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Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women's Health (US). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011.

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The Surgeon General's Call to Action to Support Breastfeeding.

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A Call to Action

Given the importance of breastfeeding for the health and well-being of mothers and children, it is critical that we take action across the country to support breastfeeding. Women who choose to breastfeed face numerous barriers. Only through the support of family members, communities, clinicians, health care systems, and employers will we be able to make breastfeeding become the easy choice, the default choice. This section describes the recommended actions and their associated implementation strategies in detail. A summary of this information is provided in table form in Appendix 1.

Mothers and Their Families

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

In the United States, women often lack information on breastfeeding, and women who decide to breastfeed their children are frequently not given support. The result is that many mothers see breastfeeding as a goal they cannot achieve for themselves and their babies. Furthermore, many mothers are not aware of the excess risks to babies’ and mothers’ health associated with not breastfeeding. To achieve their goals for breastfeeding, mothers should seek the information, support, and care they deserve.

Implementation Strategies

Help pregnant women to learn about the importance of breastfeeding for their babies and themselves. Doctors and midwives are expected to give women accurate and complete information on infant feeding as part of routine prenatal care, but if it is not provided, mothers have the right to ask for it. Mothers can obtain this information from their clinicians to ensure they have the knowledge they need to make the decision about infant feeding that is best for them.

Teach mothers to breastfeed. Like many other activities, breastfeeding requires preparation and effort at first. Pregnant women who learn about how to breastfeed are more likely to be successful than those who do not. Women can obtain helpful information about how to breastfeed from classes, books, online resources, and the U.S. Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as from other mothers who have breastfeeding experience.

Encourage mothers to talk to their maternity care providers about plans to breastfeed. Every mother and baby deserves maternity care that supports breastfeeding, and to obtain that care, a mother must let her doctor or other health care clinician know she wants to breastfeed. Mothers can discuss with their clinicians the types of care they expect during and after their maternity stay to ensure that care is compatible with breastfeeding.

Support mothers to have time and flexibility to breastfeed. To ensure the best and most supportive environment for breastfeeding, mothers can engage in conversations with family, friends, employers, child care providers, and others to ask for and create a plan that will accommodate their ability to continue breastfeeding at home and after returning to work or school. Having help around the house for the first few weeks at home after childbirth will allow a mother and her baby to concentrate on learning how to breastfeed.

Encourage mothers to ask for help with breastfeeding when needed. Some early challenges with breastfeeding are normal, while others may be signs of breastfeeding problems. If a mother experiences severe pain or other problems with breastfeeding, asking for help will assist her in achieving her breastfeeding goal. Mothers can ask for help from their doctors or midwives, lactation consultants, and other mothers with breastfeeding experience. With help from these people, mothers can resolve most breastfeeding problems and go on to enjoy their breastfeeding experiences.

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

A woman’s decision to breastfeed is strongly influenced by the beliefs and attitudes of her family and friends. Unfortunately, family and friends may discourage a mother from breastfeeding if it is not accepted within their culture. Often, when a mother is thinking about how to feed her baby, she values the advice of her partner the most, followed by the advice of her mother, family, and friends. In fact, she often values their advice more than the advice of health care professionals.

Partners are particularly important because their approval means so much to a mother, and her partner is often a mother’s primary source of support. Although fathers want the best for their family, they may become jealous or resentful or get the feeling that they will not be able to bond with their child if their partner chooses to breastfeed. The baby’s grandmothers are also very influential because mothers who have recently given birth rely on them for support and advice. To make breastfeeding successful, mothers need the support and encouragement of all of these people.

Implementation Strategies

Launch or establish campaigns for breastfeeding education that target a mother’s primary support network, including fathers and grandmothers. Local campaigns can use print, billboard, radio, and television public service announcements that feature members of a specific population for more effective reach.

Offer classes on breastfeeding that are convenient for family members to attend. Educational materials and classes that are directed toward fathers and grandmothers need to be developed to attract and involve this extended support network. To encourage the participation of family and friends, consideration should be given to involving churches, civic organizations, health clubs, community centers, and schools because these venues may be more accessible than health care institutions. Offering classes during a variety of hours and days also may improve participation.

