What happens when lazy media happens to good people? It has happened to all of us at one point or another–I certainly know I am not immune. As in the case of the recent media frenzy about Mike Bloomberg’s initiative to improve city-wide breastfeeding rates, significant health care issues can become so obscured that people begin fighting battles that don’t exist. While there are a handful of thoughtful, informative articles out there, the vast majority of pieces have catered to fear-mongering and politician-bashing, promoting the idea that this initiative is about little more than government control of women’s rights. These articles make no mention of the fact that these proposals by Mayor Bloomberg are adapted directly from recommendations of the Centers for Disease Control (CDC) and World Health Organization (WHO), nor do they tell you that infant death rates drop dramatically when breastfeeding recommendations are followed, or that the instance of childhood asthma, diabetes and cancer can all be reduced by promoting and protecting breastfeeding.
In light of all of this, I’m throwing my two cents into the ring in the hopes that some of my research on the subject can provide the kind of evidence-based information so sorely lacking in the most widely read newspaper articles on the subject. I am uploading a policy brief I wrote for a class of mine last Fall. I ended up doing an immense amount of research on the subject, and while the paper is addressed to Georgia state legislators, it has not been sent out for publication or use at this point. First, though, here are some thoughts I posted on Facebook in response to a friend’s comment on the subject today (in fact, this conversation has been the inspiration for this blog post):
“If I may offer just a bit of an alternative perspective. I don’t agree with any decision being withheld from women, and it does seem that the way Bloomberg has handled this situation is problematic. BUT, the way that formula has been distributed in hospitals for the past few decades has not at all been about the health of women and babies…it’s been about the health of the profit margin of the formula company. Formula companies have, for years, provided monetary incentives to hospitals for passing out their products. The early days of breastfeeding are difficult and new mothers are very vulnerable to every piece of advice being given out. Nurses haven’t traditionally been trained to give good breastfeeding support (it’s quite complicated and involves a lot more than just putting the baby to the breast). Instead, the health care industry has been VERY quick to push formula as an alternative to breastfeeding, even giving formula to babies whose parents have expressly asked that it not be used. When a medical institution gives out a product, it implies that the mother isn’t breastfeeding correctly, or that she may not have the necessary “stuff” that her baby needs. The result is that the US has abysmally low breastfeeding rates, despite all of the evidence that points to the profound long-term benefits of breastfeeding for both mother and baby. A LOT of the issue is that US women don’t get enough time off from work to sustain breastfeeding for long enough, but research has shown that our hospitals have not been giving good enough education and support. Patients in every other medical area, from heart disease to cancer to autoimmune diseases should demand that their health care practitioners are practicing to the evidence and making the best treatments available. If a sub-par treatment is being used more than the most effective one, steps should be taken to improve the use of the most effective treatment. We should also demand this for our new mothers. No one will keep her from using formula if she so chooses (and formula will absolutely be offered if breastfeeding isn’t a physical possibility), but she should be fully educated about what the research says. We know A LOT more about the benefits of breastfeeding now than we did even 10 years ago. Patients deserve to make fully informed decisions based on the evidence. I wish this issue in NYC had been framed better. Saying that we are “locking up” formula doesn’t really give people the fully story, and makes them feel like something important is being withheld. But passing it out freely has been for the benefit of big business, not for the benefit of moms and babies. In any case, sorry for the long rant, but the picture from inside the hospital walls is a very different one that what is being portrayed through the media.”
Below, you will find the policy brief I wrote last October, along with a hefty list of resources. I believe in giving women evidence-based information. When she is armed with appropriate and truthful information, she can then make a truly informed decision. That is the definition of choice.
Toward the Improvement of Maternity Practices in Infant Nutrition in Georgia
“The time has come to set forth the important roles and responsibilities of clinicians, employers, communities, researchers, and government leaders and to urge us all to take on a commitment to enable mothers to meet their personal goals for breastfeeding.”—Regina M. Benjamin, M.D., M.B.A. Vice Admiral, U.S. Public Health Service Surgeon General Surgeon General’s Call to Action to Support Breastfeeding
Despite ample evidence to support the infant, maternal and community benefits of breastfeeding, implementation of evidence-based practice has proven challenging for U.S. maternity facilities. Modern birth and postpartum practices, such as the routine separation of mother and baby post-birth, inappropriate interruption of breastfeeding to accommodate hospital policy and procedure, and lack of timely follow-up care after discharge have translated into well-rooted barriers to the optimal breastfeeding environment. Other factors, including the media’s representation of bottle-feeding as normative, lack of family or social support, and the routine distribution of free infant formula samples have also contributed to lower than recommended breastfeeding rates throughout the United States (Policy, 2005).
