Breastfeeding & Public Health 2012
Objectives Students will be able to: • Identify advantages to increasing breastfeeding rates in the population • List 2020 Healthy People goals for breastfeeding • Access population-based breastfeeding data and describe patterns of breastfeeding in the US • Use knowledge about the physiology of breastfeeding to advocate for policies that support breastfeeding
Benefits of Breastfeeding • Health outcomes – Infant – short term – Infant – long term – Maternal • Economic • Environmental
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries (Agency for Healthcare Research and Quality, 2007) • Systematic reviews/meta-analyses, randomized and non-randomized comparative trials, prospective cohort, and case-control studies on the effects of breastfeeding • English language • Studies must have a comparative arm of formula feeding or different durations of breastfeeding. Only studies conducted in developed countries were included in the updates of previous systematic reviews. • Studies graded for methodological quality.
Limitations of Breastfeeding Outcome Studies • Definitions of breastfeeding; misclassification • Lack of randomization; confounding & residual confounding • “Wide range in quality of evidence”
AHRQ: Positive Findings for Infants % less in BF Acute otitis media (exclusive BF 3 -6 mos. ) 50% GI infection (infants breastfeeding) 64% Lower respiratory tract diseases 72% Atopic dermatitis (exclusive BF 3 mos. ) 42% Asthma (in young children) – no family hx, family hx Type I diabetes Type 2 diabetes Childhood leukemia Sudden Infant Death Syndrome Necrotizing enterocolitis Obesity 27%, 40% 19, 27% 39% 15, 19% 36% 4 -82% 4, 7, 24%
Breastfeeding and Obesity: Reviews & Meta-analysis • Owen et al. Pediatrics. 2005 – 61 studies – Odds ratio = 0. 87 (95% CI 0. 85 -0. 89) for reduced risk of later obesity associated with breastfeeding compared to formula • Arenz et al. Int J obes relat metab disord. 2004 – 9 studies met criteria – Odds Ratio = 0. 78, 95% CI (0. 71, 0. 85) protective effect of breastfeeding for obesity – Found dose response • Harder et al. Am J Epidemiol. 2005
Breastfeeding and risk of obesity Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007
Harder et al. Am J Epidemiol. 2005 (17 studies) Length of Odds Ratio for 95% CI Breastfeeding Risk of Obesity < 1 1. 00 0. 65, 1. 55 1 -3 0. 81 0. 74, 0. 88 4 -6 0. 76 0. 67, 0. 86 7 -9 0. 67 0. 55, 0. 82 Ø 9 0. 68 0. 50, 0. 91
AHRQ: Equivocal or insignificant infant outcomes • Cognitive development in term or preterm infants • CVD • Infant mortality in developed countries
AHRQ: Positive Maternal Outcomes % less in BF Maternal Type II Diabetes (reduction in risk per 4, 12% year of lactation) Postpartum depression Breast cancer (reduction per year of lactation) Ovarian cancer association 4. 3, 28% 21%
AHRQ: Equivocal or insignificant maternal outcomes • Effect of breastfeeding in mothers on return-to-pregnancy weight was negligible • Effect of breastfeeding on postpartum weight loss was unclear • Little or no evidence for association with osteoporosis
Long-Term Protective Maternal Effects? • Wicklund et al, Pub Health Nutr, 2011: Finland; 16 -20 years post partum, women who bf < 6 mos. had higher body fat mass, fat mass% android region fat than women who bf > 6 mos. • Bobrow et al, Int J Obesity, 2012: UK Million Women Study (postmenopausal); Mean BMI lower among women who had breastfed, showing dose response 1% lower for every 6 months of breastfeeding; controlled for SES, smoking, PA.
