Five-Year Progress Update on the Surgeon General’s Call to Action to Support Breastfeeding, 2011

Abstract

In 2011, Surgeon General Regina Benjamin issued a Call to Action to Support Breastfeeding (Call to Action) in an effort to mobilize families, communities, clinicians, healthcare systems, and employers to take action to improve support for breastfeeding. The Call to Action identified 20 key action steps to address society-wide breastfeeding barriers in six areas: mothers and families, communities, healthcare, employment, research, and public health infrastructure. This report highlights major federal activities that show progress toward answering the Call to Action in the first 5 years since its launch.

“…the time has come to set forth the important roles and responsibilities of clinicians, employers, communities, researchers, and government leaders and to urge us all to take on a commitment to enable mothers to meet their personal goals for breastfeeding.” (Former U.S. Surgeon General, Dr. Regina Benjamin, 2011)

Introduction

Breast milk is well recognized as the optimal source of nutrition for infants and it provides numerous protections against illnesses and diseases for infants and mothers alike. Infants who are not breastfed or who are weaned early are more likely to suffer common childhood infections such as gastrointestinal infections and acute otitis media, as well as lower respiratory infections and sudden infant death syndrome.^1,2 Furthermore, a recent meta-analysis indicates breastfed infants are less likely to be overweight or have diabetes later in life and mothers who breastfeed are less likely to develop breast and ovarian cancer.² Increased duration of lactation is also associated with a lower prevalence of hypertension, diabetes, and cardiovascular disease in women.³

The majority of mothers in the United States want to breastfeed and most (80%) start breastfeeding.⁴ Although breastfeeding initiation and duration have consistently improved (Fig. 1),⁴ one study revealed that 60% of women do not meet their breastfeeding goals.⁵ Mothers face a range of potential barriers to breastfeeding, including lack of knowledge, concerns about milk supply, social norms, poor family and social support, embarrassment, lactation problems and pain, lack of support from employers and child care facilities, and inadequate access to healthcare services and peer or professional breastfeeding support.⁶

FIG. 1.

National immunization survey, breastfeeding rates, 2000–2012 (CDC National Immunization Survey, 2015⁴).

Current Healthy People 2020 (HP2020) breastfeeding objectives are to increase breastfeeding initiation to 81.9%, 6-month duration to 60.6%, and 1-year duration to 34.1%. HP2020 objectives for exclusive breastfeeding through 3 and 6 months of age are 46.2% and 25.5%, respectively. HP2020 also set goals to reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life to 14.2% and to increase the proportion of live births that occur in facilities that provide recommended care for breastfeeding mothers and their babies to 8.1%.⁷ Surveillance data indicate that progress has been made across all objectives since HP2020 was released in 2010 (Table 1); however, meeting these goals requires a multifaceted, multi-level approach to breastfeeding support.

Table 1.

HP2020 Breastfeeding Objectives and 2010 and 2012 Breastfeeding Prevalence

	HP2020 objectives %	2010 %	2012 %
Initiation	81.9	76.7	80.0
6 months	60.6	47.5	51.4
12 months	34.1	25.3	29.2
Exclusive 3 months	46.2	37.1	43.3
Exclusive 6 months	25.5	17.2	21.9
Formula supplementation within the first 2 days of life	14.2	22.8	19.1
Live births occurring at facilities that provide recommended care for lactating mothers and their babies	8.1	3.78	6.22

2012 is the most recent data available for breastfeeding prevalence. Healthy People 2020, CDC National Immunization Surveys, CDC Nutrition, Physical Activity and Obesity Data, Trends and Maps web site.^4,7,8

Although breastfeeding rates have increased overall and within racial/ethnic groups over time, breastfeeding disparities persist. In the United States, fewer non-Hispanic black infants start breastfeeding and continue to breastfeed at 6 and 12 months compared to non-Hispanic white infants (Fig. 2).

FIG. 2.

Percent of infants who were breastfed by race/ethnicity, 2012 (CDC National Immunization Survey, 2015⁴).

