SECTION 2: THE PRENATAL
THIS SECTION WILL ADDRESS
INFORM ALL PREGNANT WOMEN ABOUT THE
BENEFITS AND MANAGEMENT OF
AT THE CONCLUSION OF THIS SECTION, YOU
WILL BE ABLE TO:
IDENTIFY APPROACHES TO BREASTFEEDING
PROMOTION THAT HAVE A POSITIVE IMPACT
ON WOMEN IN THE PRENATAL PERIOD
The Baby Friendly Hospital Initiative
The World Health Organization (WHO) and UNICEF, specialized
health agencies of the United Nations, and have recognized
the health of all children as a global priority. One of their many
activities is to advocate for and promote programs to increase
rates of exclusive breastfeeding. The Baby Friendly Hospital
Initiative is part of their program.
Improved breastfeeding alone could save the lives of more than
3,500 children every day, more than any other preventive
On the Protection, Promotion and Support of Breastfeeding
July 30 - August 1, 1990, Florence, Italy
WHO/UNICEF held a policymakers' meeting on
"Breastfeeding in the 1990’s: A Global
Initiative”. The Innocenti Declaration was
produced and adopted by the participants at
The INNOCENTI DECLARATION states that
Breastfeeding is the global goal for optimal maternal and child health and
Reinforcement of a "breastfeeding culture“ is needed
Obstacles to breastfeeding within the health system, the workplace and
the community must be eliminated
All women are to be adequately nourished for their optimal health
All governments should develop national breastfeeding policies
All national authorities are further urged to reinforce all actions that
protect, promote and support breastfeeding
on the Protection, Promotion and Support of Breastfeeding
November 22, 2005, Florence, Italy
The WHO/UNICEF reconvened
on the 15th Anniversary of
the Innocenti Declaration.
They declared that this
document remains valid and
these actions are urgent and
necessary to ensure the best
start in life for our children.
The World Health Organization (WHO) recommends
that children should continue to be breastfed for up
to two years of age or beyond, while receiving
nutritionally adequate and safe complementary
The World Health Organization (WHO) felt so
strongly about breastfeeding they
conducted an intensive world-wide study
between 1997 and 2003 to develop
growth charts based on the breastfed
child as the biological norm for growth.
The WHO Multicentre Growth Reference
Study assessed the physical growth,
nutritional status and motor development
in ~8,500 children from six countries. The
U.S. site was located at the University of
California at Davis.
The new growth charts can be accessed at:
United States agencies who support
and promote Breastfeeding
Centers for Disease
US Department of Health
and Human Services (DHHS)
Program for Women,
Infants, and Children (WIC)
Breastfeeding Promotion and Support Is a
Health Care Priority
As part of the US Healthy People 2010
Objectives, the national health objectives
for breastfeeding are to increase the
percentage of women who breastfeed to:
at least 75% at birth
50% at six months
25% at 12 months postpartum
The 2010 Objectives for exclusive breastfeeding
40% through three months
17% through six months.
The current breastfeeding patterns
are far from the recommended
UNICEF. Breastfeeding and complementary feeding; 1990-2000.
US Surgeon General’s
“A fundamental aspect of the protection and promotion of
health is to ensure individuals are able to make informed
decisions in supportive environments. We have an ethical
responsibility to ensure that mothers are fully aware of the
health consequences of their infant feeding decisions. Breast
milk is the best source of infant nutrition. When a mother
chooses to breastfeed, we also have a responsibility to
protect and support her decision by providing an
environment that enables her to be successful.”
THE 25TH ANNIVERSARY OF THE SURGEON GENERAL’S WORKSHOP BREASTFEEDING AND HUMAN LACTATION: THE STATUS OF
BREASTFEEDING TODAY, Steven K. Galson, MD, MPH RADM, USPHS Acting Surgeon General, Public Health Reports / May–June
2009 / Volume 124:356-358
HHS Blueprint for Action on
U.S. Department of Health and Human Services
Office on Women’s Health, 2000
This ‘Blueprint for Action’ establishes a comprehensive
breastfeeding policy for the nation.
“Significant steps must be taken to increase breastfeeding rates in the United
States and to close the wide racial and ethnic gaps in breastfeeding. This
goal can only be achieved by supporting breastfeeding in the family,
community, workplace, health care sector, and society.”
National Media Campaign
The Department of Health and Human Services(DHHS) and The Ad Counsel developed
a print and television ad campaign to promote breastfeeding.