Wicklund et al, Pub Health Nutr, 2011:
Wicklund et al, Pub Health Nutr, 2011:
Economic Costs of Formula Feeding (US Breastfeeding Committee) • Families: ~$2, 000 for the first year • Employers: loss of productivity, increased absence, more health claims • Health care: 3. 6 billion a year to treat infant illnesses, $331 -475 per child for one HMO • Food assistance: costs to support breastfeeding mothers in WIC are 55% the cost for providing formula
Environmental Benefits of Breastfeeding (ADA Position Paper, 2005) • Human milk is a renewable natural resource. • Produced and delivered to the consumer directly • Formula requires manufacturing, packaging, shipping, disposing of containers – 550 million formula cans in landfills each year* – 110 billion BTUs of energy to process and transport* • Breastfeeding delays return of menses, increases birth spacing, limits population growth • Note ADA position statement 2009 – environmental benefits not included…. . *USBC
Barriers to Breastfeeding (ADA Position Paper 2005) • Individual: Inadequate knowledge, embarrassment, social reticence, negative perceptions • Interpersonal: Lack of support from partner and family, perceived threat to father-child bond • Institutional: Return to work or school, lack of workplace facilities, unsupportive health care environments • Community: discomfort about nursing in public • Policy: aggressive marketing by formula companies
2007 Health Styles Survey Neither Agree/Disag ree Question Agree Disagree Mothers who breastfeed should do so in private places only. 35. 8% 26. 0% 38. 2% I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, etc. 44. 1% 24. 6% 31. 3% I believe women should have the right to breastfeed in public places. 52. 0% 23. 8% 24. 2% Infant formula is as good as breast milk. 20. 2% 27. 2% 52. 6% - 2011 answers to this question 18. 1% 24. 5% 57. 3%
Healthy People Goals and Breastfeeding Data
National Immunization Survey • Random-digit--dialed telephone survey conducted annually by CDC • Nationally representative data • Breastfeeding questions first added in 2001 • Data organized by birth cohort, not year of data gathering • 2004 data from 17, 654 infants
Healthy People 2010: Increase the proportion of mothers who breastfeed their babies Goal US Baseline WA 2004 WA 2005 WA 2006 WA 2007 Early postpartum 75% 64% 88% 90% 86% 88% At 6 months 50% 25% 57% 58% 60% At one year 25% 16% 32% 33% 35% 33%
New 2010 Breastfeeding Objectives added in 2007 • To increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60% • To increase the proportion of mothers who exclusively breastfeed their infants through age 6 months to 25%
Exclusive breastfeeding: definition • Exclusive breastfeeding is defined as an infant receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines
Optimal Duration of Exclusive Breastfeeding: Cochrane, August 2012 • 23 studies (11 from developing countries): Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are partially breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea.
Exclusive Breastfeeding US 2004 US 2005 US 2006 US 2007 WA 2004 WA 2005 WA 2006 WA 2007 Through 3 months 31 36 33 33 50 45 49 44 Through 6 months 11 12 14 13 23 21 25 21
Healthy People 2020; & Report Card 2008 Births Goal 2009 Births National WA State Ever Breastfed 82 75 89 77 89 At 6 months 61 44 60 47 55 At 12 months 34 24 35 26 34 Exclusive at 3 months 46 35 49 36 44 Exclusive at 6 months 26 15 23 16 20
Percent of Children Ever Breastfed by State among Children Born 2000 2004 2007
National prevalence of breastfeeding initiation and duration to 6 months and 12 months, * by selected sociodemographic characteristics --- National Immunization Survey (NIS), United States, 2004 --2008 Characteristic Total Race/Ethnicity (child) Hispanic White, non-Hispanic Black, non-Hispanic American Indian/Alaska Native Asian or Pacific Islander Recipient of WIC¶ Yes No (but eligible) No (not eligible) Mother's education Less than high school diploma or GED** High school diploma or GED Some college College graduate Mother's age (yrs) <20 20 --29 ≥ 30 Initiation 6 months 12 months % % % 73. 4 41. 7 21. 0 80. 4 74. 3 54. 4 69. 8 45. 1 43. 2 26. 6 37. 1 24. 0 21. 4 11. 7 19. 4 80. 9 52. 4 29. 7 66. 1 76. 5 82. 2 32. 7 50. 4 51. 7 16. 5 30. 1 25. 5) 66. 2 65. 2 74. 8 85. 4 35. 9 31. 7 40. 5 56. 5 19. 9 15. 7 19. 7 28. 6 53. 0 69. 0 77. 5 19. 3 33. 8 48. 5 8. 1 16. 2 25. 4 Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State --National Immunization Survey, United States, 2004— 2008. Weekly March 26, 2010 / 59(11); 327 -334
