Promoting Women’s Health in Hospitals: A Focus on Breastfeeding and Lactation Support for Employees and Patients

Abstract

Hospitals often are one of the largest employers in communities, and nationwide, they employ more than 6.3 million employees. Hospitals also serve tens of millions of inpatients annually. Hospitals, therefore, can be leaders in worksite wellness and promoting breastfeeding and lactation support for new mothers. By adopting model standards and practices that promote breastfeeding, hospitals can influence women’s health. This article focuses on the efforts of the Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity to promote breastfeeding and lactation support for hospital employees and patients.

Introduction

Hospitals are well positioned to advance health and prevent chronic diseases for employees, patients, and communities. In 2010, there were more than 5700 hospitals registered with the American Hospital Association and more than 37 million inpatient admissions, 118 million emergency department visits, and 481 million outpatient visits in the United States.¹ Hospitals employ over 6.3million full-time and part-time salary and wage workers, including 4.8 million women.² Hospitals can improve their nutrition and physical activity environments, support tobacco initiatives, and increase support for breastfeeding and lactation. Participants at a 2010 CDC expert panel meeting identified several options for hospitals and public health practitioners that may influence the health and well-being of hospital employees and patrons; those related to breastfeeding are illustrated in Table 1.³

Table 1.

Recommendations to Promote Breastfeeding and Lactation Support in Hospitals for Employees and Patients*

Hospitals can support breastfeeding for employees and patients. Hospitals can provide break rooms and time for expressing breast milk for employees. Hospitals can support breastfeeding in their neighboring communities.

Adapted from Healthy Hospital Choices.³

These recommendations may be undertaken by hospitals or public health practitioners or both.

This article describes the benefits of breastfeeding and then focuses on the opportunity that hospitals have to improve the health of women by supporting breastfeeding women employed in hospitals as well as improving maternity care practices to support women who deliver infants in hospitals.

Benefits of Breastfeeding and Current Gaps in Hospital Employee Support and Quality Patient Care

Breastfeeding has been shown to have several benefits for both mothers and their babies. Breastfed infants have been shown to have lower risks of several diseases, including otitis media, episodes of diarrhea, and lower respiratory tract infections, in the first year of life and are at lower risk for sudden infant death syndrome (SIDS).^4,5 Women who breastfeed for greater durations may have a reduced risk of developing type 2 diabetes mellitus as well as breast and ovarian cancer.^5–7 Breastfeeding may also be associated with sustained weight loss in the mother during the first postpartum year.⁶ For breastfed infants, there is a dose-response relationship between the duration of breastfeeding and the risk of obesity later in childhood.⁸ Furthermore, women who breastfeed their infants may experience fewer absentee days because breastfed infants have fewer illnesses compared to formula-fed infants.⁹ Breastfeeding has been associated with fewer healthcare claims, as breastfed infants experience fewer illnesses necessitating physician visits or hospitalization and require fewer prescriptions.¹⁰

The CDC 2009 Maternity Care Practices in Infant Nutrition and Care (mPINC) survey—a survey sent to all maternity care facilities in the United States to assess policies and practices related to breastfeeding and lactation support for new mothers and hospital employees—showed that a majority of hospitals reported supporting employees by providing time (95%) and a space (72%) to express breast milk.¹¹ However, a review of the literature suggests that many opportunities to promote breastfeeding and lactation support for hospital employees may be missed, and employees do not or cannot take advantage of such supports. For example, a survey of breastfeeding physicians¹² indicated a discrepancy between breastfeeding intention, initiation rates, and the infant’s reported receipt of breast milk at 12 months of age. Inadequate supply and lack of time were identified as barriers to continue supplying breast milk. On the other hand, a comprehensive lactation support effort may increase a hospital’s employee satisfaction and return-to-work rate among breastfeeding employees on maternity leave. One study¹³ found that among women participating in an employer-sponsored lactation program, there was a 94% return-to-work rate after maternity leave, and the mean duration of breast milk expression was 6.3 months.

Support for breastfeeding employees is crucial, but birthing hospitals also play a crucial role in supporting women who deliver in their facilities to initiate and continue breastfeeding. The mPINC survey gathers information on ten indicators of practices that support breastfeeding and foster quality patient care. These indicators correspond to the Ten Steps to Successful Breastfeeding—ten evidence-based steps promoted by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) global Baby-Friendly Hospital Initiative (BFHI)¹⁴—and include (1) existence of a model breastfeeding policy, (2) staff competency assessment, (3) prenatal breastfeeding education, (4) early initiation of breastfeeding, (5) teaching breastfeeding techniques, (6) limited supplementation of breastfeeding infants, (7) rooming-in, (8) teaching feeding cues, (9) limited use of pacifiers, and (10) postdischarge support. Increasing Baby-Friendly Hospital practices has been associated with a higher likelihood of mothers being able to meet exclusive breastfeeding goals.^15,16 However, mPINC results from 2009 indicate that most hospitals do not have written breastfeeding policies that support new mothers.¹⁷ Moreover, in 2009, approximately two thirds of all U.S. hospitals had 5 or fewer Baby-Friendly practices in place.

Current Efforts to Promote Breastfeeding and Lactation Support for Hospital Employees

The Patient Protection and Affordable Care Act “amended section 7 of the Fair Labor Standards Act (“FLSA”) to require employers to provide reasonable break time for an employee to express breast milk for her nursing child” and also required employers to “provide a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk.”¹⁸ This requirement provides an opportunity for hospitals to ensure their employees have the support needed to successfully express milk and breastfeed. In the CDC expert panel meeting summary, several recommendations were provided, including that hospitals (1) increase awareness of the importance of breastfeeding at all staff levels, (2) promote policies and practices that are in line with the FLSA, and (3) create guidelines for the provision of meaningful space and time for breast milk expression.³ Recently, several success stories of hospitals supporting employees expressing breast milk, with well-equipped lactation rooms and provision of adequate time, have emerged.^19–21

CDC is actively engaged in advancing breastfeeding and lactation support in hospitals. CDC’s efforts to promote healthy choices in hospitals use information dissemination and public health guidance.^3,20,21

Quality Patient Care: Breastfeeding and Lactation Support for Hospital Inpatients

Concurrently, increasing interest in the importance of breastfeeding as a preventive measure in childhood obesity has allowed breastfeeding and lactation support for inpatients to gain ground. For example, in 2011, Kaiser Permanente committed to supporting breastfeeding and lactation in all 29 of its hospitals nationwide by adopting the Ten Steps to Successful Breastfeeding by 2013.²² This commitment has significant reach because Kaiser Permanente had over 96,000 deliveries in its hospitals in 2010. The Indian Health Service is similarly dedicated to promoting breastfeeding and lactation support in its hospitals’ maternity care practices.²³

The Prevention and Public Health Fund allocated funds “to support breastfeeding mothers and support hospitals in promoting breastfeeding.”²⁴ CDC is overseeing this 3-year project, which was awarded to the National Initiative for Children’s Healthcare Quality (NICHQ) in the fall of 2011.²⁵ The project, Best Fed Beginnings, recently announced the selection of 90 hospitals that will engage in a quality improvement process to accelerate the adoption and implementation of the Ten Steps to Successful Breastfeeding. The quality improvement process entails a 22-month learning collaborative that will increase the number of births in Baby-Friendly Hospitals in the United States. The selected hospitals in this collaborative account for more than 275,000 births each year across 29 states with the lowest breastfeeding rates in the country. By improving support for breastfeeding and lactation, these initiatives have the potential to influence women’s health.

CDC also continues to support and provide technical assistance to state-funded programs to promote breast-feeding and lactation support in hospitals.^26,27 In addition, CDC continues to work on and collaborate with partners to increase breastfeeding and lactation support; this includes convening the federal breastfeeding workgroup. Finally, CDC actively supports the BFHI through technical assistance and guidance to strategic partners implementing the Ten Steps to Successful Breastfeeding, dissemination of guidance recommending BFHI as a strategy to increase breastfeeding rates, and monitoring of both best practices and number of births taking place in Baby-Friendly Hospitals.^23,27,28

Future Directions

Moving forward, support for breastfeeding and lactation for both employees and patients who are new mothers can be enhanced by new and further collaborations among a variety of partners. For example, medical groups, hospital associations, and breastfeeding coalitions all have unique skills and capacities that can further women’s health. Breastfeeding coalitions and hospital systems or associations can partner to implement best practices. Second, disseminating best practices and lessons learned from the activities described here can also help promote and direct future work in support of breastfeeding in hospitals and in neighboring communities. Third, working with partners in the development and dissemination of specific resources, such as educational materials, may be useful in increasing the awareness of the benefits of breastfeeding. Finally, continued dissemination and use of existing surveys is needed to measure and improve support of breastfeeding and lactation. Surveys can help determine baseline availability of breastfeeding support and allow benchmarking to track change and improvements over time.