Communities

Action 3. Strengthen programs that provide mother-to-mother support and peer counseling

A mother-to-mother volunteer organization called La Leche League introduced the idea of giving support to breastfeeding women from their peers in the community—in most cases, women who are not health care professionals. Counseling by a woman’s peers has helped to increase the number of women who choose to breastfeed and the length of time they continue with breastfeeding. Success with such counseling has been achieved among economically disadvantaged women and those with diverse cultural backgrounds. Support by a woman’s peers can be provided through telephone calls; visits in the hospital, home, or clinic; group classes; or informal support groups.

Implementation Strategies

Create and maintain a sustainable infrastructure for mother-to-mother support groups and for peer counseling programs in hospitals and community health care settings. Hospitals and birth centers have a unique opportunity to ensure that mothers are connected to support systems in the community after they are discharged. With virtually all babies in the United States born in such facilities, this strategy has the potential of broad reach. Hospitals and birth centers can provide these services themselves or collaborate with community health groups to increase mothers’ access to peer support groups or peer counselors.

Establish peer counseling as a core service available to all women in WIC. With rates of breastfeeding being consistently lowest among low-income women, the provision of additional support for breastfeeding mothers is especially important in the WIC program. WIC’s existing peer counseling program has proven to be effective, but currently it is not offered in all local WIC agencies.

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

Organizations that are based in communities and do their work there are aware of the specific barriers that women in their communities face and can identify workable solutions for these women. In most cases, these organizations understand the culture and customs of the residents in the community, as well as their needs and opportunities. Questions and concerns about breastfeeding may be handled by organizations whose primary mission is to promote and support breastfeeding or by other organizations involved in family health.

Implementation Strategies

Support and fund small nonprofit organizations that promote breastfeeding in communities of color. Addressing the socioeconomic, racial, and ethnic inequities in breastfeeding requires focusing on those communities with low rates of breastfeeding. Resources for local organizations that support breastfeeding are extremely limited, making the provision of mother-to-mother support, community advocacy, and outreach efforts difficult. Educational messages, training, tools, and other resources need to reflect local culture, ethnicity, language, and literacy levels.

Integrate education and support for breastfeeding into public health programs that serve new families. A variety of people and programs are now operating in communities to meet the needs of new families, including home visitors, community-based doulas (women who help mothers during and after childbirth), advocates for prevention of domestic violence, public health nurses, and early childhood and Healthy Start programs. Assistance with breastfeeding is a natural extension of the other functions these programs provide and contributes to the common goals of improving the health and well-being of families.

Ensure around-the-clock access to resources that provide assistance with breastfeeding. Difficulties with breastfeeding can occur at any time of the day or night and on weekends. If mothers are unable to get help when they need it, they can become discouraged and give up on breastfeeding. The use of telephone triage, “warmlines,” hotlines, online networks, and pretested referral patterns in each community can provide the human contacts needed to help mothers work through their breastfeeding problems.

Action 5. Create a national campaign to promote breastfeeding

Social marketing is a promising way of ensuring that new generations understand the value of breastfeeding and can make well-informed decisions about infant feeding. Social marketing, unlike traditional marketing, engages members of the community with each other (often through forums or blogs on the Internet). The national educational campaign and the strategies used must be culturally sensitive and appropriate. Developing such a campaign calls for long-term strategies and requires careful planning and a thorough understanding of social marketing.

Implementation Strategies

Develop and implement a national public health campaign on breastfeeding that relies heavily on social marketing. A task force with wide representation should frame the problem, define the audience, determine effective messages, and choose the behaviors to be changed and promoted. To have broad reach, the campaign needs to be well funded and sustained over a prolonged period.

Use a variety of media venues to reach young women and their families. While television and print media remain viable avenues for disseminating public health messages, the increasing use of electronic communication channels opens many new possibilities for promoting breastfeeding. Use of these new social media will require that promoters adapt quickly to changing technology and develop new kinds of messages appropriate to these venues.

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

The International Code of Marketing of Breast-milk Substitutes (the Code) establishes rules for the protection of mothers from the influences of false and misleading advertising, including unethical marketing practices of substitutes for breast milk. The Code, developed in concert with manufacturers of infant formula, spells out both appropriate and inappropriate marketing practices. Although its provisions are not legally binding in the United States, various means of encouraging voluntary adherence should be developed.

Implementation Strategies

Hold marketers of infant formula accountable for complying with the International Code of Marketing of Breast-milk Substitutes. In particular, the Code precludes advertising directly to consumers and does not allow for distribution of free samples to the public. Until 1990, manufacturers of formula refrained from directly advertising to consumers. Manufacturers could voluntarily return to this practice, and hold themselves accountable through their joint participation in the International Formula Council. Public health entities could help by making information on violations of the Code publicly available.

Take steps to ensure that claims about formula are truthful and not misleading. With the proliferation of new kinds of infant formula, a variety of claims are being made about their contents and health benefits. The validity of these claims should be reviewed. Furthermore, research is needed on how consumers perceive the claims being made, whether they think messages are believable, and how these claims affect consumers’ behavior. The findings should be used to identify the marketing practices likely to have a negative impact on exclusive breastfeeding.

Ensure that health care clinicians do not serve as advertisers for infant formula. The distribution of materials such as free samples, pamphlets, notepads, growth charts, or gifts that bear logos from companies marketing infant formula implicitly endorses formula feeding. Displays of posters, products, or decorations from these companies in a health care professional’s office or in a hospital or clinic leave the impression that clinicians favor formula feeding over breastfeeding. Given the health consequences of not breastfeeding, clinicians should not implicitly promote infant formula by providing venues for its advertisement.

Health Care

Action 7. Ensure that maternity care practices throughout the United States are fully supportive of breastfeeding

In the United States, nearly all infants (99 percent) are born in hospital settings, and guidelines based on available evidence have been established to ensure the delivery of appropriate maternity care in these settings. Unfortunately, the evidence-based guidelines for quality maternity care are applied inconsistently. In fact, maternity care practices often reflect clinicians’ personal experiences with breastfeeding and may be based on misinformation that interferes with successful breastfeeding. Maternity care of high quality will be delivered to all patients only if standards are consistently applied to every mother and infant.

Implementation Strategies

Accelerate implementation of the Baby-Friendly Hospital Initiative. In order to help hospitals work together, learn from each other, and share successful strategies to achieve Baby-Friendly designation, public health agencies need to expand their capacity to provide assessment of and technical assistance with Baby-Friendly practices. These strategies include examining the different ways of designating an institution as Baby-Friendly that are used internationally. Creating incentives for participation in the initiative may be helpful.

Establish transparent, accountable public reporting of maternity care practices in the United States. The Joint Commission can add the responses of maternity facilities on their Perinatal Care Core Measure set to the Joint Commission Quality Reports and related data reports that the commission provides to facilities to help them improve practices.

Establish a new advanced certification program for perinatal patient care. Such a program would recognize facilities for making exceptional efforts to foster better quality of care, improve breastfeeding support, and achieve better health outcomes in maternal and newborn care. Criteria for certification would include following the practices for maternal and newborn care in the Ten Steps to Successful Breastfeeding established by the World Health Organization and the United Nations Children’s Fund. The Joint Commission has existing certification programs, such as its Disease-Specific Care Certification Programs, which could serve as models for perinatal care.

Establish systems to control the distribution of infant formula in hospitals and ambulatory care facilities. Control systems for medications are generally used to ensure appropriate preparation, dosing, and administration; to track lot numbers; to monitor expiration dates; and to control inventories. The same procedures could be applied to infant formula use in hospitals and ambulatory care settings to support the safety of infants and to improve quality of care. Failure to monitor infant formula through these procedures leads to overuse of formula and excessive supplementation without medical indications.

