Breastfeeding & Public Health 2011

Structures, Policies, SystemsLocal, state, federal policies and laws to

regulate/support healthy actions

InstitutionsRules, regulations, policies &

informal structures

CommunitySocial Networks, Norms, Standards

InterpersonalFamily, peers, social networks,

associations

IndividualKnowledge, attitudes,

beliefs

Levels of Influence in the Social-Ecological Model

Functions of Public Health

• Assessment

• Policy Development

• Assurance

Objectives

Students will be able to:• Identify advantages to increasing breastfeeding

rates in the population• List 2010 Healthy People goals for breastfeeding• Access population-based breastfeeding data

and describe patterns of breastfeeding in the US• Apply evidence-based approaches to improve

breastfeeding rates• 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%

Atopic dermatitis (exclusive BF 3 mos) 42%

GI infection (infants breastfeeding) 64%

Lower respiratory tract diseases 72%

Asthma (in young children) – no family hx, family hx 27%, 40%

Obesity 4, 7, 24%

Type I diabetes 19, 27%

Type 2 diabetes 39%

Childhood leukemia 15, 19%

Sudden Infant Death Syndrome 36%

Necrotizing enterocolitis 4-82%

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 year of lactation)

4, 12%

Postpartum depression association

Breast cancer (reduction per year of lactation)

4.3, 28%

Ovarian cancer 21%

AHRQ: Equivocal or insignificant maternal outcomes

• Effect of breastfeeding in mothers on return-to-pre-pregnancy weight was negligible

• Effect of breastfeeding on postpartum weight loss was unclear

• Little or no evidence for association with osteoporosis

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 Breastfeeding

Odds Ratio for Risk of Obesity

95% CI

< 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

9 0.68 0.50, 0.91

Breastfeeding & Obesity: Support for the Evidence

• Secular trends– Trend for increased breastfeeding is opposite that for obesity

• Dose Response– Some studies find, others do not

• Plausible mechanisms– Changes in leptin production and sensitivity– Lower energy and protein intake in breastfed infants– Insulin response to feeding; higher in formula fed infants– Differences in the feeding relationship; self-regulation of

energy intake– Changing composition of human milk during feedings

Dubois et al. Public Health Nutrition, 2003

• Social inequalities in infant feeding during the first year of life. The Longitudinal Study of Child Development in Quebec (LSCDQ 1998-2002)

• “Social disparities in diet during infancy could play a role in the development of social and health inequalities more broadly observed at the population level.”

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

Question AgreeNeither

Agree/Disagree

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%

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

babiesGoal US

Base-line

WA

2004

WA 2005 WA 2006 WA 2007

Early post-partum

75% 64% 88% 90% 86% 88%

At 6 months

50% 25% 57% 57% 58% 60%

At one year

25% 16% 32% 33% 35% 33%

Percent of U.S. children who were breastfed, by birth year

Breastfeeding Among U.S. Children Born 1999—2008, CDC National Immunization Survey

Exclusive Breastfeeding

Percent of U.S. breastfed children who are supplemented with infant formula, by

birth year

Provisional Rates of Any and Exclusive Breastfeeding by Age among Children Born

in 2008, National Immunization Survey

Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007

Demographics of Breastfeeding (NIS 2004)

Percent of Children Ever Breastfed by State among Children Born

2000

2007

Percent of Children Ever Breastfed by State among Children Born

20042005

20062007

Percent of Children Breastfed at 6 Months of Age by State

2004

2006

2007

2000

Percent of Children Breastfed at 12 Months of Age by State2004

2006

2007

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

Exclusive BreastfeedingUS

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

Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)

Maternal Education %

Less than high school 24

High school 23

Some college 33

College graduate 42

Income/poverty ratio

< 100 24

100 - 184 29

185 - 340 34

>350 39

Rates of Exclusive Breastfeeding at 3 months (NIS, 2004)

Education %

Hispanic 31

White, non-Hispanic 33

Black, non-Hispanic 20

Asian, non-Hispanic 31

Other

Mother’s age at birth of child

< 20 17

20-29 26

> 30 35

Percent of Children Exclusively Breastfed Through 3 Months of Age among Children born

National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

20052007

Percent of Children Exclusively Breastfed Through 6 Months of Age among Children

Born

20072005

Healthy People 2020; 2011 Report Card (2008 births)

Goal National WA State

Ever Breastfed

82 75 89

At 6 months

61 44 60

At 12 months

34 24 35

Exclusive at 3 months

46 35 49

Exclusive at 6 months

26 15 23

Formula before 2 days

14 25 18

Assurance:Evidence-Based Interventions

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

Four Interventions: Effectiveness not established, encourage rigorous evaluation

1. Use contermarketing techniques to limit the negative impact of formula marketing

2. Improve the knowledge, skills and attitudes of health care providers re breastfeeding

3. Increase public acceptance of breastfeeding

4. Provide assistance to breastfeeding mothers through hotlines or other information sources

Breastfeeding Policy Documents1984   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 & FamiliesWorksites & Childcare

HealthcareLegislation

Mothers & Families

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, high-quality 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.

