3. 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
Levels of Influence in the Social-Ecological Model
4. 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
5. Benefits of Breastfeeding
• Health outcomes
– Infant – short term
– Infant – long term
– Maternal
• Economic
• Environmental
6. • “Human milk is species-specific, and all
substitute feeding preparations differ
markedly from it, making human milk
uniquely superior for infant feeding.”
Breastfeeding and the Use of Human Milk
American Academy of Pediatrics, 2005
7. Health Benefits for Infant: AAP
• Lowered risk of infectious diseases in both
developed and developing countries: diarrhea,
respiratory tract infection, otitis media, bacterial
meningitis, botulism, UTI, necrotizing
enterocolitis, bacteremia
• Enhanced immune response to polio, tetanus,
diptheria, haemophilus influenza immunization
• Possible lowered risk of sudden infant death
syndrome
• Possible lowered risk of diabetes (type 1 &
2),leukemia, Hodgkin disease, lymphoma
• Probable enhanced cognitive development
• Provides analgesia to infants during painful
procedures
8. Health Benefits for Mother: AAP
• Possible reduction in hip fractures after
menopause
• Less postpartum bleeding & more rapid
uterine involution
• Reduced risk of breast and uterine cancer
• Increased child spacing
9. 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.
10. Limitations of Breastfeeding
Outcome Studies
• Definitions of breastfeeding;
misclassification
• Lack of randomization; confounding &
residual confounding
• “Wide range in quality of evidence”
11. 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%
12. AHRQ: Equivocal or insignificant
infant outcomes
• Cognitive development in term or preterm
infants
• CVD
• Infant mortality in developed countries
13. 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%
14. 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
15. 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
16. Breastfeeding and risk of obesity
Does Breastfeeding Reduce the Risk of Pediatric Overweight? CDC. 2007
17. 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
18. 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
19. 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.”
20. 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
21. 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
*USBC
22. 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
24. Moses Lake Resident Survey (N = 254)
Brzezney A. Unpublished Data (2003)
Statements about the
Community
%
Agree
%
Disagree
Babies in our community are more
likely to be bottle-fed first 6
months
55.1% 28.3%
It is not customary to breastfeed a
baby in public
61.0% 26.4%
25. Moses Lake Resident Survey (N = 254)
Brzezney A. Unpublished Data (2003)
Statements about
Worksites
%
Agree
%
Disagree
Workplaces in our community
make it easier for mother to
bottle-feed
61.4% 21.3%
Workplaces in our community
make it easier for mother to
breastfeed
8.7% 67.3%
(Barrier) Mothers don’t want to
breastfeed…mothers must
return to work
87.8% 3.5%
26. Moses Lake Resident Survey (N = 254)
Brzezney A. Unpublished Data (2003)
Statements about
Childcare
%
Agree
%
Disagree
(Barrier) Mothers don’t want to
breastfeed…baby starts
attending day care
71.7% 14.2%
29. Percent of U.S. children who
were breastfed, by birth year
Breastfeeding Among U.S. Children Born 1999—
2005, CDC National Immunization Survey
30. The resurgence of breastfeeding at the
end of the second millennium
(Wright and Schanler, J Nutr. 131, 2001)
• Between 1971 and 1995 increase was for all
groups.