Lower breastfeeding rates are also observed among infants in low-income families and who live in rural communities.^4,9,10 Because minority women are disproportionately affected by a range of adverse health outcomes, some of which may be reduced by breastfeeding, the benefits of breastfeeding may be even greater for minority women and their infants.¹¹ The persistent gap in rates between non-Hispanic black and non-Hispanic white infants is indicative of the need to intensify efforts to understand the underlying factors contributing to disparities and how best to address them.

In January 2011, the Office of the Surgeon General issued The Surgeon General’s Call to Action to Support Breastfeeding (Call to Action), which outlines a series of 20 action steps that call for action at a local level all the way up to national policies in a society-wide approach to support all breastfeeding mothers and babies. These 20 action steps focus on strategies related to six areas: mothers and families, communities, the healthcare system, the workforce, research and surveillance, and public health infrastructure (Table 2).⁶ The federal government and its partners across the United States made important progress in improving breastfeeding support; this progress report summarizes noteworthy achievements in the first 5 years since the release of the Call to Action. Although there has also been great progress at the state and local community levels, which also contributed to improved outcomes, this report highlights the efforts made at the federal level and associated national partner-level work.

Table 2.

The Surgeon General’s Call to Action to Support Breastfeeding, 2011

Mothers and their families
Action 1	Give mothers the support they need to breastfeed their babies.
Action 2	Develop programs to educate fathers and grandmothers about breastfeeding.
Communities
Action 3	Strengthen programs that provide mother-to-mother support and peer counseling.
Action 4	Use community-based organizations to promote and support breastfeeding.
Action 5	Create a national campaign to promote breastfeeding.
Action 6	Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding.
Healthcare
Action 7	Ensure that maternity care practices throughout the United States are fully supportive of breastfeeding.
Action 8	Develop systems to guarantee continuity of skilled support for lactation between hospitals and healthcare settings in the community.
Action 9	Provide education and training in breastfeeding for all health professionals who care for women and children.
Action 10	Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.
Action 11	Ensure access to services provided by International Board Certified Lactation Consultants.
Action 12	Identify and address obstacles to greater availability of safe banked donor milk for fragile infants.
Employment
Action 13	Work toward establishing paid maternity leave for all employed mothers.
Action 14	Ensure that employers establish and maintain comprehensive, high-quality lactation support programs for their employees.
Action 15	Expand the use of programs in the workplace that allow lactating mothers to have direct access to their babies.
Action 16	Ensure that all child care providers accommodate the needs of breastfeeding mothers and infants.
Research and surveillance
Action 17	Increase funding of high-quality research on breastfeeding.
Action 18	Strengthen existing capacity and develop future capacity for conducting research on breastfeeding.
Action 19	Develop a national monitoring system to improve the tracking of breastfeeding rates as well as the policies and environmental factors that affect breastfeeding.
Public health infrastructure
Action 20	Improve national leadership on the promotion and support of breastfeeding.

Surgeon General’s Call to Action to Support Breastfeeding, 2011.

Five-Year Progress Update

Mothers and families

Although breastfeeding rates have been steadily increasing, mothers face a range of barriers that may deter them from achieving their breastfeeding goals.⁶ Strategies identified by the Call to Action for supporting mothers include efforts to educate mothers about the importance of breastfeeding, teaching mothers to breastfeed, encouraging mothers to talk to their providers about breastfeeding, and encouraging mothers to seek help when needed. In addition, the Call to Action recommends that programs be developed to educate fathers, grandmothers, and other family members who can have an impact on breastfeeding by providing support to the mother.⁶ Federal activities to improve breastfeeding support for mothers and families include the following:

• Several federal agencies developed publications and resources that support women to meet their breastfeeding goals. For example, in 2011, the Office on Women’s Health (OWH) released updated versions of Your Guide to Breastfeeding and Your Guide to Breastfeeding for African American Women. These easy-to-read publications with expert tips and illustrations provide women with how-to-breastfeed information, answers to common breastfeeding questions, and tear-out tools for mothers to use.¹²

