SUGGESTIONS FOR FUTURE ACTIVITIES

Forty-one percent (46/113) of respondents recommended action related to
public education, including:

o Conduct media campaigns at the national, State, and local levels. Use
printed materials and television and radio public service announcements,
and request that local television and radio talk shows run segments on
breastfeeding.

o Work toward making breastfeeding the normative mode of infant feeding,
through media campaigns, but also by advocating for positive depiction of
breastfeeding on television shows, including soap operas and prime time
series and movies.

o Incorporate information about breastfeeding and human lactation in
elementary and secondary school biology, health, and family life curricula.

o Target programs for Hispanics, blacks, and low-income women

o Designate a breastfeeding month at the national or State level.

26


SUPPORT IN THE HEALTH CARE SYSTEM

      Recommendation:
Strengthen the support for breastfeeding in
    the health care system

ACTIVITIES REPORTED

The 1984 Surgeon General's workshop recognized that increasing support
for breastfeeding in the health care system is crucially important in
breastfeeding promotion efforts. The workshop report states: "Support for
breastfeeding needs to be conspicuous in primary care, prenatal care, and
postpartum care provided in a wide variety of ambulatory care settings as well
as labor, delivery, postpartum, and infant care provided in hospital settings"
(DHHS 1984, p. 69). Seventy-three percent (83/113) of respondents indicated
that they engage in some activities related to this recommendation. Activities
reported include developing policies, standards, and protocols; establishing
hospital-community liaisons; establishing laws and regulations; and training
peer counselors as a way of strengthening support in the health care system.

Policies, Standards, and Protocols

Sixty-four percent (72/113) of the respondents reported that they promoted
coordinated policies and practices to increase support for breastfeeding in the
health care system. Activities described include developing prenatal
breastfeeding promotion protocols, issuing standards for staff education, and
instituting hospital policies regarding breastfed babies (e.g., allowing rooming-
in or continuous feeding and prohibiting supplemental feedings). Several
examples of such efforts are described below.

In 1990 the United States signed a WHO/UNICEF joint statement, the
Innocenti Declaration, as one of the participants in the WHO/UNICEF
policymakers' meeting on "Breastfeeding in the 1990s: A Global Initiative"
(see appendix I, page 106). This meeting, cosponsored by the United States
Agency for International Development and the Swedish International
Development Authority, was held at the Spedale degli Innocenti in Florence,
Italy, from July 30 to August 1, 1990. The declaration describes the current
state of breastfeeding promotion worldwide, and outlines goals to be reached
by 1995. One of these goals is for governments to ensure "that every facility
providing maternity services fully practices all ten of the Ten Steps to
Successful Breast-feeding set out in the joint WHO/UNICEF statement
Protecting, Promoting, ad Supporting Breast-feeding: The Special Role of Maternity
Services. " Two sections of that statement-the Ten Steps to Successful Breast-
feeding, and the Checklist for Evaluating the Adequacy of Support for Breast-

27


feeding in Maternity Hospitals, Wards, and Clinics-are reprinted in appendix
J, on page 108.

The Maternal and Child Health Bureau, DHHS, has allocated funds for 15
maternal and child health improvement SPRANS projects, designed to assist
States to develop a continuing State program capacity in breastfeeding
promotion. Arkansas, Colorado, Kentucky, West Virginia, and Wisconsin were
awarded grants for 3 years beginning in October 1990. Five additional grants
were awarded in October 1991, and another five will be awarded in 1992.
These projects are implementing a variety of activities, including providing
education to professionals and patients, as well as working to enhance support
for breastfeeding in the health care system through the adoption of
breastfeeding policies, standards, and protocols.

In 1990 the National Association of WIC Directors (NAWD) issued
Grtidelines for Breastfeenng Promotion in the WIG Program, in order to assist State
and local agencies in initiating and/or strengthening existing breastfeeding
promotion and support programs. Each of the nine guidelines set forth is
accompanied by specific strategies for implementation. (The guidelines are
reprinted in appendix H, see page 98). In early 1991, the NAWD Breastfeeding
Promotion Committee surveyed State WIC agencies to determine the
utilization of the guidelines. The survey showed that 46 out of 59 programs
surveyed had implemented activities coordinated with health care programs
and professional organizations in 1990, and 47 planned to do so in 1991.

In 1988, the Healthy Mothers, Healthy Babies coalition conducted a survey
of hospital practices related to breastfeeding. The questionnaire included a
request form to enable the respondent to obtain an assortment of resources on
breastfeeding at no charge. Nearly 900 hospitals responded, and the survey
results were analyzed by the Center to Prevent Childhood Malnutrition. In
1989, a followup survey was conducted in order to determine the usefulness of
the publications which had been distributed and to assess changes in hospital
breastfeeding promotion efforts. Thirty-five percent of the hospitals responding
reported that they had organized breastfeeding committees at their institution.

The goal of the Arkansas Best Start Breastfeeding Promotion Project (funded
through a SPRANS grant from MCHB) is to increase the incidence and duration
of breastfeeding throughout the State-particularly among the WIC and MCH
clients of the Pulaski Central Health Unit of Pulaski County-by developing
and implementing a comprehensive breastfeeding promotion program for low-
income women. Hospitals in Pulaski County with maternity services are being
surveyed about their breastfeeding practices and policies. Pediatricians,
obstetricians, and family practitioners in the area are also being surveyed about
their breastfeeding management and patient education practices. This
information will then be utilized to determine recommended practices and
policies for in-hospital breastfeeding management. Training sessions on the
recommended practices and policies will be offered to interested hospital
health professionals. There are also plans to review current breastfeeding
policies and counseling standards in the State maternity and child health
manuals; to draft and review policies related to commitment to breastfeeding;
and to provide support and training for all staff in targeted clinics in order to

28


promote and support attitudes and approaches that provide positive
reinforcement for breastfeeding families.

The Alameda County (California) Infant Feeding Project, an MCHB-funded
SPRANS project, worked with low-income minority women from areas with
high infant mortality rates who gave birth at a county public hospital. In-
hospital and prenatal protocols which promote breastfeeding have been
completed, and the project staff are planning ways to find funding for
continuing breastfeeding counseling in the hospital.

