Breastfeeding: Strategies for Environmental Change

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Breastfeeding Strategies for Environmental Change
Association of State Territorial Public Health
Nutrition Directors June 12, 2007
Laurence Grummer-Strawn, PhD Nutrition
Branch Division of Nutrition and Physical
Activity Centers for Disease Control and
Prevention
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Overview

• Laurence Grummer-Strawn
• Breastfeeding and chronic disease
• Evidence-based interventions on breastfeeding
• Breastfeeding infrastructure
• Rachel Colchamiro A Focus on Maternity Care
  Practices The Massachusetts Experience
• Karen Flynn Breastfeeding as a Public Health
  Issue in Vermont
• Lynn Hellenga Environmental Change to Support
  Breastfeeding in Montana

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Percent reduction in relative risk of chronic
disease outcomes for breastfeeding vs. not
breastfeeding
Source Agency for Research on Healthcare
Research and Quality, 2007
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Percent reduction in relative risk of maternal
outcomes for breastfeeding vs. not breastfeeding
Source Agency for Research on Healthcare
Research and Quality, 2007
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Effect of breastfeeding vs. formula feeding on
childhood obesity
Source Arenz et al. Intl J Obes, 2004
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Breastfeeding Obesity

• Duration 4 reduction of odds of overweight per
  additional month breastfeeding (31 reduction for
  9 mo. vs. never bf) (Harder et al. 2005)
• Exclusivity Reduction in risk is greater among
  studies looking at exclusive bf (24) than among
  all studies (13) (Owen et al. 2005)
• Length of follow-up Effect similarly strong for
  adults as for school-age and younger children
  (Owen et al. 2005)

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Potential biological mechanisms

• Direct effects of formula
• Learned self-regulation of intake
• Altered parent-child interactions
• Residual confounding

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Program Purpose Prevent and control obesity and
other chronic diseases by supporting States in
the development and implementation of
science-based nutrition and physical activity
interventions
CDC Funded States for Nutrition Physical
Activity to Prevent Obesity and Other Chronic
Diseases
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CDC Funded States for Nutrition Physical
Activity to Prevent Obesity and Other Chronic
Diseases

• Calls for using evidence-based interventions to
  change behaviors
• Need for guidance in selecting evidence-based
  breastfeeding interventions

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The CDC Guide to Breastfeeding Interventions

• Evidence-Based Interventions
• Interventions Whose Effectiveness Has Not Been
  Established

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Evidence-Based Interventions

• Maternity Care Practices
• Workplace Support
• Peer Support
• Educating Mothers
• Professional Support
• Media and Social Marketing

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Maternity Care Practices

• Take place during the intrapartum hospital stay
• Includes the WHO/UNICEF Ten Steps to Successful
  Breastfeeding
• Includes birthing practices

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Ten Steps to Successful Breastfeeding

1. A written breastfeeding policy that is
   communicated to all healthcare staff
2. Staff training in the skills needed to implement
   the policy
3. Education of pregnant women about the benefits
   and management of breastfeeding
4. Early initiation of breastfeeding
5. Education of mothers on how to breastfeed and
   maintain lactation
6. Limited use of any food or drink other than human
   breast milk
7. Rooming-in
8. Breastfeeding on demand
9. Limited use of pacifiers and artificial nipples
10. Fostering of breastfeeding support groups and
    services

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Maternity Care Practices

• Program Examples
• 53 Baby Friendly facilities in the United States
• Breastfeeding Coalition of the Inland Empire (CA)
  implemented practice change increasing
  skin-to-skin contact
• Academy for Breastfeeding Medicine - Model
  Breastfeeding Policy recommendations
• Massachusetts ban on distribution of infant
  formula sample packs (www.banthebags.org)

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Maternity Care Practices

• Potential Action Steps
• Pay for hospital staff to attend 18 hour training
• Examine state maternity care facility regulations
  update if necessary
• Establish links between maternity facilities and
  community breastfeeding support networks
• Work to change ONE
• hospital practice to be
• evidence-based

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Workplace Support

• Components of worksite lactation programs
• Space to express milk or breastfeed
• Provision or access to a pump
• Maternity leave
• Flexible work arrangements telecommuting,
  part-time work, job sharing, flex time
• On-site child care
• Breaks for expressing milk or breastfeeding
• Workplace education and clinical support
• Protection for breastfeeding women in sexual
  harassment policy

