Mothers and Their Families

Mothers who are knowledgeable about the numerous health benefits of breastfeeding are more likely to breastfeed.^61,166 Research has shown that mothers tend to believe that breastfeeding is best for their babies, but they appear to know less about the specific reductions in health risks that occur through breastfeeding and the consumption of breast milk.⁶¹ Without knowing this information, mothers cannot properly weigh the advantages and disadvantages of breastfeeding versus formula feeding, and thus they cannot make a truly informed decision about how they want to feed their babies.

Although having information about the health advantages of breastfeeding is important, knowing how to breastfeed is crucial. Mothers who do not know how to initiate and continue breastfeeding after a child is born may fear that it will always be painful or that they will be unable to produce enough milk to fully feed the baby. As a result, they may decide to formula feed the child. Expectant mothers who believe that breastfeeding is difficult or painful identify the fear of discomfort as a major negative influence on their desire to initiate breastfeeding,^68,74 and mothers often expect that breastfeeding will be difficult during the first couple of months.^67,167

Prenatal classes can be used to help inform women about the health advantages of breastfeeding, both for babies and mothers, and instructors can explain to women the process and techniques they can use to breastfeed.¹⁶⁸ Furthermore, these classes can help prepare expectant mothers for what they should actually experience by providing them with accurate information on breastfeeding. However, pregnant women may not be aware of where classes on breastfeeding are offered, or even that they exist. Thus, clinicians have an important responsibility to help their patients find a breastfeeding class in which they can participate before their babies are born. If clinicians do not readily provide information about such classes, mothers can ask their clinicians for assistance and advice about how they can find a class. In addition, women can turn to other mothers for information and help with breastfeeding. These women could include other breastfeeding mothers in their communities, whether they are family, friends, or mothers they have met through mother-to-mother support groups, as well as women who are knowledgeable and have previous experience with breastfeeding.

Women should be encouraged to discuss with others their desire and plans to breastfeed, whether such persons are clinicians, family and friends, employers, or child care providers. When a woman has decided she wants to breastfeed, discussing her plans with her clinician during prenatal care and again when she is in the hospital or birth center for childbirth will enable her clinician to give her the type of information and assistance she needs to be successful.¹²⁴ Her partner and the baby’s grandmothers also play critical support roles when it comes to breastfeeding, both with regard to assisting in decision making about how the baby is fed and in providing support for breastfeeding after the baby is born.^92,169

Many women mistakenly think they cannot breastfeed if they plan to return to work after childbirth, and thus they may not talk with their employers about their desire to breastfeed or how breastfeeding might be supported in the workplace.¹⁰¹ If employers are unaware of what is required, mothers can explain that federal law now requires employers to provide breastfeeding employees with reasonable break time and a private, non-bathroom place to express breast milk during the workday, up until the child’s first birthday.

In 2009, half of all mothers with children under the age of one year were employed,¹⁷⁰ and thus supportive child care is essential for breastfeeding mothers. Before the child is born, parents can visit child care facilities to determine whether the staff and facility can provide the type of child care that helps a mother to provide breast milk to her baby even if she is separated from the baby because of work. By telling these important people she wants to breastfeed and by discussing ways they can be supportive, an expectant mother is taking a proactive role in ensuring that she and her baby have an environment that gives breastfeeding the best possible start.

Despite the best planning, however, problems or challenges may arise, and when they do, mothers deserve help in solving them. Many sources of assistance are available, such as certified lactation consultants and other clinicians, WIC staff, and peer counselors.^171–174 Ideally, a mother will have access to trained experts who can help her with breastfeeding, and by asking her health care or WIC provider about obtaining help if she needs it, a mother is taking appropriate action to build a support system. Even after childbirth, a mother can ask for referrals to community-based or other types of support, including telephone support. The important thing for mothers to remember is that they should be able to receive help, but they may have to ask for it.

As noted previously, fathers can have a tremendous influence on breastfeeding. Some father-focused efforts are under way in the United States, including the USDA’s Fathers Supporting Breastfeeding program, which uses a video, posters, and brochures designed to target African American and other fathers to positively influence a woman’s decision to breastfeed.¹⁷⁵ In addition, an innovative pilot study in a Texas WIC program used a father-to-father peer counseling approach to improve breastfeeding rates among participants’ wives and partners. The program not only demonstrated improved breastfeeding rates but also showed improvements in fathers’ knowledge about breastfeeding and their beliefs that they could provide support to their breastfeeding partners.¹⁷⁶ Elsewhere, an intervention intended for both fathers and the baby’s grandmothers that discussed the benefits and mechanics of breastfeeding, as well as the need for emotional and practical support, was described as enjoyable, acceptable, and useful by participants.¹⁷⁷

Grandmothers also have tremendous influence on a woman’s decisions and practices relative to feeding her infant.^177,178 If a baby’s grandmother previously breastfed, she can share her experience and knowledge and can support a mother through any challenges with breastfeeding.¹⁶⁹ Conversely, if a baby’s grandmother did not breastfeed, she may try to discourage it or suggest formula feeding whenever a problem arises.¹⁷⁹ Mothers who breastfeed want their own mothers to be supportive of them and of their decision to breastfeed, regardless of how they fed their own children, and they want them to be knowledgeable about current information on breastfeeding.¹⁶⁹

In conclusion, knowing about the health risks of not breastfeeding is important for mothers, but knowing how to breastfeed is critical as well. Prenatal classes on breastfeeding are valuable, and mothers should discuss with a variety of other people their interest in breastfeeding. Talking to their clinicians about their intention to breastfeed is important, as is asking about the provisions for breastfeeding or expressing milk where they work. Both the father of the child and the woman’s mother may play important roles in the decision to breastfeed. Mothers deserve help with this important decision.