FIGURE. Prevalence of initiating breastfeeding* among Hispanics, non. Hispanic whites, and non-Hispanic blacks --National Immunization Survey, United States, 2004 --2008† Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State --- National Immunization Survey, United States, 2004— 2008. Weekly March 26, 2010 / 59(11); 327 -334
Percent of Children Breastfed at 6 Months of Age by State 2000 2004 2006 2007
Percent of Children Breastfed at 12 Months of 2004 Age by State 2006 2007
Percent of Children Exclusively Breastfed Through 3 Months of Age among Children born 2005 2007 National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services
Rates of Exclusive Breastfeeding at 3 months (NIS, 2004) Maternal Education Less than high school High school Some college College graduate Income/poverty ratio < 100 - 184 185 - 340 >350 % 24 23 33 42 24 29 34 39
Rates of Exclusive Breastfeeding at 3 months (NIS, 2004) Education Hispanic White, non-Hispanic Black, non-Hispanic Asian, non-Hispanic Other Mother’s age at birth of child < 20 20 -29 > 30 % 31 33 20 31 17 26 35
Percentage of children <six months old exclusively breastfed (2000 -2006) http: //www. unicef. org/nutrition/index_24824. html
Percentage of infants under the age of six months who are exclusively breastfed, 1995– 2010 http: //www. childinfo. org/breastfeeding_progress. html
State of the World’s Mothers Report, 2012: Save the Children
Assurance: What Works to Support Breastfeeding?
Levels of Influence in the Social-Ecological Model Structures, Policies, Systems Local, state, federal policies and laws to regulate/support healthy actions Institutions Rules, regulations, policies & informal structures Community Social Networks, Norms, Standards Interpersonal Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs
The CDC Guide to Breastfeeding Interventions, 2005 Six evidence-based interventions • Individual: – Educating mothers – Professional support • Intrapersonal: – Peer support/counseling programs • Institutional – Maternity care practices • Media and social marketing
Breastfeeding Policy Documents 1984 U. S. Surgeon General’s Workshop 1990 Innocenti Declaration, WHO and UNICEF 2000 HHS Blueprint for Action on Breastfeeding 2001 US Breastfeeding Committee Strategic Plan 2003 WHO: Global Strategy for Infant and Young Child Feeding 2010 Breastfeeding A Vision for the Future (USBC & others) 2011 Surgeon General’s “Call to Action to Support Breastfeeding”
Supporting Breastfeeding Mothers & Families Worksites & Childcare Healthcare Legislation
Mothers & Families
Support for healthy breastfeeding mothers with healthy term babies. Cochrane, May 2012 • “All women should be offered support to breastfeed their babies to increase the duration and exclusivity of breastfeeding. Support is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support that is only offered reactively, in which women are expected to initiate the contact, is unlikely to be effective; women should be offered ongoing visits on a scheduled basis so they can predict that support will be available. ”
The Surgeon General’s Call to Action to Support Breastfeeding Actions for Mothers and Their Families: 1. Give mothers the support they need to breastfeed their babies. 2. Develop programs to educate fathers and grandmothers about breastfeeding. Actions for Communities: 3. Strengthen programs that provide mother-to-mother support and peer counseling. 4. Use community-based organizations to promote and support breastfeeding. 5. Create a national campaign to promote breastfeeding. 6. Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding
Worksites & Child Care
The Surgeon General’s Call to Action to Support Breastfeeding Actions for Employment: 13. Work toward establishing paid maternity leave for all employed mothers. 14. Ensure that employers establish and maintain comprehensive, highquality lactation support programs for their employees. 15. Expand the use of programs in the workplace that allow lactating mothers to have direct access to their babies. 16. Ensure that all child care providers accommodate the needs of breastfeeding mothers and infants.