Launched June 2004, Ended April 2006
The American Academy of
Family Physicians (AAFP)
The American College of
Academy of Pediatrics
American College of
Health Association (APHA)
American Academy of Pediatrics (AAP)
Policy on Breastfeeding
“Exclusive breastfeeding for approximately the
first six months and support for breastfeeding
for the first year and beyond as long as
mutually desired by mother and child. “
AMERICAN ACADEMY OF PEDIATRICS (AAP)
The AAP goes to say in their policy statement that all
pediatricians need to “promote, support, and protect
breastfeeding enthusiastically”. And that breastfeeding
needs to be viewed as the “cultural norm” for infant feeding.
American College of OB-GYN
ACOG Committee Opinion
Committee on Health Care for Underserved Women
Committee on Obstetric Practice
“Evidence continues to mount regarding the value of breastfeeding for both
women and their infants. The American College of Obstetricians and
Gynecologists strongly support breastfeeding and calls on its Fellows,
other health care professionals caring for women and their infants,
hospitals, and employees to support women in choosing to breastfeed
their infants. Obstetrician-gynecologists and other health care
professionals caring for pregnant women should provide accurate
information about breastfeeding to expectant mothers and be prepared
to support them should any problems arise while breastfeeding.”
Pediatricians and the Promotion and Support of Breastfeeding
Lori B. Feldman-Winter, MD, MPH; Richard J. Schanler, MD; Karen G.
O’Connor, BS; Ruth A. Lawrence, MD
Arch Pediatr Adolesc Med. 2008;162(12):1142-1149.
However, in a recent study of
toward breastfeeding, the
results showed that their
attitudes have deteriorated.
The ‘Guilt’ Factor
Many health care providers worry that if they advocate for
breastfeeding, they will make parents feel guilty. Research
actually shows that parents will feel less guilt if they have had
the opportunity to make a fully informed decision on how
they will feed their baby. (1)
“Marketing” by Health Care Providers
Health care providers have been aggressively solicited by
manufacturer’s of human milk substitutes to market their
products and develop brand loyalty. The use of ‘free’ giveaway’s, such as conferences, free samples, patient literature,
office supplies with their logo, have been shown to “decrease
breastfeeding rates and increase premature weaning”. (2)
AN EARLY AND CONSISTENT MESSAGE ON THE
POSITIVE HEALTH BEHAVIOR OF
BREASTFEEDING NEEDS TO COME FROM ALL
HEALTH CARE PROVIDERS
In support of breastfeeding,
ACOG and the AAP developed a
“Breastfeeding Handbook for Physicians” in 2006.
“As leaders of the medical team, both play a
role in promoting breastfeeding to their
patients. But numerous studies have
shown that lack of knowledge and training
in lactation issues prevents them from
According to ACOG and AAP, the handbook will
encourage physicians to become
champions of breastfeeding and to be able
to teach, promote, and support the
Promotion and support from the healthcare
Studies have shown that the
physician's recommendation to
breastfeed increases breastfeeding
initiation and duration rates.
Ongoing parental support through inperson visits and phone contacts
with health care providers results
in increased breastfeeding
The role of a father has been shown to
be one of the most powerful influences
on a mother’s decision to breastfeed in
the United States. To support and
increase breastfeeding initiation and
continuation, the opinion, attitude, and
the father’s knowledge about
breastfeeding and his relationship to
his baby and the baby’s mother must
Extended Family Support
Encouragement from the maternal grandmother is an important
factor in the initiation of breastfeeding.
What Can Be Done to Help Mothers
“There are many opportunities for creating a supportive
environment for breastfeeding through the media, the health
care system, the workplace, our community support systems,
and all levels of our educational system. By investing in efforts
to eliminate barriers, we can ensure that all children will have
the very best start in life.” (21)
Basic breastfeeding education
is needed in professional
education so all health care
providers can educate,
support, and appropriately
refer their patients (19-21)
Despite growing evidence of the health risks of not
breastfeeding, research shows that physicians do not
receive adequate training about supporting
. (22, 23)
Health Care Systems play a
central role in the promotion
and support of breastfeeding. A
mother’s experiences during
preconception and prenatal
visits, the hospital stay,
postpartum and pediatric visits
can potentially contribute to her
infant feeding decisions and,
ultimately, to her breastfeeding
Breastfeeding can be
established as the norm by
incorporating infant feeding
education into the health
and science curricula in
public education at all levels.
All pregnant and
should have access to
support from mothers, who
are their peers, families,
All businesses and educational centers
must create an environment that fully
supports breastfeeding mothers.
Many studies have shown that women who are employed while
their children are young initiate breastfeeding at the same
rate as unemployed women, but they stop exclusive
breastfeeding sooner and wean earlier. (29-36)
Health care providers are in a unique position to enhance a
mother's breastfeeding success as she transitions back into
the workplace. (37)
Proposed National Legislation to
Support Working Mothers
US Rep. Carolyn Maloney from New York, has been an
advocate for employed women for many years.
