Certain changes in cultural aspects of Western civilization have contributed to the widespread use of artificial feedings for human infants as well as to the changing structure of the family. Urbanization has been associated not only with industrialization but also with the separation of generations. This has produced the nuclear family. Nuclear families are smaller, mobile, isolated families often stranded in a large urban population. In a nuclear family, a young couple and their new infant are totally without personal human resources. That is, no one cares enough to give individual support to the family. They have no one to turn to and from whom to receive advice, encouragement, and support.
Historical Perspective
Rites of passage were described by the French author Van Gennep as the ceremonies and rituals that mark special changes in people’s lives. The list includes marriage, motherhood, birth, death, circumcision, graduation, ordination, and retirement. In our present culture, support exists for most of these events except birth and motherhood. The most critical rite of passage in a woman’s life, Raphael points out, is when she becomes a mother. Raphael further distinguishes this period of transition with the term matrescence , “to emphasize the mother and to focus on her new life-style.” Traditional cultures herald a mother giving birth, whereas our culture announces the birth of an infant. The former highlights the mother, the latter the infant. Matrescence is a time of coddling. In preindustrial societies, a mother is coddled for some time after birth, having only the responsibility of the infant’s care while the mother’s needs are met by doulas. Mothering the mother should be part of the postpartum support for a new mother.
A number of other forces added momentum to the bottle feeding trend that began in the 1920s, when manufacturers finally were able to mass produce an inexpensive container and rubber nipple with which to feed infants inexpensively. Pediatrics was a new specialty to guard the health of children. The focus was on measuring and calculating. Physicians seemed more secure when they could prescribe a measure of nutrition. The rise in the female labor force has also been credited with having an impact on the method of feeding infants, who were no longer taken everywhere with the mothers to be nursed but instead were left behind to be bottle fed. The technology of the infant food industry was a continuing influence on the nutritional thinking of both medical and lay groups.
Breastfeeding was never totally abandoned. Always groups of women prepared themselves for childbirth and read and researched feeding and nutrition and chose to breastfeed. In the mid-1940s, Dr. Edith Jackson began the Rooming-In Project at Yale University in New Haven, Connecticut. Families in New Haven who sought “childbirth without fear” and an opportunity to room-in with their infants usually chose to breastfeed. In the rooming-in unit, breastfeeding was often “contagious” because one mother successfully nursing would encourage others to try. Hospital stays averaged 5 to 7 days, during which time a mother-infant couple was cared for as a pair. More than 70% of the patients left this hospital breastfeeding. The national average at that time (1945 to 1955) was less than 25%.
Students and staff who were exposed to the philosophy of this unit went to many parts of the country, taking with them tremendous commitment to prepared childbirth and nurturing through breastfeeding. The classic article on the management of breastfeeding by Barnes et al. was published as a result of counseling hundreds of nursing mothers. The students of Jackson inoculated many hundreds of hospitals and communities with a zeal for breastfeeding.
Development of Mother Support Groups
The need remained for nuclear families to have access to support and conversation about healthy infants, mothering, and breastfeeding. The La Leche League, developed by a group of seven mothers to meet these needs, was established in Franklin Park, Illinois, in 1957. The original intent was to provide other nursing mothers with information, encouragement, and moral support. Thousands of local chapters and a network of 32,000 state and regional coordinators synchronized their activities with the headquarters in Schaumburg, Illinois. La Leche League International’s (LLLI) 4000 groups were in 66 countries, including the United States, Canada, parts of Europe, New Zealand, Africa, and other parts of the world.
An excellent publication, The Womanly Art of Breastfeeding, was prepared by the original group of mothers involved in the La Leche League. The League celebrated its fiftieth anniversary in Chicago in 2007 and published the eighth edition of this publication. La Leche League continues to provide information and updated publications about common questions that arise during lactation. Local groups offer classes to prepare mothers to breastfeed. They help with suggestions about the nitty-gritty details of preparation, nutrition, clothing, and mothering in general. They also provide every mother with a telephone counselor. To be qualified to serve as a counselor to another mother, a member must demonstrate knowledge and expertise in breastfeeding as well as an understanding of how to counsel and render support. “Telephone mothers” do not give medical advice and are instructed to tell a troubled mother to call her own physician for such advice. Interested local physicians provide medical expertise for the group when a medical opinion is appropriate. The league provides support for mothers to reduce the time the physician needs to spend counseling on the nonmedical aspects of lactation. Most information needed by new mothers is not medical.
In the decades that this support system has been in place, no good substitute for this mother-to-mother program has evolved because a woman needs a true doula.