Communities

A woman’s ability to initiate and sustain breastfeeding is influenced by a host of factors, including the community in which she lives.⁵⁴ A woman’s community has many components, such as public health and other community based programs, coalitions and organizations, schools and child care centers, businesses and industry, and the media. The extent to which each of these entities supports or discourages breastfeeding can be crucial to a mother’s success in breastfeeding.

Although the USDA’s WIC program has always encouraged breastfeeding, federal regulations enacted as part of the 2009 appropriations for the program contain robust provisions that expand the scope of WIC’s activities to encourage and support its participants in breastfeeding.¹⁸⁰ Federal regulations specify the actions that state agencies must take to ensure 1) a sustainable infrastructure for breastfeeding activities; 2) the prioritization of breastfeeding mothers and children in the WIC certification process; 3) activities to support education in nutrition for breastfeeding mothers, including peer support; and 4) allowances for using program funds to carry out activities that improve support for breastfeeding among WIC participants. WIC has begun a nationwide training program for all local agencies called Using Loving Support to Grow and Glow in WIC: Breastfeeding Training for Local WIC Staff to ensure that all WIC staff can promote and support breastfeeding.¹⁸¹

Exclusive breastfeeding is rewarded in the WIC program in multiple ways, including offering a food package with a higher monetary value for breastfeeding participants than for participants who do not breastfeed or who do so only partially. In 2009, a variety of items, including larger amounts of fruits and vegetables, was added to the food package for women who breastfeed to provide enhanced support for them. Additionally, the new food package provided higher quantities of complementary foods to be given to breastfed babies who are at least six months old. Before their babies are born, WIC clients receive education and counseling about breastfeeding and are followed up soon after the birth. Many breastfeeding mothers in WIC receive breast pumps and other items to support the continuation of breastfeeding. The USDA uses a social marketing approach to encourage and support breastfeeding that began with the campaign Loving Support Makes Breastfeeding Work,¹⁸² as well as a research-based, culturally sensitive set of social marketing resources known as Breastfeeding: A Magical Bond of Love, which is specifically for Hispanic participants.¹⁸³

Clinicians are another important source of education and support for breastfeeding. When a mother is discharged from a maternity facility after childbirth, she may need continued breastfeeding support, not only from her family but also from professionals affiliated with the maternity facility. Professional post-discharge breastfeeding support of mothers can take many forms, including planned follow-up visits at the maternity facility, telephone follow-ups initiated by the maternity facility, referrals to community-based support groups and organizations, and home visits. The Affordable Care Act passed in 2010 includes a provision to expand home visitation programs for pregnant women and children from birth through kindergarten entry.¹⁸⁴ This funding has the potential to greatly improve follow-up breastfeeding care for low-income families if breastfeeding is adequately incorporated into the programs.

Posting information on Web sites, providing online support, and having breastfeeding “warmlines” and hotlines that mothers can call whenever they need help or to ask specific breastfeeding-related questions are additional ways that mothers typically find help postpartum.^10,185,186 To be most effective, however, postpartum support needs to be a comprehensive strategy designed to help women overcome challenges in sustaining exclusive, continued breastfeeding.^{10,148,187,188}

The provision of peer support is another method that has been shown to improve breastfeeding practices.^{173,174,189–191} Peer support can be given in structured, organized programs, or it can be offered informally by one mother to another. Peer counselors are mothers who have personal experience with breastfeeding and are trained to provide counseling about and assistance with breastfeeding to other mothers with whom they share various characteristics, such as language, race/ethnicity, and socioeconomic status. They reinforce breastfeeding recommendations in a socially and culturally appropriate context. Peer counselors may be effective in part because they are seen as role models¹⁹² and also because they often provide assistance through phone calls or home visits.¹⁷³

Peer-counseling programs that provide breastfeeding support for low-income women who are enrolled in or eligible for WIC have been found to be effective at both agency and individual levels in improving breastfeeding rates.¹⁹³ For example, using peer counselors for prenatal WIC participants increased the agency’s enrollment of breastfeeding postpartum women.¹⁷² Individually, a breastfeeding support program that included peer counseling increased breastfeeding initiation among WIC participants in Michigan by about 27 percentage points and the duration of breastfeeding by more than three weeks.¹⁷¹ Hispanic immigrant mothers in Houston who were eligible for WIC and who received breastfeeding support from peer counselors were nearly twice as likely as nonparticipants to be exclusively breastfeeding at four weeks postpartum, and they were significantly less likely to supplement breast milk feedings with water or tea.¹⁹⁴ Several investigations of peer counseling have identified the prenatal period as particularly important for establishing relationships between peer counselors and WIC participants. Results of these studies indicate that counseling during this period allows peer counselors to proactively address participants’ questions and concerns about breastfeeding and enables both the counselor and the mother to prepare for support that will be provided in the early postpartum days.¹⁷²

Peer support also can be given through volunteer community-based groups and organizations, such as La Leche League (www.llli.org) and other nursing mothers’ support groups. In addition, newer community organizations are emerging, such as the African-American Breastfeeding Alliance, the Black Mothers’ Breastfeeding Association (www.blackmothersbreastfeeding.org), and Mocha Moms (www.mochamoms.org). Beyond advocating for community support for breastfeeding, these organizations and groups provide peer support focused on women of color and provide culturally tailored breastfeeding support that may not be available or sought after from other support groups. These new groups and organizations, however, may have limited membership rolls and thus very small budgets. Financial assistance from foundations and government may be needed early on to firmly establish and support these organizations, which strive to meet the needs of communities that are typically underserved in terms of health and social services.