In Florida, the State breastfeeding coordinator worked with the Florida
Healthy Mothers, Healthy Babies coalition and the Florida Section of NAACOG
to develop hospital protocols for breastfeeding. The WIC program has awarded
a grant to the Florida HMHB coalition for the development of a training
manual to implement the hospital protocols, Model Hospital Policies arui
Protocols to Support Breastfeeditq Mothers: Trainitlg Program for Hospital Staf/I
Staff from 57 of the 100 hospitals in Florida participated in these training
>essions. These facilities account for more than 70 percent of the hospital beds
in the State. Participants also included 9 of the 10 target hospitals selected for
special attention because they provide care to most of the WIG program
patients in the State.

Indiana's Breastfeeding Promotion Program, another MCHB-funded SPRANS
project, also sought to increase the percentage of infants who are breastfed. A
breastfeeding advisory council met quarterly to guide this project, and three
working subcommittees were responsible for implementation of activities. The
Health Care Systems Subcommittee focused on activities which helped to
develop institutional and professional policies that were congruent with the
project's breastfeeding promotion philosophy. The project completed a survey
of physicians and hospitals in order to evaluate breastfeeding management
practices and assist in developing a training curriculum for education of health
professionals on breastfeeding.

One of the goals of the Montgomery County (Maryland) Breastfeeding
Coalition is to identify and support pathways to a satisfying breastfeeding
experience during the prenatal period, in the hospital, in the community, and
in the workplace. The coalition has distributed model hospital policies from
Wellstart and UNICEF to all hospitals in the county, and also urged hospitals,
health department maternity clinics, and WIC programs to develop their own
policies. The coalition plans to continue to work within the health care system
in order to encourage and support the development and implementation of
model policies, standards, protocols, and curricula that reflect a concern for
lactation and the promotion of breastfeeding.

In 1991, the Tennessee Department of Health and Environment
implemented a policy for all health departments in the State against the
display of infant formula products and materials. The policy calls for all print
materials, audiovisual materials, and office supplies to be free of formula
product names; for health department staff to exhibit a positive attitude
toward breastfeeding and to make appropriate educational materials available
to patients; and for efforts to be made to provide an area for women to
breastfeed their infants in the program or clinic setting.

29


The Family Resource Center, Charleston Area Medical Center, under
contract with the West Virginia Maternal and Child Health Program, is
currently developing breastfeeding protocols to increase the rate of
breastfeeding within its client population. To date, promotional and
educational materials have been developed, prenatal and postnatal
breastfeeding classes have been planned, two nurse-lactation specialists have
been hired, and a hospital "warm-line" has been established to answer
questions from discharged patients to facilitate the maintenance of
breastfeeding.

Hospital-Community Liaisons

Liaisons between community agencies and hospitals are important in
fostering coordination and continuity of breastfeeding promotion activities in
the health care system. Forty-two percent (47/113) of respondents reported
that they worked to establish hospital-community liaisons. Several of these
efforts are described below.

Arkansas' Best Start Program has developed a joint multidisciplinary team
with representatives from the Arkansas Department of Health, the University
of Arkansas for Medical Sciences, and the University of Arkansas Hospital. The
team is participating in the first field trial of the curriculum entitled "Health
Professionals Curriculum in Lactation Management," which was developed by
Wellstart in 1990. Its objective is to establish a model system for breastfeeding
management and support using the facilities of the University of Arkansas
Hospital and a large local health unit in the same county.

In December 1986, the Arizona Healthy Mothers, Healthy Babies coalition
formed a breastfeeding task force. This interdisciplinary task force includes
hospital nurses, private lactation consultants, public health nutritionists, and
physicians. The task force issued a model breastfeeding hospital policy which
was endorsed by 14 health professional organizations, developed a hospital
breastfeeding education protocol, and completed a survey of hospital
breastfeeding practices.

The Tennessee Hospital Association, in conjunction with the Tennessee
Department of Health and Environment, has sponsored two mailings to all
Tennessee hospitals and public and private prenatal and pediatric health care
providers addressing the Best Start campaign and the need for supportive
hospital practices. A third letter is planned to encourage hospital staff to
complete the infant feeding information on the metabolic newborn screening
form so statewide data on the incidence of breastfeeding in the hospital can be
obtained. The letter will outline ways in which the information from the form
is being put to practical use.

Laws and Regulations

The USDA's Food and Nutrition Service has established regulatory
provisions for the WIC program and Commodity Supplemental Food Program
(CSFP) to encourage mothers to breastfeed and to provide appropriate

30


nutritional support for breastfeeding participants. For example, both WIG and
CSFP have designated breastfeeding women to be at a higher level of
nutritional risk than nonbreastfeeding, postpartum women, and thus they
have a higher priority for receiving services.

In early 1991, NAWD conducted a survey of WIC programs in 48 States and
11 American Indian nations and territories in order to determine how well the
State agencies were progressing with the implementation of the new WIC
Reauthorization Act breastfeeding provisions and the NAWD guidelines. The
survey showed that the majority of WIG programs conducted activities related
to the new provisions and guidelines in 1990, and plan to conduct more such
activities in 1991. For example, 42 programs reported appointing a
breastfeeding coordinator. Examples of activities undertaken by two WIC
programs to implement the new requirements are described below.

The Florida WIC program reported implementing several activities related to
the new regulations. These included appointing a State breastfeeding
coordinator and establishing a breastfeeding promotion team. AI1 WIC local
agencies were asked to develop a breastfeeding promotion plan, identify a staff
member to be the local breastfeeding coordinator, and provide training on
breastfeeding management and promotion for local coordinators. Sixteen State
grants were awarded to local agencies for breastfeeding promotion activities.

The Nebraska Department of Health reported that its WlC program had
designated a breastfeeding promotion coordinator, established policies for a
positive clinic environment, and identified other promotion efforts at the local
level.

Training Peer Counselors

Twenty-eight percent (32/113) of respondents reported training peer
counselors as a way to strengthen support for breastfeeding in the health care
system. Peer counselor programs are discussed in greater detail in the fifth
chapter, Support Services in the Community (see page 33).