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

Upon discharge from their stay in the hospital, many mothers are unable to find and receive skilled breastfeeding support. Mothers often are left on their own to identify resources to help with questions and problems they may have with breastfeeding. Furthermore, hospitals, clinicians in the community, and community organizations typically lack systems to help connect mothers to skilled persons who can offer support for breastfeeding. Ideally, there would be a system to ensure that breastfeeding mothers and their infants would receive skilled support with lactation from informed and available health care teams. Hospitals, primary care clinicians, and community organizations share responsibility for creating such systems.

Implementation Strategies

Create comprehensive statewide networks for home- or clinic-based follow-up care to be provided to every newborn in the state. Follow-up support for breastfeeding needs to be integrated into home visitation and postpartum care programs. Staff training in breastfeeding management would be fundamental to this care.

Establish partnerships for integrated and continuous follow-up care after discharge from the hospital. Communities often provide a variety of resources to help breastfeeding mothers, including peer support networks, breastfeeding clinics, lactation consultants, and support groups. Health care systems can ensure that their patients are informed about such resources and can facilitate connections to these resources. They can also help to strengthen or create these programs.

Establish and implement policies and programs to ensure that participants in WIC have services in place before discharge from the hospital. Community partners and key stakeholders, such as hospitals, lactation consultants, and other clinicians, can work with WIC to establish continuity of care for WIC participants who breastfeed their infants. In addition, WIC state agencies can collaborate with state hospital associations to identify key barriers to the provision of WIC services within the hospital setting. WIC state agencies and hospitals can partner to establish policies to ensure that WIC participants receive in-hospital education and support for breastfeeding, including identification of a WIC peer counselor and scheduling of follow-up support for breastfeeding by WIC staff in the community.

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

Clinicians are consistently identified by patients as preferred sources of information and guidance on breastfeeding. Therefore, clinicians need to demonstrate competency in supporting lactation and breastfeeding. Inadequate education and training of clinicians has been identified as a major barrier to breastfeeding, and education on breastfeeding is not a core element of most medical school or residency programs or of programs in nursing education. Unfortunately, there are few opportunities for future physicians and nurses to obtain education and training on breastfeeding, and the information on breastfeeding in medical texts is often incomplete, inconsistent, and inaccurate. In addition, breastfeeding mothers and their children have health care needs that are unrelated to lactation, but clinicians should understand the impact their services may have on breastfeeding.

Implementation Strategies

Improve the breastfeeding content in undergraduate and graduate education and training for health professionals. Because preprofessional education and training provide the foundation that supports later clinical practice, quality breastfeeding content is necessary to prepare those who will eventually care for breastfeeding women or their infants. However, even health care professionals whose services are not directly related to breastfeeding often encounter breastfeeding mothers and their children. Therefore, all health care professionals need to ensure that the care they provide is compatible with breastfeeding.

Establish and incorporate minimum requirements for competency in lactation care into health professional credentialing, licensing, and certification processes. Competency in lactation care among multiple health professional disciplines and specialties is required to ensure optimal breastfeeding management and support. These disciplines and specialties include but are not limited to physicians, nurses, physician assistants, midwives, lactation consultants, dietitians, social workers, physical therapists, and pharmacists. In addition to developing standards, certifying boards and other professional organizations can ensure competency in lactation care through training, continuing education, exams, and quality improvement programs.

Increase opportunities for continuing education on the management of lactation to ensure the maintenance of minimum competencies and skills. Education on breastfeeding can be integrated into related topic areas in continuing education. Flexible, practice-based learning approaches may be especially effective.

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

Midwives, obstetricians, family physicians, nurse practitioners, and pediatricians provide care that supports their patients’ interests and health needs, including breastfeeding. Their full support of breastfeeding may be limited by the use of practices that unintentionally and unnecessarily interfere with breastfeeding. These practices directly affect mothers’ and babies’ abilities to start and continue breastfeeding.

