including illicitdrugs, antimetabolites, chemotherapeutic agents, and radioactive isotope therapies, is cause or notbreasteeding.25

Federal Policy on BreasteedingOver the last 25 years, the Surgeons General o the United States have worked to protect,promote, and support breasteeding. In 1984, Surgeon General C. Everett Koop convened therst Surgeon Generals Workshop on Breasteeding, which drew together proessional and layexperts to outline key actions needed to improve breasteeding rates.32 Participants developedrecommendations in six distinct areas: 1) the world o work, 2) public education, 3) proessionaleducation, 4) health care system, 5) support services, and 6) research. Follow-up reports in 1985and 1991 documented progress in implementing the original recommendations.33,34

In 1990, the United States signed onto the Innocenti Declaration on the Protection, Promotion and

Support o Breasteeding, which was adopted by the World Health Organization (WHO) and theUnited Nations Childrens Fund (UNICEF). Tis declaration called upon all governments tonationally coordinate breasteeding activities, ensure optimal practices in support o breasteedingthrough maternity services, take action on the International Code o Marketing o Breast-milkSubstitutes(the Code),35 and enact legislation to protect breasteeding among workingwomen.36

In 1999, Surgeon General David Satcher requested that a departmental policy on breasteedingbe developed, with particular emphasis on reducing racial and ethnic disparities in breasteeding.Te ollowing year, the Secretary o the U.S. Department o Health and Human Services (HHS),under the leadership o the departments Oce on Womens Health (OWH), released the HHSBlueprint or Action on Breasteeding.37 Tis document, which has received widespread attention

in the years since its release, declared breasteeding to be a key public health issue in the UnitedStates.

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Rates of Breastfeeding

Over the last ew decades, rates o breasteeding have improved, but in recent years, rates generally

have climbed more slowly. Figure 1 presents data rom 1970 through 2007 rom two sources.Data beore 1999 are rom the Ross Mothers Survey.3840 Data or 1999 through 2007 are romthe Centers or Disease Control and Preventions (CDC) annual National Immunization Survey(NIS), which includes a series o questions regarding breasteeding practices.41

National objectives or Healthy People 2010, in addition to calling or 75 percent o mothersto initiate breasteeding, called or 50 percent to continue breasteeding or six months and 25percent to continue breasteeding or one year.22 Healthy People 2010also included objectives orexclusive breasteeding: targets were or 40 percent o women to breasteed exclusively or threemonths and or 17 percent to do so or six months.22

Te most recent NIS data shown in Figure 1 indicate that, while the rate o breasteedinginitiation has met the 2010 target, rates o duration and exclusivity still all short oHealthy People2010objectives.41 Among children born in 2007, 75 percent o mothers initiated breasteeding,43 percent were breasteeding at six months, and 22 percent were breasteeding at 12 months(see Figure 1). Although human milk is the only nutrition most babies need or about the rstsix months, many women discontinue breasteeding or add other oods or liquids to their babysdiet well beore the child reaches six months o age. Among breasted inants born in 2007, anestimated 33 percent were exclusively breasted through age three months, and only 13 percentwere exclusively breasted or six months.

Although much is known about rates o breasteeding in the population, mothers breasteeding

practices have not been well understood until recently. Te Inant Feeding Practices Study II, 42conducted during 20052007 by the U.S. Food and Drug Administration (FDA) in collaborationwith CDC, was designed to ll in some o the gaps. For this longitudinal study o women ollowedrom late pregnancy through their inants rst year o lie, participants were selected rom across

the United States. On average,members o the study group hadhigher levels o education, were older,were more likely to be white, weremore likely to have a middle-levelincome, and were more likely to beemployed than the overall U.S. emalepopulation.42

Some o the ndings rom this studywere discouraging; or instance,almost hal o breasted newbornswere supplemented with inantormula while they were still in the

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hospital ater birth.43 Most healthy, ull-term, breasted newborns have no medical need to receivesupplemental inant ormula,44 and supplementing with inant ormula can be detrimental tobreasteeding.25 In addition, more than 40 percent o inants in the Inant Feeding PracticesStudy II sample were consuming solid oods within the rst our months ater birth43 despite

recommendations by the AAP that no inant, whether breasted or ormula ed, should be givenany solid oods until at least the age o our months.25

Figure 1. National Trends in Breastfeeding Rates

Percent

Healthy100

80

60

40

20

0201020052000199519901985198019751970

Ever

At 6 months

At 1 year

Exclusive6 months

Exclusive3 months

People2010Targets

Year

Note: Data rom beore 1999 are rom a diferent source, as indicated by the line break.Sources: 19701998, Ross Mothers Survey;38,39,40 19992007, Centers or Disease Control and Prevention, National Immunization Survey.41

Disparities in Breasteeding Practices

Despite overall improvements in breasteeding rates, unacceptable disparities in breasteeding havepersisted by race/ethnicity, socioeconomic characteristics, and geography (see able 2). For example,breasteeding rates or black inants are about 50 percent lower than those or white inants at birth,age six months, and age 12 months, even when controlling or the amilys income or educationallevel. On the other hand, the gap between white and black mothers in initiation o breasteeding has

diminished over time, rom 35 percentage points in 1990 to 18 percentage points in 2007. Yet, thegap in rates o breasteeding continuation at six months has remained around 15 percentage pointsthroughout this period.45,46

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Table 2. Provisional Breastfeeding Rates Among Children Born in 2007*

Sociodemographic FactorEver Breasted

(%)Breasteeding at6 Months (%)

Breasteeding at12 Months (%)

United States 75.0 43.0 22.4Race/ethnicity

American Indian or Alaska Native 73.8 42.4 20.7

Asian or Pacic Islander 83.0 56.4 32.8

Hispanic or Latino 80.6 46.0 24.7

Non-Hispanic Black or Arican American 58.1 27.5 12.5

Non-Hispanic White 76.2 44.7 23.3

Receiving WIC

Yes 67.5 33.7

No, but eligible 77.5 48.2 30.7

Ineligible 84.6 54.2 27.6

Maternal education

Not a high school graduate 67.0 37.0 21.9

High school graduate 66.1 31.4 15.1

Some college 76.5 41.0 20.5

College graduate 88.3 59.9 31.1

* Survey limited to children aged 1935 months at the time o data collection. Te lag between birth and collection o data allows or tracking obreasteeding initiation as well as calculating the duration o breasteeding.