On Thursday June 11, 2009, she reintroduced the
Breastfeeding Promotion Act
(H.R. #2819 - 2009 version)
on Capitol Hill.
US Senator Jeff Merkley from Oregon
a companion Senate bill (S. #1244).
The Proposed Breastfeeding Promotion Act
includes five provisions:
(1) To amend the Civil Rights Act of 1964 to protect breastfeeding in the
This would ensure that women cannot be fired or discriminated against in
the workplace for expressing milk or breastfeeding during lunch or breaks.
(2) To provide tax incentives for businesses that establish private
lactation areas in the workplace.
With more than half of mothers with infants (< one year of age) in the work
force, it is important to promote a mother-friendly work environment. The
bill would encourage employers to set up a safe, private, and sanitary
environment for women to express (or pump) breast milk by providing a tax
credit for employers who set up a lactation location, purchase or rent
lactation-related equipment, hire a lactation consultant or otherwise
promote a lactation-friendly work environment.
(3) To provide for a performance standard for breast pumps.
The bill would require the Food and Drug Administration to develop
minimum quality standards for breast pumps to ensure that products on
the market are safe and effective based on efficiency, effectiveness, and
(4) To allow breastfeeding equipment to be tax deductible for families.
The bill would amend the tax laws to include breastfeeding equipment and
services as deductible medical care expenses.
(5) To protect the privacy of breastfeeding mothers.
The bill would require employers to provide break time to express breast
milk as well as make reasonable efforts to provide a private place for
mothers to do so.
Breastfeeding is recognized by the international,
national, and professional community as a
desired health behavior for all mothers and
their children. As health care providers, we
need to continue our efforts to promote,
protect and support breastfeeding.
The U.S. Healthy People 2010 Goals are:
a) 100% at birth, 75% at 6 months and 50% at 1 year
b) 75% at birth, 50% at 6 months and 25% at 1 year
(*correct answer: These are the goals set for 2010.)
a) 50% at birth, 25% at 6 months and 15% at 1 year
b) 75% at birth, 40% at 3 months and 17% at 6 months
A national breastfeeding policy has been developed
and can be found in the:
a) Academy of Breastfeeding Medicine Policy
b) American Academy of Pediatrics Policy
c) HHS Blueprint for Action on Breastfeeding
(* correct answer: The Blueprint for Action is the U.S. Policy on Breastfeeding)
a) American College of Ob-Gyn Policy
Initiation of breastfeeding is important to the
mother when support comes from all of the
a) The maternal grandmother
b) Father of the baby
c) American Medical Association (* correct answer:
The AMA is in support of breastfeeding, however they are not a direct
influence on a mother’s initiation of breastfeeding)
d) Her health care provider
To create a supportive breastfeeding environment
in the U.S., we need to:
a) Encourage all businesses to support breastfeeding
b) Provide for mother-to-mother community support
c) Incorporate breastfeeding into the health/science curriculum of
d) Have health care systems provide evidence-based women’s
e) Integrate a breastfeeding curriculum into HCP’s professional
f) All of the above (* correct answer)
Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical professional. 6th ed. St. Louis: Mosby, 2005.
Gartner LM, Morton J, Lawrence RA, et al., for the American Academy of Pediatrics Section on Breastfeeding. Breastfeeding
and the use of human milk. Pediatrics. 2005;115(2):496-506.)
.Jones G, Steketee RW, Black RE, et al. How many child deaths can we prevent this year? Lancet 2003;362:65–71.
Horta BL, Bahl R, Martinés J, et al. Evidence on the longterm effects of breastfeeding: systematic reviews and metaanalysis.
2007. (http://whqlibdoc.who.int/publications/2007/9789241595230_eng.pdf )
Bentley M, Caulfield L, Gross S, et al. Sources of influence on intention to breastfeed among African-American women at
entry to WIC. J Hum Lact 1999; 15(1):27–34.
U.S. Preventative Services Task Force. Behavioral Interventions to Promote Breastfeeding: Recommendations and Rationale.
Agency for Healthcare Research and Quality, Rockville, MD, 2003.
Sikorski J, Renfrew M, Pindoria S, Wade A. Support for breastfeeding mothers: A systematic review. Paediatr Perinatal
de Oliveira M, Camacho L, Tedstone A. A method for the evaluation of primary health care units’ practice in the promotion,
protection, and support of breastfeeding: Results from the state of Rio de Janeiro, Brazil. J Hum Lact 2003;19(4):365–373.