Similar programs have been developed in more than 70 other countries. A well-established and respected program in Norway is Ammehjelpen International Group; in Australia, the Nursing Mothers’ Association of Australia; and in the United Kingdom, the National Childbirth Trust.
The group dynamics are important and feelings of normalcy are reinforced. The information and experience were shown to be important, but the support from the group had far greater influence on success in breastfeeding. Meara reports similar observations on league activities in a nonsupportive culture.
The Breastfeeding Association of South Africa is a nongovernmental, nonprofit, voluntary organization founded in 1978 by South Africans for the express needs of South African women. Their special problems and solutions are well described by Bergh. Support groups for all life’s events, especially those covering health, have become a common feature (more than 150 parent support groups exist). In the field of perinatal care, groups are available for infertile couples; couples who are expecting; those who have experienced pregnancy loss, loss of a premature infant, or loss of a term baby; those who had a cesarean delivery; and so on. Physicians should be aware of the groups that function in their communities and the policies and philosophies they embrace.
The International Childbirth Education Association also provides resources for a new family in many countries. Its program makes preparation and training available for couples during pregnancy and afterward as parents. Its scope embraces the entire childbirth concept, of which breastfeeding is part.
Adolescents need special support to improve the outcome of their pregnancies, to encourage them to breastfeed, and to establish the special relationship with, and commitment to, their infants. A study done in the Breastfeeding Educated and Supported Teen Club in Melbourne, Florida, looked at the impact of specific breastfeeding education provided by a lactation consultant in group classes. Teens were randomly assigned to the program or as a control; ethnicity and age were not significant factors. Of the 43 adolescents in the education group, 28 (65%) initiated breastfeeding, but of the 48 control subjects without education, only 7 (14.6%) initiated breastfeeding ( p < 0.001). The authors concluded that targeted education makes a difference in adolescents.
When a similar study was performed involving low-income women, a community-based program studied a hospital, home visit, and telephone support system provided by a community health nurse and a peer counselor for 6 months. After random assignment, those receiving intervention breastfed longer. The infants had fewer sick visits and use of medicines than the group with “standard care.” The cost of the program per mother was $301, which was offset by the savings on the cost of formula and health care.
In another study, adult women without a personal breastfeeding support system at home were randomized to receive support or not. The support group received support in the hospital and at home from a practicing midwife in the community. She visited in the hospital daily and was available by pager continually. After discharge, she telephoned within 72 hours and then weekly for 4 weeks. At home, the participants had access to the midwife by phone and pager. One home visit was made the first week and then as necessary. In the supported group, 26 of 26 were still breastfeeding at 1 month, but only 17 of 25 (68%) in the unsupported group were breastfeeding, proving that intensive professional support works. The costs of the program were not provided.
Active support outreach clearly affects the duration of breastfeeding and ultimately saves health care dollars. Such programs can be included in private practice.
Community Resources
Most hospitals provide training in preparation for childbirth. Part of the program is about the new infant and how to plan for neonatal care. These programs often serve as the initial stimulus to consider breastfeeding. Many such programs are given by hospital-based lactation consultants.
When a large health maintenance organization looked at 5213 new mothers enrolled in a commercial managed care plan by telephone survey at 4 to 6 months postpartum, 75% had breastfed for some time. Of these, 75% breastfed for more than 6 weeks. Breastfeeding for more than 6 weeks was associated with level of education, employment status (part-time, 84%), and adequacy of postpartum information. Health plans and employers should consider promoting breastfeeding, concluded the authors.
Because hospitals have become competitive and are marketing their services, many are developing birthing centers and are trying to capture the attention of the childbearing public with special services. These services often include classes on child rearing, including breastfeeding. Physicians should investigate the programs and printed materials distributed by the hospitals where their patients deliver. Many pediatricians are coping with the flood of patient information from conflicting sources by printing up an office manual (desktop printers make this quite feasible). This is especially helpful if the patients give birth at more than one hospital or more than one lay advocacy group is active in the community. Hospital procedures and policies can influence the success or failure of breastfeeding mothers. Pediatricians should be aware of the policies at the hospital(s) with which they are associated.
In a few short decades, we have gone from a paucity of support groups and resource literature to an overwhelming flood. Health care books and childbearing and family-rearing advice books are cascading off the presses, written by everyone from qualified experts to poorly informed freelance writers. Some are written by health care professionals who have personal experience in childbearing. Pediatricians should be familiar with a few good references for parents and provide a list for patients in the practice.