WIC = Special Supplemental Nutrition Program or Women, Inants, and Ch ldren; U.S. Department o Agriculture.Source: Centers or Disease Control and Prevention, National Immunization Survey.41

Te reasons or the persistently lower rates o breasteeding among Arican American womenare not well understood, but employment may play a role.47 Arican American women tend toreturn to work earlier ater childbirth than white women, and they are more likely to work inenvironments that do not support breasteeding.48 Although research has shown that returning towork is associated with early discontinuation o breasteeding,40 a supportive work environmentmay make a dierence in whether mothers are able to continue breasteeding.49,50

With regard to socioeconomic characteristics, many studies have ound income to be positivelyassociated with breasteeding.40,51 For example, a study that included children participating inthe U.S. Department o Agricultures (USDA) Special Supplemental Nutrition Program or

Women, Inants, and Children (WIC), which uses income to determine eligibility, ound theywere less likely to be breasted than children in middle- and upper-income amilies.40 Educationalstatus is also associated with breasteeding; women with less than a high school education are arless likely to breasteed than women who have earned a college degree. Geographic disparitiesare also evident; women living in the southeastern United States are less likely to initiate andcontinue breasteeding than women in other areas o the country (see Figure 2), and womenliving in rural areas are less likely to breasteed than women in urban areas.51,52 Understanding

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the reasons or these disparities is crucial or identiying, developing, and implementing strategiesto overcome the barriers to breasteeding that women and amilies experience throughout ourcountry. Research suggests that 1) race and ethnicity are associated with breasteeding regardlesso income, and 2) income is associated with breasteeding regardless o race or ethnicity.51 Other

possible contributors to the disparities in breasteeding include the media, which has oten citedmore diculties with breasteeding than positive stories,5355 hospital policies and practices,52

the recommendations o WIC counselors,56 marketing o inant ormula,57 policies on work andparental leave,58,59 legislation,52,60 social and cultural norms,57 and advice rom amily and riends.47

Figure 2. Percentage of Children Ever Breastfed Among Children Bornin 2007,* by State

* Survey limited to children aged 1935 months at the time of data collection. Te lag between birth and collection of data allowed for tracking ofbreastfeeding initiation as well as calculating the duration of breastfeeding.Source: Centers for Disease Control and Prevention, National Immunization Survey.41

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Barriers to Breastfeedingin the United States

Even though a variety o evidence indicates that breasteeding reduces many dierent health risksor mothers and children, numerous barriers to breasteeding remainand action is needed toovercome these barriers.

Lack o Knowledge

Most women in the United States are aware that breasteeding is the best source o nutrition ormost inants, but they seem to lack knowledge about its specic benets and are unable to citethe risks associated with not breasteeding.6163 For example, a recent study o a national sample owomen enrolled in WIC reported that only 36 percent o participants thought that breasteeding

would protect the baby against diarrhea.61 Another national survey ound that only a quarter othe U.S. public agreed that eeding a baby with inant ormula instead o breast milk increases thechances the baby will get sick.62 In addition, qualitative research with mothers has revealed thatinormation about breasteeding and inant ormula is rarely provided by womens obstetriciansduring their prenatal visits.64 Moreover, many people, including health proessionals, believe thatbecause commercially prepared ormula has been enhanced in recent years, inant ormula isequivalent to breast milk in terms o its health benets;62,63 however, this belie is incorrect.

Mothers are also uncertain about what to expect with breasteeding and how to actually carry itout.64,65 Even though breasteeding is oten described as natural, it is also an art that has to belearned by both the mother and the newborn. Skills in how to hold and position a baby at the

breast, how to achieve an eective latch, and other breasteeding techniques may need to be taught.Not surprisingly, some women expect breasteeding to be easy, but then nd themselves aced with

challenges. Te incongruitybetween expectations aboutbreasteeding and the reality othe mothers early experienceswith breasteeding herinant has been identiedas a key reason that manymothers stop breasteedingwithin the rst two weekspostpartum.66 On the otherhand, a misperception thatmany women experiencediculties with breasteedingmay cause excessive concernamong mothers about itseasibility.6770

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Te perceived inconvenience o breasteeding is also an issue; in a national public opinion survey,45 percent o U.S. adults indicated that they believed a breasteeding mother has to give uptoo many habits o her liestyle.71 In addition, the commitment required by breasteeding anddiculties in establishing breasteeding are sometimes seen as threats to mothers reedom and

independence.7276

Unortunately, education about breasteeding is not always readily available to mothers nor easilyunderstood by them. Many women rely on books, leaets, and other written materials as theironly source o inormation on breasteeding,64,65,77 but using these sources to gain knowledgeabout breasteeding can be ineective, especially or low-income women, who may havemore success relying on role models.78 Te goals or educating mothers include increasing theirknowledge and skills relative to breasteeding and positively inuencing their attitudes about it.

Social Norms

In the United States, bottle eeding is viewed by many as the normal way to eed inants.Moreover, studies o mothers who are immigrants that examine the eects o acculturationhave ound that rates o breasteeding decrease with each generation in the United States andthat mothers perceive bottle eeding as more acceptable here than in their home countries.7986

Widespread exposure to substitutes or human milk, typically ed to inants via bottles, islargely responsible or the development o this social norm. Ater reviewing data rom marketresearch and studies conducted during 19802005, the U.S. Government Accountability Oce(GAO) reported that advertising o ormula is widespread and increasing in the United States.87

Furthermore, the strong inverse association between the marketing o human milk substitutesand breasteeding rates was the basis o the WHO International Code o Marketing o Breast-

milk Substitutes(the Code).35

Te Code has been rearmed in several subsequent World HealthAssembly resolutions. However, its provisions are not legally binding in the United States.

Certain cultural belies and practices also contribute to what women consider to be normal eedingpractices,76,88 although some o these practices are not recommended today. Te mistaken belie that,or babies, big is healthy, can lead to both ormula eeding and inappropriate early introductiono solid oods.89,90 Te alse idea that larger babies are healthier is common among many racial andethnic groups, and mothers who are part o social networks that hold this belie may be encouragedto supplement breasteeding with ormula i the inant is perceived as thin.91

Low-income Hispanic women in Denver, Colorado, were ound to avor a practice called best o

both (i.e., providing both breast milk and inant ormula). Despite guidance that breast milk is theonly source o nutrition a child needs or about the rst six months o lie, some women mistakenlysee the best o both as a way to ensure that their babies get both the healthy aspects o human milkand what they believe to be the vitamins present in inant ormula.67 Another practice associatedwith cultural belies is the use o cereal in a bottle because o the misperception that it will prolonginants sleep.90

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Poor Family and Social Support

Women with riends who have breasted successully are more likely to choose to breasteed. Onthe other hand, negative attitudes o amily and riends can pose a barrier to breasteeding. Some

mothers say that they do not ask or help with breasteeding rom their amily or riends becauseo the contradictory inormation they receive rom these sources.74

In many amilies, athers play a strong role in the decision o whether to breasteed.92,93 Fathers maybe opposed to breasteeding because o concerns about what their role would be in eeding, whetherthey would be able to bond with their inant i they were personally unable to eed the baby, andhow the mother would be able to accomplish household responsibilities i she breasted.64,72,94,95

Studies o Arican American amilies in which education on breasteeding was directed at the atheround a 20 percent increase in breasteeding rates, indicating that paternal inuences on maternaleeding practices are critically important in early decision making about breasteeding.92,96

Although they can constitute a barrier to breasteeding, athers can also be a positive inuence.A randomized controlled trial o a two-hour prenatal intervention with athers on how to besupportive o breasteeding ound a ar higher rate o breasteeding initiation among participantspartners (74 percent) than among partners o controls (14 percent).93 In another trial, 25 percento women whose partners participated in a program on how to prevent and address commonproblems with lactation (such as pain or ear o insucient milk) were still breasteeding at sixmonths, compared with 15 percent o women whose partners were inormed only about thebenets obreasteeding.97 Among women who experienced challenges with breasteeding, theprogram eect was even stronger, with 24 percent o participants partners breasteeding at sixmonths versus less than 5 percent o partners in the comparison group.97

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Embarrassment

A study that analyzed data rom a national public opinion survey conducted in 2001 ound thatonly 43 percent o U.S. adults believed that women should have the right to breasteed in public

places.98

Restaurant and shopping center managers have reported that they would either discouragebreasteeding anywhere in their acilities or would suggest that breasteeding mothers move to anarea that was more secluded.73,99,100When they have breasted in public places, many mothers havebeen asked to stop breasteeding or to leave.99 Such situations make women eel embarrassed andearul o being stigmatized by people around them when they breasteed.68,95,101,102 Embarrassmentremains a ormidable barrier to breasteeding in the United States and is closely related todisapproval o breasteeding in public.76,102104 Embarrassment about breasteeding is not limitedto public settings, however. Women may nd themselves excluded rom social interactions whenthey are breasteeding because others are reluctant to be in the same room while theybreasteed.65

For many women, the eeling o embarrassment restricts their activities and is cited as a reason orchoosing to eed supplementary ormula or to give up breasteeding altogether.104,105

In American culture, breasts have oten been regarded primarily as sexual objects, while theirnurturing unction has been downplayed. Although ocusing on the sexuality o emale breastsis common in the mass media, visual images o breasteeding are rare, and a mother may neverhave seen a woman breasteeding.106109 As shown in both quantitative and qualitative studies, theperception o breasts as sexual objects may lead women to eel uncomortable about breasteedingin public.68,101 As a result, women may eel the need to conceal breasteeding, but they havediculty nding comortable and accessible breasteeding acilities in public places.110,111

Lactation Problems

Frequently cited problems with breasteeding include sore nipples, engorged breasts, mastitis,leaking milk, pain, and ailure to latch on by the inant.64,112Women who encounter theseproblems early on are less likely to continue to breasteed unless they get proessionalassistance.64,90 Research has ound that mothers base their breasteeding plans on previousexperiences, and resolution o these problems may aect their uture decisions about eeding.64,90

Concern about insucient milk supply is another requently cited reason or early weaning o theinant.90,113116 One national study on eeding practices ound that about 50 percent o mothers citedinsucient milk supply as their reason or stopping breasteeding.112 Having a poor milk supply canresult rom inrequent eeding or poor breasteeding techniques,115,117119 but lack o condence inbreasteeding or not understanding the normal physiology o lactation can lead to the perception oan insucient milk supply when in act the quantity is enough to nurture the baby.120,121

Women report receiving conicting advice rom clinicians about how to solve problems withbreasteeding.94,122,123 Successul initiation depends on experiences in the hospital as well as accessto instruction on lactation rom breasteeding experts, particularly in the early postpartum period.Most problems, i identied and treated early, need not pose a threat to the continuation osuccessul breasteeding.124128