HHS Blueprint: Worksites “Facilitate breastfeeding or breastmilk expression at the workplace by providing private rooms, commercial grade breastpumps, milk storage arrangements, adequate breaks during the day, flexible work schedules and onsite childcare facilities. ”
CDC Healthstyle Survey (Nationally representative postal survey N~5000) Agree 2006 Agree 2009 I believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers 51 56 I believe employers should provide extended maternity leave to make it easier for mothers to breastfeed. 49 47 Agree 2011 64
Healthstyle Survey, cont. Agree 2006 Agree 2009 Agree 2011 I believe employers should provide a private room for breastfeeding mothers to pump their milk at work. 47 46 56 I would support tax incentives for employers who make special accommodations to make it easier for mothers to breastfeed. 30 25
WA Healthy Worksite Survey • Content: Measures policies, & environments to support healthy nutrition, physical activity, breastfeeding and to discourage tobacco use. • Population: WA businesses with 50+ employees, selected from WA Department of Employment Security. • Sampling: Representative geographic sample across WA. 900 contacted, 540 responded. • Administration: Fall 2005. 15 minute phone survey of HR managers, conducted by Gilmore. Repeat in 2007. • Background: DOH STEPS/CDNPA/Tobacco collaboration
Of the 400 Businesses with Female Employees < age of 50: • 11% had a specific policy to support breastfeeding • 82% provided flexible scheduling to allow employees adequate break time to breastfeed or pump/express breast milk • 31% had a designated room or location (not counting bathroom stalls) for mothers to breastfeed or pump/express breast milk
Characteristics of Breastfeeding Rooms
Interventions in the workplace to support breastfeeding for women in employment. Cochrane, 2012 • “No trials have evaluated the effectiveness of workplace interventions in promoting breastfeeding among women returning to paid work after the birth of their child. ”
Childcare: HHS Blueprint for Action • Safe storage • Follow mothers’ instructions • Provide quiet and comfortable place for mothers
Health Care
The Surgeon General’s Call to Action to Support Breastfeeding Actions for Health Care: 7. Ensure that maternity care practices around the United States are fully supportive of breastfeeding. 8. Develop systems to guarantee continuity of skilled support for lactation between hospitals and health care settings in the community. 9. Provide education and training in breastfeeding for all health professionals who care for women and children. 10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians. 11. Ensure access to services provided by International Board Certified Lactation Consultants. 12. Identify and address obstacles to greater availability of safe banked donor milk for fragile infants.
Code of Marketing of Breastmilk Substitutes WHO (1981) • “No facility of a health care system should be used for the purpose of promoting infant formula or other products…”
HHS Blueprint: Health Care System 1. Train health care providers who provide maternal and child care on the basics of lactation, breastfeeding counseling and lactation management during coursework, clinical and in-service training and continuing education. ” 2. Ensure that breastfeeding mothers have access to comprehensive, up-to-date, and culturally tailored lactation services provided by trained physicians, nurses, lactation consultants and nutritionists/dietitians.
National Survey of Maternity Care Practices in Infant Nutrition and Care (m. PINC) • 2, 546 hospitals, 121 birth centers in the 50 states, DC, Puerto Rico • 35 questions; 7 categories – – – labor and delivery, breastfeeding assistance, mother-newborn contact, newborn feeding practices, breastfeeding support after discharge, nurse/birth attendant breastfeeding training and education, – structural and organizational factors related to breastfeeding MMWR. June 13, 2008 / 57(23); 621 -625
http: //www. cdc. gov/mmwr/preview/mmwrhtml/mm 5723 a 1. htm#fig
FIGURE. Percentage of hospitals that implemented recommended maternity care practices related to breastfeeding* --- Maternity Practices in Infant Nutrition and Care Survey (m. PINC), United States, 2007 and 2009 Recommended maternity care practices are indicators of the Ten Steps to Successful Breastfeeding MMWR, August 5, 2011 / 60(30); 1020 -1025