In a review of 34 trials that included more than 29,000 mother-infant pairs across 14 countries, professional and lay support together were found to increase the duration of any breastfeeding, as well as the duration of exclusive breastfeeding.¹⁸⁹ For women who received both forms of support, the risk of breastfeeding cessation was significantly lower at six weeks and at two months than it was among those who received the usual care. Exclusive breastfeeding was significantly extended when counselors were trained using a program sponsored by WHO and UNICEF.¹⁸⁹

Marketing of infant formula within communities is another negative influence on breastfeeding. The WHO International Code of Marketing of Breast-milk Substitutes declares that substitutes for breast milk should not be marketed in ways that can interfere with breastfeeding.³⁵ Yet formula is marketed directly to the consumer through television commercials and print advertisements and indirectly through logo-bearing calendars, pens, and other materials in hospitals or doctors’ offices. Formula also is marketed through the distribution of gift packs at discharge that contain samples of formula or coupons, often in bags with a manufacturer’s name or logo.

Research indicates that the marketing of substitutes for breast milk has a negative effect on breastfeeding practices. For example, advertising infant formula in doctors’ offices that women visit before their babies are born lowers the rate of breastfeeding among these women.¹⁹⁵ In the immediate postpartum period, such as in the hospital after childbirth, the marketing of infant formula can deter exclusive breastfeeding¹⁹⁶ and may have an even stronger effect among women who do not have well-defined goals for breastfeeding.¹⁹⁷ In addition, women who receive commercial discharge packs that include formula are less likely to be breastfeeding exclusively at 10 weeks postpartum than are women who do not receive them.¹⁴⁹ A Cochrane review concluded that women who received discharge packs were less likely to be exclusively breastfeeding at any time postpartum than women who did not receive a discharge pack.¹⁹⁸

Some of the marketing strategies used by infant formula companies may require review to ensure they are truthful and that they are not detrimental to breastfeeding. For example, in December 2009, a federal court upheld a $13.5 million jury verdict against manufacturer Mead Johnson & Co. for false and misleading advertising; the court permanently barred Mead Johnson from claiming that its Enfamil LIPIL infant formula would give babies better visual and brain development than ingredients in store-brand formula.¹⁹⁹ In 2006, the GAO found that manufacturers of infant formula had violated the USDA Food and Nutrition Service rules by using the WIC logo and acronym in advertising formula.⁸⁷ Voluntary adherence by formula manufacturers to recommended guidelines on formula marketing may not be effective or consistent throughout the industry, and thus formal guidelines and monitoring may be necessary to ensure that policies and procedures are followed.

In recent years, advertising and social marketing have been used more frequently to promote and support breastfeeding. The USDA national breastfeeding promotion campaign mentioned earlier, Loving Support Makes Breastfeeding Work, was launched in 1997 to promote breastfeeding to WIC participants and their families by using social marketing techniques, including mass media and educational materials, and through staff training. The goals of the campaign are to encourage WIC participants to initiate and continue breastfeeding, to increase referrals to WIC for support for breastfeeding through community outreach, to increase the public’s acceptance and support of breastfeeding, and to provide technical assistance to state and local WIC staff who are promoting and supporting breastfeeding.

This campaign emphasizes the concept that the support of family and friends, the health care system, and the community are all essential for a breastfeeding mother to be successful.¹⁸² An evaluation in 1997 of the campaign’s effects in Iowa demonstrated an increase in initiation of breastfeeding from 57.8 percent at baseline to 65.1 percent one year after implementation of the campaign. The percentage of mothers continuing to breastfeed at six months postpartum also increased, from 20.4 percent at baseline to 32.2 percent one year after the campaign was implemented.²⁰⁰ Campaign materials continue to be available.

In 2004, the HHS/OWH and the Advertising Council launched a national campaign encouraging first-time mothers to breastfeed exclusively for six months. The tagline of the two-year campaign was “Babies were born to be breastfed.”²⁰¹ The campaign focused on research showing that babies who are breastfed exclusively for six months are less likely to develop certain illnesses or to become obese than babies who are not breastfed, and it consistently emphasized the importance of exclusive breastfeeding for six months. Awareness of the breastfeeding campaign increased from 28 percent to 38 percent a year after it was started.²⁰¹ Additionally, the percentage of those sampled who agreed that babies should be exclusively breastfed for six months increased from 53 percent before the campaign to 62 percent one year after the campaign was implemented.²⁰¹

As the 2004–2006 national breastfeeding awareness campaign demonstrated, people seek and find health information from a variety of sources. Evidence points to increasing reliance on the Internet for health information, particularly among those aged 18–49 years. In a report of findings from the 2008 Pew Internet and American Life Project Survey of more than 2,000 adults, when asked what sources they turned to for health or medical information, 86 percent reported asking a health professional, such as a physician, 68 percent asked a friend or family member, and 57 percent said they used the Internet.²⁰² Social networking sites, such as Facebook and MySpace, appear to be less likely sources for gathering or sharing actual health information; instead, they serve as tools to help users refine the health questions they ask their clinicians.²⁰² To date, most educational outreach on breastfeeding has been conducted interpersonally, on a face-to-face basis, sometimes with a videotape included as part of the instruction. As more people become regular users of various types of electronic communication such as social networking sites and mobile messaging, new strategies will be needed for conducting outreach and for communicating health information to families.

In summary, a woman’s ability to initiate and continue breastfeeding is influenced by a host of community-based factors. Family members, such as fathers and babies’ grandmothers, are important parts of a mother’s life. It may be important for community-based groups to include them in education and support programs for breastfeeding. Postpartum support from maternity facilities is an important part of helping mothers to continue breastfeeding after discharge. Community-based support groups, organizations, and programs, as well as the efforts of peer counselors, expand on the support that women obtain in the hospital and provide a continuity of care that can help extend the duration of breastfeeding.

In addition, public health efforts such as the 2004–2006 national breastfeeding awareness campaign may influence women to initiate and continue breastfeeding by helping to improve their knowledge and understanding of the reduced health risks and other positive outcomes associated with breastfeeding. The sources from which these messages are communicated, however, may need to evolve as more people use Web-based technologies to search for health and other types of information. In summary, a multifaceted approach to promoting and supporting breastfeeding is needed at the community level.