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Employment and Child Care

Employed mothers typically nd that returning to work is a signicant barrier to breasteeding.Women oten ace inexibility in their work hours and locations and a lack o privacy or

breasteeding or expressing milk, have no place to store expressed breast milk, are unable tond child care acilities at or near the workplace, ace ears over job insecurity, and have limitedmaternity leave benets.13,101,116,129131 In 2009, the Society or Human Resource Managementreported that only 25 percent o companies surveyed had lactation programs or made specialaccommodations or breasteeding.132 Small businesses (ewer than 100 employees) are the leastlikely to have lactation programs, and whether the workplace is large or small, inants are generallynot allowed to be there.132 Many mothers encounter pressure rom coworkers and supervisorsnot to take breaks to express breast milk, and existing breaks oten do not allow sucient timeor expression.133When mothers who do not have a private oce at work do not have a place tobreasteed or express breast milk, they may resort to using the restroom or these purposes, anapproach that is unhygienic and associated with premature weaning.134137

Lack o maternity leave can also be a signicant barrier to breasteeding. Studies show that womenintending to return to work within a year ater childbirth are less likely to initiate breasteeding,and mothers who work ull-time tend to breasteed or shorter durations than do part-time orunemployed mothers.129,138Women with longer maternity leaves are more likely to combinebreasteeding and employment.139 In a survey o 712 mothers, each week o maternity leaveincreased the duration o breasteeding by almost one-hal week.140 Jobs that have less exibilityand require long separations o mother and baby urther complicate breasteeding.131 Hourly wage

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workers ace dierent challenges than salaried workers, as the ormer typically have less controlover their schedules, and their pay may be reduced i they take breaks to express breast milk.141

Barriers Related to Health ServicesStudies have identied major decits relevant to breasteeding in hospital policies and clinicalpractices, including a low priority given to support or breasteeding and education about it,inappropriate routines and provision o care, ragmented care, and inadequate hospital acilities orwomen who are breasteeding.142,143 A recent report that summarizes maternity practices related tobreasteeding in 2,687 hospitals and birth centers in the United States indicated that these practicesare oten not evidence based and requently interere with breasteeding.52 For example, 24 percento birth acilities in the survey reported giving supplemental eeding to more than hal o healthy,ull-term, breasted newborns during the postpartum stay,52 a practice shown to be unnecessary anddetrimental to breasteeding.144,145 In addition, 70 percent o acilities that participated in the survey

reported giving breasteeding mothers git packs containing samples o inant ormula,

52

which canhave a negative inuence on both the initiation and duration o breasteeding.146149

Separating mothers rom their babies during their hospital stay has a negative impact on theinitiation and duration o breasteeding,150,151 yet DiGirolamo and colleagues152 reported that only57 percent o U.S. hospitals and birth centers allowed newborns to stay in the same room as theirmothers. In addition, an inverse relationship exists between breasteeding rates and invasive medicalinterventions during labor and delivery, such as cesarean section.153 Cesarean delivery is associatedwith delayed skin-to-skin contact between mother and baby, increased supplemental eeding,and separation o mother and baby, all o which lead to suboptimal breasteeding practices.153157

Nevertheless, cesarean births are not rare; preliminary data or 2007 indicate that almost one-third o

women (32 percent) in the United States gave birth by cesarean section in that year, which is higherthan the prevalence o 21 percent reported just 10 years prior in 1997.158,159

Obstetrician-gynecologists, pediatricians, and other providers o maternal and child care havea unique opportunity to promote and support breasteeding. Although pregnant women andmothers consider the advice o clinicians to be very important with regard to their decisions aboutbreasteeding, clinicians oten underestimate their own inuence on breasteeding.160,161 Cliniciansreport eeling that they have insucient knowledge about breasteeding and that they havelow levels o condence and clinical competence in this area.143 A recent survey o pediatriciansshowed that many believe the benets o breasteeding do not outweigh the challenges that maybe associated with it, and they reported various reasons to recommend against breasteeding.162

Physicians who are ambivalent about breasteeding or who eel inadequately trained to assistpatients with breasteeding may be unable to properly counsel their patients on specics aboutbreasteeding techniques, current health recommendations on breasteeding, and strategies tocombine breasteeding and work.90,101,143,161,163165 Furthermore, a study o clinicians knowledge andattitudes about breasteeding ound that some clinicians used their own breasteeding experiencesto replace evidence-based knowledge and recommendations they shared with their patients.160

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Breastfeeding from thePublic Health Perspective

Mothers and Their Families

Mothers who are knowledgeable about the numerous health benets o breasteeding are morelikely to breasteed.61,166 Research has shown that mothers tend to believe that breasteeding isbest or their babies, but they appear to know less about the specic reductions in health risksthat occur through breasteeding and the consumption o breast milk.61Without knowing thisinormation, mothers cannot properly weigh the advantages and disadvantages o breasteedingversus ormula eeding, and thus they cannot make a truly inormed decision about how theywant to eed their babies.

