Breastfeeding: Strategies for Environmental Change

Laurence Grummer-Strawn, PhDNutrition BranchDivision of Nutrition and Physical ActivityCenters for Disease Control and Prevention

Association of State & Territorial Public Health

Nutrition Directors

June 12, 2007

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

Percent reduction in relative risk of chronic disease outcomes for breastfeeding vs. not breastfeeding

0 10 20 30 40 50 60 70

Childhood Obesity

SIDS

Acute myelogenous lymphoma

Acute lymphocytic lymphoma

Type 2 diabetes

Type 1 diabetes

Asthma

Atopic dermatitis

Source: Agency for Research on Healthcare Research and Quality, 2007

Percent reduction in relative risk of maternal outcomes for breastfeeding vs. not breastfeeding

0 5 10 15 20 25 30 35

Ovarian cancer

Breast cancer

Type 2 diabetes

Source: Agency for Research on Healthcare Research and Quality, 2007

Effect of breastfeeding vs. formula feeding on childhood obesity

0 1

O'Callaghan 1997

Bergmann 2003

Hediger 2001

Li 2003

Poulton 2001

von Kries 1999

Liese 2001

Toschke 2001

Gillman 2001

Meta-analysis

Adjusted odds-ratioSource: Arenz et al. Intl J Obes, 2004

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)

Potential biological mechanisms

• Direct effects of formula

• Learned self-regulation of intake

• Altered parent-child interactions

• Residual confounding

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

• Calls for using evidence-based interventions to change behaviors

• Need for guidance in selecting evidence-based breastfeeding interventions

CDC Funded States for Nutrition & Physical Activityto Prevent Obesity and Other Chronic Diseases

The CDC Guide to Breastfeeding Interventions

• Evidence-Based Interventions

• Interventions Whose Effectiveness Has Not Been Established

Evidence-Based Interventions

• Maternity Care Practices

• Workplace Support

• Peer Support

• Educating Mothers

• Professional Support

• Media and Social Marketing

Maternity Care Practices

• Take place during the intrapartum hospital stay

• Includes the WHO/UNICEF Ten Steps to Successful Breastfeeding

• Includes birthing practices

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

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)

Maternity Care PracticesPotential 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

Workplace SupportComponents 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

Workplace Support

Increases:• Breastfeeding duration

• Staff productivity and loyalty

• Public image of employers

Decreases:• Absenteeism

• Employer health care costs

• Employee turnover

Workplace Support

Program Examples

• Employer recognition programs – Oregon’s 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

Workplace SupportPotential 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

Peer Support

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

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

Peer SupportPotential 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

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

Educating MothersProgram Examples

• Hospital-based prenatal breastfeeding classes

• Intrapartum education

• Postpartum follow-up and information

• WIC• Breastfeeding education throughout

prenatal period

• Breastfeeding instruction available postpartum

Educating MothersPotential Action Steps

• Encourage health professional organizations to provide training for their members in providing breastfeeding education to mothers

• Incorporate breastfeeding education into Early Intervention, women’s programs, teen pregnancy programs, and home visiting programs

• Encourage health plans to offer prenatal classes on bf to their members

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

Professional Support

• 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

Program examples

Professional SupportPotential 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

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

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

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

Thank You

http://www.cdc.gov/breastfeeding

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