Evidence-based practices known to encourage and increase breastfeeding rates are well known and well rooted in the literature; yet, Georgia State policies lack the specificity and urgency so desperately needed to encourage consistent adherence. Given the projected benefits that improved breastfeeding rates will have for the long-term health of mothers and babies, as well as the economic benefits for both families and communities, vigorous advocacy for improved hospital practices is warranted. The State of Georgia has shown consistently poor performance in the area of breastfeeding initiation and duration (CDC, 2011). The time has come for the State of Georgia Department of Public Health to follow in the steps of the Surgeon General by issuing both a call to action and the implementation of more viable policy for the improvement of statewide breastfeeding rates.
Breastfeeding’s Benefits and Challenges:
The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of the infant’s life, citing research that highlights noteworthy benefits of human milk consumption for mother, baby, community and environment, including:
- Decreasing the incidence and severity of a wide range of infectious diseases worldwide (Policy, 2005)
- Reducing U.S. postneonatal mortality rates by 21% (Policy, 2005)
- Decreasing rates of sudden infant death syndrome within the first year of life
- Reducing type 1 and type 2 diabetes mellitus, lymphoma, leukemia, and Hodgkin disease, hypercholesterolemia, and asthma in older children and adults who had been breastfed (Policy, 2005)
- Reducing rates of overweight and obesity (Nommsen-Rivers, 2004)
- Elevation of IQ scores in breastfed infants (Policy, 2005)
- Decreasing maternal postpartum bleeding (Policy, 2005)
- Decreasing the maternal risk of breast and ovarian cancers, anemia and osteoporosis (Policy, 2005)
- Earlier return to prepregnancy weight (Policy, 2005)
- Reducing health care costs for mothers and babies (Policy, 2005)
- Reducing economic costs related to purchasing infant formula and bottle-feeding supplies (Policy, 2005)
- Fewer missed days of work on the part of breastfeeding mothers (Policy, 2005)
- Potential for decreased annual health care costs of approximately $3.6 billion in the United States (Policy, 2005)
While the World Health Organization (WHO) explicitly opposes the distribution of free formula samples to postpartum women at the time of hospital discharge, and the Centers for Disease Control (CDC), the American College of Obstetricians (ACOG), and the Government Accountability Office (GAO) all recommend against the practice, U.S. hospitals have been slow to sever relationships with the distributers of infant formula. In the state of Georgia, 98% of hospitals continue to distribute free sample packs of formula, exposing an estimated 94 % of Georgia infants to formula. The distribution of infant formula by medical institutions and staff tends to imply endorsement of the product’s superiority to breast milk (Rosenberg, 2008)). One study concludes that women who received discharge packs including infant formula were more likely to breastfeed their infants for fewer than 10 weeks as compared to those women who did not receive the discharge packs (Rosenberg, 2008).
The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have responded to the growing need for improved breastfeeding rates worldwide by sponsoring the Baby-Friendly Hospital Initiative, which recognizes those facilities who provide optimal lactation support. This recognition is based on adherence to specific criteria established by WHO/UNICEF: Ten Steps to Successful Breastfeeding for Hospitals (Lang, 1998). Maternity facilities and birth centers worldwide can seek the Baby-Friendly designation, which involves rigorous external evaluation to ensure that criteria are adequately met. Since the establishment of the Baby-Friendly Hospital Initiative, more than 15,000 facilities in 134 countries have been awarded the designation. The United States boasts only 119 of those designations, and the state of Georgia has zero facilities that have achieved such recognition (BFHI, 2011).
Ten Steps to Successful Breastfeeding for Hospitals, as established by WHO (BFHI, 2011):
- Have a written breastfeeding policy that is routinely communicated to all health care staff.