Although having inormation about the health advantages o breasteeding is important,knowing how to breasteed is crucial. Mothers who do not know how to initiate and continuebreasteeding ater a child is born may ear that it will always be painul or that they will be unableto produce enough milk to ully eed the baby. As a result, they may decide to ormula eed thechild. Expectant mothers who believe that breasteeding is dicult or painul identiy the ear odiscomort as a major negative inuence on their desire to initiate breasteeding,68,74 and mothersoten expect that breasteeding will be dicult during the rst couple o months.67,167

Prenatal classes can be usedto help inorm women aboutthe health advantages o

breasteeding, both or babiesand mothers, and instructorscan explain to women theprocess and techniques theycan use to breasteed.168

Furthermore, these classescan help prepare expectantmothers or what theyshould actually experience byproviding them with accurate

inormation on breasteeding.However, pregnant womenmay not be aware o whereclasses on breasteeding areoered, or even that theyexist. Tus, clinicians have animportant responsibility to

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help their patients nd a breasteeding class in which they can participate beore their babies areborn. I clinicians do not readily provide inormation about such classes, mothers can ask theirclinicians or assistance and advice about how they can nd a class. In addition, women can turnto other mothers or inormation and help with breasteeding. Tese women could include other

breasteeding mothers in their communities, whether they are amily, riends, or mothers theyhave met through mother-to-mother support groups, as well as women who are knowledgeableand have previous experience with breasteeding.

Women should be encouraged to discuss with others their desire and plans to breasteed, whethersuch persons are clinicians, amily and riends, employers, or child care providers. When a womanhas decided she wants to breasteed, discussing her plans with her clinician during prenatal careand again when she is in the hospital or birth center or childbirth will enable her clinician to giveher the type o inormation and assistance she needs to be successul.124 Her partner and the babysgrandmothers also play critical support roles when it comes to breasteeding, both with regard toassisting in decision making about how the baby is ed and in providing support or breasteeding

ater the baby is born.92,169

Many women mistakenly think they cannot breasteed i they plan to return to work aterchildbirth, and thus they may not talk with their employers about their desire to breasteed orhow breasteeding might be supported in the workplace.101 I employers are unaware o what isrequired, mothers can explain that ederal law now requires employers to provide breasteedingemployees with reasonable break time and a private, non-bathroom place to express breast milkduring the workday, up until the childs rst birthday.

In 2009, hal o all mothers with children under the age o one year were employed,170 and thussupportive child care is essential or breasteeding mothers. Beore the child is born, parents canvisit child care acilities to determine whether the sta and acility can provide the type o childcare that helps a mother to provide breast milk to her baby even i she is separated rom the babybecause o work. By telling these important people she wants to breasteed and by discussing waysthey can be supportive, an expectant mother is taking a proactive role in ensuring that she and herbaby have an environment that gives breasteeding the best possible start.

Despite the best planning, however, problems or challenges may arise, and when they do, mothersdeserve help in solving them. Many sources o assistance are available, such as certied lactationconsultants and other clinicians, WIC sta, and peer counselors.171174 Ideally, a mother willhave access to trained experts who can help her with breasteeding, and by asking her health care

or WIC provider about obtaining help i she needs it, a mother is taking appropriate action tobuild a support system. Even ater childbirth, a mother can ask or reerrals to community-basedor other types o support, including telephone support. Te important thing or mothers toremember is that they should be able to receive help, but they may have to ask or it.

As noted previously, athers can have a tremendous inuence on breasteeding. Some ather-ocused eorts are under way in the United States, including the USDAs Fathers SupportingBreasteeding program, which uses a video, posters, and brochures designed to target Arican

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American and other athers to positively inuence a womans decision to breasteed.175 Inaddition, an innovative pilot study in a exas WIC program used a ather-to-ather peercounseling approach to improve breasteeding rates among participants wives and partners. Teprogram not only demonstrated improved breasteeding rates but also showed improvements

in athers knowledge about breasteeding and their belies that they could provide support totheir breasteeding partners.176 Elsewhere, an intervention intended or both athers and thebabys grandmothers that discussed the benets and mechanics o breasteeding, as well as theneed or emotional and practical support, was described as enjoyable, acceptable, and useul byparticipants.177

Grandmothers also have tremendous inuence on a womans decisions and practices relative toeeding her inant.177,178 I a babys grandmother previously breasted, she can share her experienceand knowledge and can support a mother through any challenges with breasteeding.169

Conversely, i a babys grandmother did not breasteed, she may try to discourage it or suggestormula eeding whenever a problem arises.179 Mothers who breasteed want their own mothers

to be supportive o them and o their decision to breasteed, regardless o how they ed their ownchildren, and they want them to be knowledgeable about current inormation on breasteeding.169

In conclusion, knowing about the healthrisks o not breasteeding is important ormothers, but knowing how to breasteedis critical as well. Prenatal classes onbreasteeding are valuable, and mothersshould discuss with a variety o other peopletheir interest in breasteeding. alking to

their clinicians about their intention tobreasteed is important, as is asking aboutthe provisions or breasteeding or expressingmilk where they work. Both the ather othe child and the womans mother may playimportant roles in the decision to breasteed.Mothers deserve help with this importantdecision.

Communities

A womans ability to initiate and sustainbreasteeding is inuenced by a host o actors,including the community in which she lives.54

A womans community has many components,such as public health and other community-based programs, coalitions and organizations,schools and child care centers, businesses

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and industry, and the media. Te extent to which each o these entities supports or discouragesbreasteeding can be crucial to a mothers success in breasteeding.

Although the USDAs WIC program has always encouraged breasteeding, ederal regulations

enacted as part o the 2009 appropriations or the program contain robust provisions that expandthe scope o WICs activities to encourage and support its participants in breasteeding.180 Federalregulations speciy the actions that state agencies must take to ensure 1) a sustainableinrastructure or breasteeding activities; 2) the prioritization o breasteeding mothers and childrenin the WIC certication process; 3) activities to support education in nutrition or breasteedingmothers, including peer support; and 4) allowances or using program unds to carry out activitiesthat improve support or breasteeding among WIC participants. WIC has begun a nationwidetraining program or all local agencies called Using Loving Support to Grow and Glow in WIC:Breasteeding raining or Local WIC Sta to ensure that all WIC sta can promote and supportbreasteeding.181