BARRIERS TO BREASTFEEDING

Of respondents who listed barriers to breastfeeding, 33 percent (28/84)
mentioned the problems that exist in the health care system. Characteristics of
the hospital environment-such as separation of the mother and infant,
glucose water feeding, and negative attitude of the staff-were mentioned by
31 percent (26/84) of respondents. Advertising by formula companies,
distributing free formula packs at hospitals and clinics providing health care
for maternity patients and infants, as well as through WIC programs, and
mailing formula packs and coupons to new mothers were mentioned as having
a negative impact by 26 percent (22/84) of respondents. Physical problems
such as maternal illness or cesarean section were reported by 13 percent (11/84)
as a barrier to breastfeeding.

31


SUGGESTIONS FOR FUTURE ACTIVITIES

Twenty-seven percent (30/113) of respondents suggested improving support
for breastfeeding in the health care system, including the following:

o Develop and advocate for adoption of hospital policy guidelines that
support breastfeeding. Issues that should be addressed are distribution of
discharge formula or coupons, separation of mother and infant,
breastfeeding on demand, use of glucose water, and availability of lactation
management services and support.

o Establish and distribute national guidelines for perinatal care, including
proper breastfeeding management.

o Work to coordinate breastfeeding promotion efforts and services provided
by different agencies and by private health care providers.

o Make clinic and hospital environments more supportive of breastfeeding
by removing formula company materials, displaying posters and other
materials which promote breastfeeding, and providing an area in the
waiting room where women can breastfeed.

32


SUPPORT SERVICES IN THE COMMUNITY

      Recommendation:
Develop a broad range of support services
     in the community

.kl-IVITIES REPORrED

In order to cope with questions and problems related to breastfeeding and
lactation, women need to have access to services which encourage and assist
lactation and breastfeeding during the prenatal, delivery, and postpartum
periods. The report of the 1984 Surgeon General's workshop stated that
community support services should: ". . _ 1) emphasize the strengths of the
family; 2) respect the variations found within different cultural, ethnic, and
economic groups as well as life styles; 3) offer a continuum of care for the
mother and baby throughout the reproductive cycle and infancy; and 4)
effectively use community resources" (DHHS 1984, p. 19). This
recommendation has received considerable attention from the respondents to
our survey: 74 percent (84/113) reported engaging in at least one activity
related to this recommendation. Activities reported by respondents include
providing client education and followup services, developing support groups,
and providing telephone hotlines.

Client Education and Followup Services

The delivery of breastfeeding information, counseling, and support to
expectant and new mothers is an important component of breastfeeding
promotion. These mothers need information to help them with their infant
feeding decisions; require instruction at the initiation of breastfeeding; and
benefit from lactation management, counseling, and support services
throughout the breastfeeding period. Many programs offer client education
and followup services; some are described below (see table 6).

Table G-Client education and followup services

Type of Activity

  Percentage of
Respondents Reporting
   (kll3)

Client education                            70% (79)
   Prenatal period                       61% (69)
   Hospital stay                         29% (33)
    Postdischarge                         50% (57)
Individual counseling of clients and families               58% (65)
Follow-up services related to breastfeeding management        42% (48)

33


The Children's Rehabilitation Unit at the University of Kansas Medical
Center in Kansas City, Kansas, provides client counseling and community
outreach as part of its breastfeeding promotion effort. The program is staffed by
a pediatric nurse practitioner for 20 hours each week and by a registered
dietitian for 5 hours each week.

The program goal of the breastfeeding project of the Missouri Department of
Health is to facilitate and support the woman's decision to breastfeed.
Questionnaires are administered to clients in order to assess their knowledge
and attitudes about breastfeeding and to identify and eliminate
misconceptions. Pregnant women in this WIC program participate in no less
than two group discussions/classes about breastfeeding, and information about
what to expect at the hospital is provided to pregnant women at 32-40 weeks'
gestation. A nutritionist has established daily communication with the nursing
staff at the University of Missouri Hospitals and Clinic in order to identify
mothers who have recently delivered and who are breastfeeding. The
nutritionist and a peer counselor make contact with new mothers during a
hospital or home visit to offer support and answer questions.

The Oregon Health Sciences University (OHSU) in Portland, Oregon,
established a breastfeeding service in 1985. This program offers prenatal classes,
provides management of OHSU patients, and accepts community referrals for
inpatients and outpatients.

The Texas Children's Hospital Lactation Support Program, in order to
encourage feeding hospitalized infants their own mother's milk, provides
equipment, instructions, and supplies for expressing breastmilk, as well as
facilities for storage and for screening for contamination. It also provides for
lactation counseling and assistance with establishment of suckling following
term and preterm deliveries, fortification of maternal milk for feeding
premature infants, home visits, and an outpatient lactation clinic. The program
is staffed by nurses (assigned to the program as lactation counselors), a
neonatologist, and a lactation physiologist. Approximately 100 women
participate each month. This number is expected to grow in the next few years
as the program expands. The agencies collaborating on this project are Texas
Children's Hospital, Baylor College of Medicine, Children's Nutrition Research
Center, and St. Luke's Episcopal Hospital.

Support Groups

The provision of culturally appropriate support groups which provide
assistance and counseling for breastfeeding women was one of the strategies to
strengthen community support for breastfeeding suggested by the Surgeon
General's workshop. Support groups, which 37 percent (42/l 13) of respondents
reported utilizing, are commonly a gathering of new mothers who meet
regularly to discuss their experiences with breastfeeding. The groups can be a
formal class led by a professional, or a less formal discussion led by a peer.
Most of the groups described by respondents were peer support groups.
Descriptions of a few of these activities follow.

34


La Leche League's Breastfeeding Peer Counselor Program was piloted in
Illinois in 1987. It has trained 60 program coordinators and over 100 mothers
as peer counselors in the Illinois area. These women assist health professionals
in breastfeeding promotion programs, talk to mothers in clinic waiting rooms,
lead breastfeeding support groups, and provide phone help to mothers who
have questions about breastfeeding. There are currently 10 of these programs
in Florida, as well.