• Between 1984 and 1995 increase was in groups
less likely to breastfeed (low income, low
education, African American, WIC)
• Early resurgence of breastfeeding concurrent to
“natural childbirth” and women’s movement in
white well educated families
31. More recent increases associated with:
• Increased knowledge of the benefits of
breastfeeding by professionals (AAP
1997)
• Successful breastfeeding interventions -
especially in WIC
– 47% of US infants on WIC
– early 90s brought increased WIC & for
breastfeeding promotion and increased
maternal food package for BF
33. 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
34. Healthy People 2010: Increase the proportion
of mothers who breastfeed their babies
Goal US
Base-
line
US
2004
WA
2004
WA
2005
Early
post-
partum
75% 64% 74% 88% 90%
At 6
months
50% 25% 42% 57% 57%
At one
year
25% 16% 21% 32% 33%
37. Percent of Children Ever Breastfed by State
among Children Born in 2004
National Immunization Survey, Centers for Disease Control and Prevention,
Department of Health and Human Services
39. Percent of Children Breastfed at 6 Months of
Age by State among Children Born in 2004
National Immunization Survey, Centers for Disease Control and
Prevention, Department of Health and Human Services
40. Percent of Children Breastfed at 6 Months of
Age by State among Children Born in 2005
41. Percent of Children Breastfed at 12 Months of
Age by State among Children Born in 2004
National Immunization Survey, Centers for Disease Control and
Prevention, Department of Health and Human Services
42. Percent of Children Breastfed at 12 Months of
Age by State among Children Born in 2005
43. 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%
44. 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
46. 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
47. 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
48. Percent of Children Exclusively Breastfed
Through 3 Months of Age among Children born
in 2004
National Immunization Survey, Centers for Disease Control and
Prevention, Department of Health and Human Services
49. Percent of Children Exclusively Breastfed Through
3 Months of Age among Children born in 2005
(Provisional)
50. Percent of Children Exclusively Breastfed
Through 6 Months of Age among Children Born
in 2004
National Immunization Survey, Centers for Disease Control and
Prevention, Department of Health and Human Services
51. Percent of Children Exclusively Breastfed
Through 6 Months of Age among Children
Born in 2005
53. Six evidence-based interventions
• Individual:
– Educating mothers
– Professional support
• Intrapersonal:
– Peer support/counseling programs
• Institutional
– Maternity care practices
• Media and social marketing
54. 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
56. Breastfeeding Policy Documents
1984 U.S. Surgeon General’s Workshop
1990 Innocenti Declaration, WHO and UNICEF
2000 Healthy People 2010: Objectives
2000 HHS Blueprint for Action on Breastfeeding
2001 US Breastfeeding Committee Strategic Plan
2003 WHO: Global Strategy for Infant and Young Child
Feeding
2003 WA State Nutrition & Physical Activity Plan
57. Key Policy Documents: 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…”
58. 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.”
59. CDC Healthstyle Survey – 2006
(Nationally representative postal survey N~5000)
Agree Neither
agree/
Disagree
Disagree
I believe employers should provide
flexible work schedules, such as
additional break time, for
breastfeeding mothers
51 32 18
I believe employers should provide
extended maternity leave to make it
easier for mothers to breastfeed.
49 31 19
60. Healthstyle Survey, cont.
Agree Neither
agree/
Disagree
Disagree
I believe employers should provide
a private room for breastfeeding
mothers to pump their milk at work.
47 29 24
I would support tax incentives for
employers who make special
accommodations to make it easier
for mothers to breastfeed.
30 34 36
61. 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
62. 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
63. Amenities Located in Breastfeeding Rooms
0% 20% 40% 60% 80% 100%
Locking door for privacy
Electrical outlet
Handwashing sink
Refrigerator to store
pumped/expressed milk
Characteristics of Breastfeeding
Rooms
64. 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.
65. 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.
66. Key Policy Documents: Health Care
International 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…”
67. 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.
68. 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.
69. 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
71. mPINC: Key Findings
• 70% of facilities reported providing discharge
packs containing infant formula samples to
breastfeeding mothers
• 88% of facilities taught the majority of mothers
techniques related to breastfeeding
• 24% of facilities reported giving supplements
(and not breast milk exclusively) as a general
practice with more than half of all healthy, full-
term breastfeeding newborns
MMWR. June 13, 2008 / 57(23);621-625
73. Moses Lake & Centralia
Moses
Lake
Centralia
Total participants 247 250
White 71% 90%
Hispanic 42% 24%
< HS grad 25% 24%
WIC/MSS 69% 75%
Mean number of
children
2.3 2.2
75. Moses Lake Centralia
Mother was
given free
formula
91% 80%*
Mother given
coupons for
formula
82% 76%
p = 0.003
76. Moses Lake Centralia
Mother referred
to support group
20% 14%
Mother received
follow-up on
breastfeeding
29% 40%*
*p = 0.025
77. State Breastfeeding Legislation
• Breastfeeding in public: 18 states give the
right to breastfeed in any place it is legal to be
• Employment: 10 states encourage employers to
support breastfeeding mothers
• 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.
78. 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.”
79. 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
80. CDC Breastfeeding Report Card
2007 – Process Indicators
US WA
Percent of live births occurring
at facilities designated as Baby
Friendly (BFHI)
3.31 8.97
Number of IBCLCs ** per 1000
live births
2.12 4.15
Number of state health dept
FTEs dedicated to
breastfeeding
81 1
81. CDC Report Card, cont.
US WA
State legislation about
breastfeeding in public
places
46 yes
State legislation about
lactation and employment
14 yes
Presence of an active
statewide breastfeeding
coalition
43 yes
82. 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
Levels of Influence in the Social-Ecological Model