Implementation Strategies

Define standards for clinical practice that will ensure continuity of care for pregnant women and mother-baby pairs in the first four weeks of life. The standard of care should include actions that are important for the promotion and support of breastfeeding, including providing prenatal counseling on feeding decisions, setting accountability standards for postpartum follow-up care, monitoring neonatal weight gain, and establishing referral mechanisms for skilled lactation care. Models should be established to integrate assistance with breastfeeding into routine practice settings.

Conduct analyses and disseminate their findings on the comparative effectiveness of different models for integrating skilled lactation support into settings where midwives, obstetricians, family physicians, nurse practitioners, and pediatricians practice. Skilled lactation support may be provided by trained physicians, by lactation consultants affiliated with a physician practice, through stand-alone clinics, or by referrals. Models of care differ in the degree to which care is provided for all breastfeeding mothers to prevent difficulties and the extent to which care is provided for women already having problems. Identification of best practices and optimal care models is needed.

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

International Board Certified Lactation Consultants (IBCLCs) are the only health care professionals certified in lactation care. They have specific clinical expertise and training in the clinical management of complex problems with lactation. Better access to the care provided by IBCLCs can be achieved by accepting them as core members of the health care team and creating opportunities to prepare and train more IBCLCs from racial and ethnic minority groups that are currently not well represented in this profession.

Implementation Strategies

Include support for lactation as an essential medical service for pregnant women, breastfeeding mothers, and children. Third party payers typically define a standard package of health benefits for women and children. Including standard coverage for IBCLCs as “covered providers” when they perform services within the scope of their certification would ensure that mothers and children have access to these services through insurance maternity benefits. Federally funded health benefit programs, such as Medicaid, the Children’s Health Insurance Programs, Tricare, and the Federal Employee Health Benefit program, could serve as models for such a standard benefit package.

Provide reimbursement for IBCLCs independent of their having other professional certification or licensure. The taxonomy for health care clinicians defines qualifications of clinicians to be reimbursed. One option for reimbursement would be to place certified lactation consultants within the category of “nursing service related providers,” and specifying the nature of care they provide would allow for reimbursement of IBCLCs without requiring that they are also registered nurses. Alternatively, developing state licensure of lactation consultants could help to achieve the same purpose.

Work to increase the number of racial and ethnic minority IBCLCs to better mirror the U.S. population. Racial and ethnic minority communities tend to be underserved by lactation consultants. More students from these communities could be trained in human lactation to increase careers in lactation consultation. Area Health Education Centers could be encouraged to establish community-based training sites in lactation services.

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

Growing evidence supports the role of donated human milk in assisting infants with special needs, such as infants in newborn intensive care units who are unable to receive their own mothers’ milk, to achieve the best possible health outcome. In these situations, use of banked donor milk may protect the infant from the risks that might result from not breastfeeding. Unfortunately, demand for donor milk outpaces supply because of logistical challenges related to transportation of donated milk, the lack of clarity in oversight, and the high cost of providing banked human milk. A national strategy is needed to efficiently and effectively address the issues involved in providing banked donor milk to vulnerable infant populations.

Implementation Strategies

Conduct a systematic review of the current evidence on the safety and efficacy of donor human milk. A systematic review will provide a common understanding of the health outcomes resulting from the use of this milk by analyzing the results of all of the available published research. Additionally, a systematic review will help identify any areas where the evidence is not conclusive and where more research is needed.

Establish evidence-based clinical guidelines for the use of banked donor milk. Necessary components of the guidelines include discussion of the use of donor human milk for a variety of infants, such as those who have a low or very low birth weight, are premature, or have particular medical needs; issues related to collection of and payment for donor milk; and the complex biomedical ethics of prioritizing the distribution of banked donor milk.

Convene a study on federal regulation and support of donor milk banks. Such a study could examine possible models for regulating and funding milk banks. In addition, it should consider policy options to address concerns about biomedical ethics related to compensation for donating milk and the for-profit sale of banked donor milk. It also could examine models for payment, including WIC or health insurance program benefits that cover the use of banked donor milk. It is important also to consider how human milk banks might be a resource in planning responses to national emergencies.