The Colorado Departrnent of Health reported that a chapter of the Nursing
Mothers Counsel (NMC) has been organized in the State. NMC is a
nonaffiliated, nonprofit, volunteer organization whose goal is to help mothers
enjoy a relaxed and happy relationship with their babies. NMC members
provide one-on-one counseling for new and expectant parents. Telephone
contact is made to provide information and answer questions about
breastfeeding. The counselor then remains available to the mother after the
birth and throughout the mother's nursing experience to offer any additional
information, support, and encouragement needed. NMC chapters also exist in
California and Indiana.

The Ohio State University Research Foundation was awarded a SPRANS
grant by MCHB in order to improve breastfeeding rates in a low-income, urban
population. An integral component of this project was the use of peer
counselors in both the prenatal education and postpartum support aspects of
the program. Project evaluation showed that women who, in addition to
receiving education from professional staff, were introduced to a peer
counselor of similar ethnic, racial, and socioeconomic background, were more
likely to have chosen to breastfeed at delivery than women who received the
education component only.

The Tennessee Department of Health and Environment (TDHE) and the
Center to Prevent Childhood Malnutrition have initiated Breastfeeding and
Baby Care Support Group Projects designed to encourage local women to take
charge of bringing their peers together for support and to share information on
breastfeeding. In June 1989, three WIC participants in two rural southwest
Tennessee counties were hired to work 10 hours a week to organize and lead
these monthly breastfeeding peer support meetings. These peer counselors
were trained and supervised by the coordinator of a SPRANS breastfeeding
promotion project targeting the WIC programs in the two rural counties. Since
September 1989 these peer counselors have led breastfeeding support meetings
and organized "enrichment" meetings, where guest speakers talk to the group
about topics important to them, such as exercising with their baby, dressing on
a budget, using coupons, and cardiopulmonary resuscitation. The peer
counselors also contact 50 to 80 women a month by telephone to invite them
to meet with breastfeeding counselors, inquire about their breastfeeding, and
to administer a self-esteem questionnaire. The project has now been expanded
to include eight peer counselors. The Center to Prevent Childhood
Malnutrition is evaluating this project for its impact on self-esteem and on
breastfeeding rates. The TDHE has implemented six projects statewide based on
this model.

35


The San Antonio Breastfeeding Project is an l&month program designed to
test the hypothesis that women who receive prenatal intervention from a
culturally sensitive, breastfeeding doula (peer counselor) will have higher
breastfeeding rates than those who receive education only and those who
receive no intervention. Women in the experimental group viewed a
breastfeeding skills training video and discussed cultural concerns about
breastfeeding with a peer counselor who was breastfeeding during the
discussion session. Study results are currently being compiled.

The Breastfeeding Peer Counseling Program developed by Children's
Hospital in Washington, DC, is designed to train mothers in the WIC program
to serve as breastfeeding support and peer counselors. The program has
produced the Breastfeeding Peer Counselor Manual which describes program
implementation, peer counselor training and monitoring, followup training
activities, and program evaluation measures.

The West Virginia WIC program has developed a peer counselor training
manual, using the Best Start counseling strategy, to teach mothers with
breastfeeding experience to counsel, encourage, and educate women in the art
of breastfeeding. These trained peer counselors will give prenatal and postnatal
breastfeeding support and information to women in local WIC clinics and
specific prenatal health clinics.

Telephone Hotlines

The use of telephone hotlines as a method of providing outreach and
followup support to lactating women was reported by 22 percent (25/113) of
respondents. A variety of types of hotlines were reported. Some were staffed by
peer counselors and others by community health professionals such as
dietitians. Phone lines were in operation from 24 hours per day for 7 days a
week to 6 hours per day for 3 days a week.

The Arkansas Best Start Program has implemented a statewide breastfeeding
helpline to provide information and problem-solving services to breastfeeding
families and health care professionals. The line is answered during working
hours by the staff of the breastfeeding center.

La Leche League International provides a national toll-free phone
information service. Callers can get referrals to local La Leche League groups, a
free catalog of breastfeeding and parenting literature, and answers to
breastfeeding questions.

The New Hampshire Division of Public Health reported that one local WIC
agency has received funding from a foundation for the "Breastfeeding
Connection," a telephone support system for breastfeeding mothers. It has
been operated by a staff nutritionist for several years.
North Carolina's First Step Hotline provides information and referral on all
aspects of prenatal and infant care, including breastfeeding. The hotline is
jointly sponsored by the North Carolina Division of Maternal and Child
Health, the March of Dimes, the Governor's Commission on Infant Mortality,
and the Healthy Start Foundation.

The phone number for the telephone counseling service of the Children's

36


Nutrition Research Center (CNRC) in Texas is given to all individuals who refer
potential research subjects to CNRC and to a11 potential research volunteers
referred. In addition, some 1,000 women are contacted each month either
prenatally or 2 weeks postnatally and offered lactation consultation if needed.
Lactation consultants, dietitians, and a lactation physiologist are available
during working hours to answer questions. In addition, backup and
consultation is provided by pediatricians, neonatologists, nutritionists,
pediatric gastroenterologists, and other faculty members. The target audience
for this service includes nurses, physicians, dietitians, and research volunteers
in the Houston area, but calls are received from throughout the United States.
The agencies collaborating in this effort are Baylor College of Medicine, Texas
Children's Hospital, Children's Nutrition Research Center, St. Luke's Episcopal
Hospital, Methodist Hospital, and the MacGregor Clinics.

BARRIERS TO BREASTFEEDING

Of the 84 respondents who listed barriers to breastfeeding, 60 percent (50/84)
mentioned barriers related to community support services (see table 7).

Table 7-Community support services barriers to initiation and continuation of
breostfeeding

Barriers

Percentage of Respondents
     (N--84)

Lack of support from family and friends                52% (44)

Lack of knowledge, education among women             45% (38)

Lack of postpartum support services                 26% (22)

Lack of role models who breastfeed                  17% (14)

SUGGESTIONS FOR FUTURE ACTIVITIES
Thirty-five percent (40/l 13) of respondents recommended improving or
expanding breastfeeding support services, including:
o Sponsor peer support groups and train peer counselors.
o Provide toll-free information hotlines and telephone support systems.
o Expand the use of lactation counselors, both in the hospital and in the
community.

o Provide postpartum followup for new mothers via home visits or phone
calls.

o Promote breastfeeding in prenatal classes.
o Include families in breastfeeding education efforts.