The Young Women’s Christian Association (YWCA) in most communities may also provide preparation for childbirth. Its classes usually provide programming that appeals to young and unwed women, a group in need of services rarely provided by other sources.
The Visiting Nurses Association and the public health nurses on the staff of the local county health department are special resources particularly skilled at counseling new mothers with their infants. They can provide valuable information to the physician who is working with an infant who fails to thrive at the breast by witnessing the breastfeeding scene at home. As discharge from the hospital occurs earlier and earlier, pediatricians should consider employing nurse practitioners who are prepared to make house calls immediately after birth.
Many other organizations, local and national in scope, have the perinatal period and the family as their focus. Many of these are also interested in promoting breastfeeding as part of their overall goals.
The World Health Organization (WHO) and United Nations International Children’s Education Fund (UNICEF) have joined an international effort to create a supportive atmosphere in hospitals around the world by developing the Baby Friendly Hospital Initiative (BFHI) (see Chapter 1 ). Both WHO and UNICEF provide international support for breastfeeding, especially in developing countries. The ten steps toward becoming a Baby Friendly Hospital are listed in Box 1-2 in Chapter 1 .
The BFHI was designed originally to rid hospitals of their dependence on artificial infant formulas and to encourage the support of breastfeeding in these facilities. It is designed to create a supportive atmosphere with trained and knowledgeable staff. The ten steps describe the essentials of the program. In 2009, the BFHI materials were revised by WHO. The program was expanded to integrate BFHI with the Global Strategy for Infant and Young Child Feeding. This revision included the expectation that staff be trained to provide support and education for mothers who were not breastfeeding. The 2009 update also included a review of labor and delivery practices. Step 4 has been extensively revised to promote skin-to-skin and the process of the infant finding the breast and latching on, immediately after delivery. BFHI expects that every infant will spend up to an hour accomplishing the first feeding while skin-to-skin with the mother.
Worldwide achievement of Baby Friendly Hospitals accreditation has been extensive. In the United States progress has been slow. The provision of millions of dollars in grant money has allowed many hospitals to train their staff and rebuild their programs to meet the 10 steps and achieve accreditation.
Government Organizations
The United States government has taken an active interest in the promotion of breastfeeding as well. In the goals for national health prepared by a multidisciplinary task force in 1978, it is stated that by 1990, 75% of infants leaving the hospital shall be breastfed and at 6 months of age at least 35% will still be breastfeeding. The rates in 1990 fell well short of the goals, and they were thus restated to be achieved by the year 2000, extending to 50% the number to still be breastfeeding at 5 to 6 months. The goals for 2010 included 75% breastfeeding at hospital discharge, 50% at 6 months, and at least 25% breastfeeding at 1 year. A midcourse correction indicated that 60% exclusive breastfeeding should continue for at least 3 months and exclusivity should continue for 6 months for 25%. National statistics continue to fall short of predictions although the gap is shrinking.
The U.S. Office of the Surgeon General conducted a national workshop on breastfeeding and human lactation in Rochester, New York, in June 1984 to develop recommendations for national policy. A publication from the workshop was available from the U.S. Government Printing Office in Washington, District of Columbia. A follow-up workshop was held in Washington, District of Columbia in 1985, gathering the representatives of the major official national organizations for obstetrics, pediatrics, and family physicians, including the credentialing organizations for physicians, nurses, nurse midwives, and dietitians. The organizations responded to a request for each to approve a model statement in support of breastfeeding. This was accomplished by January 1987. The organizations prepared a review of curriculum within their disciplines to ensure adequate education, training, and accreditation regarding human lactation and breastfeeding for their members. Although improvements have been made and certifying examinations have incorporated questions about breastfeeding and human lactation, curriculum development in most institutions has lagged behind. Available curricula to solve this problem have been developed by the AAP/ACOG and Wellstart.
Although C. Everett Koop, U.S. Surgeon General in the 1980s, maintained his commitment to breastfeeding, later Surgeons General did not. Twenty-five years to the day later, June 9, 2009, the Academy of Breastfeeding Medicine convened the first summit on breastfeeding in Washington, District of Columbia. Dr. Koop opened the meeting with a televised message, the same message he concluded with in 1984. The summit was directed at a different audience, not at breastfeeding zealots and supporters but the United States government and its many agencies and the health care and insurance industries. The purpose was to educate the participants on the value of breastfeeding and the necessity to support breastfeeding, including reimbursement for services provided to patients in hospitals and at home. Progress has been made. The Centers for Disease Control and Prevention (CDC), the Office of Women’s Health, and the Surgeon General took action and have participated in collecting data, and changing programs. The sitting Surgeon General issued the first “call to action” charge.
