The 1984 Surgeon General’s Workshop on Breastfeeding and Human Lactation was the first national meeting to focus exclusively on breastfeeding. The breastfeeding strategies developed at that workshop are still being used as the United States and the world move toward the breastfeeding objectives set in Healthy People 2010: National Health Promotion and Disease Prevention Objective .
Although many of the objectives have been addressed, the education of the health care professional remains a challenge. A second meeting of the National Planning Committee of the Surgeon General’s Workshop convened in Washington, District of Columbia in 1985 to address the issue of that education. The leaders of major professional organizations attended, including the American College of Obstetricians and Gynecologists, American Academy of Pediatrics (AAP), American Academy of Family Physicians, National Association of Pediatric Nurse Practitioners, American Dietetic Association, Nurses of American College of Obstetricians and Gynecologists, National Association of Nurse-Midwives, and National Board of Medical Examiners. These organizations developed and ratified a policy in support of educating and certifying its membership in human lactation and breastfeeding. Discussion was initiated about developing a curriculum appropriate to each professional level of training and specialization.
In June 2009, 25 years later, an anniversary meeting commemorating the first Surgeon General’s Workshop was held in Washington, District of Columbia to review the progress that had been made and look at the gaps. Professional education was once again a workshop. The challenges were similar but the strategies more aggressive. It was suggested that federal funds be allocated specifically for professional education. Consistency of curriculum and a system of accreditation were urged. Accountability for professional training on the part of the educational institutions was deemed essential through all professional levels.
Continuing Efforts
Most physicians who are supportive of breastfeeding have breastfed their own children but acknowledge their training was insufficient. Work continues in scattered ad hoc special presentations that may or may not have some affiliation with a medical school or hospital. However, no central unified program has been developed to change the curriculum at the seat of learning: United States medical schools and nursing schools.
Lack of support or encouragement from physicians and nurses was a continuing barrier, and no substantive progress had been made in developing curricula or credentialing. Excellent programs have been provided by Wellstart International , for teams consisting of a physician, a nurse, a nutritionist, and a hospital administrator from the same institution. Wellstart’s programs have been international, and they provide resources around the world. Many other universities have served as co-sponsors for a program, seminar, or workshop in their own geographic area. However, the programs have not been integrated into the total medical school curriculum or the training in a residency program, and they are not taught by medical school faculty at all levels of training.
The failure of medical schools to address the issue of education about the breast and training in the clinical issues of breastfeeding was addressed at the University of Texas at San Antonio by Newton. He initiated a program on the obstetric service for medical students and residents. He also reported the results of his national survey of medical schools’ curricula: 55% of the 127 United States obstetric and pediatric departments had no didactic lectures for medical students. Of obstetric and pediatric residencies, 30% provided no didactic lectures to their students. Most programs relied on clinical opportunities for learning.
When Freed et al. investigated the attitudes and education of pediatric house staff concerning breastfeeding, they found that third-year residents did not know any more than interns about the subject. Furthermore, only personal experience seemed to provide any in-depth knowledge about simple problems, such as sore nipples.
The Problem
That breastfeeding is important to infants and their mothers for nutritional, immunologic, psychologic, and other health reasons is an established fact. Since the first Surgeon General’s Workshop, United States health goals have been to increase the incidence and duration of breastfeeding. Little formal education is provided on the topic in medical schools and residency training programs. No planned curricula or testing mechanisms have been available.
Breastfeeding has another unique problem of interest to the lay persons who have become involved. Many nonphysicians have become involved in training. Some attempts at educating physicians have been made by nonphysicians and sometimes by people who are not health care professionals. , The message to medical students is that understanding and encouraging breastfeeding are not in a physician’s job description. When other care providers give presentations to medical students or residents, it is assumed the provider is describing the work for information only and not for its role in a physician’s work. Childbirth is of great interest to the lay public and to consumer advocacy groups as well, but they do not provide physicians’ training in childbirth. This training is provided by skilled specialists who have doctoral degrees, residency training, board certification, and, in many cases, additional fellowship training and subspecialty certification, which are minimal qualifications for medical school faculty.
How much do residents and physicians know about managing breastfeeding? The data suggest the answer is “very little.” In a study of obstetric residents, Freed et al. mailed a survey to more than 600 residents, and 64% responded. Only 38% had any education from the faculty about breastfeeding and indicated what little they knew came from other residents and nurses. All participants agreed, however, that they should have a role in the management of breastfeeding for their patients. A survey of 87 of a possible 108 pediatric residents (81%) evenly distributed among levels I, II, and III in a large hospital reported that level III residents were no more competent than their PL-1 counterparts. If they or their spouse breastfed, they were more confident in their knowledge base. No differences were found between men and women or between those breastfed or not breastfed as an infant. ,
The knowledge, training, and attitudes of obstetricians concerning the management of breastfeeding were evaluated by the American College of Obstetricians and Gynecologists. A survey was sent to 1200 fellows of the college, and only 397 (33%) practitioners responded. Obstetricians considered counseling their patients and managing breastfeeding care an important part of their clinical responsibilities. They thought that they were very qualified to treat mastitis, prescribe maternal medications, and advise their lactating patients about contraception. They were less confident about educating their patients about breastfeeding and solving any problems. Personal breastfeeding experience for the women was a predictor of confidence. Four of ten physicians thought their training was inadequate in lactation.