• Social media brought increased attention to breastfeeding in recent years and federal agencies are engaging with and using these communication tools to disseminate public health information. In 2015, the Office of the Assistant Secretary for Preparedness and Response (ASPR) and the Administration for Children and Families (ACF) cohosted a Twitter chat, Emergency Preparedness for Moms and Little Ones, in collaboration with several federal and nonfederal partners. The Twitter chat provided information, resources, and tools to help pregnant women and new mothers keep themselves and their babies healthy before, during, and after an emergency, including tips on maintaining breastfeeding and safe handling and storage of expressed breast milk.¹³

Communities

A host of community factors impact a woman’s ability to initiate and sustain breastfeeding. Community breastfeeding support can come from a range of sources, such as community-based interventions, local health department programs, and breastfeeding-friendly policies and practices within child care centers, businesses, and local governments.⁶ Strategies outlined in the Call to Action to improve community support for breastfeeding include strengthening peer counseling programs and mother-to-mother support groups, integrating support for breastfeeding into existing community programs, funding community-based organizations, and implementing a national campaign to promote breastfeeding.⁶

The marketing of infant formula may also influence a woman’s decision to breastfeed.^14,15 The Call to Action promotes ensuring that this marketing is done in a way that minimizes its impacts on exclusive breastfeeding.⁶ Federal activities focused on community support for breastfeeding include the following:

• In 2011, an updated curriculum, Loving Support© Through Peer Counseling: A Journey Together, was implemented by the United States Department of Agriculture (USDA) to improve training for managers and peer counselors in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).¹⁶

• In 2013, the OWH launched It’s Only Natural. Mother’s Love. Mother’s Milk. This public education campaign is targeted to African American women and includes video testimonials, articles, fact sheets, and radio public service announcements designed to provide information, support, and tips to help women make breastfeeding work in their lives.¹⁷

• In 2014, with support from the Centers for Disease Control and Prevention (CDC), the National Association of County & City Health Officials (NACCHO) awarded funding to 69 local health departments and community-based organizations to provide peer and professional lactation support to African American and underserved women and infants. The Reducing Disparities in Breastfeeding through Peer and Professional Lactation Support project aims to increase implementation of evidence-based and innovative breastfeeding programs, practices, and services at the community level, and to develop and maintain public health partnerships critical to building community support for breastfeeding.¹⁸

• The Food and Drug Administration (FDA) finalized a rule in 2014 that sets standards for manufacturers of infant formula and includes the following:

  • ○
    required testing for the harmful pathogens (disease-causing bacteria) Salmonella and Cronobacter,
  • ○
    demonstration that infant formulas support normal physical growth,
  • ○
    required testing for nutrient content in the final product stage, before entering the market, and at the end of the products’ shelf life.¹⁹

Healthcare

Most mothers in the United States give birth in hospitals,²⁰ where the care they receive during the intrapartum period and immediately postpartum can impact breastfeeding outcomes.²¹ In 1991, the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) launched the Baby-Friendly Hospital Initiative (BFHI), which includes the Ten Steps to Successful Breastfeeding (Ten Steps) to specify best practices and policies to deliver optimal maternity care, and support women to begin breastfeeding and continue breastfeeding as long as they desire.²² Hospitals that demonstrate adherence to the Ten Steps and the International Code of Marketing of Breast Milk Substitutes can become designated as a Baby-Friendly hospital.^22,23

As described in the Call to Action, in addition to hospital support, mothers need ongoing support from healthcare providers and lactation specialists following discharge. Healthcare providers are an important source of information and guidance and can significantly influence mothers’ decisions about how to feed their babies. Coordinated continuity of care between hospitals and healthcare settings in the community would better ensure that mothers receive the continued support they need. The Call to Action identifies strategies to improve provider support for breastfeeding such as incorporating breastfeeding content into education and training programs for healthcare providers and integrating skilled lactation support into healthcare settings that serve mothers and babies.⁶

For fragile infants, access to safe, banked donor human milk can be lifesaving.²⁴ The Call to Action calls for more research on the safety and efficacy of donor human milk, establishment of evidence-based guidelines for donor milk use, and identification of regulation and funding needs to support donor milk banks, which may begin to address the barriers to accessing safe, banked donor milk for vulnerable infants.⁶ Federal activities aimed at improving the quality of maternity care practices and increasing access to safe banked donor milk for fragile infants include the following:

• In 2011, the CDC funded the National Institute for Children’s Health Quality (NICHQ) to increase the number of U.S. hospitals designated as Baby Friendly. Best-Fed Beginnings (BFB), a nationwide hospital-based quality improvement project, supported 89 hospitals to improve maternity care in pursuit of the Baby-Friendly designation. All 89 hospitals progressed to the final phase of the Baby-Friendly designation process, and as of December 31, 2015, 68 BFB hospitals were designated Baby Friendly.²⁵

• In 2011, the Indian Health Service (IHS) launched its Baby-Friendly Hospital Initiative to encourage breastfeeding in IHS hospitals with obstetric services as part of the “Let’s Move! in Indian Country” campaign dedicated to reducing childhood obesity. By the end of 2014, all 13 (100%) IHS hospitals with obstetric services achieved designation as Baby Friendly.^26,27

• In 2014, the CDC funded Abt Associates to increase the number of U.S. hospitals designated as Baby Friendly. EMPower Breastfeeding: Enhancing Maternity Practices (EMPower), a hospital-based quality improvement initiative, is designed to support hospitals to implement evidence-based maternity care and achieve the Baby-Friendly designation. By the end of 2015, 94 U.S. hospitals were participating in the EMPower initiative.²⁸

• Congress passed the 2015 National Defense Authorization Act (NDAA), which requires TRICARE (the Department of Defense healthcare program) to cover breastfeeding support, supplies, and counseling for military women and women in military families.²⁹

• Beginning in 2012, the Health Resources and Services Administration (HRSA), with ACF, implemented the Maternal Infant and Early Childhood Home Visiting Program (MIECHV), which funds states, territories, and tribal entities to develop and implement voluntary, evidence-based, home-visiting programs, including programming to support breastfeeding.³⁰ A new performance measure added in 2015 includes the percent of infants who were ever breastfed and who are breastfed at 6 months.³¹

• The National Institutes of Health (NIH) funded research to identify and address obstacles to greater availability of safe, banked donor milk for fragile infants. Two such funded NIH projects include (1) understanding the safety and limitations of donor milk and (2) reaffirming health outcomes of feeding donor milk compared to formula and determining factors predictive of breastfeeding success in the term and late-preterm populations admitted to Neonatal Intensive Care Units (NICUs), to support breastfeeding duration among these mothers and infants.

It is likely that a number of these activities contributed to improvements in hospital care that supports breastfeeding. Data from the CDC’s survey of Maternity Practices in Infant Nutrition and Care (mPINC), which monitors and evaluates hospital practices related to breastfeeding, indicate that nationally, hospitals implementing more than half of the Ten Steps increased from 28.7% in 2007 to 53.9% in 2013.³² When the Call to Action was released in 2011, 4.53% of U.S. births occurred in 126 Baby-Friendly designated facilities across 30 states. In 2015, over 325 U.S. hospitals and birthing centers in 48 states and the District of Columbia held the Baby-Friendly designation, representing 16.23% of all U.S. births and far surpassing the HP2020 objective (8.1%) for live births occurring at facilities that provide recommended care for lactating mothers and their babies.^33,34

Employment

Employment has been identified as a significant barrier for women to meet their breastfeeding goals.⁶ From 2011 to 2014, over half of mothers with infants under the age of 1 year participated in the work force (55.8% and 57.1%, respectively).^35,36 Employed mothers are less likely to initiate breastfeeding and more likely to stop breastfeeding earlier than mothers who are not employed.³⁷ Employed mothers who are breastfeeding may face a number of challenges such as inflexible work schedules and a lack of privacy to express their milk, unsupportive employers, limited maternity leave benefits, and concerns about their child care arrangements. The Call to Action strategies for improving breastfeeding support for employed mothers include working toward paid maternity leave, worksite accommodations for breastfeeding employees, and childcare providers who follow breastfeeding standards.⁶ Federal activities related to improving breastfeeding support for employed mothers include the following:

• The Department of Labor (DOL) Wage and Hour Division (WHD) works to enforce the “Break Time for Nursing Mothers” provision of the Fair Labor Standards Act (FLSA) (Section 7) that was amended by the Patient Protection and Affordable Care Act in 2010, and developed several resources to inform consumers and employers about the provisions of the law. The “Break Time for Nursing Mothers” provision requires employers to provide a nursing mother with a private place other than a bathroom and reasonable break time to express breast milk after the birth of her child.³⁸ The provision applies to nonexempt employees covered by the FLSA, which includes some salaried and most hourly wage-earning employees.³⁹

• In 2012, the OWH created Supporting Nursing Moms at Work: Employer Solutions to build upon The Business Case for Breastfeeding, a national resource kit and training/technical assistance initiative of the Maternal and Child Health Bureau (MCHB).⁴⁰

• Let’s Move! Child Care (LMCC) is a web-based initiative that offers free resources and tools to assist early care and education providers to implement a core set of 15 obesity prevention standards, including supporting breastfeeding mothers. In 2012, LMCC created a resource section dedicated to breastfeeding support.⁴¹

• In 2012, the CDC created guidance for states on how to embed comprehensive obesity prevention standards, and support for implementing these standards, into their Early Care and Education systems; breastfeeding support standards are one component of these standards.⁴² CDC also supported the National Resource Center for Health and Safety in Child Care and Early Education to develop and disseminate an Infant Feeding Licensing Toolkit, which provides tailored action sheets for child care providers and state licensing agencies; and an education brief for state decision makers.⁴³

• In 2015, USDA released proposed changes to the Child and Adult Care Food Program (CACFP), which includes changing allowable reimbursement related to providing breast milk to children. Whereas the current CACFP requirements only reimburse CACFP-participating programs for giving expressed breast milk to infants 6 months and younger, the proposed new rule would allow programs to be reimbursed when mothers breastfeed their infants on-site at the child care facility. The rule is expected to be made final in 2016.⁴⁴

• In 2015, DOL awarded paid leave analysis grants to eight states to study the feasibility of developing and expanding statewide paid family and medical leave programs.⁴⁵

• In 2015, the U.S. Army released a revised breastfeeding and lactation support policy to strengthen workplace support for breastfeeding women, including important language concerning the meaning of “adequate time” to pump, the significance of breastfeeding, lactation support in TRICARE, and clarification on what lactation rooms should include.⁴⁶

Research and surveillance

The CDC uses National Immunization Survey (NIS) data to monitor breastfeeding rates with national- and state-level indicators that reflect the HP2020 breastfeeding objectives. Since 2007, the CDC has provided state-by-state comparisons of these indicators in the Breastfeeding Report Card, along with information on formula supplementation of breastfed infants during the first 2 days of life, the quality of birth facility support for breastfeeding, and access to Baby-Friendly hospitals. Breastfeeding support indicators also describe prevalence of mother-to-mother and professional lactation support, and whether each state’s child care regulations support on-site breastfeeding.³⁴ States use the Breastfeeding Report Card to track changes over time and compare their own rates to other states.

The National Institute of Child Health and Human Development (NICHD) supports and conducts research on breastfeeding and breast milk. These efforts are often done in collaboration with other NIH Institutes and Centers, as well as with other governmental and nongovernmental organizations in the United States. NIH funds breastfeeding-related research across a range of topics, including breast milk composition, quantity, and quality; breastfeeding practices, barriers, and support; growth and obesity; and others.⁴⁷ However, the Call to Action suggests that additional high-quality research on breastfeeding is needed to better understand the barriers among populations with low rates of breastfeeding, the economics of breastfeeding, and best practices for the management of lactation. Strategies identified by the Call to Action to improve research and surveillance efforts include providing funding for high-quality research, developing a national consortium on breastfeeding research, and developing a national monitoring system to better track changes in breastfeeding behavior and attitudes.⁶ Federal activities that address these research and surveillance strategies include the following:

• Infrastructural funding from the NIH’s National Center for Advancing Translational Science, supported the University of California San Diego’s (UCSD) Clinical and Translational Research Institute (CTRI) in 2014 to create a breast milk repository dedicated to research. This repository was opened to enable scientists from diverse fields to answer a multitude of questions about breast milk, including what are its unique biochemical properties and the extent to which pharmaceuticals and other agents to which nursing mothers are exposed can be passed to the infant during breastfeeding and their effects on the infant.⁴⁸