Exclusive breasteeding is rewarded in the WIC program in multiple ways, including oering aood package with a higher monetary value or breasteeding participants than or participantswho do not breasteed or who do so only partially. In 2009, a variety o items, including largeramounts o ruits and vegetables, was added to the ood package or women who breasteed

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to provide enhanced support or them. Additionally, the new ood package provided higherquantities o complementary oods to be given to breasted babies who are at least six months old.Beore their babies are born, WIC clients receive education and counseling about breasteedingand are ollowed up soon ater the birth. Many breasteeding mothers in WIC receive breast

pumps and other items to support the continuation o breasteeding. Te USDA uses a socialmarketing approach to encourage and support breasteeding that began with the campaign LovingSupport Makes Breasteeding Work,182 as well as a research-based, culturally sensitive set o socialmarketing resources known as Breasteeding: A Magical Bond o Love, which is specically orHispanic participants.183

Clinicians are another important source o education and support or breasteeding. When a motheris discharged rom a maternity acility ater childbirth, she may need continued breasteedingsupport, not only rom her amily but also rom proessionals aliated with the maternity acility.Proessional post-discharge breasteeding support o mothers can take many orms, includingplanned ollow-up visits at the maternity acility, telephone ollow-ups initiated by the maternity

acility, reerrals to community-based support groups and organizations, and home visits. TeAordable Care Act passed in 2010 includes a provision to expand home visitation programs orpregnant women and children rom birth through kindergarten entry.184 Tis unding has thepotential to greatly improve ollow-up breasteeding care or low-income amilies i breasteeding isadequately incorporated into the programs.

Posting inormation on Web sites, providing online support, and having breasteeding warmlinesand hotlines that mothers can call whenever they need help or to ask specic breasteeding-relatedquestions are additional ways that mothers typically nd help postpartum.10,185,186 o be mosteective, however, postpartum support needs to be a comprehensive strategy designed to help

women overcome challenges in sustaining exclusive, continued breasteeding.10,148,187,188

Te provision o peer support is another method that has been shown to improve breasteedingpractices.173,174,189191 Peer support can be given in structured, organized programs, or it can beoered inormally by one mother to another. Peer counselors are mothers who have personalexperience with breasteeding and are trained to provide counseling about and assistance withbreasteeding to other mothers with whom they share various characteristics, such as language,race/ethnicity, and socioeconomic status. Tey reinorce breasteeding recommendations in asocially and culturally appropriate context. Peer counselors may be eective in part because theyare seen as role models192 and also because they oten provide assistance through phone calls orhome visits.173

Peer-counseling programs that provide breasteeding support or low-income women who areenrolled in or eligible or WIC have been ound to be eective at both agency and individuallevels in improving breasteeding rates.193 For example, using peer counselors or prenatal WICparticipants increased the agencys enrollment o breasteeding postpartum women.172 Individually,a breasteeding support program that included peer counseling increased breasteeding initiationamong WIC participants in Michigan by about 27 percentage points and the duration o

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breasteeding by more than three weeks.171 Hispanic immigrant mothers in Houston who wereeligible or WIC and who received breasteeding support rom peer counselors were nearly twice aslikely as nonparticipants to be exclusively breasteeding at our weeks postpartum, and they weresignicantly less likely to supplement breast milk eedings with water or tea.194 Several investigations

o peer counseling have identied the prenatal period as particularly important or establishingrelationships between peer counselors and WIC participants. Results o these studies indicate thatcounseling during this period allows peer counselors to proactively address participants questionsand concerns about breasteeding and enables both the counselor and the mother to prepare orsupport that will be provided in the early postpartum days.172

Peer support also can be given through volunteer community-based groups and organizations, suchas La Leche League (www.llli.org) and other nursing mothers support groups. In addition, newercommunity organizations are emerging, such as the Arican-American Breasteeding Alliance,the Black Mothers Breasteeding Association (www.blackmothersbreasteeding.org), and MochaMoms (www.mochamoms.org). Beyond advocating or community support or breasteeding, these

organizations and groups provide peer support ocused on women o color and provide culturallytailored breasteeding support that may not be available or sought ater rom other support groups.Tese new groups and organizations, however, may have limited membership rolls and thus verysmall budgets. Financial assistance rom oundations and government may be needed early on tormly establish and support these organizations, which strive to meet the needs o communities thatare typically underserved in terms o health and social services.

In a review o 34 trials that included more than 29,000 mother-inant pairs across 14 countries,proessional and lay support together were ound to increase the duration o any breasteeding, as wellas the duration o exclusive breasteeding.189 For women who received both orms o support, the risk

o breasteeding cessation was signicantly lower at six weeks and at two months than it was amongthose who received the usual care. Exclusive breasteeding was signicantly extended when counselorswere trained using a program sponsored by WHO and UNICEF.189

Marketing o inant ormula within communities is another negative inuence on breasteeding. TeWHO International Code o Marketing o Breast-milk Substitutesdeclares that substitutes or breastmilk should not be marketed in ways that can interere with breasteeding.35Yet ormula is marketeddirectly to the consumer through television commercials and print advertisements and indirectlythrough logo-bearing calendars, pens, and other materials in hospitals or doctors oces. Formulaalso is marketed through the distribution o git packs at discharge that contain samples o ormulaor coupons, oten in bags with a manuacturers name or logo.

