Surgeon General's Perspectives

HELPING WOMEN ACHIEVE THEIR BREASTFEEDING GOALS: THE ROLE OF HOSPITALS

June 2014 marked the 30th anniversary of the Surgeon General's Workshop on Breastfeeding and Human Lactation. Recognizing breast milk as the best source of nutrition for infants, former Surgeon General Dr. C. Everett Koop held the workshop in 1984 to develop strategies to protect and support breastfeeding mothers.¹ The Office of the Surgeon General has continued to champion breastfeeding as a public health goal ever since, including the 2000 “HHS Blueprint for Action on Breastfeeding”² and the 2011 “Surgeon General's Call to Action to Support Breastfeeding.”³ These documents provide a comprehensive framework for national action on breastfeeding and outline specific steps the health-care system, employers, communities, and families can take to ensure that all mothers are able to meet their personal breastfeeding goals.

More than 80% of mothers in the United States indicate prenatally that they intend to breastfeed their babies,⁴ and 76.5% start breastfeeding. However, only 16.7% meet the American Academy of Pediatrics recommendation to exclusively breastfeed for about the first six months of the child's life (i.e., giving the child breast milk with no solids or other liquids except vitamin/mineral supplements or medications). Only 27.0% of women breastfeed for the recommended $12 months.^5,6 These low rates of exclusive and continued breastfeeding have major implications for public health. Babies who are not breastfed are at increased risk for ear, respiratory, and gastrointestinal infections; asthma; sudden infant death syndrome; and necrotizing enterocolitis. Additionally, breastfeeding reduces a mother's risk of breast and ovarian cancers.⁷ Suboptimal breastfeeding rates in the U.S. result in an estimated $2.2 billion annually in direct medical costs.⁸

In the Infant Feeding Practices Study II (2005–2007), the largest longitudinal study of infant feeding in the U.S., when asked about their breastfeeding experience after they had stopped breastfeeding, 60% of mothers reported that they were not able to breastfeed as long as they had wanted. The reasons they gave for breastfeeding cessation were mostly related to problems with breastfeeding, including infants having trouble latching, pain when breastfeeding, concerns about sufficient milk, and babies not gaining enough weight.⁹ These problems can generally be overcome with early professional support and management. For women who plan to breastfeed, experiences and support during the first hours and days after birth are critical. They influence the mother's ability to continue breastfeeding months later. Because nearly all U.S. births occur in hospitals, policies that govern hospital practices can influence the feeding behaviors of the approximately 4 million infants born in the U.S. each year.¹⁰

In 1991, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) developed the Baby-Friendly Hospital Initiative.¹¹ To be designated as Baby-Friendly, a hospital must implement the WHO/UNICEF Ten Steps to Successful Breastfeeding¹² and comply with the International Code of Marketing of Breast-milk Substitutes (the Code), which requires hospitals to pay fair market value for infant formula and not promote items that are detrimental to breastfeeding, including discharge bags that contain formula.¹³ The first U.S. hospital achieved Baby-Friendly designation in 1996, but participation in this global program has been slow in the U.S. A decade after the first U.S. hospital was designated as Baby-Friendly, less than 2% of births occurred in Baby-Friendly hospitals.¹⁴ Recognizing the important role hospitals have in helping women initiate and continue breastfeeding, and the Baby-Friendly Hospital Initiative as a marker for optimal lactation care, Healthy People 2020 added an objective to increase the proportion of live births occurring in facilities that provide recommended care for lactating mothers and their babies.¹⁵

In 2007, the Centers for Disease Control and Prevention (CDC) launched the biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey, which assesses maternity policies and practices related to breastfeeding at all birth facilities in all states, the District of Columbia, and U.S. territories. This survey serves as both a surveillance system, providing valuable data on the state of maternity care practices that support breastfeeding in U.S. hospitals, as well as an educational tool for participating facilities. Each facility that participates in mPINC receives a report of its own results showing how its practices compare with recommended practices and with practices of facilities around the country. These reports can help hospitals develop and implement a plan to improve care to better support breastfeeding, with the goal of preparing hospitals to move more quickly toward Baby-Friendly designation.¹⁶

Several other national initiatives are also underway to increase the percentage of births that occur at Baby-Friendly hospitals. As part of First Lady Michelle Obama's Let's Move! in Indian Country campaign, the Indian Health Service has committed to achieving Baby-Friendly designation for all 13 of its maternity hospitals. Since 2012, nine of those hospitals have achieved Baby-Friendly designation. Five of those hospitals were the first to be designated as Baby-Friendly in their states.^17,18 Additionally, the National Institute for Children's Health Quality, under a cooperative agreement with CDC, has been leading the Best Fed Beginnings project, which is supporting 89 hospitals in earning the Baby-Friendly designation. These hospitals account for approximately 275,000 births each year in 29 states.¹⁹

Together, these and other efforts are contributing to continued improvements in maternity care practices that support breastfeeding. More than 7% of all births in the U.S. now occur in facilities that have been designated as Baby-Friendly.²⁰ Other hospitals have not yet achieved Baby-Friendly designation but are making improvements to their policies and practices to better support breastfeeding mothers. CDC's mPINC data show that from 2007 to 2011, the percentage of hospitals implementing six or more of the Ten Steps to Successful Breastfeeding increased from 28.6% to 43.4%. During this same time period, the percentage of hospitals giving packs that contain infant formula to breastfeeding moms at discharge decreased from 72.6% to 54.5%.²¹ These data demonstrate substantial improvements in the implementation of evidence-based practices that support mothers in breastfeeding, but they also indicate that the quality of care in many hospitals continues to fall short of best practices, and there is much more work ahead.

The Office of the Surgeon General remains committed to supporting breastfeeding mothers. Systematically improving maternity care practices, including increased adherence to the Ten Steps to Successful Breastfeeding,¹² will help women who intend to breastfeed get the support they need to meet their breastfeeding goals.

Boris D. Lushniak, MD, MPH RADM, U.S. Public Health Service Acting Surgeon General