37


SUPPORT IN THE WORKPLACE

        Recommendation:
Initiate a National Breastfeeding Promotion Effort
  Directed to Women in the World of Work

ACTIVITIES REPORTED

The 1984 Surgeon General's Workshop on Breastfeeding and Human
Lactation identified several barriers women often encounter in the workplace
and at school, including lack of information on the part of the public,
employers, and health care providers; logistical problems such as lack of time,
equipment, and space for nursing or using breast pumps; and a social,
psychological, and political climate which significantly separates the worlds of
work and home that can be hostile to a working woman's attempts to combine
breastfeeding and employment.

Forty-four percent (50/113) of the survey respondents reported some
activities related to building support for breastfeeding in the workplace. Such
activities included educating employees and employers; providing
breastfeeding facilities and implementing policies in the respondent's own
workplace; promoting policies and guidelines for other workplaces; conducting
surveys and assessments; initiating breast pump loan programs; and
implementing model or demonstration projects.

Education

Provision of education and educational materials was the most commonly
reported activity. Twenty-nine percent (33/113) of the respondents provided
education to employees and 14 percent (16/113) provided education to
employers.

The Healthy Mothers, Healthy Babies coalition's Subcommittee on
Breastfeeding Promotion has prepared a resource list of publications which
address breastfeeding and working women, and is developing a breastfeeding
fact sheet to send to employers. In addition, the Healthy Mothers, Healthy
Babies National Conference, held in the fall of 1991, had a workshop which
focused on breastfeeding and working women.

The Arizona Department of Health Services staff have provided support to
the Nutrition Council of Arizona Breastfeeding Advocates, which is developing
a consumer guide on storing and feeding breastmilk, preparing a list of electric
breast pump rental stations, and distributing these materials to hospitals and
health care professionals. The department has also provided training sessions
on working and breastfeeding at three meetings: the Childbirth Education
Association of Greater Phoenix Conference in November 1986, the Northern

38


Arizona Nutrition Education Workshop in July 1987, and the Nutrition
Council of Arizona Annual Meeting in April 1989.

The Oregon Health Sciences University has developed information for
employers on the establishment of facilities to promote breastfeeding among
working women.

Breastfeeding Facilities and Practices in Respondents' Workplaces

The provision of facilities for employees to pump and store breastmilk
and/or the implementation of practices to support breastfeeding employees at
the respondent's workplace were reported by 22 percent (25/113) of
respondents (see table 8).

In Arizona, two county health departments have implemented formal
policies which enable breastfeeding employees to bring infants up to 4 months
of age to work.

The Center to Prevent Childhood Malnutrition, in Bethesda, Maryland,
provides its employees with 3 months of maternity leave, and allows breastfed
infants to be brought to work until at least 6 months of age.

Through combined efforts the New Mexico Department of Health and
Environment's Division of Health Promotion and the New Mexico
Breastfeeding Task Force are providing two electric breast pumps for use by
working mothers employed in the health department's South Capitol
Complex.

The Division of Maternal and Child Health of the Ohio Department of
Health permits a 6-month maternity leave, which makes it easier for women to
establish a breastfeeding relationship with their infants in the early months of
life. In addition, Ohio's Governor has mandated that day care facilities be
incorporated into each new State office building. As a result, two day care
facilities have recently been established in downtown Columbus, thus allowing
breastfeeding mothers easier access to their infants.

At the Children's Nutrition Research Center (CNRC) in Texas, individual
assistance from a lactation consultant is provided to employees upon request.
In addition, the CNRC, in conjunction with Texas Children's Hospital,
provides a private room, an electric pump, sterile collection kits, and freezer
space for lactating employees.

In November 1991, a room equipped with a breast pump and refrigeration
was established for nursing mothers at the Food and Nutrition Service, USDA,
in Alexandria, Virginia. A baseline survey was completed to assess attitudes
toward breastfeeding and employee needs and to provide input for better
project planning. A pamphlet providing basic information on breastfeeding,
expressing and storing breastmilk, and the services available through the
breastfeeding mothers' room will be produced and distributed to interested
employees.

La Leche League International reported that employees at the National
Security Agency (NSA) in Washington, DC-with the help of the NSA Medical
Center and a parent group at NSA called the Child Development Care

39


Association-have acquired five electric breast pumps and several rooms for the
use of breastfeeding employees.

At Georgetown University Hospital in Washington, DC, two electric breast
pumps are available for staff use in a special private area of the hospital's
Lactation Center. Refrigeration is available in most work areas.

Table g--Respondents who reported provision of breastfeeding facilities and/or
implementation of practices to support breastfeeding in their workplace

University Medical Center
Tucson, AZ

Wellstart
San Diego, CA

Denver Department of Health
and Hospitals
Denver, CO

Community Health Centers, inc.
Colorado Springs, CO

Georgetown University Hospital
Washington, DC

Florida Department of Health and
Rehabilitative Services
WIC and Nutrition Services
Tallahassee, FL

Grady Memorial Hospital
Atlanta, GA

University of Illinois School of
Public Health
Chicago, I1

La Leche League International
Franklin Park, IL

American Academy of Pediatrics
Elk Grove Village, IL

Indiana State Board of Health
Maternal and Child Health Division
Indianapolis, IN

Indian Health Service
Rockvile, MD

Northern Michigan Hospitals
Petoskey, MI

Community Nutrition Resource Center
Butte, MT

Montana Migrant Council, Inc.
Billings, MT

New Mexico Health and
Environment Department
Public Health Division
Santa Fe, NM

Nevada WIC Program
Carson City, NV

New York State Department of Health
Bureau of Nutrition
Albany, NY

Columbia University School of
Public Health
New York, NY

Children's Hospital/The Ohio State
University College of Medicine
Columbus, OH

Oregon Health Sciences University
Portland, OR

South Dakota Department of Health
Nutritional Services
Spearfish, 5 D

Children's Nutrition Research Center
Houston, TX

Food and Nutrition Service, USDA
Alexandria, VA

Washington Department of Health
and Social Services
Division of Parent/Child Health Services
Olympia, WA

40


Policies and Guidelines

Sixteen percent (18/l 13) of respondents reported promoting workplace
policies and practices supportive of breastfeeding. These efforts frequently took
the form of the issuance of guidelines or recommendations for employers. TWO
examples of these efforts are described below.