- Train all health care staff in skills necessary to implement this policy.
- Inform all pregnant women about the benefits and management of breastfeeding.
- Help mothers initiate breastfeeding within one hour of birth.
- Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
- Give newborn infants no food or drink other than breastmilk, unless medically indicated.
- Practice “rooming in”– allow mothers and infants to remain together 24 hours a day.
- Encourage breastfeeding on demand.
- Give no pacifiers or artificial nipples to breastfeeding infants.
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
The positive impact of Baby-Friendly practices has been well established in the literature. One study examined results from a National Survey and found that breastfeeding rates in U.S. Baby-Friendly hospitals had breastfeeding rates above state, regional and national rates. These results persisted in a variety of settings and pertained to both initiation and exclusivity of breastfeeding. This elevation was also consistent across demographics, showing improvement in breastfeeding rates even for those populations that have traditionally exhibited low rates of breastfeeding (Merewood, 2005). Another such study looked at the influence of Baby-Friendly practices on the duration of breastfeeding, and concluded that, “Evidence supporting greater maternal exposure to Baby-Friendly practices, especially exclusive breastfeeding, in substantially extending breastfeeding duration was clearly present in our findings (Tarrant, 2011).”
CDC and Healthy People 2020 Recommendations for Breastfeeding Promotion:
Acknowledging the numerous health benefits breastfeeding has for mothers and babies, the Centers for Disease Control has taken an active stance in promoting and supporting measures to increase nationwide breastfeeding rates. In 2007, the CDC began issuing the Breastfeeding Report Card, detailing state and national trends in breastfeeding, and created the Maternity Practices in Infant Nutrition and Care (mPINC) survey to provide detailed information and recommendations to each state (CDC, 2011). The 2009 mPINC survey for the state of Georgia reveals the following inadequacy in the area of breastfeeding policy: a scant 5% of Georgia state maternity facilities have comprehensive breastfeeding policies that comply with the recommendations of the Academy of Breastfeeding Medicine (CDC, 2011). In addition, the state of Georgia falls well below the objective breastfeeding rate targets set forth by Healthy People 2020, as well as below U.S. national averages in every category:
Objective: MICH-21: Increase the Proportion of infants who are breastfed
Healthy People 2020 Target
U.S. National Average
|At 6 months||
|At 1 year||
|Exclusive at 3 months||
|Exclusive at 6 months||
* Table adapted from Breastfeeding Report Card—United States 2011 (CDC, 2011)
Implications and Recommendations for the State of Georgia:
The Georgia Department of Public Health promotes breastfeeding as the preferred method of infant nutrition and acknowledges its support for the Healthy People 2010 and 2020 Goals for improving breastfeeding rates and duration across the State of Georgia. Likewise, the Georgia Department of Human Resources has released a position paper on breastfeeding that iterates the sentiments of the American Pediatrics Committee on Nutrition and echoes the policies set forth by the World Health Organization (State of Georgia, 2011). Despite these positive gestures in support of sound breastfeeding promotion, Georgia’s poor performance in the realm of breastfeeding initiation and exclusivity implies that these statements may not be adequately conveying the appropriate level of urgency needed to encourage real change. The Centers for Disease Control (CDC) suggest that, “State health departments are a valuable resource that can provide technical assistance to hospitals seeking the Baby-Friendly Designation (CDC, 2011).” The CDC also suggests that state infrastructure should support the designation of adequate numbers of full-time equivalents (FTEs) responsible for ensuring appropriate breastfeeding support. Currently, the state of Georgia boasts only two such FTEs (CDC, 2011).