Employment

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

Most women of childbearing age in the United States are in the labor force. Numerous studies have demonstrated that providing paid maternity leave for employed mothers increases the success of breastfeeding. The International Labor Organization, an arm of the United Nations, recommends a paid maternity leave of 18 weeks and also recommends that employers not be solely responsible for funding maternity leave, as this could create a disincentive to hire women. The International Labor Organization’s recommendations might be reasonable goals for the United States. In this country, the Family and Medical Leave Act of 1993 provides for 12 weeks of unpaid leave that can be used for maternity leave. However, unpaid leave is usually not an option for lower-income mothers, who are disproportionately women of color. Therefore, paid leave is necessary to reduce the differential effect of employment on breastfeeding among disadvantaged racial, ethnic, and economic groups, which in turn would allow disadvantaged populations to benefit from the health effects of breastfeeding.

Implementation Strategies

Add maternity leave to the categories of paid leave for federal civil servants. This change is an important step toward filling gaps and expanding access to paid maternity leave. A benefit of paid maternity leave for federal government workers would be useful to mothers employed by the federal government and encourage other work sectors to implement similar programs. Several private-sector employers have successfully provided paid leave. The federal government should assess existing model programs to develop a program for its employees.

Develop and implement programs in states to establish a funding mechanism for paid maternity leave. Currently, several states have passed or are considering legislation to establish paid family or maternity leave. The funding mechanisms used or proposed include the State Temporary Disability Insurance program and state-administered insurance systems for family leave that are financed by employer or employee payroll deductions. States are encouraged to be creative in developing ways to fund paid maternity leave.

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

In the United States, a majority of mothers have returned to the workplace by the time their infants are six months old. Continuation of breastfeeding after returning to work is facilitated if the employer offers a lactation support program. The evidence demonstrates that supportive policies and programs at the workplace enable women to continue providing human milk for their infants for significant periods after they return to work. High-quality lactation programs go beyond just providing time and space for breast milk expression, but also provide employees with breastfeeding education, access to lactation consultation, and equipment such as high-grade, electric breast pumps. Currently, only a quarter of U.S. employers provide breastfeeding employees with a place to express breast milk at the workplace.

Implementation Strategies

Develop resources to help employers comply with federal law that requires employers to provide the time and a place for nursing mothers to express breast milk. As part of the Affordable Care Act enacted in 2010, the Fair Labor Standards Act was amended to require employers to provide reasonable break time and a private place for nursing mothers to express milk while at work. Programs are needed to educate employers about the new law, supply examples of how it can be implemented in a variety of work settings, and provide assistance to businesses that find compliance difficult.

Design and disseminate materials to educate employers about the benefits of providing more comprehensive, high-quality support for breastfeeding employees. The Health Resources and Services Administration resource kit, The Business Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite, is one model of how to promote employer support for breastfeeding employees. Developing Web sites, videos, conference exhibits, and peer-to-peer marketing strategies could all be useful for expanding the use of lactation programs and implementing effective programs across a variety of work settings. New materials that focus on the unique concerns of non-office work environments and workplaces with few employees should be developed.

Develop and share innovative solutions to the obstacles to breastfeeding that women face when returning to work in non-office settings. While there are numerous examples of creating lactation rooms in office buildings and large stores, many work environments are more challenging for breastfeeding women returning to work. For example, farm workers may find it difficult to access a private place shielded from public view. Service workers who are on the road may not have a regular workplace where they can express milk. Challenges also exist in allowing break time for breast milk expression in businesses where there are few employees to cover during breaks. Many employers have already worked with workplace lactation consultants to develop innovative solutions, such as special trailers, makeshift temporary spaces, or “floater” employees, to enable nursing mothers to take breaks.

Promote comprehensive, high-quality lactation support programs as part of a basic employee benefits package. There are cost savings from better retention of experienced workers, higher employee morale, greater loyalty and productivity of employees, reduction in absenteeism and sick leave taken by parents of young children, and lower costs for health care and health insurance. While the percentage of employers having lactation support programs has increased over the past decade, many women still find it difficult to combine breastfeeding with work.

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

Although working mothers can express and store their milk for other persons to feed to their infants, this option should be only one approach in a multipronged strategy to achieve the goal of increasing support in the workplace. Directly breastfeeding the infant during the workday is the most effective strategy of combining employment and breastfeeding because it increases both the duration and intensity of breastfeeding. Possible strategies for working mothers include having the mother keep the baby with her while she works, allowing the mother to go to the baby to breastfeed during the workday, telecommuting, offering flexible work schedules, maintaining part-time work schedules, and using on-site or nearby child care centers.

Implementation Strategies

Create incentive or recognition programs for businesses that establish, subsidize, and support child care centers at or near the business site. If mothers are able to go to their babies during the work day, they would be able to breastfeed and not need to express and store their milk. Program incentives provided for expressing and storing milk should also be provided for strategies that enable direct breastfeeding.

Identify and promote innovative programs that allow mothers to directly breastfeed their babies after they return to work. These innovative solutions can then be widely disseminated to businesses and other employers. The Business Case for Breastfeeding resource kit was adapted recently to apply specifically to the conditions in Fortune 500 companies. Organizations can use case studies of programs already functioning successfully in such large businesses or agencies as models for implementing programs.

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

Because most employed mothers return to work in their babies’ first year of life, providers of child care have a critical role to play in supporting employed mothers who breastfeed. Child care centers are regulated by the individual states, and although there are national standards on support of breastfeeding mothers and caring for breastfed infants, few states have regulations mandating that these standards be enforced at the state level.

Implementation Strategy

Promote adoption of the breastfeeding standards in Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care. Some states have developed their own child care guidelines based on these standards,281 and these guidelines can serve as models for other states. States should facilitate training for these providers on how to support breastfeeding mothers and how to feed breast milk to infants. Facilitation might include developing instructional materials, providing incentives for training, or requiring training in breastfeeding-related topics for all providers who care for infants. Because the national guidelines recommend such training, models are already available. The federal government might encourage adoption of the national guidelines through educational programs for state health departments or other state agencies that license or oversee child care.

Research and Surveillance

Action 17. Increase funding of high-quality research on breastfeeding

In particular, new research is needed on

  • Methods to increase rates of breastfeeding among populations with current low rates. At present, the evidence available for selecting the most cost-effective interventions to promote and support breastfeeding is quite limited. Randomized designs and evaluations of existing programs designed to advance breastfeeding could add to this evidence.
  • The economic impact of breastfeeding in the United States. Increasingly, public health investments must be justified by analyses that demonstrate economic value for society as a whole, for health care institutions, or for purchasers of care. Although some studies have documented the potential for significant cost savings through breastfeeding, more precise information is needed on who will benefit from these savings.
  • Ways to better manage lactation and breastfeeding. Health professionals must deal with a variety of special situations (such as physiological problems, infectious diseases, or medical interventions) that may make breastfeeding challenging or that may need to be managed differently if a woman is breastfeeding. The evidence base for making clinical decisions in these situations is often lacking and thus needs to be expanded.

Implementation Strategy

Designate additional research funding for studies on how to increase breastfeeding rates, the economics of breastfeeding, and management of lactation. This objective can be accomplished by issuing program announcements, requests for research applications, and contract proposals.

Action 18. Strengthen existing capacity and develop future capacity for conducting research on breastfeeding

Researchers who study breastfeeding need more opportunities to collaborate with other investigators, such as behavioral scientists, medical researchers, economists, and lawyers. In addition, enhanced training opportunities are needed to ensure that a skilled cadre of future scientists is ready to undertake research on breastfeeding.