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Workplace Support

• Increases
• Breastfeeding duration
• Staff productivity and loyalty
• Public image of employers
• Decreases
• Absenteeism
• Employer health care costs
• Employee turnover

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Workplace Support

• Program Examples
• Employer recognition programs Oregons
  Breastfeeding Mother Friendly Employer project
• Employer incentives HRSA workplace initiative
  The Business Case for Breastfeeding
• Employee Support AZ Dept of Health Services
  breastfeeding policy for employees

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Workplace Support

• Potential Action Steps
• Provide information to employers about workplace
  support local resources
• Establish a model lactation support program for
  all state employees
• Promote legislation to support work site
  lactation programs
• Recognize work sites
• and employers who
• support their breastfeeding
• employees

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Peer Support

• Encouragement support provided by mothers who
  are breastfeeding or who have done so in the past

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Peer Support
Peer support is a cost-effective, individually
tailored approach, especially important where
professional support is unavailable
Source Chapman et al., 2004

• Peer support programs are effective by themselves
  in increasing breastfeeding initiation duration
• Source Fairbank et al., 2000

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Peer Support

• Potential Action Steps
• Coordinate peer counseling services for women not
  eligible for WIC
• Expand coverage of the WIC peer counseling
  program
• Improve existing peer support programs
• Ensure support and
• supervision of peer
• counselors by an IBCLC

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Educating Mothers

• Although many women know benefits of
  breastfeeding, they lack information on how to do
  it
• US Preventive Services Task Force
• Maternal education is the most effective
  single intervention for increasing breastfeeding
  initiation and short-term duration

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Educating Mothers

• Program Examples
• Hospital-based prenatal breastfeeding classes
• Intrapartum education
• Postpartum follow-up and information
• WIC
• Breastfeeding education throughout prenatal
  period
• Breastfeeding instruction available postpartum

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Educating Mothers

• Potential Action Steps
• Encourage health professional organizations to
  provide training for their members in providing
  breastfeeding education to mothers
• Incorporate breastfeeding education into Early
  Intervention, womens programs, teen pregnancy
  programs, and home visiting programs
• Encourage health plans
• to offer prenatal classes
• on bf to their members

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Professional Support

• Lack of professional support is a major barrier
  to breastfeeding
• Many women do not know how to get help from a
  lactation consultant
• Most third-party payers do not reimburse for
  IBCLC services

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Professional Support
Program examples

• ILCA provides a Find a Lactation Consultant
  directory to connect mothers providers to
  professional lactation support
• Hospital-based bf clinics ensure professional
  support and follow-up for bf dyads

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Professional Support

• Potential Action Steps
• Work with state Medicaid and insurance
  commissioners to ensure lactation support is a
  standard, reimbursable service
• Fund establishment of sustainable, financially
  supported, walk-in clinics for all new mothers
  with IBCLCs
• Develop disseminate a
• resource directory of
• locally available lactation
• support services

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Media Social Marketing

• Media campaigns, particularly TV, improves
  breastfeeding attitudes and initiation
• Social marketing approach has increased
  initiation duration of breastfeeding while
  improving community support for breastfeeding

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Media Social Marketing

• Potential Action Steps
• Identify local experts who can pitch stories to
  the media that highlight breastfeeding
• Provide Loving Support materials to interested
  local physicians, schools, clinics, hospitals,
  and child care centers

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Breastfeeding infrastructure and communications

• Need for state breastfeeding coalitions
• Clinical care providers
• Public health
• Businesses
• National Conference of State Breastfeeding
  Coalitions--Jan. 2006 2008
• Breastfeeding listserv
• State Breastfeeding Coalitions national
  teleconference every 2 months

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Thank You

• http//www.cdc.gov/breastfeeding

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State Breastfeeding Report Card

• Breastfeeding outcome indicators
• Breastfeeding process indicators
• of babies born in Baby Friendly facilities
• Lactation consultants per 1000 live births
• Mother-to-mother support groups per 1000 live
  births
• Legislation protecting breastfeeding in public
• Legislation supporting breastfeeding at work
• Existing coalition
• Coalition website
• State staff dedicated to breastfeeding