Health Care

The U.S. Preventive Services Task Force (USPSTF) specifically recommends that promotion and support for breastfeeding be provided throughout the encounters women have with health professionals during prenatal and postpartum care, as well as during their infants’ medical care.¹⁶⁸ In addition, education and counseling on breastfeeding are unanimously recognized by the AAP and the American College of Obstetricians and Gynecologists in their Guidelines for Perinatal Care ²⁰³ as a necessary part of prenatal and pediatric care. Similarly, the American Academy of Family Physicians²⁷ and the American College of Nurse-Midwives²⁹ call for the consistent provision of breastfeeding education and counseling services. Yet many clinicians are not adequately prepared to support mothers who wish to breastfeed.

The USPSTF¹⁶⁸ concluded that promotion and support of breastfeeding are likely to be most effective when integrated into systems of care that include training of clinicians and other health team members, policy development, and support from senior leadership. Moreover, the task force noted that many successful multicomponent programs that support pregnant women and mothers of young children include the provision of lay support or referral to community-based organizations. The task force also noted that breastfeeding interventions, like all other health care interventions designed to encourage healthy behaviors, should strive to empower individuals to make informed choices supported by the best available evidence. As with interventions to achieve a healthy weight or to quit smoking, the task force calls for breastfeeding interventions to be designed and implemented in ways that do not make women feel guilty when they make an informed choice not to breastfeed.

In the United States, the majority of pregnant women plan to breastfeed,¹⁶⁶ and yet there is a clear gap between the proportion of women who prenatally intend to breastfeed and those who actually do so by the time they are discharged after a brief hospital stay.^166,204 The experiences that mothers and infants have as patients during the maternity stay shape the infant’s feeding behaviors;¹⁶¹ however, the quality of prenatal, postpartum, and pediatric medical care in the United States has been inconsistent.^152,205 Mothers’ experiences as they receive this care have an influence on their intention to breastfeed,²⁰⁶ the biologic establishment of lactation,¹⁴⁴ and breastfeeding duration.²⁰⁷

Nearly all births in the United States occur in hospital settings,¹⁵⁹ but hospital practices and policies in maternity settings can undermine maternal and infant health by creating barriers to supporting a mother’s decision to breastfeed. National data from the ongoing CDC survey of Maternity Practices in Infant Nutrition and Care (mPINC), which assesses breastfeeding-related maternity practices in hospitals and birth centers across the United States, indicate that barriers to breastfeeding are widespread during labor, delivery, and postpartum care, as well as in hospital discharge planning.²⁰⁸ Results of the 2007 mPINC survey showed that, on average, U.S. hospitals scored only 63 out of a possible 100 points on an overall measure of breastfeeding-related maternity care.²⁰⁸ Furthermore, geographic disparities in care⁵² correspond closely with the geographic patterns of state-level breastfeeding,⁴¹ highlighting the southern United States as particularly in need of improvement in the quality of routine maternity care.

Examples of barriers to breastfeeding include placement of the stable, healthy, full-term newborn on an infant warmer immediately upon delivery rather than skin-to-skin with the mother,⁶⁴ provision of infant formula or water to breastfed newborns without medical indication,⁴⁴ removal of the newborn from the mother’s room at night,²⁰⁹ inadequate assurance of post-discharge follow-up for lactation support,¹⁰ and provision of promotional samples of infant formula from manufacturers.¹⁴⁹ Many studies have shown that practices such as these are associated with a shorter duration of breastfeeding.^152,210

A set of maternity care practices has been identified that, when implemented together,^148,211,212 results in better breastfeeding outcomes.^{152,213–216} The Baby-Friendly Hospital Initiative²¹⁷ established by WHO and UNICEF in 1991 includes these maternity practices, which are known as the Ten Steps to Successful Breastfeeding. The Joint Commission, an organization that accredits and certifies health care organizations and programs in the United States, has identified the concept of bundles of care such as those in the Ten Steps to Successful Breastfeeding as a promising strategy to improve the care provided to patients.²¹⁸ In addition, researchers in California have found that disparities in in-hospital rates of exclusive breastfeeding are not found in hospitals that have implemented the policies and practices of the Baby-Friendly Hospital Initiative, while the opposite is true in hospitals that are in the same geographic region but are not designated as Baby-Friendly.²⁰⁴

Upon discharge from the hospital, mothers may have no means of identifying or obtaining the skilled support needed to address their concerns about lactation and breastfeeding; further, there may be barriers to reimbursement for needed lactation care and services.²¹⁹ In addition, limited communication between clinicians across health care settings²²⁰ and between clinicians and mothers also may make mothers less likely to comply with recommended postpartum health care visits than they were during the prenatal period.²⁰⁵

Increased recognition of the responsibility that clinicians have to encourage and support breastfeeding²⁵ has led to the development of initiatives to improve continuity of care and support for breastfeeding. The AAP’s Safe and Healthy Beginnings program provides a framework for continuity of care from the prenatal period through childbirth to the postpartum period and beyond, and it includes standards of care to prevent breastfeeding problems and hyperbilirubinemia.^205,222 In various communities, the health care system has successfully coordinated with community networks to provide breastfeeding support to ensure that mothers have access to breastfeeding assistance after they return home. An important part of this assistance is having access to trained individuals who have established relationships with members of the health care community,²²³ are flexible enough to meet mothers’ needs outside of traditional work hours and locations,²²⁴ and provide consistent information.²²⁵

For any kind of health service, adequate education and training are essential. Even so, a study of obstetricians’ attitudes, practices, and recommendations²⁰⁶ found that although 86 percent of clinicians reported having prenatal discussions about infant feeding, and 80 percent of them recommended breastfeeding, nearly 75 percent admitted they had either inadequate or no training in how to appropriately educate mothers about breastfeeding. The information on breastfeeding included in medical texts is often incomplete, inconsistent, and inaccurate.²²⁶ In addition, although formative research has revealed that hospital management recognizes the public health importance of breastfeeding and agrees that it is the optimal nutrition for most infants, management is largely unaware of the specific characteristics of supportive breastfeeding care. Despite recognizing the demand for evidence-based health care, many hospital executives are unable to accurately identify which current routine maternity practices are evidence based.²²⁶

Notwithstanding the widespread recognition of the need for health care professionals to provide education and counseling on breastfeeding to their patients, both education and counseling are often inadequate or inappropriate. Interestingly, Taveras and colleagues¹⁶¹ found that clinicians’ perceptions of the counseling they provided on breastfeeding did not match their patients’ perceptions of the counseling received. By linking clinicians’ and patients’ reports on the counseling, they found that among mothers whose prenatal clinicians stated they always or usually discussed breastfeeding with their patients, only 16 percent of mothers indicated that breastfeeding had been discussed during their prenatal visits. Further, among mothers whose pediatric clinicians reported routine counseling on breastfeeding, only 25 percent of mothers indicated receipt of such counseling.

International Board Certified Lactation Consultants (IBCLCs) are health care professionals who specialize in the clinical management of breastfeeding. The only health care professionals certified in lactation management, they carry certification by the International Board of Lactation Consultant Examiners (IBLCE). Like all other U.S. certification boards for health care professionals, the IBLCE operates under the direction of the U.S. National Commission for Certifying Agencies and maintains rigorous professional standards. IBCLC candidates must demonstrate sufficient academic preparation as well as experience in supervised, direct consultation on breastfeeding to be eligible to take the certification exam.²²⁷

Upon certification, IBCLCs work in inpatient, ambulatory, and community care settings. IBCLC certification helps ensure a consistent level of empirical knowledge, clinical experience, and professional expertise in the clinical management of complex lactation issues. Evidence indicates that, on discharge, rates of exclusive breastfeeding and of any breastfeeding are higher among women who have delivered their babies in hospitals with IBCLCs on staff than in those without these professionals.^228,229 Further, employment of IBCLCs in neonatal intensive care units increases the percentage of a particularly vulnerable infant population—those born at other facilities and transferred to neonatal intensive care units—who leave the hospital receiving human milk.²³⁰

Ample evidence of the need for support from IBCLCs has not yet translated, however, to comprehensive availability of their care. A major barrier to availability is the lack of third-party reimbursement. Not surprisingly, availability varies widely across the United States, with nearly 10 IBCLCs per 1,000 live births in Vermont and only 0.83 per 1,000 live births in Nevada.²³¹ Data from Mannel and Mannel²³² indicate a need for approximately 8.6 IBCLCs per 1,000 live births, an estimate that accounts for prenatal education on breastfeeding, inpatient support during the maternity stay, outpatient follow-up after discharge, telephone follow-up, and program development and administration. In most states, there currently are not enough IBCLCs to meet the needs of breastfeeding mother-infant pairs.^231–233

In 2006, an estimated 12.8 percent of all U.S. births were preterm (less than 37 completed weeks of gestation), and 8.3 percent of infants had a low birth weight (less than 2,500 grams).²³⁴ In many cases, mothers of these babies initially have difficulty producing enough milk to meet their infants’ immunologic and nutritional needs.^235,236 However, use of infant formula introduces multiple health risks,² such as NEC, in addition to the inherent health risks of prematurity and low birth weight.²³⁴ Formula feeding appears to be a risk factor for NEC, and the use of donor milk (milk donated by lactating women for infants other than their own) may have the potential to prevent some cases of NEC.^237–241 Approximately 12 percent of preterm infants weighing less than 1,500 grams will suffer from NEC infection.²⁴² Early mortality in surgical cases is nearly 50 percent, making it the most common cause of death among neonates requiring gastrointestinal surgery.²⁴³ Hospitalization for all surgical NEC averages 62 days, at a cost of nearly $300,000 per patient.²⁴⁴ Researchers estimate that across the United States, NEC treatment costs account for 19 percent of all initial newborn health care costs.²⁴⁵ Human milk is vital to the survival of vulnerable neonates and plays an important role in addressing the substantial burden imposed by NEC on affected families and in reducing health care costs associated with NEC.²⁴⁶

Donor milk banks collect, pasteurize, store, and distribute the human milk that has been donated. Currently, 12 donor milk banks operate across the United States and Canada; 11 are nonprofit²⁴⁷ and 1 is commercial (Prolacta Bioscience, Inc., Monrovia, CA). Milk banking poses numerous challenges because of the necessity of ensuring that donor milk is both safe and nutritionally sound. Breast milk is a means of viral transmission, and thus it is essential that donors are screened for significant viral diseases, such as HIV, human T-cell leukemia virus, and hepatitis C. Pathogens can also be introduced during collection, transportation, or processing. Although heat treatment can destroy most infectious pathogens in milk, excessive heat will destroy some of the nutritional components of the milk as well.²⁴⁸

The Human Milk Banking Association of North America (HMBANA) has developed guidelines for its member milk banks to address some of these challenges and has set standards for health history screening; for serum screening; and for milk collection, processing, pasteurization, storage, and dispensing.²⁴⁹ Although HMBANA requires that its members adhere to these guidelines as a condition of membership, they are not enforced by the FDA. Informal mechanisms for sharing of donor human milk through newspaper or Internet sites have also arisen, but these pose significant risks because of the inability to screen the donor and ensure that the milk has not been infected, diluted, or contaminated.

In 2008, the 11 nonprofit milk banks distributed 1.4 million ounces of milk to hospitals. However, to meet the needs of just the infants born weighing less than 1,500 grams, an estimated 9 million ounces would be required.²⁵⁰ Barriers to having more donor milk available include lack of knowledge among clinicians, confusion on the part of payers, and ambivalence in public health policy about the role of banking donor milk.²⁵¹ In the United States, there is no federal infrastructure to regulate the screening, collection, storage, and distribution of donor milk. The lack of a proactive federal policy on donor milk has contributed to a lack of clarity in policies that affect its banking and in the regulatory responsibilities for state versus federal agencies.²⁵²

In summary, most women plan to breastfeed, but the policies and practices of the institution where they give birth may undermine their intentions. The Ten Steps to Successful Breastfeeding is a standard for hospital performance. Once discharged, mothers may find that the health care system is not supportive. The support of health care professionals is particularly important at this time; unfortunately, many health professionals have had inadequate education and training in breastfeeding. IBCLCs are an excellent source of assistance for breastfeeding mothers.

Employment

The percentage of women in the U.S. workforce has increased dramatically over the last century, particularly in the last 50 years. In 2004, more than 70 percent of women of childbearing age (20–44 years) were in the civilian labor force.²⁵³ An estimated 67 percent of mothers who had their first child in 2001–2003 worked during their pregnancy, mostly on a full-time basis.²⁵⁴ In 2009, 50.1 percent of all mothers with children younger than 12 months were employed, and 69 percent of those employed worked full-time (35 or more hours per week).¹⁷⁰

In 2001, child care arrangements for infants were such that 26 percent of nine-month-old infants were regularly cared for by relatives, 15 percent were cared for by a nonrelative in either their own or another family’s home, and 9 percent were in center-based care.²⁵⁵ By percentage, more black than white infants were in center-based care.²⁵⁵ The Child Care and Development Fund helps low-income families obtain child care so they can work or attend training or education. Among infants served by this program, 49 percent were in center-based care.²⁵⁶

Among employed mothers, studies have found lower initiation rates^257–259 and shorter duration of breastfeeding.^{58,138,257,258,260–265} Rates of breastfeeding initiation and duration are higher in women who have longer maternity leave,^{58,140,257,258,260–265} work part-time rather than fulltime, ^138,259,260.^263,264,266 and have breastfeeding support programs in the workplace.^50,267,268

Because most lactating mothers who are employed express milk at work for a child care provider to bottle feed to the infant later,⁴² these providers are essential in helping employed mothers continue to breastfeed after returning to work. However, a mother feeding her infant directly from the breast during the workday is the most effective strategy of combining employment and breastfeeding because it promotes the duration and intensity of breastfeeding⁴⁹ and strengthens the relationship between mother and infant in the critical first months of life. The skin-to-skin closeness that occurs during breastfeeding promotes bonding and attachment between mother and infant, increases the efficiency of breastfeeding, and enhances the neurological and psychosocial development of the infant.^269,270

Currently, among 173 countries, the United States is one of only four without a national policy requiring paid maternity leave (the others are Swaziland, Liberia, and Papua New Guinea).²⁷¹ The Family and Medical Leave Act of 1993 generally provides for up to 12 weeks of unpaid, job-protected maternity leave, but unpaid leave is not feasible for many low-income families. The International Labor Organization (ILO) recommends a minimum of 18 weeks of paid maternity leave.²⁷² In the European Union (EU), 13 member countries meet this minimum, and the EU has proposed that all members adopt the minimum of 18 weeks with full pay, although it makes a provision for a ceiling on pay.²⁷³ The European Commission, which presents proposals for European law, recommends that full earnings be paid but allows for an upper limit on the amount paid, while the ILO recommends that the full wage be paid.²⁷² Canada provides 50 weeks of partially paid maternity and parental leave.²⁷⁴

In 2009, approximately 14 percent of U.S. employers offered paid maternity leave beyond short-term disability benefits.¹³² Although relatively few workers have this benefit, economic disparities exist even within this group. Higher income workers are more likely than low-income workers to have a paid maternity leave benefit; the U.S. Department of Labor estimates that of those with an average wage of more than $15 per hour, 11 percent have paid leave, compared with just 5 percent of those making less than $15 per hour. Additionally, some employment sectors are more likely to have paid maternity leave than others. Studies estimate that 14 percent of management, professional, and similar workers have a paid family leave benefit, while only 5 percent of service, 9 percent of sales and office, and 4 percent of industrial workers have it.²⁷⁵

As of March 2010, five states had laws that ensure some level of paid maternity leave (California, Hawaii, New Jersey, New York, and Rhode Island).²⁷⁶ More workers in these states are covered by laws ensuring paid maternity leave than are covered by the Family and Medical Leave Act; these laws could serve as a model for national programs that include lower-income workers. Two of these states cover all female workers, two cover all workers who participate in the state unemployment and disability insurance program, and one covers all women in the private sector. Two other states, Minnesota and New Mexico, have at-home infant care programs that fund low-income parents to stay home with their infants.²⁷⁷ In the United States, those states that have some form of maternity leave usually cover only part of the wage and have an upper limit on the benefit.^58,278 Criteria for eligibility that are based on the number of employees, hours of work per week, or duration of employment effectively exclude large percentages of low-wage workers and women who are leaving welfare to work. Low-income families have fewer resources than middle-class families, and providing fully paid maternity leave might increase all employees’ ability to take such leave, irrespective of income.

Various models and guidelines exist for implementing support for lactation and direct breastfeeding in the workplace. One example is the comprehensive resource kit, The Business Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits, which was developed by the Health Resources and Services Administration (HRSA).²⁷⁹ The kit includes booklets for business and human resource managers, an employee’s guide to breastfeeding and working, reproducible resources, and a CD-ROM.²⁷⁹ Program components outlined in the kit include flexible breaks and work schedules, a sanitary and private place to express milk, education for pregnant and lactating women, and support from supervisors and coworkers.

In 2010, the Affordable Care Act included a provision requiring employers to provide workplace accommodations that enable employees who are breastfeeding to express their milk. Specifically, Section 4207 of the Affordable Care Act amends the Fair Labor Standards Act of 1938 by requiring employers to provide reasonable, though unpaid, break time for a mother to express milk and a place, other than a restroom, that is private and clean where she can express her milk.¹⁸⁴

Given that 26 percent of mothers employed full-time in 2003 were breastfeeding when their infant was aged six months,²⁶⁴ it is clear that a substantial percentage of U.S. mothers manage to combine breastfeeding and paid work. However, U.S. mothers overall have less support for continuing to breastfeed after returning to work than is recommended by the ILO. The ILO recommends that provision be made for a place to breastfeed under hygienic conditions at or near the workplace and that the frequency and length of nursing breaks be adapted to particular needs.²⁷² Legislation in EU countries generally meets the ILO standards.²⁸⁰ In 2009, 15 U.S. states required that employers support breastfeeding employees when they return to work.²³¹ An employee benefits survey conducted in 2009 in the United States indicated that 25 percent of employers have on-site lactation rooms, with smaller businesses least likely to have these rooms.¹³²

In 2008, 31 percent of employed mothers with infants worked part-time (34 or fewer hours per week),²⁵⁴ suggesting that many mothers are using part-time employment to help them balance work and family needs. The 2005–2007 Infant Feeding Practices Study II found that among mothers who worked and breastfed, 32 percent kept the infant at work and breastfed during the workday, 8 percent went to the infant to breastfeed, and 3 percent had the baby brought to them at the work site in order to breastfeed.⁴⁹

Breastfeeding mothers with out-of-home arrangements for child care need the cooperation and support of the child care provider in order to continue breastfeeding. These mothers represent a very large number of women, as approximately half of infants of working mothers are in out-of-home child care.²⁵⁵ The current national guidelines on out-of-home child care from the National Resource Center for Health and Safety in Child Care and Early Education,²⁸¹ which are supported by HRSA, are under revision and will be released in a third edition in 2011. Meanwhile, selected standards from the new third edition have been published online and provide information about how child care providers should support breastfeeding mothers and families.²⁸² The new guidelines recommend that those who provide child care should encourage, make arrangements for, and support breastfeeding families, such as by providing a space for a mother to breastfeed or express milk for her child. Additionally, the new guidelines include information about preparing, storing, and handling expressed human milk, as well as the importance of feeding all children on cue rather than on a schedule.²⁸²

However, the 2002 guidelines still have not been implemented in all states,²⁸³ and in some states, child care homes that serve small numbers of children are not covered by the guidelines. Furthermore, some states, such as Colorado and Wisconsin, have developed their own guidelines and training materials for child care providers with respect to breastfed infants.^284–286 A recent study in Colorado found that providers of child care scored low on a test of proper procedures for storing and feeding breast milk but that they were interested in receiving information or training about infant feeding.²⁸⁷

In conclusion, employment is now the norm for U.S. women of childbearing age. Employed women currently are less likely to initiate breastfeeding, and they tend to breastfeed for a shorter length of time than women who are not employed. Most employed mothers who are lactating must express milk at work for their children and should be provided with accommodations to do so. However, directly breastfeeding a child during the workday offers additional opportunities for mother-child bonding and helps to sustain the exclusivity and duration of breastfeeding.⁴² Mothers should have a hygienic area in or near their workplace to breastfeed, and their breaks for nursing should be adapted to their particular needs. Further, child care providers need to support mothers who wish to breastfeed.

Research and Surveillance

Although there is a body of research on breastfeeding and some national monitoring is in place to track trends, significant knowledge gaps are evident.^2,288–291 These gaps must be filled to ensure that accurate, evidence-based information is available to parents, health clinicians, public health programs, and policy makers. New studies can provide insight into questions, such as how to 1) reduce disparities in breastfeeding rates that are associated with race/ethnicity, income, and preterm birth; 2) identify the comprehensive cost savings for parents, insurers, and the government that result from breastfeeding; and 3) develop best practices for management and support of lactation and breastfeeding. Expanded surveillance of breastfeeding would provide a more timely and representative understanding of patterns of breastfeeding in this country and of areas that could be prioritized to improve support for breastfeeding.

Paradoxically, rates of breastfeeding are not optimal among those most likely to benefit from it. For example, breastfeeding rates are particularly low among low-income women,⁴¹ and yet the health benefits that accrue from breastfeeding are especially important for women with low incomes and their families, as they already suffer a higher burden of illness and are the least able to pay for health services or afford time away from work because of illness. Because of their increased susceptibility to life-threatening illnesses, human milk also is particularly beneficial to preterm infants. In 2006, 12.8 percent of live births were preterm.²³⁴ Mothers who give birth preterm often face challenges with breastfeeding, and rates of breastfeeding are lower among preterm infants compared with full-term infants.²⁹² New research is needed to identify barriers to and supports for breastfeeding among populations with low rates of breastfeeding. Evidence-based findings could lead to the implementation of improved strategies that could result in higher breastfeeding rates and have a major impact on public health.

In addition to improving knowledge about ways to increase breastfeeding rates, research on the economic benefits accrued from high rates of continued breastfeeding and, conversely, the costs of low rates of breastfeeding is needed to understand the financial impact of breastfeeding. Although previous research found significant cost savings associated with breastfeeding,^20,23,24 current and comprehensive economic studies that more precisely estimate the complete cost-benefit ratio of breastfeeding and related activities are critical to inform policy making.

Despite overwhelming evidence of the reduced health risks associated with breastfeeding and consuming breast milk, there are still gaps in our knowledge regarding management and support for lactation and breastfeeding under both typical and special circumstances. Identification of evidence-based best practices would provide essential insights for programs that promote breastfeeding and enhance the acceptance of these programs by clinicians and the public at large.

Challenges exist in conducting studies on breastfeeding. For instance, researchers often have to rely on retrospective information provided by a mother when asking her to recall details about her previous breastfeeding experiences and practices. In addition, the absence of uniform definitions for such terms as “breastfeeding” and “exclusive breastfeeding” has rendered generalization across studies difficult.² Both increasing the validity of measures and standardizing the terminology are necessary to improve the accuracy and interpretation of research findings. Another concern is that there may not be enough researchers in the field; enhancing the opportunities for collaboration among researchers and providing new training opportunities for emerging scientists would help ensure the availability of scientific talent to usher in a new era of breastfeeding research.

Increasing the number of scientists properly trained to study breastfeeding could allow both current and new researchers to design and carry out scientifically sound and rigorous studies on breastfeeding topics.² Because of ethical considerations, research on the health outcomes of different modes of infant feeding is limited to observational studies, the results of which can only provide inferences on the association between feeding type and outcomes (unlike experimental or randomized controlled trials, which permit assessment of cause and effect). Thus, researchers need to develop innovative study designs that will improve our understanding of the relationships between breastfeeding and various outcomes. For example, women could be randomly assigned to receive an intervention that increases the proportion who exclusively breastfeed their children for six months and continue breastfeeding at least one year. Health outcomes in those children could be tracked and compared with health outcomes of children who received less breast milk.

At present, several national systems provide data on national breastfeeding rates, but few systems exist to collect data at state and local levels. The NIS²⁹³ provides annual state-level breastfeeding rates, but its sample is too small to permit interpretation of year-to-year changes for most states. The Pregnancy Risk Assessment Monitoring System allows for the calculation of breastfeeding initiation rates and duration up to 2–4 months, but currently only 31 states participate in this system.²⁹⁴ Local breastfeeding statistics are generally unavailable except for data from the Pediatric Nutrition Surveillance System, but these data are primarily from WIC participants, and not all states participate.²⁹⁵ Some information is available through birth certificate data, but only 28 states currently capture initiation of breastfeeding on the birth certificate.²⁹⁶

In addition to monitoring breastfeeding rates, it is important to track changes in the policies that affect breastfeeding and how it is supported. The CDC Breastfeeding Report Card²³¹ reports annually on a handful of breastfeeding-related indicators but is limited in scope. To date, little is known about the extent to which businesses are making accommodations for breastfeeding mothers, whether the United States has an adequate supply of skilled certified lactation consultants for women having difficulties with breastfeeding, or how broadly peer counseling programs are being operated in this country.

Another way that trends in breastfeeding and related indicators are monitored is through the Healthy People initiative.²⁹⁷ Healthy People, which provides a framework for health promotion and disease prevention for the nation, is designed to identify the most significant threats to public health and establish national goals to help reduce these threats. The breastfeeding objectives in Healthy People 2010 were retained in Healthy People 2020, but with higher targets. New objectives related to maternity practices, reduction in the early supplementation of breastfed newborns with formula, and worksite lactation support have been added (see Table 3).

Table 3

Healthy People 2020 Objectives for Breastfeeding.

In summary, additional research and surveillance are needed on many aspects of breastfeeding in the United States. For example, more research is needed on the barriers to breastfeeding among populations with low rates of breastfeeding. Economic research is also needed on how breastfeeding affects mothers and employers, as is research on best practices for management and support of lactation and breastfeeding. Building capacity for research on breastfeeding should be a priority. Although national surveillance on breastfeeding has improved considerably in the last decade, surveillance at state and local levels is limited.

Public Health Infrastructure

An effective national public health program requires the basic coordination and monitoring of services. Activities to promote and support breastfeeding originate from a wide variety of entities, including federal, state, and local governments; nonprofit organizations; and professional associations. Within the federal government, numerous agencies have developed programs on breastfeeding, and others have programs that affect breastfeeding indirectly. The USDA operates the WIC program, which serves more than half the infants born in the United States. In HHS, several breastfeeding initiatives exist within the Maternal and Child Health Bureau, the National Institutes of Health, CDC, FDA, AHRQ, OWH, and the Indian Health Service. In addition, the U.S. Department of Defense sets standards for accommodating breastfeeding among military personnel.

Although the work of each of these agencies is valuable, no formal structure for coordination of federal breastfeeding initiatives exists to reduce overlap or to identify gaps in current programs. Creation of a federal interagency work group on breastfeeding could help overcome these challenges and improve coordination and collaboration across agencies to improve support for breastfeeding.

The United States Breastfeeding Committee (USBC) (www.usbreastfeeding.org) provides a forum for nongovernmental organizations and liaisons from the federal government to collaborate on joint initiatives in support of breastfeeding. The committee was formed in 1995 with the support of then Assistant Surgeon General Audrey Nora, M.D., M.P.H. The mission of the USBC is to protect, promote, and support breastfeeding in the United States and, thus far, it has taken several steps toward accomplishing this mission. To start, the USBC unveiled Breastfeeding in the United States: A National Agenda,²⁹⁸ which served as the first step in a strategic plan for improving breastfeeding in the United States. Much like this Call to Action, the USBC’s national agenda recognizes the importance of breastfeeding and sets forth a societal approach to help improve breastfeeding practices.

In addition to writing position statements on breastfeeding, the USBC has been instrumental in bringing important partners together to move forward the breastfeeding agenda. For instance, it held the First National Conference of State Breastfeeding Coalitions in 2006; these important meetings have continued every two years to enable states to network and share successful strategies to improve support for breastfeeding.

All 50 states have now formed breastfeeding coalitions, and there are many local, tribal, and territorial coalitions as well. These coalitions catalyze local and state efforts to promote and support breastfeeding. Although the USBC supports state coalitions with technical assistance, Web-based communications support, and a biannual conference, most of these coalitions are small and unfunded. Additionally, most state health departments have no staff responsible for breastfeeding activities, except within the WIC program. This lack of a state infrastructure makes it difficult to carry out any new breastfeeding programs at the state level.

In summary, many organizations and agencies, both inside and outside the government, are currently working to increase rates of breastfeeding and to support mothers and their infants in a variety of ways. The USBC is a focal point for efforts in this area, and all 50 states have their own breastfeeding coalitions.