A subsequent study confirmed that residents’ knowledge was low and their misinformation disturbingly high. The authors concluded that residency training programs must provide comprehensive education on breastfeeding to prepare residents to meet the needs of patients and other parents. Another study of pediatricians in training given a 15-minute, self-administered, and anonymous questionnaire resulted in 53% participation (29 respondents). On a six-point scale of support of breastfeeding, the group averaged 2.6 (1 being most supportive), revealing an attitude barely above neutral. They averaged only 53% on the management questions, and their confidence in their skills was low, confirming the need for didactic and clinical training in breastfeeding.
The effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians was evaluated using before and after questionnaires. Their behaviors in the clinical setting were also measured before and after an interactive multimedia curricular intervention to increase their knowledge about common lactation issues. The investigators also telephoned the mothers after the clinic visit. Acceptable management of breastfeeding adequacy and the correct management went from 22% to 65% after the training. The resident physicians especially improved in assessing of problems ( Figures 23-1 and 23-2 ).
A national survey of 1099 family medicine residents, 71% of whom responded, indicated that they thought they should be involved in breastfeeding promotion and support. They demonstrated significant deficits, however, in knowledge about benefits and clinical management. These same investigators also polled practitioners regarding their beliefs and knowledge base. The results indicated a similar level of support and lack of knowledge.
Others have investigated the level of knowledge of physicians in training in other countries. A self-administered questionnaire was returned by 76 obstetric residents (84%) in metropolitan areas of South Korea. Korean breastfeeding rates have decreased, especially among well-educated women; the rate was only 17% in 1994. The questionnaire responses indicated that the residents were neutral about breastfeeding. They considered themselves competent to handle breastfeeding situations, but they scored only 38% on the management quiz.
Improved breastfeeding education clearly is needed in obstetrics, pediatrics, and family medicine, the physicians who should be most involved in supporting and promoting breastfeeding.
The Solution
To begin to solve this educational problem, a curriculum should be developed. It should span all 4 years of medical school, being carefully woven into the fabric of medical school for all students, as well as into the residency years for those specializing in obstetrics, pediatrics, and family medicine.
The program should be taught by physicians who are qualified faculty members recognized by their peer group and certified by specialty examining boards. The classes should be part of the total curriculum and not something a student can elect to do only in the fourth year, when most of the assignments are by electives. Graduate physicians in practice rarely will go to a teaching day exclusively on breastfeeding, and they rarely attend programs directed at a broad-based audience of nonphysicians. It does not serve their educational needs when they are also responsible for keeping up to date on the constant flow of advancements in every branch of medicine.
Breastfeeding topics should become part of a well-rounded continuing education program that includes a number of other important issues, such as infectious diseases, endocrine problems, growth, development, and perinatology. When breastfeeding is included in programs on infant nutrition and presented by a physician, it will gain the status it needs.
Suggested Curriculum for Medical Students
If first-year students have a program in human nutrition, breastfeeding can be presented in the section on child nutrition, and the discussion should provide information about the reasons breastfeeding and human milk are superior to formula feeding.
When second-year students have a program on women’s health issues, including hormonal maturation, menarche, sex, contraception, childbearing, menopause, and the breast, the additional curriculum can be dedicated to the use of the breast, that is, the anatomy and physiology of lactation. The pathology, including augmentation mammoplasty, reduction mammoplasty, and benign and malignant tumors, is an additional topic.
The third year begins with the general clerkship, wherein skills in history taking and physical examination are sharpened. Obstetrics and gynecology concentrates on breast and pelvic examinations. It is expected that all students, residents, and practitioners will always make these physical examinations part of the physical examination of women.
Third-year medical students spend time on obstetrics, treating patients prenatally, intrapartum, at delivery, and postpartum. Breastfeeding should be part of that continuum, from the discussion of infant feeding prenatally through the postpartum checks for physiologic engorgement and the mother’s questions about her afterpains, for example.
The third-year students also spend time on the pediatric service, including the ward, the outpatient, and emergency service. Each student spends a short time in the newborn nursery going crib to crib, checking the newborn’s adaptation to extrauterine life. The student also examines infants and talks to mothers. Observing a feeding is part of all discharge examinations on the nursery service and mandatory if the infant is breastfed. The student learns about the breastfed infants’ feeding and weight patterns and early lactation. The student learns to identify problems and treat them.
The weeks in the clinic provide additional experience when seeing well babies. The students are exposed to the early weeks and months of breastfeeding and learn about infant weight gain and any problems that arise. The preceptors are experienced, board-certified pediatricians. The daily lecture series, which starts the day for all the residents and students assigned to the outpatient service, is directed at reviewing routine clinical issues. At least one of ten lectures should be about breastfeeding. Students are encouraged to visit their patients while they breastfeed and to accompany the mother-baby nurse when assisting the nursing dyad. They also attend the breastfeeding classes for mothers given by the lactation consultants, who are college-prepared nurses and board-certified lactation consultants (IBCLC).