Research indicates that the marketing o substitutes or breast milk has a negative eect onbreasteeding practices. For example, advertising inant ormula in doctors oces that womenvisit beore their babies are born lowers the rate o breasteeding among these women.195 Inthe immediate postpartum period, such as in the hospital ater childbirth, the marketing oinant ormula can deter exclusive breasteeding196 and may have an even stronger eect amongwomen who do not have well-dened goals or breasteeding.197 In addition, women who receive

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commercial discharge packs that include ormula are less likely to be breasteeding exclusively at10 weeks postpartum than are women who do not receive them.149 A Cochrane review concludedthat women who received discharge packs were less likely to be exclusively breasteeding at anytime postpartum than women who did not receive a discharge pack.198

Some o the marketing strategies used by inant ormula companies may require review toensure they are truthul and that they are not detrimental to breasteeding. For example, inDecember 2009, a ederal court upheld a $13.5 million jury verdict against manuacturerMead Johnson & Co. or alse and misleading advertising; the court permanently barred MeadJohnson rom claiming that its Enamil LIPIL inant ormula would give babies better visualand brain development than ingredients in store-brand ormula.199 In 2006, the GAO oundthat manuacturers o inant ormula had violated the USDA Food and Nutrition Service rulesby using the WIC logo and acronym in advertising ormula.87Voluntary adherence by ormulamanuacturers to recommended guidelines on ormula marketing may not be eective orconsistent throughout the industry, and thus ormal guidelines and monitoring may be necessary

to ensure that policies and procedures are ollowed.

In recent years, advertising and social marketing have been used more requently to promoteand support breasteeding. Te USDA national breasteeding promotion campaign mentionedearlier, Loving Support Makes BreasteedingWork, was launched in 1997 to promotebreasteeding to WIC participants andtheir amilies by using social marketingtechniques, including mass media andeducational materials, and through sta

training. Te goals o the campaign are toencourage WIC participants to initiate andcontinue breasteeding, to increase reerrals toWIC or support or breasteeding throughcommunity outreach, to increase the publicsacceptance and support o breasteeding,and to provide technical assistance to stateand local WIC sta who are promoting andsupporting breasteeding.

Tis campaign emphasizes the concept

that the support o amily and riends, thehealth care system, and the community areall essential or a breasteeding mother to besuccessul.182 An evaluation in 1997 o thecampaigns eects in Iowa demonstrated anincrease in initiation o breasteeding rom57.8 percent at baseline to 65.1 percent one

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year ater implementation o the campaign. Te percentage o mothers continuing to breasteed atsix months postpartum also increased, rom 20.4 percent at baseline to 32.2 percent one year aterthe campaign was implemented.200 Campaign materials continue to be available.

In 2004, the HHS/OWH and the Advertising Council launched a national campaign encouragingrst-time mothers to breasteed exclusively or six months. Te tagline o the two-year campaignwas Babies were born to be breasted.201 Te campaign ocused on research showing that babieswho are breasted exclusively or six months are less likely to develop certain illnesses or to becomeobese than babies who are not breasted, and it consistently emphasized the importance o exclusivebreasteeding or six months. Awareness o the breasteeding campaign increased rom 28 percentto 38 percent a year ater it was started.201 Additionally, the percentage o those sampled who agreedthat babies should be exclusively breasted or six months increased rom 53 percent beore thecampaign to 62 percent one year ater the campaign was implemented.201

As the 20042006 national breasteeding awareness campaign demonstrated, people seek and nd

health inormation rom a variety o sources. Evidence points to increasing reliance on the Internetor health inormation, particularly among those aged 1849 years. In a report o ndings romthe 2008 Pew Internet and American Lie Project Survey o more than 2,000 adults, when askedwhat sources they turned to or health or medical inormation, 86 percent reported asking a healthproessional, such as a physician, 68 percent asked a riend or amily member, and 57 percent saidthey used the Internet.202 Social networking sites, such as Facebook and MySpace, appear to be lesslikely sources or gathering or sharing actual health inormation; instead, they serve as tools to helpusers rene the health questions they ask their clinicians.202 o date, most educational outreach onbreasteeding has been conducted interpersonally, on a ace-to-ace basis, sometimes with a videotapeincluded as part o the instruction. As more people become regular users o various types o

electronic communication such as social networking sites and mobile messaging, new strategies willbe needed or conducting outreach and or communicating health inormation to amilies.

In summary, a womans ability to initiate and continue breasteeding is inuenced by a hosto community-based actors. Family members, such as athers and babies grandmothers, areimportant parts o a mothers lie. It may be important or community-based groups to includethem in education and support programs or breasteeding. Postpartum support rom maternityacilities is an important part o helping mothers to continue breasteeding ater discharge.Community-based support groups, organizations, and programs, as well as the eorts o peercounselors, expand on the support that women obtain in the hospital and provide a continuity ocare that can help extend the duration o breasteeding.

In addition, public health eorts such as the 20042006 national breasteeding awarenesscampaign may inuence women to initiate and continue breasteeding by helping to improvetheir knowledge and understanding o the reduced health risks and other positive outcomesassociated with breasteeding. Te sources rom which these messages are communicated,however, may need to evolve as more people use Web-based technologies to search or health andother types o inormation. In summary, a multiaceted approach to promoting and supportingbreasteeding is needed at the community level.

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Health Care

Te U.S. Preventive Services ask Force (USPSF) specically recommends that promotionand support or breasteeding be provided throughout the encounters women have with health

proessionals during prenatal and postpartum care, as well as during their inants medical care.168In addition, education and counseling on breasteeding are unanimously recognized by the AAPand the American College o Obstetricians and Gynecologists in their Guidelines or Perinatal Care203 as a necessary part o prenatal and pediatric care. Similarly, the American Academy o FamilyPhysicians27 and the American College o Nurse-Midwives29 call or the consistent provision obreasteeding education and counseling services. Yet many clinicians are not adequately preparedto support mothers who wish to breasteed.