• In 2014, the U.S. Preventive Services Task Force (USPSTF) developed a research plan to guide a systematic review of the evidence that will form the basis of the USPSTF Recommendation Statement on interventions to support breastfeeding.⁴⁹

• A follow-up study of children participating in the Infant Feeding Practices Study II, the largest longitudinal study of infant feeding in the United States, was completed. Analyses examined the long-term outcomes of infant feeding practices and were published in a special Pediatrics supplement in 2014.⁵⁰

• In 2015, CDC launched an online interactive database, Data, Trends, and Maps, which allows users to create national maps, trend lines, and bar charts of breastfeeding data.⁴

Public health infrastructure

The Call to Action acknowledges that many organizations and public health agencies have dedicated resources to improving support for breastfeeding; however, coordination of efforts is needed to develop and implement an action plan to promote and support breastfeeding. In the Call to Action, the Surgeon General called for the creation of a federal interagency workgroup on breastfeeding and for efforts to increase the capacity of the United States Breastfeeding Committee (USBC) and affiliated state coalitions.⁶ Federal activities include the following:

• In May 2011, the Federal Interagency Breastfeeding Work Group was created and has continued to meet at regular intervals throughout each year. Members represent 16 individual agencies that include the Office of Personnel Management (OPM), DOL, USDA, and nearly all the operating divisions within the Department of Health and Human Services (DHHS). This workgroup provides a forum for information exchange across federal agencies and encourages collaborative approaches to address recommendations outlined in the Call to Action.

• USBC is a multisectoral national breastfeeding committee composed of representatives from relevant government departments, nongovernmental organizations, and health professional associations. USBC collaborates with federal agencies such as the CDC and the OWH, and serves as the lead national organization that promotes and supports breastfeeding activities across the United States. In 2014, USBC underwent a structural reorganization and unveiled its first strategic framework: Protecting, Promoting and Supporting Breastfeeding: A Public Health Imperative. The strategic framework for USBC is built around all 20 action steps in the Call to Action, and fits within the following four goal areas: (1) Be the national collective voice for breastfeeding, (2) Ensure organizational vitality, (3) Engage stakeholders in a Collective Impact model, and (4) Create and model a culture of inclusion, diversity, and equity.⁵¹

Conclusion

The Call to Action outlines a multifaceted approach to improve breastfeeding support. Although this report has focused primarily on federal activities addressing the action steps, it is important to acknowledge that some society-wide strategies are better suited to efforts by national organizations, state and local health departments, community-based organizations, and breastfeeding coalitions. The numerous ongoing efforts to advance support for breastfeeding at these levels have not been highlighted in this report. Through various collaborations, federal funding provided states and communities with resources to promote and support breastfeeding. Many federal and national programs focus on implementing policy, systems, and environmental changes that result in sustainable, community-wide improvements in breastfeeding support with a large reach. Grassroots and community-level efforts can complement and extend these national programs by increasing breastfeeding support at the level of mothers and their babies.

As described throughout this progress update, numerous efforts to improve breastfeeding support are underway across many federal agencies. Breastfeeding mothers were supported by an increased focus on maternity care practices and workplace lactation support programs. National surveillance data provide an understanding of the U.S. breastfeeding landscape so that future efforts can be targeted and evidence-based. USDA WIC redoubled its efforts to support breastfeeding by continuing to broaden the peer counseling program and train peer counselors with frequently updated materials. Federal agencies funded several programs to support states and communities to work on improving breastfeeding support across worksites, maternity care facilities, and within the community. The number of hospitals pursuing adoption of the Ten Steps increased since 2011. New laws and regulations ensure that more women will have access to professional lactation support services and pumping equipment. Although the momentum and progress of the past 5 years is highly encouraging, more work remains to reach every mother who needs support, particularly among communities with low breastfeeding rates. The Call to Action is a long-term vision and provides a roadmap to continue to build upon the accomplishments achieved since 2011.