Fourth-year medical students have a few required courses but the rest of the year is given to electives. A student may elect extra time in the newborn nursery or the outpatient service or even at the Lactation Study Center. Summer fellowships are available to medical students throughout the 4 years to do a research project with a faculty member. Reports of the questions on the national board examination confirm that human lactation and breastfeeding are included. The recent qualifying examinations have had questions about breastfeeding and human lactation.
Residents in obstetrics and pediatrics can be assigned to the nursery and receive experience in managing the breastfeeding mother-baby dyad. The obstetric house officer may receive additional experiences by following patients prenatally and postpartum. Formal lectures should be provided in the grand round series of both departments. Special lectures directed specifically at the house officer on topics in breastfeeding and lactation are scheduled as part of attending rounds (e.g., drugs in breast milk, mastitis, failure to thrive).
The breastfeeding and lactation curriculum for medical students is not unlike the approach to studying other organ systems, such as the cardiovascular system or the renal system. It includes the anatomy, physiology, biochemistry, pharmacology, normal function, pathology, and finally the clinical application in a wide range of clinical settings.
Expertise and Leadership Issues
As in other medical issues, physicians learn about interacting with patients and families and study all the psychosocial implications. When a medical school offers a visible clinical and research program that focuses attention on a subject, it improves the image of the subject matter. Cancer centers, poison centers, and sports medicine clinics are examples of how certain medical problems have been elevated to positions of importance in education and training by pooling resources and expertise. The Breastfeeding and Human Lactation Study Center at the University of Rochester School of Medicine has served as an information center, a resource of expertise for the educational matrix, and an ongoing research program that allows students, residents, and fellows to develop their own investigational work. Newton’s work in East Carolina University Medical School, Neifert’s at the University of Colorado at Denver, and that of many others are examples of medical school-based programs that are developing models for physician training.
The greatest obstacle to initiating a self-sustaining program on human lactation in medical schools is the need for leadership among the faculty. At least one interested, knowledgeable, credible faculty member must emerge to develop the curriculum so that it becomes part of the permanent learning plan. Faculty more recently trained are more interested in breastfeeding than senior faculty trained in the heyday of formula feeding.
The physician does not put the infant to the breast; that is the responsibility of the mother-baby nurse. The physician does, however, have to understand the process so that problems in clinical outcome can be solved. The nurse does not choose the medications prescribed to a lactating woman, but should understand the importance of lactation in those selections. The mother should be reminded to notify her internist that she is lactating should it impact her medical condition or its treatment. The health management of breastfeeding and lactation is a team effort, and it is the job of the physicians, nurses, and nutritionists working in perinatal medicine to assist in the process.
The AAP Section on Breastfeeding has developed and tested a residency curriculum on breastfeeding directed at all residents and tested in university hospitals with obstetrics, pediatrics, and family medicine residency programs. It begins with the evidence that breastfeeding matters. There are three major sections to the program: advocacy, clinical management, and delivering culturally competent breastfeeding care. The program is organized to be delivered flexibly over a 1-year period and is organized to meet the core competencies of the Accreditation Council for Graduate Medical Education. The evaluation tools are designed to facilitate review and tracking by the residency director. This curriculum has been pilot tested at seven sites with seven matched control sites. Each test site had at least 20 residents participating. The site directors attended a training meeting at the AAP and an evaluation meeting at the end. Each site hosted a teaching day with a visiting professor. The residents took a pretest and a posttest; 100 charts were reviewed at each site and breastfeeding stats were collected, including a 6-month follow-up. The comparison sites administered the pretest and posttest and collected breastfeeding statistics.
Required activities included completing the Wellstart Self-Study Module, Level I. The residents also watched Jane Morton’s 15 Minutes of Breastfeeding help video as well as the Jane Morton video: Breastfeeding: A Guide to Getting Started (available at www.Breastfeeding.com ). Other activities with patients were also mandated.
Outcome measures included pre- and posttest scores (mean difference posttest minus pretest).
Test sites showed an increase in breastfeeding rates. Calculated cost saving in health care was $303 per baby per year. Cost saving at the seven sites for 1 year was estimated to be $2,488,311. This breastfeeding residency curriculum has its own website and is available for downloading at http://www.aap.org/breastfeeding/curriculum/ .
Wellstart Program
Wellstart International has developed a multidisciplinary approach to breastfeeding education that includes various health professionals, such as nurses, midwives, nutritionists, and physicians. The training materials are predicated on training the team together. This model works well when an institution can send a team simultaneously to the training with the intent that the team members will return and each train members of their own discipline, thus ensuring credible expertise across medicine, nursing, and nutrition. Naylor et al. point out that “for the continuum of health care and the safety of the mother and infant, the physician has the final responsibility for diagnosis and medical management, including the treatment of illnesses, lactation problems and growth abnormalities.” The authors agree that the material must be integrated into courses that already exist, whether in traditional didactic curricula or problem-based models. Table 23-1 presents the curriculum recommended in the Wellstart model, and Box 23-1 provides the model’s breastfeeding policy for hospitals.