Te USPSF168 concluded that promotion and support o breasteeding are likely to be mosteective when integrated into systems o care that include training o clinicians and other healthteam members, policy development, and support rom senior leadership. Moreover, the task

orce noted that many successul multicomponent programs that support pregnant women andmothers o young children include the provision o lay support or reerral to community-basedorganizations. Te task orce also noted that breasteeding interventions, like all other healthcare interventions designed to encourage healthy behaviors, should strive to empower individualsto make inormed choices supported by the best available evidence. As with interventions toachieve a healthy weight or to quit smoking, the task orce calls or breasteeding interventions tobe designed and implemented in ways that do not make women eel guilty when they make aninormed choice not to breasteed.

In the United States, the majority o pregnantwomen plan to breasteed,166 and yet there is aclear gap between the proportion o women whoprenatally intend to breasteed and those whoactually do so by the time they are dischargedater a brie hospital stay.166,204 Te experiencesthat mothers and inants have as patients duringthe maternity stay shape the inants eedingbehaviors;161 however, the quality o prenatal,postpartum, and pediatric medical care inthe United States has been inconsistent.152,205

Mothers experiences as they receive this care have

an inuence on their intention to breasteed,206the biologic establishment o lactation,144 andbreasteeding duration.207

Nearly all births in the United States occur inhospital settings,159 but hospital practices andpolicies in maternity settings can undermine

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maternal and inant health by creating barriers to supporting a mothers decision to breasteed.National data rom the ongoing CDC survey o Maternity Practices in Inant Nutrition andCare (mPINC), which assesses breasteeding-related maternity practices in hospitals and birthcenters across the United States, indicate that barriers to breasteeding are widespread during

labor, delivery, and postpartum care, as well as in hospital discharge planning.208 Results o the2007 mPINC survey showed that, on average, U.S. hospitals scored only 63 out o a possible 100points on an overall measure o breasteeding-related maternity care.208 Furthermore, geographicdisparities in care52 correspond closely with the geographic patterns o state-level breasteeding,41

highlighting the southern United States as particularly in need o improvement in the quality oroutine maternity care.

Examples o barriers to breasteeding include placement o the stable, healthy, ull-term newbornon an inant warmer immediately upon delivery rather than skin-to-skin with the mother,64

provision o inant ormula or water to breasted newborns without medical indication,44 removalo the newborn rom the mothers room at night,209 inadequate assurance o post-discharge

ollow-up or lactation support,10 and provision o promotional samples o inant ormula rommanuacturers.149 Many studies have shown that practices such as these are associated with ashorter duration o breasteeding.152,210

A set o maternity care practices has been identied that, when implemented together,148,211,212 resultsin better breasteeding outcomes.152,213216 Te Baby-Friendly Hospital Initiative217 established byWHO and UNICEF in 1991 includes these maternity practices, which are known as the en Stepsto Successul Breasteeding. Te Joint Commission, an organization that accredits and certieshealth care organizations and programs in the United States, has identied the concept o bundleso care such as those in the en Steps to Successul Breasteeding as a promising strategy to improve

the care provided to patients.218

In addition, researchers in Caliornia have ound that disparitiesin in-hospital rates o exclusive breasteeding are not ound in hospitals that have implemented thepolicies and practices o the Baby-Friendly Hospital Initiative, while the opposite is true in hospitalsthat are in the same geographic region but are not designated as Baby-Friendly.204

Upon discharge rom the hospital, mothers may have no means o identiying or obtaining theskilled support needed to address their concerns about lactation and breasteeding; urther, theremay be barriers to reimbursement or needed lactation care and services.219 In addition, limitedcommunication between clinicians across health care settings220 and between clinicians andmothers also may make mothers less likely to comply with recommended postpartum health carevisits than they were during the prenatal period.205

Increased recognition o the responsibility that clinicians have to encourage and supportbreasteeding25 has led to the development o initiatives to improve continuity o care andsupport or breasteeding. Te AAPs Sae and Healthy Beginnings program provides aramework or continuity o care rom the prenatal period through childbirth to the postpartumperiod and beyond, and it includes standards o care to prevent breasteeding problems andhyperbilirubinemia.205,222 In various communities, the health care system has successully

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coordinated with community networks to provide breasteeding support to ensure that mothershave access to breasteeding assistance ater they return home. An important part o this assistanceis having access to trained individuals who have established relationships with members o thehealth care community,223 are exible enough to meet mothers needs outside o traditional work

hours and locations,224 and provide consistent inormation.225

The Ten Steps to Successful Breastfeeding

1. Have a written breasteeding policy that is routinely communicated to all health care sta.

2. Train all health care sta in skills necessary to implement this policy.

3. Inorm all pregnant women about the benefts and management o breasteeding.

4. Help mothers initiate breasteeding within one hour o birth.

5. Show mothers how to breasteed and how to maintain lactation, even i they are separated rom their inants.

6. Give newborn inants no ood or drink other than breastmilk, unless medically indicated.

7. Practice rooming inallow mothers and inants to remain together 24 hours a day.

8. Encourage breasteeding on demand.

9. Give no pacifers or artifcial nipples to

breasteeding inants.10. Foster the establishment o breasteeding support

groups and reer mothers to them on dischargerom the hospital or clinic.

Baby-Friendly USA221

For any kind o health service, adequateeducation and training are essential. Even so,a study o obstetricians attitudes, practices,and recommendations206 ound that although86 percent o clinicians reported havingprenatal discussions about inant eeding,and 80 percent o them recommendedbreasteeding, nearly 75 percent admittedthey had either inadequate or no training

in how to appropriately educate mothersabout breasteeding. Te inormationon breasteeding included in medicaltexts is oten incomplete, inconsistent,and inaccurate.226 In addition, althoughormative research has revealed that hospitalmanagement recognizes the public healthimportance o breasteeding and agrees thatit is the optimal nutrition or most inants,management is largely unaware o the specic

characteristics o supportive breasteedingcare. Despite recognizing the demand oreviden

Documents

Call to Action to Support Breast Feeding