Exploring Challenges and Opportunities for Breastfeeding in Hawai‘i During the COVID-19 Pandemic

Abstract

Increasing exclusive breastfeeding rates is an established public health strategy to reduce chronic disease and protect infants from illness. The role of breastfeeding in addressing health disparities takes on new significance as the COVID-19 pandemic has disproportionately impacted some communities in Hawai‘i, and those with chronic conditions face increased risk of hospitalization and death. However, there are myriad policy, systemic, and environmental barriers that make it difficult for parents to breastfeed, some of which have been exacerbated by the COVID-19 pandemic. This editorial discusses the importance of breastfeeding in reducing chronic disease, reviews the status of breastfeeding in Hawai‘i, explores the challenges parents face in breastfeeding their infants, especially in the time of COVID-19, and presents opportunities for improved access to lactation care to reduce health disparities.

Introduction

Exclusive breastfeeding for 6 months is the optimal early infant feeding practice.^1-3 Breastmilk offers complete nutrition for infants that is essential for good health outcomes and optimal development.⁴ A growing body of evidence supports that higher rates of breastfeeding initiation and longer duration are associated with lower rates of chronic disease, including cardiovascular disease, hypertension, obesity, diabetes, asthma, and cancer, for both the breastfeeding parent and child.^5-8 The protective effects of breastfeeding on chronic disease are visible as early as age 2.⁹

Despite the benefits, Hawai‘i lags behind World Health Organization breastfeeding recommendations. While 89% of infants born in Hawai‘i in 2017 initiated breastfeeding, only 30.6% were breastfeeding exclusively at 6 months.¹⁰ Additionally, although exclusive breastfeeding rates at 6 months in Hawai‘i have improved over time,¹¹ breastfeeding disparities by racial/ethnic group, geography, and income persist,^12,13 which contribute to health disparities later in life for mothers and babies.¹⁴

Hawai‘i is a multiethnic state with no majority race.¹⁵ Native Hawaiian and Other Pacific Islander (NHOPI) and Filipino adults experience higher rates of chronic conditions, such as obesity, diabetes, cardiovascular disease, asthma, and cancer, than whites, Japanese, and Other Asians in Hawai‘i.¹⁹ Chronic conditions such as these increase the risk of severe illness and mortality among those infected with COVID-19.²⁰ This is reflected in the greater risk factors and higher COVID-19 infection rates for NHOPI and Filipino populations.²¹ These chronic disease health disparities start early in life²² and are affected by breastfeeding duration.²³ Thus, breastfeeding disparities by race/ethnicity mirror those seen for other health disparities.^24-26 Hawai‘i data have shown that NHOPI and Filipinos are less likely to be exclusively breastfeeding at hospital discharge than their white and Japanese counterparts.²⁷ This trend is seen for breastfeeding duration as well, with NHOPI and Asian subgroups in Hawai‘i at a higher risk for exclusive breastfeeding attrition at 8 weeks postpartum compared to whites.²⁸

Breastfeeding disparities exist in rural areas compared to urban areas in Hawai‘i as well.¹⁶ Although rural areas approximate 93.9% of total land area, they are inhabited by only 8.1% of the state's population.¹⁵ The majority of Hawai‘i's people reside in Honolulu county.¹⁵ These population distributions contribute to inequities in the determinants of health in rural county areas compared to urban areas,¹⁶ including lower per capita income, higher poverty rates, higher unemployment rates, and shortages of health care professionals.¹⁷ They also explain some of the variations seen in exclusive breastfeeding at 8 weeks by county. Rural counties like Hawai‘i and Maui report lower exclusive breastfeeding rates at 8 weeks than the state average.²⁹ Rural areas in Hawai‘i have additional challenges providing access to adequate breastfeeding services²⁵ to support all breastfeeding parents and infants in these communities.

Breastfeeding Challenges

Hawai‘i parents who desire to breastfeed their infants face numerous barriers. The first days after delivery are crucial to establishing breastfeeding,³⁰ and the first hours through first 2 weeks are a key opportunity for early breastfeeding intervention.³¹ Counseling and hands-on support by trained lactation workers within the first 3 days of birth reduce feeding problems such as poor positioning and attachment.³² Lactation consultant interventions during these critical times increase both breastfeeding duration and exclusivity.^33–35 Unfortunately, access to and insurance coverage for lactation supports are a major challenge for many parents. Here, we focus on 4 specific barriers Hawai‘i families face in accessing lactation care and support, some of which have been worsened by the COVID-19 pandemic: (1) inadequate supports in-hospital, (2) inconsistent insurance coverage for outpatient lactation care, (3) shortages of Indigenous and community-based breastfeeding counselors, and (4) lack of culturally appropriate lactation care.

In-Hospital Supports

Maternity care practices strongly influence breastfeeding initiation and duration.^36,37 Yet, Hawai‘i hospitals fall below national averages in all areas of maternity care practices measured by the Centers for Disease Control and Prevention's (CDC) national survey of Maternity Practices in Infant Nutrition and Care.³⁸ Prior to the pandemic, there were wide disparities in employment of lactation consultants at Hawai‘i hospitals, meaning that families across Hawai‘i have had unequal access to in-patient lactation support.²⁵ Furthermore, poor referral to lactation providers at time of hospital discharge delays timely follow-up care.^39,40 COVID-19 has only exacerbated hospital challenges in providing lactation consultant care before discharge. Many hospitals face significant budget shortages due to increases in costs for caring for COVID-19 patients and reductions in profits from elective procedures.⁴¹ In the face of budget crises, some hospitals have decreased lactation consultant staffing,⁴² which increases patient vulnerability to breastfeeding attrition and formula use.⁴³

Current research recommends breastfeeding parents with suspected or confirmed cases of COVID-19 continue best practice breastfeeding care, including skin-to-skin, early breastfeeding initiation, and exclusive breastfeeding for 6 months.^43,44,45 Breastfeeding also has protective effects for infants against COVID-19 due to a transfer of antibodies through breastmilk.^46,47,48 Early in the pandemic, due to uncertainty over how COVID-19 was transmitted, many hospitals adopted infection prevention and control measures that contradicted evidence-based practices to support breastfeeding.⁴² For example, some hospitals separated mothers and infants, and discouraged skin-to-skin contact and breastfeeding to prevent vertical transmission. The impacts of these infection control measures may lead to poorer breastfeeding outcomes in Hawai‘i.

Inconsistent Insurance Coverage

Although the Affordable Care Act (ACA) requires insurers to cover lactation support and counseling by trained providers, coverage is inconsistent.⁵⁰ Many insurance plans deny lactation counseling coverage or lack lactation provider networks.⁵¹ Medicaid coverage for skilled lactation care is often limited to a few providers,⁵² many of whom are concentrated in urban centers.⁵³ Under Med-QUEST, Hawai‘i's Medicaid policy, lactation care is reimbursed only when billed by a physician or nurse practitioner,⁵³ and fewer than 5 eligible providers statewide are trained in clinical lactation care.⁵⁴ Reimbursement does not cover International Board Certified Lactation Consultants (IBCLC), which is the highest level of breastfeeding professional certification, unless an IBCLC is completing the visit with, or is also licensed as, a physician or nurse practitioner. It also does not cover care from those with other certifications, like certified lactation counselors, breastfeeding peer counselors, certified lactation educators, or Indigenous breastfeeding counselors. This policy leaves few ways for Med-QUEST-insured families to secure coverage for lactation care. This is an equity concern, as Med-QUEST covers high percentages of rural populations in Hawai‘i, including many Native Hawaiians.⁵⁵ It is also a concern for population health as Med-QUEST covered 34% of all births in 2018.⁵⁶ This will likely be higher in the coming years due to a spike in Med-QUEST applications prompted by pandemic-related job losses.⁵⁷

Community Resource Shortages

Hospital discharge for healthy mothers and babies in Hawai‘i typically occurs 24–72 hours after birth,^40,58 often before a parent's milk comes in and breastfeeding problems arise.⁵⁹ Thus, parents need access to outpatient and community support to maintain breastfeeding. However, community breastfeeding resources are limited. Some rural counties in Hawai‘i have large disparities in access to care due to shortages of lactation consultants, and few home visiting programs and peer breastfeeding programs.^25,60

Telelactation services, which connect families to remote lactation consultants through audio-visual technology, have been proposed as a solution for rural gaps in lactation care.⁶¹ While telelactation visits fill an important gap in care, they cannot fully replace an in-person latch assessment or manual positioning to address feeding issues.⁴³ Additionally, unless an IBCLC is also a licensed billable provider, or completes a telelactation visit with such a provider, parents must pay out-of-pocket.⁶¹ There are also issues around equitable access to telehealth. A Hawai‘i telehealth needs assessment found that a greater percentage of neighbor island providers than Honolulu County providers reported their clients have poor internet connections.⁶³

The pandemic has reemphasized these healthcare access issues and the lack of broadband infrastructure in rural communities. Important community resources like the Women, Infants and Children (WIC) program provide breastfeeding peer counselors to low income families in Hawai‘i. However, a representative from the Hawai‘i State Department of Health WIC reported that a lack of broadband infrastructure for some rural participants challenges WIC's ability to expand peer counseling to all rural communities.⁶⁴ This is especially concerning in light of an increased WIC caseload this year.

Lack of Culturally Appropriate Care

Culturally appropriate care can have positive impacts on breastfeeding rates.⁶⁵ A study of Native Hawaiian/part-Hawaiian women receiving healthcare at the Wai‘anae Coast Comprehensive Health Center concluded that incorporating traditional Native Hawaiian breastfeeding practices may improve breastfeeding duration within their community.⁶⁶ Evidence in Hawai‘i suggests that language interpretation and communication style challenges between provider and patient may also negatively impact maternity care.⁶⁷ Unfortunately, Hawai‘i breastfeeding stakeholders have noted an underrepresentation of NHOPI and Filipino women in the lactation consultant workforce, leading to language and cultural barriers that may inhibit parents from seeking breastfeeding support.²⁵

Opportunities

Breastfeeding lowers the risk of chronic disease for breastfeeding parents and infants,^5–9 and protects infants from COVID-19.^47–49 This pandemic provides an opportunity for action in Hawai‘i to increase comprehensive coverage and access to community-based lactation care. There are 4 key recommendations Hawai‘i should consider to support breastfeeding practices during this pandemic and beyond.

1). Improve In-Hospital Supports and Referrals

Providing access to lactation specialists in hospitals and at discharge is a key clinical practice that can reduce breastfeeding attrition.⁶⁸ Despite pandemic challenges, hospitals must invest in evidence-based maternity care practices. A recent CDC report on supportive breastfeeding hospital practices advises increasing postnatal breastfeeding support and follow-up, and monitoring breastfeeding exclusivity to understand the long-term impact of COVID-19 on maternal and infant health.⁴² In particular, all hospital policies and procedures should include discharge plans with referrals to community breastfeeding support resources and scheduled follow-up visits.⁶⁹ Hawai‘i should incentivize hospitals to adopt maternity care practices that facilitate breastfeeding initiation and ensure parents leave the hospital with the tools they need to successfully continue breastfeeding.

2). Expand Insurance Coverage

The ACA's mandated coverage of breastfeeding support services is clear evidence that improved access to lactation services across the nation was needed. However, inconsistencies and gaps in coverage still need to be addressed through expanded coverage of IBCLCs. High access to IBCLCs is associated with increased breastfeeding by low-income parents, and expanding Medicaid coverage of IBCLCs would result in an estimated annual cost savings of $2.33 million.⁷⁰ Expanding Med-QUEST coverage in Hawai‘i to include IBCLCs who are not already covered as licensed providers in other disciplines, and including additional support from certified lactation counselors, breastfeeding peer counselors, certified lactation educators, and Indigenous breastfeeding counselors under covered services will increase access and support to rural and low-income families.

3). Bolster Community Resources

Community-based breastfeeding counseling has consistently been shown to increase breastfeeding initiation and duration among low-income women.^35,71,72 Programs that train community members as breastfeeding counselors increase access to culturally relevant breastfeeding care. One example of a successful program is the Indigenous Breastfeeding Counselor Training, sponsored by Breastfeeding Hawai‘i, a statewide breastfeeding coalition. This training included physiology and anatomy lessons and incorporated Native Hawaiian cultural breastfeeding practices. Such training supports the time-honored Native Hawaiian tradition of breastfeeding (referred to as hānai waiū in ‘Ōlelo Hawai‘i), trains new breastfeeding counselors, and increases access to community-based lactation support to Indigenous parents. Dedicated funding is needed to conduct more of these trainings.

4). Broaden Telehealth Services

Telelactation can support parents through breastfeeding challenges,⁶¹ filling established gaps in community resources. Some lactation consultants are expanding services to virtual medical platforms. One pediatric provider offers breastfeeding medicine services and has increased telemedicine visits for lactation support to anywhere in Hawai‘i,⁷³ and Breastfeeding Hawai‘i is making Zoom access available to providers giving lactation advice.⁷⁴ Concurrently, the Federal Communications Commission Fund is providing funding to Hawaiian Telcom to increase broadband service in rural areas of the state.⁷⁵ This investment may enable increased access to telelactation services. However, Hawai‘i needs to continue to invest in telehealth infrastructure and work to improve Med-QUEST reimbursement for telelactation services in order to increase and sustain access to lactation care in all communities.

Conclusion

Breastfeeding mitigates numerous health disparities for breastfeeding parents and children. With COVID-19 exacerbating barriers to breastfeeding and widening health disparities, breastfeeding support is even more crucial. Improving Med-QUEST reimbursement for lactation consultants, strengthening hospital maternity practices and referrals, increasing access to culturally appropriate breastfeeding care, and expanding telehealth offer a first step toward reducing these health disparities and giving all infants a healthier start in life.

Abbreviations

ACA

Affordable Care Act

CDC

Centers for Disease Control and Prevention

IBCLC

International Board Certified Lactation Consultant

WIC

Women, Infants and Children

Conflict of Interest

None of the authors identify a conflict of interest.