The Office of Women’s Health and others invested time, talent, and resources in the issues of maternal employment. Annual summits were convened, continuing to involve the government agencies, the health care industry, and insurance providers.
Six summits have been convened and the seventh will have been held in June 2015, sponsored and executed by the Academy of Breastfeeding Medicine. Most significant has been the generous grant support from the WW Kellogg Foundation from the very first summit. Not only did Kellogg fund the summits but the foundation has dedicated its grant resources to breastfeeding issues across the country. Kellogg now supports over 100 programs large and small. Nothing has done more to facilitate the progress of breastfeeding than the commitment of the Kellogg Foundation. The credit for this contact goes to the brilliant grant writing by ABM and the overwhelming support of Mary Ann Liebert Publishers, Inc.
During these 6 years of summits, much progress has occurred among minority groups who have formed their own organizations such as Mocha Mothers and Black Mother’s Breastfeeding Association. The Women, Infants, and Children (WIC) program has changed its policy to encourage breastfeeding and support breastfeeding mothers. Employers are supporting their lactating employees one company at a time.
Issues of rural health have begun to include those surrounding birth and the infant’s welfare. Programs are being developed to increase breastfeeding among rural women. Although the incidence of breastfeeding has increased among well-educated, self-motivated, middle-class Americans, the number of impoverished, less well-educated women who breastfeed remains small. Progress is being made, community by community, by dedicated health care workers, dietitians, and WIC staff. Health professionals often serve as a catalyst in developing such programs but should always be ready to serve as knowledgeable, supportive consultants to the efforts of others.
The U.S. Department of Agriculture’s Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition services provides supplemental nutrition and counseling to more than 50% of U.S. families with young children. There are large differences in rates of breastfeeding among the different racial groups in WIC. A study of services in North Carolina confirmed the racial/ethnic disparities in breastfeeding rates.
The differences in availability of support services were also associated with racial/ethnic composition of the catchment area. These observations of disparity among services at WIC were also reported in an analysis of data from the Early Childhood Longitudinal Study-Birth Cohort. Breastfeeding duration was a result of cultural trends, not WIC programming. Multiple studies have done analysis outcomes at WIC sites. When the barriers to reaching the national goals for breastfeeding among the WIC population were counted, they were (1) lack of support in and outside the hospital; (2) returning to work; (3) practical issues; (4) WIC related issues; and (5) social, cultural barriers. Issues included young age, non-Hispanic ethnicity, obesity, and depression.
Solutions that worked for local WIC programs have been peer counselors, breast pump programs, and discontinuing free formula at the hospital and by the WIC program. The major obstacle to WIC program success is budgetary. Nationally, WIC spends 25 times more money on formula than on breastfeeding initiatives. The new food packages, however, implemented in the fall of 2009, have improved breastfeeding outcomes in Los Angeles County where exclusive breastfeeding rates at 3 and 6 months have doubled.
The U.S. Department of Agriculture’s breastfeeding program, through the WIC’s Nutrition Program, has launched a major effort to increase breastfeeding initiation and duration throughout the 50 states. The program, Best Start, included social marketing research, a media campaign, a staff support kit, a breastfeeding resource guide, a training conference, and continuing education and technical assistance. WIC has been made a permanent national health and nutrition program, and breastfeeding has been written into the legislation (see Chapter 1 ). The program even mandates that every WIC agency must have accommodations for employees who are breastfeeding their infants to pump and store their milk.
Best Start: The Concept of Social Marketing
Using the concept of social marketing, Bryant et al. designed an approach to promoting breastfeeding that utilized the counseling strategies, educational materials, policies, and community-based activities that formed the Best Start Program. Social marketing “combines the principles of commercial marketing with health education to promote a socially beneficial idea, practice or product.” Typically a well-articulated program involves a combination of mass media, print materials, personal counseling, and community-based activities and services.
From these findings, a multifaceted breastfeeding promotion campaign was designed for new mothers, family members, health professionals, and the community at large. The Best Start Program proved to be extremely successful and has been replicated by others successfully.
Utilizing strategies developed in social marketing and segmentation modeling for health communication, Best Start developed a multimedia program, Loving Support Makes Breastfeeding Work. This program was the substance of the WIC National Breastfeeding Promotion Project launched in April 1997. , Best Start has turned the program over to WIC for its continuation.
The United States Breastfeeding Committee
In order to fulfill a mandate of the Innocenti Declaration signed in 1990 in Italy by representatives of 90 countries, including Audrey Nora, MD, Assistant Surgeon General of the United States, a group of interested breastfeeding supporters and advocates met in Florida in January 1996. The declaration states that each member country should have a national breastfeeding committee, and many countries have complied.