The New Mexico Breastfeeding Task Force has developed workplace
recommendations for the support of breastfeeding. These recommendations
outline the minimum workplace conditions needed to support breastfeeding as
well as additional conditions that help women maximize their parenting and
breastfeeding skills.

The Texas Department of Health pledges in its policy statement on
breastfeeding to encourage industry to promote and support breastfeeding by
providing information on practices that foster a positive environment for the
breastfeeding employee.

Surveys and Assessments of Need

Several respondents reported conducting surveys of employers'
breastfeeding facilities and policies, while others reported conducting
assessments of the need for services for working women. These efforts are
outlined below.

The nationwide survey of 900 hospitals conducted in 1988 by the Healthy
Mothers, Healthy Babies coalition included questions on what provisions the
hospitals made for their own breastfeeding employees. Sixty-two percent of the
responding hospitals reported providing facilities for lactating employees. Of
these, 83 percent had a place for employees to express breastmilk, 67 percent
provided an electric pump, and 86 percent had a refrigerator.

The Nutrition/Breastfeeding Subcommittee of the Connecticut Healthy
Mothers, Healthy Babies coalition sent questionnaires to 70 hospitals and
health care facilities in order to examine the level of support which these
employers provide for women who continue breastfeeding after returning to
work. Thirty-eight responses were received. Forty percent of respondents
allowed infants to be brought to work to be breastfed, but only one hospital
allowed infants to be kept at work all day. Between 30 percent and 40 percent
said that extended lunch and flextime hours were available. Day care was
provided at 34 percent of the facilities, and at an additional 44 percent
provision of day care was being planned. Twenty-six percent of the
respondents had a women's lounge. Half of these lounges were private, and 60
percent were smokefree. All facilities had a refrigerator. Additional activities
planned by the Nutrition/Breastfeeding Subcommittee include sending
breastfeeding packets to the hospitals which participated in the survey and
expanding the survey to other types of employers.

The Day Care/Industry Subcommittee of the Indiana State Board of Health's
SPRANS breastfeeding promotion project sent surveys to 600 employers in
Indiana, and 157 surveys were returned. Thirty-six percent of the respondents
provided a refrigerator, 23 percent provided a private space for women to
breastfeed or express milk, 10 percent allowed extended breaks for collecting

41


milk, 7 percent offered flextime, 2 percent provided onsite day care, and less
than 1 percent allowed mothers to bring their infants to work or had an
electric pump available.

The Oregon Health Sciences University (OHSU) conducted a survey of its
employees who returned to work 6 months or less after giving birth, in order to
assess the need for facilities and policies allowing working women to continue
breastfeeding. As a result of this survey, OHSU has made a room and a breast
pump available to its lactating employees.

The Texas Healthy Mothers, Healthy Babies coalition conducted a survey of
workplace policies and facilities related to breastfeeding. Questionnaires were
sent to 350 employers who had 50 or more employees in central Texas; 37
employers completed the survey. Fifty-nine percent of the respondents
provided a refrigerator; 32 percent made flextime, job sharing, or part-time
employment available; 24 percent provided a private space for breastfeeding or
milk expression; 16 percent provided extended breaks for collecting milk; and
11 percent had onsite day care. None of the employers allowed women to
bring their infants to work.

Breast Pump Loan Programs

Three respondents-all WIC State agencies-described breast pump loan
programs.

The Indiana WIC program has made breast pumps available to breastfeeding
women-including those returning to work-who may benefit from having a
pump.

The New Mexico WIC program has purchased 16 electric breast pumps
which are available for limited loan to mothers enrolled in the WIC program
throughout the State. These pumps are intended for use when there is a critical
situation involving separation and/or a medical problem. Working mothers of
twins or triplets are eligible to borrow a pump. Other working mothers may
also be considered, but they have a lower priority.

The Tennessee WIC program has three breast pump loan programs available
to its patients: (1) A manual breast pump program for which sterilization
procedures for both the patient and the health department have been
developed; (2) portable electric pumps for women whose infants are
hospitalized for prematurity or other medical complications; and (3) electric
pumps for inhospital use by WIC patients, on permanent loan to the hospitals
serving a large caseload of WIC participants.

Model/Demonstration Programs

The Maternal and Child Health Bureau, DHHS, has funded two
breastfeeding SPRANS demonstration projects which focused on breastfeeding
and the workplace. These projects are described below.
One of the major goals of the Indiana State Board of Health's Breastfeeding
Promotion Project was to address the lack of support for breastfeeding mothers
in the workplace. As described above in the Surveys and Assessment section,
the Day Care/Industry Subcommittee completed an employer survey of support

42


and facilities available to breastfeeding women. The subcommittee also
developed and distributed an educational brochure for employers, What Does
Your Business Have in Common With a Breastfed Baby?, which outlines steps
employers can take to support lactating workers and discusses ways in which
support of lactating workers can benefit employers.

Promoting Breastfeeding at the Worksite and in the Neighborhood, a
SPRANS project implemented by the National Child Nutrition Project in
Philadelphia, sought to increase the incidence and duration of breastfeeding
among low-income women who were returning to work or school. Activities
included producing educational materials for women, health professionals,
child care providers, and employers; developing working parent advocacy
committees; and implementing a peer counseling program.

BARRIERS TO BREASTFEEDING

Problems associated with women's return to work or school soon after
giving birth were the most frequently cited barriers to the initiation and
continuation of breastfeeding. Sixty-nine percent (58/84) of respondents who
listed barriers to breastfeeding cited women's need to return to work and the
lack of flexible schedules, maternity leave, and facilities for pumping and
storing breastmilk.