Worksites

Global Strategy for Infant & Young Child Feeding

WHO/ UNICEF (2003)

Innocenti Declaration WHO/ UNICEF (1990)

“Women in paid employment can be helped to continue breastfeeding by bring provided with minimal enabling conditions. paid maternity leave, part- time work arrangements, onsite crèches, facilities for expressing and storing breastmilk and breastfeeding breaks.”

“…obstacles to breastfeeding within the…workplace…

must be eliminated…”

HHS Blueprint: Worksites

1. “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.”

2. “Establish family and community programs that enable breastfeeding continuation when women return to work in all possible settings.”

3. “Encourage childcare facilities to provide quality breastfeeding support.”

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

Healthstyle Survey, cont.

Agree 2006

Agree 2009

I believe employers should provide a private room for breastfeeding mothers to pump their milk at work.

47 46

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

Amenities Located in Breastfeeding Rooms

0% 20% 40% 60% 80% 100%

Locking door for privacy

Electrical outlet

Handwashing sink

Refrigerator to storepumped/expressed milk

Characteristics of Breastfeeding Rooms

Key Policy Documents: Childcare

HHS Blueprint for Action (2000)

WA State Nutrition & Physical

Activity Plan

(2003)

•Safe storage•Follow mothers’ instructions•Provide quiet and comfortable place for mothers

•“Assure that…child care facilities are breastfeeding friendly.”•Follow guidelines of Breastfeeding coalition of Washington.

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.

Key Policy Documents: Health Care

Global Strategy for Infant & Young Child Feeding

WHO/ UNICEF (2003)

WA State Nutrition & Physical Activity Plan

(2003)

“Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. They should also have access to skilled practical help from, for example, trained health workers, lay and peer counselors, and certified lactation consultants…”

•Support King County model breastfeeding standards.

Key Policy Documents: Health CareInternational Code of

Marketing of Breastmilk Substitutes

WHO (1981)

Innocenti Declaration

WHO/ UNICEF(1990)

“No facility of a health care system should be used for the purpose of promoting infant formula or other products…”

“Health workers should encourage and protect breastfeeding…”

“…obstacles to breastfeeding within the…health system…must be eliminated…”

“…every facility providing maternity services fully practices all ten of the Ten Steps to Successful Breastfeeding…”

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.

Health Care System, cont.

3. Establish hospital and maternity center practices that promote breastfeeding, such as the “Ten Steps to Successful Breastfeeding.”

4. Develop breastfeeding education for women, their partners, and other significant family members during the prenatal and postnatal visits.

National Survey of Maternity Care Practices in Infant Nutrition and Care (mPINC)

• 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/mm5723a1.htm#fig

FIGURE. Percentage of hospitals that implemented recommended maternity care practices related to breastfeeding* --- Maternity Practices in Infant Nutrition and Care Survey (mPINC), 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

mPINC 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

Maternity Practices in Infant Nutrition and Care (mPINC)

(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 )

mPINC 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 and respond to infant feeding cues instead of feeding on a set schedule

77.0 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 26.8

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..

CDC Breastfeeding Report Card 2009 – Process Indicators

US WA

Percent of live births occurring at facilities designated as Baby Friendly (BFHI)

2.87 6.85

Number of IBCLCs ** per 1000 live births

2.20 4.16

Number of state health dept FTEs dedicated to breastfeeding

80 1.4

CDC Report Card, cont.

US WA

State legislation about breastfeeding in public places

46 yes

State legislation mandating employer support

15 no

Presence of an active statewide breastfeeding coalition

41 yes

The Surgeon General’s Call to Action to Support Breastfeeding

Actions for Research and Surveillance: 17. Increase funding of high-quality research on breastfeeding.

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

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

Action for Public Health Infrastructure: 20. Improve national leadership on the promotion and support of breastfeeding.

A Vision for the Future

• We look forward to a society where:

• There is widespread knowledge of the importance of breastfeeding and the risks of not breastfeeding.

• Mothers and families make informed choices about feeding children.

• Women begin and continue to breastfeed for as long as they wish.

http://org2.democracyinaction.org/o/5162/p/dia/action/public/?action_KEY=4610

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.