This small group of breastfeeding advocates met to discuss the need for coordination of breastfeeding activities in the United States. After conducting an intensive needs assessment, the National Alliance for Breastfeeding Advocacy (NABA) was formed to address needs not being met by organizations, government agencies, or individuals, and convened the first National Breastfeeding Leadership Roundtable to determine if another organization was needed to move breastfeeding forward in this country. Working on the international model, the formation of this committee, if successful, would satisfy one of the four operational targets set forth by the 1990 Innocenti Declaration. This was to establish a multisectoral, national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations, and health professional associations in every country.
It was agreed at that meeting of 19 breastfeeding leaders to do four things: (1) to support ongoing breastfeeding projects in the United States; (2) to develop a strategic plan for breastfeeding in the United States; (3) to reorganize the National Breastfeeding Leadership Roundtable into the U.S. Breastfeeding Committee (USBC); and finally, (4) to incorporate the organization of the USBC and its leadership. The organization continued to meet twice a year and in January 1998 voted to declare itself, with the encouragement of Assistant Surgeon General Audrey Nora, MD, the USBC.
The USBC is a collaborative partnership of organizations. The mission of the committee is to protect, promote, and support breastfeeding in the United States. The USBC exists to assure the rightful place of breastfeeding in society. Major organizations that are members include but are not limited to the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), the American Academy of Family Practice (AAFP), the LLLI, the International Lactation Consultant Association (ILCA), and Wellstart and the NABA. The National Institutes of Health (NIH), Maternal and Child Health Bureau of the Health Resources Division of the U.S. Department of Health and Human Services, Women’s Health, the Food and Drug Administration (FDA), and the CDC also participated. After more than 10 years of developing its organizational skill and attracting more than 30 organizational members, it has assumed a vital role in national breastfeeding activity. It has organized coalitions in all states, has hosted coalition meetings to train state representatives, and provided a forum for sharing strategies among the members. USBC is an organization of organizations, not individuals. An important effort has been to create federal legislation to support breastfeeding women. The problems of employment for working mothers have been a major thrust that has resulted in cooperation of the summits in the development of the national program, the Business Case for Breastfeeding. Because of the interdisciplinary nature of its membership as a forceful network, USBC has been developed to promote, protect, and support breastfeeding. The USBC’s website is http://www.usbreastfeeding.org .
Wellstart International
A program to extend the scope of global breastfeeding promotion was launched by Wellstart International in a cooperative agreement with the U.S. Agency for International Development (AID). Wellstart International, a private, nonprofit organization headquartered in San Diego, grew out of clinical and teaching experiences at the University of California, San Diego Medical Center in the late 1970s. In 1983, in response to a clear need to improve the breastfeeding knowledge of health professionals, a Lactation Management Education program was initiated with funding from AID. Almost 400 participants of the Lactation Management Education program now form a network of Wellstart Associates in 28 countries.
In late 1991, Wellstart joined in a cooperative agreement with AID to expand and diversify its global breastfeeding promotion activities. The Expanded Promotion of Breastfeeding can work in any country at the request of the local AID mission. Wellstart continues to provide educational information for the training of physicians, nurses, and dietitians. Wellstart was active in global events as well. These activities include the development of the “ten steps” for hospital care of the mother-baby dyad and the Innocenti Declarations of 1990 and 2005, the formation of the World Alliance for Breastfeeding Advocates, and the initiation of World Breastfeeding Week and the BFHI; Wellstart also and they served as one of the initial organizers of the USBC.
Other lactation centers were created in health care facilities. The purpose of these programs was to provide consultation services for mothers as well as education, training, and information for health care workers. Efforts have been made to change hospital policy regarding breastfeeding to increase the success rate. An impressive program was initiated in the Philippines. It has not only increased the incidence of breastfeeding but also lowered the morbidity rate from sepsis, diarrhea, and malnutrition. Breastfeeding programs now exist in many large cities in the United States and around the world.
Breastfeeding and Human Lactation Study Center
The Lactation Study Center of the University of Rochester School of Medicine and Dentistry in New York encourages and promotes human lactation and breastfeeding through physician education and support. The goal is to provide information that will help practitioners encourage and support breastfeeding for all patients. Information is available to the health care professional by telephone. Originally federally funded and established at the request of the Office of the Surgeon General in 1984, the center now depends on private grants and donations from users. The drug information line operates Monday through Friday from 9 am to 4 pm EST. Physician consultation is available by call back.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