Implementation Strategies

Develop a national consortium on breastfeeding research. Such a consortium would help overcome the limitations that researchers now face in designing studies, increase the generalizability of research on breastfeeding, help prioritize key research areas, enable expanded and advanced research to be performed, and foster the timely translation of research into practice. Such a consortium would bring together researchers to

  • Standardize definitions of specific terms and measures used to classify the variables used in research on breastfeeding.
  • Promote the use of these definitions.
  • Identify ethical study designs that would expand the knowledge that has been generated thus far from observational studies.
  • Develop and update national agendas for surveillance and research on topics related to breastfeeding and infant nutrition.
  • Spearhead funding strategies to help accomplish the agenda developed by the consortium.
  • Facilitate communication among researchers.
  • Promote the dissemination of research findings and monitor the translation of research into best practices.

Enhance the training of scientists in basic and applied research on lactation, breastfeeding, and women’s and children’s health. These enhancements may include the development of specific curricula in medical schools, in educational programs for other health professionals, and in health science programs to ensure that a skilled cadre of scientists is available and appropriately trained to undertake this research.

Action 19. Develop a national monitoring system to improve the tracking of breastfeeding rates as well as the policies and environmental factors that affect breastfeeding

Although the Centers for Disease Control and Prevention (CDC) tracks breastfeeding rates annually through the National Immunization Survey and other systems, representative local data are generally unavailable and are not as timely as needed. Furthermore, few systems exist to track changes in breastfeeding behavior and attitudes.

Implementation Strategies

Enhance the CDC Breastfeeding Report Card by including a broader array of process indicators and showing trends over time. Currently, the Breastfeeding Report Card tracks breastfeeding rates, as well as indicators of state-level factors that affect breastfeeding rates, such as the strength of breastfeeding coalitions, state infrastructure, legislation, maternity practices, and professional support. However, a more comprehensive set of indicators would make the tool more useful over time.

Collect data in all states on the initiation of breastfeeding and in-hospital supplementation with formula through the U.S. Standard Certificate of Live Birth. Since 2003, the U.S. Standard Certificate of Live Birth developed by CDC has included a question on whether the infant was ever breastfed. To date, only 28 states have adopted this question. New Jersey has expanded the question to ask about in-hospital feeding of infant formula, which allows for the calculation of exclusive breastfeeding rates, as well as rates of supplementation.

Develop systems to collect key information on policy and environmental supports for breastfeeding. The CDC Survey on Maternity Practices in Infant Nutrition and Care (mPINC) is one model of tracking how institutions are supporting breastfeeding. Similar models are needed to track other supports for breastfeeding, such as workplace accommodations for breastfeeding, the accessibility of certified lactation consultants, the availability and use of peer counselors in breastfeeding, and the level of knowledge among clinicians about breastfeeding. Such systems can provide ongoing feedback about strengths and weaknesses in the overall environment so that successes can be noted and needed improvements can be identified.

Public Health Infrastructure

Action 20. Improve national leadership on the promotion and support of breastfeeding

Low rates of breastfeeding are a public health problem of national significance. Although many organizations and public health agencies have contributed to improvements in breastfeeding over time, coordinated leadership of these efforts is still lacking. Increased efforts are needed to develop and implement an action plan on breastfeeding.

Implementation Strategies

Create a federal interagency work group on breastfeeding. The federal government needs to play a central role in coordinating efforts to promote, protect, and support breastfeeding. No single federal agency can take full responsibility for breastfeeding because activities occur in many different agencies, including those devoted to health, agriculture, labor, defense, and education. All of these agencies have roles and responsibilities related to the promotion and support of breastfeeding. The U.S. Department of Health and Human Services could lead an interagency work group to bring together relevant staff to plan, carry out, and monitor initiatives in breastfeeding.

Increase the capacity of the United States Breastfeeding Committee and affiliated state coalitions to support breastfeeding. This committee brings together professional, civic, and academic organizations that have a shared vision of better support for breastfeeding, but it requires increased funding and staff to carry out its strategic plan. The United States Breastfeeding Committee is affiliated with state breastfeeding coalitions in all 50 states that carry out activities at state and local levels. The capacity of state breastfeeding coalitions should be enhanced to enable them to be an effective force in promoting and supporting breastfeeding.

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