Breastfeeding: Strategies for Environmental Change

1. 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

2. 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

3. Percent reduction in relative risk of chronic disease outcomes for breastfeeding vs. not breastfeeding Source: Agency for Research on Healthcare Research and Quality, 2007

4. Percent reduction in relative risk of maternal outcomes for breastfeeding vs. not breastfeeding Source: Agency for Research on Healthcare Research and Quality, 2007

5. 1 Adjusted odds-ratio 0 Li 2003 Liese 2001 Gillman 2001 Poulton 2001 Hediger 2001 Toschke 2001 Meta-analysis von Kries 1999 Bergmann 2003 O'Callaghan 1997 Effect of breastfeeding vs. formula feeding on childhood obesity Source: Arenz et al. Intl J Obes, 2004

6. 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)

7. Potential biological mechanisms • Direct effects of formula • Learned self-regulation of intake • Altered parent-child interactions • Residual confounding

8. CDC Funded States for Nutrition & Physical Activity to Prevent Obesity and Other Chronic Diseases 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

9. 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

10. Evidence-Based Interventions Interventions Whose Effectiveness Has Not Been Established The CDC Guide to Breastfeeding Interventions

11. Evidence-Based Interventions • Maternity Care Practices • Workplace Support • Peer Support • Educating Mothers • Professional Support • Mediaand Social Marketing

12. Maternity Care Practices • Take place during the intrapartum hospital stay • Includes the WHO/UNICEF Ten Steps to Successful Breastfeeding • Includes birthing practices

13. Ten Steps to Successful Breastfeeding • A written breastfeeding policy that is communicated to all healthcare staff • Staff training in the skills needed to implement the policy • Education of pregnant women about the benefits and management of breastfeeding • Early initiation of breastfeeding • Education of mothers on how to breastfeed and maintain lactation • Limited use of any food or drink other than human breast milk • Rooming-in • Breastfeeding on demand • Limited use of pacifiers and artificial nipples • Fostering of breastfeeding support groups and services

14. 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)

15. 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

16. 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

17. Increases: Breastfeeding duration Staff productivity and loyalty Public image of employers Decreases: Absenteeism Employer health care costs Employee turnover Workplace Support

18. 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

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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, women’s programs, teen pregnancy programs, and home visiting programs • Encourage health plans to offer prenatal classes on bf to their members

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Thank You http://www.cdc.gov/breastfeeding

33. 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