SUGGESTIONS FOR FUTURE ACTIVITIES

Eighteen percent (20/l 13) of respondents made recommendations related to
reducing barriers to breastfeeding in the workplace, including:

. Encourage employers to provide maternity leave, facilities for expressing
and storing breastmilk, breaks for breast pumping, flextime, job sharing,
onsite day care, and the like.

o Advocate for legislation on issues such as maternity leave and day care.

o Provide education to employers and employees on the importance of
breastfeeding and ways to make it possible for working women to
breastfeed.

o Provide facilities in State and Federal buildings for breastfeeding and for
pumping and storing breastmilk to set an example.

o Set up a model project in a local industry which demonstrates how work
and breastfeeding can be combined.

o Involve consumer groups, trade unions, and women's groups in
breastfeeding promotion committees and other breastfeeding promotion
activities which address the issue of supporting breastfeeding in the
workplace, since these groups may have more influence than health
professionals on employers.

43


RESEARCH

         Recommendation:
Expand research in human lactation and breastfeeding

ACTIVITIES REPORTED

The 1984 Surgeon General's workshop emphasized the need for research on
breastfeeding and human lactation in order to improve knowledge, guide
policy, improve strategies, and evaluate programs.

Forty-seven percent (53/l 13) of the respondents reported being involved in
research related to breastfeeding and human lactation. The types of research
activities reported focused mainly on social and behavioral factors related to
breastfeeding practices, program evaluation, and nutritional and physiological
aspects of human lactation. Examples of these reported research projects are
described below.

Research on Social and Behavioral Factors

Most of the research reported in this category focused on determining
factors which influence the mother's decision to initiate breastfeeding and
factors which influence the continuation of breastfeeding. Twenty-five percent
(28/113) of respondents reported being involved in social or behavioral
research, although only a few projects-outlined below-were described in any
detail.

The Department of Family Studies and Consumer Sciences and the School of
Public Health's Division of Maternal and Child Health at San Diego State
University, California, have conducted a study designed to identify the causes
of lactation failure among 10 Hispanic primiparous low-income women. The
mothers received one to three indepth, l-hour assessments, depending upon
how long each woman continued to breastfeed. Data was obtained on duration
of breastfeeding, initiation of formula supplementation, and introduction of
solid foods; maternal attitudes toward infant feeding methods; and maternal
perception of social and familial pressures and support related to breastfeeding,
bottle feeding, and introduction of solids. Problem areas identified in this
study will be used to improve the assessment instrument for clinical use.

As discussed in the third chapter, the Best Start Program is a joint effort by
eight Southeastern States to implement a comprehensive campaign of
breastfeeding promotion based on social marketing techniques. As part of this
project, 35 focus groups were conducted with economically disadvantaged
women living in the Southeastern United States in order to determine their
attitudes about breastfeeding. It was found that factors that attracted women to
breastfeeding included the desire for a special, close relationship with the baby,

44


and the health benefits of breastmilk. Barriers to breastfeeding included
embarrassment, lack of confidence, loss of freedom and lifestyle restrictions,
and the return to work or school.

Determinants of Infant Feeding: Breast vs. Bottle, a SPRANS-funded study
conducted from 1986 to 1988 at the Johns Hopkins School of Hygiene and
Public Health, analyzed the major determinants of infant feeding behavior in
new mothers. Women enrolled in the study were contacted by telephone or in
person, once during the prenatal period and three times during the postpartum
period. The study of women who prenatally stated an intention to breastfeed
identified four variables that were significant predictors of failure to breastfeed
for more than 7 days: (1) lack of confidence in ability to breastfeed, (2) less
certainty in the decision to breastfeed, (3) delayed first breastfeeding, and (4)
not having the baby rooming-in. The study also found that, while planning to
be employed within 6 months postpartum did not affect breastfeeding
incidence rates, actually being employed during that time period had a
negative affect on breastfeeding duration rates.

Cornell University Cooperative Extension is conducting a study on the
infant feeding decisions of low-income women. The project is designed to
elucidate the complex interrelationships existing among personal, social, and
cultural factors that influence women's infant feeding expectations and
decisions. Women's learning philosophies will also be studied to understand
how they influence both learning about breastfeeding and infant feeding
practices. The research will be conducted through indepth, open-ended,
personal interviews with 50 low-income, nulliparous pregnant women ages 18
years and older.

The goals of Acculturation, Psychosocial Predictors, and Breastfeeding, a
SPBANS-funded study at the University of Texas Medical Branch at Galveston,
are to identify the reasons mothers from the United States-Mexico border
population choose to breastfeed, to determine factors important to the
maintenance of breastfeeding, and to study infant health and nutritional status
as a function of breastfeeding. A number of psychosocial variables will be
measured to assess their importance in the initiation of breastfeeding, and
these data will be analyzed within ethnic groups by degree of acculturation.

Program Evaluation

Program-related research-monitoring and/or evaluating a program's
breastfeeding intervention strategy to determine its effectiveness-was reported
by 20 percent (23/113) of respondents.  Two examples of these research
activities are described below.

The USDA's WIC Breastfeeding Promotion Study and Demonstration
evaluated the implementation of selected breastfeeding promotion approaches
at seven WIG local agencies. These approaches included three major
components: (1) A special group, such as a task force or committee, which
coordinated breastfeeding promotion and support activities for WIC
participants; (2) a prenatal component addressing participants' concerns and
lack of knowledge about breastfeeding, and incorporating positive peer

45


influence; and (3) an in-hospital/postpartum component providing support
after birth. These demonstration projects are described in detail in the two-
volume set, WIC Breastfeeding Promotion Study and Demonstration: Phase IV
Report (see appendix E, page 79).

Operation Breastfeed, a research project conducted by the Texas Department
of Health, is designed to increase the number of participants in the WIC
program who are breastfeeding at 6 weeks postpartum and to measure the
impact of nutrition education on the decision to breastfeed. Activities include
surveys of pregnant and postpartum participants on their attitudes regarding
breastfeeding, monthly nutrition education classes for pregnant and lactating
women which emphasize breastfeeding, and breastfeeding support for new
mothers.