Lu MC, Lange L, Slusser W, Hamilton J, Halfon N. Provider encouragement of breast-feeding: evidence from a national
survey. Obstet Gynecol. 2001;97(2):290-295.
Velillas JJ, et al. A breastfeeding e-learning project based on a web forum. Breastfeeding Medicine. 2007;2(4):219-228.
Bunik M, Gao D, Moore L. An investigation of the field trip model as a method for teaching breastfeeding to pediatric
residents. J Hum Lact. 2006;22(2):195-202.
Rogan WJ. Pollutants in breast milk. Arch Pediatr Adolesc Med. 1996;150(9):981-990.
Littman H, Mendendorp SV, Goldfarb J. The decision to breastfeed. The importance of the father’s approval. Clin Pediatr
Scott JA, Binns CW, Aroni RA. The influence of reported paternal attitudes on the decision to breast-feed. J Paediatr Child
Sharma M, Petosa R. Impact of expectant fathers in breast-feeding decisions. J Am Diet Assoc. 1997;97(11):1311-1313.
Mahoney MC, James DM. Predictors of anticipated breastfeeding in an urban, low-income setting. J Fam Pract.
Moxley S, Kennedy M. Strategies to support breastfeeding. Discarding myths and outdated advice. Can Fam Physician.
O'Campo P, Faden RR, Gielen AC, Wang MC. Prenatal factors associated with breastfeeding duration: recommendations for
prenatal interventions. Birth. 1992;19(4):195-201.
19. Naylor AJ, Creer AE , Woodward-Lopez G, Dixon S. Lactation management education for physicians. Semin Perinatol 1994;18:525-31.
20. Satcher DS . DHHS blueprint for action on breastfeeding. Public Health Rep 2001;116:72-3.
21. “Investing in California’s future” Breastfeeding Promotion Committee , California Department of Health Report to the Services Primary
Care and Family Health Division, January~2007.
22. Freed GL, Clark SJ, Sorenson J, Lohr JA, Cefalo R, Curtis P. National assessment of physicians' breast-feeding knowledge, attitudes,
training, and experience. JAMA. 1995;273(6):472-476.
23. Freed GL, Clark SJ, Curtis P, Sorenson JR. Breast-feeding education and practice in family medicine. J Fam Pract. 1995;40(3):263-269.
24. Lewallen LP , Dick MJ, Flowers J, et al. Breastfeeding support and early cessation. J Obstet Gynecol Neonatal Nurs 2006;35:166-72.
25. Labarere J, Gelbert-Baudino N, Ayral AS , et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine,
preventive visit: a prospective, randomized, open trial of 226 mother infant pairs. Pediatrics 2005;115:e139-46.
26. Chapman DJ, Damio G, Young S, Perez-Escamilla R. Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina
population: a randomized controlled trial. Arch Pediatr Adolesc Med 2004;158:897-902.
27. Coutinho SB, de Lira PI , de Carvalho Lima M, Ashworth A. Comparison of the effect of two systems for the promotion of exclusive
breastfeeding. Lancet 2005;366:1094-100.
28. Bonuck KA, Trombley M, Freeman K, McKee D. Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention
on duration and intensity of breastfeeding up to 12 months. Pediatrics 2005;116:1413-26.
29. Greiner T. Factors associated with the duration of breastfeeding may depend on the extent to which mothers of young children are
employed. Acta Paediatr. 1999:88(12): 1311-1312.
30. Lindberg LD. Women’s Decisions about Breastfeeding and Maternal Employment. Journal of Marriage and Family. 1996:58(1):239-252.
31. McLeod D, Pullon S, Cookson T. Factors influencing continuation of breastfeeding in a cohort of women. J Hum Lact. 2002:18(4):335-342.
32. Novotny R, Hla MM., Kieffer EC, Park CB, Mor J, Thiele M. Breastfeeding duration in a multiethnic population in Hawaii. Birth.
33. Roe B, Whittington LA, Fein SB, Teisl MF. Is there competition between breast-feeding and maternal employment? Demography. 1999 :
34. Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with
breastfeeding discontinuation. Pediatrics. 2003:112(1):108-115.
35. Vogel A, Hutchison BL, Mitchell EA. Factors associated with the duration of breastfeeding. Acta Paediatr. 1999:88(12):1320-1326.
36. Yinyam S, Morrow M. Breastfeeding practices among employed Thai women in Chiang Mai. J Hum Lac. 1999:15(3):225-232.
37. Angeletti , MA, Breastfeeding Mothers Returning to Work: Possibilities for Information, Anticipatory Guidance and Support from US
Health Care Professionals Journal of Human Lactation, May 1, 2009, Vol. 25, No. 2, 226-232 (2009)