Maternity Practices in Infant Nutrition and Care (m. PINC) (2, 690 hospital & birth facilities participated; 2, 672 facilities participated in 2009; based on Ten Steps to Successful Breastfeeding; MMWR, August 5, 2011 / 60(30); 1020 -1025 ) m. PINC Indicator 2007 (%) 2009 (%) 1. Model breastfeeding policy: hospital has a written breastfeeding policy that includes 10 model policy elements§ 11. 7 14. 4 2. Staff competency assessment: nurses/birth attendants are assessed for competency in basic breastfeeding management and support at least once per year 44. 6 49. 7 3. Prenatal breastfeeding education: breastfeeding education is included as a routine element of prenatal classes 92. 5 92. 8 4. Early initiation of breastfeeding: ≥ 90% of healthy full-term breastfed infants initiate breastfeeding within one hour of uncomplicated vaginal birth 43. 5 50. 9 5. Teach breastfeeding techniques: ≥ 90% of mothers who are breastfeeding or intend to breastfeed are taught breastfeeding techniques (e. g. , positioning, how to express milk, etc. ) 87. 8 89. 1
m. PINC Indicator 2007 (%) 2009 (%) 6. Limited use of breastfeeding supplements: <10% of healthy full-term breastfed infants are supplemented with formula, glucose water, or water 20. 6 21. 5 7. Rooming-in: ≥ 90% of healthy full-term infants, regardless of feeding method, remain with their mother for at least 23 hours per day during the hospital stay 30. 8 33. 2 8. Teach feeding cues: ≥ 90% of mothers are taught to recognize 77. 0 and respond to infant feeding cues instead of feeding on a set schedule 81. 8 9. Limited use of pacifiers: <10% of healthy full-term breastfed infants are given pacifiers by maternity care staff members 25. 3 30. 1 10. Post-discharge support: hospital routinely provides three modes of post-discharge support to breastfeeding mothers: physical contact, active reaching out, and referrals¶ 26. 8
Data Source: Baby-Friendly facilities : www. babyfriendlyusa. org & Live Births: CDC NCHS Live Births by State.
CDC Breastfeeding Report Card Process Indicators 2009 US WA 2012 US WA Percent of live births occurring at facilities designated as Baby Friendly (BFHI) 2. 9 6. 2 9. 2 Number of IBCLCs ** per 1000 live births 2. 2 4. 2 3. 2 5. 3 Number of state health dept. FTEs dedicated to breastfeeding 80 1. 4 135 4. 7
State Breastfeeding Legislation • Breastfeeding in public: 23 states give the right to breastfeed in any place it is legal to be • Jury duty: 7 states exempt breastfeeding mothers from jury duty • Family law: three states require breastfeeding status to be considered in divorce or custody decisions.
WA Breastfeeding Legislation 1. Amendment to indecent exposure law – “A person is guilty of indecent exposure if he or she intentionally makes any open and obscene exposure of his or her person or the person of another knowing that such conduce is likely to cause reasonable affront or alarm. The act of breastfeeding or expressing breast milk is not indecent exposure. ”
WA breastfeeding legislation • “Am employer may use the designation “ infant friendly” on its promotional materials if the employer has an approved workplace breastfeeding policy addressing at least the following: – Flexible work schedule, place to nurse/express with handwashing facilities and refrigerator • DOH to approve employers, but no funds to do this, so no worksites have been designated
HB 1596 - 2009 • An act relating to protecting a woman’s right to breastfeed in a place of public resort, accommodation, assemblage, or amusement; amending RCW 49. 60. 030 and 49. 60. 215. • Adds breastfeeding to rights protecting discrimination because or race, creed, color, national origin, sex, honorably discharged veteran, sexual orientation or the presence of…. disability. .
1. Meet and exceed the Healthy People objectives to increase the proportion of mothers who breastfeed. 2. Implement maternity care practices that foster normal birth and breastfeeding in every facility that cares for childbearing women. 3. Ensure that health care providers provide evidence-based, culturally competent birth and breastfeeding care. 4. Create and foster work environments that support breastfeeding mothers. 5. Ensure that all federal, state, and local laws relating to child welfare and family law recognize the importance of breastfeeding and support its practice.
6. Implement curricula that teach students of all ages that breastfeeding is the normal and preferred method of feeding infants and young children. 7. Reduce the barriers to breastfeeding imposed by the marketing of human milk substitutes. 8. Protect a woman’s right to breastfeed in public. 9. Encourage greater social support for breastfeeding as a vital public health strategy.
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