Nutritional and Physiological Research

Thirteen percent (15/113) of respondents reported engaging in nutrition
research, and 9 percent (10/113) reported involvement in physiological
research related to breastfeeding and human lactation. Nutrition research
reported was related to the nutritional needs of lactating mothers, the
nutritional status of breastfed babies, and the nutrient composition of
breastmilk. Physiological research reported was focused on the factors related
to the production of breastmilk; the ability of the infant to utilize breastmilk;
the transmission of infectious diseases, drugs, and alcohol through breastmilk;
and the immunological impact of breastmilk on the infant. Two examples of
these research efforts are described below.

The purpose of the research program at the Children's Nutrition Research
Center (CNRC) in Texas is to define the nutritional requirements that will
ensure the health of pregnant and lactating women and their infants. The
CNRC has conducted numerous nutritional and physiological studies,
including research on infant nutrition and growth and on breastmilk
composition. The CNRC is funded in part by the USDA's Agricultural Research
Service.

Federal agencies within the Department of Health and Human Services and
the Department of Agriculture have funded a variety of studies related to
human lactation. The Maternal and Child Health Bureau, DHHS, funds
research projects related to breastfeeding through its SPRANS grants, many of
which have been described in this report. The National Institutes of Health,
DHHS, primarily through the National Institute of Child Health and Human
Development, supports numerous research projects related to the physiology of
lactation, maternal and nutritional aspects of lactation, infant physiology and
nutrition related to lactation, immunological aspects of lactation, effects of
environmental exposures on human milk, and the composition of human milk
(see appendix K, page 112). Research on human lactation and breastfeeding
supported by the U.S. Department of Agriculture has also focused on maternal
nutrition and infant nutrition and on developmental aspects related to
lactation (see appendix L, page 115).

46


SUGGESTIONS FOR FUTURE ACTIVITIES

The Institute of Medicine's study, Nutrition During Lactation (described in the
second chapter), assessed current research on the nutritional needs of lactating
women, and recommended the following topics in need of further research:
(1) the development of indicators of nutritional status for lactating women; (2)
identification of groups of lactating women in the United States who are at
nutritional risk or who could benefit from nutrition intervention programs;
and (3) the effects of maternal diet and nutritional status on milk volume, milk
composition, maternal health, and infant nutritional status, growth, and
health.

47


DATA COLLECTION

Data collection is a very important part of monitoring the Nation's progress
toward the achievement of the year 2000 health objective for breastfeeding.
One of the strategies proposed in the 1984 Report of the Surgeon General's
Workshop on Breastfeeding and Human Lactation was to develop a national data
base on the initiation and duration of lactation. To followup on this particular
strategy, survey respondents were asked to describe any data collection
activities they undertook in order to monitor breastfeeding rates and to include
the definition(s) of breastfeeding which were used. Fifty-two percent (59/113)
of respondents answered this data collection question.

DEFINITIONS OF BREASTFEEDING

Fifty-nine percent (35/59) of respondents who answered this data collection
question included a description of the definition of breastfeeding which was
used. Definitions varied widely, as did the time at which the assessment of
feeding method was made. "Ever breastfed for any duration and frequency"
was the most commonly reported definition of breastfeeding (37 percent, or
13/35). Other definitions reported include: "breastfed one or more times per
day" (29 percent, 10/35); "partially breastfed, with infant formula
supplementation" (23 percent, or 8/35); "exclusively breastfed" (6 percent, or
2/35) ; and "nurse's determination of infant feeding method at the hospital
after delivery" (6 percent, or 2/35).

In April 1988, the Institute for International Studies in Natural Family
Planning (now the Institute for Reproductive Health) at Georgetown
University, with support from the United States Agency for International
Development (USAID), moderated a meeting of the Interagency Working
Group on Breastfeeding in Washington, DC. The goal of this meeting of
national and international health and development agencies was to develop a
simple means of presenting definitions and types of information essential to
accurately describe breastfeeding practices throughout the world. The
breastfeeding definitions developed are based on frequency of breastfeeding
episodes, usual length of time for each feeding, and amounts of other foods or
liquids given (see figure 5).

DATA COLLECTION ACTIVITIES

Forty-two percent (47/113) of respondents indicated that they collected data
on the incidence of breastfeeding, while only 24 percent (27/113) reported

48


1

] BREASTFEEDING
,

I

     Full
71

   Exclusive
No other liquid or solid is
given to the infant.

Reproduced with the permission of the
Population Council, from Miriam
Labbok and Katherine Krasovec,
"Toward Consistency in Breastfeeding
Definitions," Studies in Family Planning
Vol. 21, no. 4 (july/August 1990): 27.

/ :;<;~::o 1
juice or rikalistic f&ds g&n


collecting data on the duration of breastfeeding. For the most part, the
maximum length of time for which breastfeeding duration was tracked by the
respondents ranged from 2 weeks to 6 months postpartum, although some
research projects tracked their subjects through the first year of the infant's life.

The types of data collection activities undertaken differed widely among
respondents (see figure 6). The most commonly reported activity was collecting
data on participants in the WIC program (36 percent, or 17/48). Data
collection activities for the Centers for Disease Control (CDC) Surveillance
Systems were also frequently cited (24 percent, or 1 l/48) by respondents. These
CDC-related data collection activities are described in more detail below. Other
forms of data collection reported include data collection for research purposes,
documentation of infant feeding method at hospital discharge, documentation
of infant feeding method on newborn metabolic screening forms in the
hospital, and collection of data for statewide data systems. Brief descriptions of
some of the reported breastfeeding data collection activities follow.

National Data Collection Activities

In order to compile the required report entitled Biennial Report to Congress
on the Characteristics of Participants irl the Special Supplemental Food Program for
Women, Infants, aild Children, the Food and Nutrition Service collects statistics
on WIC programs and program participants, including some information on
breastfeeding rates. The Food and Nutrition Service does not require States to
collect and submit data on breastfeeding incidence and duration, but
breastfeeding incidence and duration data have been designated optional items

Figure 64lreastfeeding data collection activities reported by respondents (N=48)

Other
10% (5/481

  WIG
State agency
36% (17/48)

CDC surveillance
24% (11148)

50