The U.S. Preventive Services Task Force determined that a comprehensive and multifaceted approach is vital to successful breastfeeding intervention (Godfrey, 2010). To effectively address the consistently inadequate breastfeeding rates in the State of Georgia, specific, multifactorial policy needs to be written and implemented. Such policy should include the following:
- Active endorsement of the Baby-Friendly Hospital Initiative and the Ten Steps to Successful Breastfeeding for Hospitals (Merewood, 2005)
- Provide support and technical assistance for achieving designation as a Baby-Friendly facility (CDC, 2011)
- Actively oppose and discourage the distribution of free formula in hospital discharge packages (Merewood, 2010)
- Financial incentive for those hospitals refusing to distribute free samples of baby formula
- Increase the number of full-time equivalents responsible for ensuring appropriate breastfeeding support (CDC, 2011)
- Pay for hospital staff across Georgia to participate in 18-hour training courses in breastfeeding (CDC, 2011)
- Produce and promote active media campaigns detailing the benefits of exclusive breastfeeding and media portrayal of the act of breastfeeding
Conclusion: It is clear that Georgia must make strides towards improving breastfeeding initiation and duration. The health benefits to mothers and babies, and the theoretical reduction in long-term health care costs associated with breastfeeding should provide the impetus for prioritizing this issue. Policy makers must do more than lend words to this issue; they must create the opportunity for change by incentivizing those measure that have been proven to create change. With adequate funding, appropriate policy, including helping maternity facilities achieve the Baby-Friendly designation, Georgia can anticipate significant improvement in this vital preventive health measure (Vital, 2011).
BFHI USA (2011). Baby-Friendly Hospitals and Birth Centers. Retrieved from http://www.babyfriendlyusa.org/eng/10Steps.html
BFHI USA (2011). The Ten Steps to Successful Breastfeeding. Retrieved from http://www.babyfriendlyusa.org/eng/03.html
Centers for Disease Control (2011). Breastfeeding Report Card—United States, 2011. Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard.htm
Godfrey, J., & Lawrence, R. (2010). Toward optimal health: the maternal benefits of breastfeeding…. Ruth A. Lawrence, M.D. Journal of Women’s Health (15409996), 19(9), 1597-1602. doi:10.1089/jwh.2010.2290
Lang, S., & Dykes, F. (1998). Education. WHO/UNICEF Baby Friendly Initiative — educating for success… the first of a two part series. British Journal of Midwifery, 6(3), 148-150. Retrieved from EBSCOhost.
Merewood, A., Grossman, X., Cook, J., Sadacharan, R., Singleton, M., Peters, K., & Navidi, T. (2010). US Hospitals Violate WHO Policy on the Distribution of Formula Sample Packs: Results of a National Survey. Journal of Human Lactation, 26(4), 363-367. doi:10.1177/0890334410376947
Merewood, A., Mehta, S., Chamberlain, L., Philipp, B., & Bauchner, H. (2005). Breastfeeding rates in US baby-friendly hospitals: results of a national survey. Pediatrics, 116(3), 628-634. Retrieved from EBSCOhost.
Merewood, A., Patel, B., Newton, K., MacAuley, L., Chamberlain, L., Francisco, P., & Mehta, S. (2007). Breastfeeding duration rates and factors affecting continued breastfeeding among infants born at an inner-city US baby-friendly hospital. Journal of Human Lactation, 23(2), 157-164. Retrieved from EBSCOhost.
Nommsen-Rivers, L. (2004). More evidence of the protective effect of breastfeeding against childhood obesity. Journal of Human Lactation, 20(2), 255-256. Retrieved from EBSCOhost.
Policy statement. Breastfeeding and the use of human milk. (2005). Pediatrics, 115(2 Part 1), 496-506. Retrieved from EBSCOhost.
Rosenberg, K., Eastham, C., Kasehagen, L., & Sandoval, A. (2008). Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding. American Journal of Public Health, 98(2), 290-295. Retrieved from EBSCOhost.
Spatz, D. L. (2011). The surgeon general’s call to breastfeeding action-policy and practice implications for nurses. Nursing Outlook, 59(3), 174-176. doi:10.1016/j.outlook.2011.03.006
State of Georgia Department of Public Health (2011). Georgia Department of Human Resources Position Paper on Breastfeeding. Linked from http://www.health.state.ga.us/programs/nutrition/breastfeeding/index.asp
Tarrant, M., Wu, K. M., T., Y., Y., Sham, A., & … Dodgson, J. E. (2011). Impact of Baby-Friendly Hospital Practices on Breastfeeding in Hong Kong. Birth: Issues in Perinatal Care, 38(3), 238-245. doi:10.1111/j.1523-536X.2011.00483.x
Vital signs: hospital practices to support breastfeeding — United States, 2007 and 2009. (2011).
Here is a link to one of the inflammatory articles I mentioned earlier: