uHuRNm
NAllONAi LIBRARY OF MEDICINE
BEFORE LAST DATE SHOWN

Shelley Spisak, M.H.S., and Susan Shapiro GTOSS, M.P.H., R.D.

       Supported by
   Maternal and Child Health Bureau
Health Resources and Services Administration
      Public Health Service
U.S. Department of Health and Human Services

          Published by
National Center for Education in Maternal and Child Health
         Washington, DC
                 1991


Cite as: Spisak, S. and Gross, S. S. (1991). Second followup TepOTk The Surgeon
General's workshop on breastfeeding and human lactation. Washington, DC:
National Center for Education in Maternal and Child Health.

Second followup report: The Surgeon General's workshop on breastfeeding and human
lactation is not copyrighted. Readers are free to duplicate and use all or part of
the information contained in this publication. In accordance with accepted
publishing standards, the National Center for Education in Maternal and Child
Health (NCEMCH) requests acknowledgment, in print, of any information
reproduced in another publication.

The National Center for Education in Maternal and Child Health (NCEMCH)
provides information services, educational materials, and technical assistance
to organizations, agencies, and individuals with maternal and child health
interests. NCEMCH was established in 1982 at Georgetown University, within
the Department of Obstetrics and Gynecology. NCEMCH is funded primarily
by the U.S. Department of Health and Human Services, through its Maternal
and Child Health Bureau.

Published by:

National Center for Education in Maternal and Child Health
38th and R Streets, N.W.
Washington, DC 20057
(202) 625-8400

Single copies are available at no charge from:
National Maternal and Child Health Clearinghouse
8201 Greensboro Drive, Suite 600
McLean, VA 22102
(703) 821-8955, ext. 254

This publication has been produced by the National Center for Education in
Maternal and Child Health under its cooperative agreement (MCU-117007)
with the Maternal and Child Health Bureau, Health Resources and Services
Administration, Public Health Service, U.S. Department of Health and Human
Services.

The original drawing on the cover was done by Bob Conge of Rochester, NY.


PREFACE

The 1984 Surgeon General's Workshop on Breastfeeding and Human
Lactation was a time of firsts for this Nation in promoting breastfeeding. It was
the first time a national leader called attention to this method of nurturing
infants, and it was the first time a national meeting focused exclusively on
supporting breastfeeding. In addition, the breastfeeding strategies developed at
the workshop are still used today as we move toward the breastfeeding
objectives as published in Healthy People 2000: National Health Promotion and
Disease Prevention Objectives.

Two publications resulted from the workshop: The Report of the Surgeon
General's Workshop on Breastfeeding and Human Lactation (1984) and the
Followup Report: Surgeon General's Workshop on Breastfeeding and Human
Lactation (1985). The 1984 report contains the proceedings, recommendations,
and strategies generated at the workshop; the followup report describes
breastfeeding promotion activities to implement workshop recommendations
in the year following the conference.. Both of these publications, currently out
of print, have become valuable resources.

Now this third publication, the Second Followup Report: The Surgeon General's
Workshop on Breastfeeding and Human Lactation, has been developed to update
breastfeeding promotion activities since 1985. It is hoped that all who read
this second followup report will discover new inspiration.

To obtain the information for the report, questionnaires were sent to State
health agencies, voluntary and professional organizations, and educational
institutions that have an interest in maternal and child health. Over one
hundred organizations responded with information on activities such as:
legislation, policies, guidelines, meetings, publications, media campaigns,
service delivery models, sbpport systems, training, and research related to the
six major recommendation areas identified at the Surgeon General's workshop.

We hope this new publication will help tear down many of the barriers that
must be overcome in promoting informed decisions by more women to
breastfeed their infants. We applaud these new efforts to improve the health
of mothers and children.

       VINCE L. HUTCHINS, M.D.
Director, Maternal and Child Health Bureau

. . .
111


ACKNOWLEDGMENTS

The Second Followup Report: Surgeon General's workshop otl Breastfeediltg and
Human Lactation represents the efforts of many individuals. It was initiated
and funded by the Maternal and Child Health Bureau, U.S. Department of
Health and Human Services, through the efforts of Elizabeth Brannon, Director
of Maternal and Child Health Training, who provided invaluable leadership,
expertise, and assistance throughout the duration of the project. Our deepest
gratitude also goes to Mary C. Egan for her wisdom, guidance, and helpful
comments throughout the preparation of this report. We would also like to
extend a warm thank you to Carolyn Sharbaugh for her continuous support
and helpful comments at every phase of this project.

Also greatly appreciated are the efforts and expertise of Carol Bryant, Darla
Danford, Kathy Davis, Kathy Dugas, Sandra Huffman, Minda Lazarov, Brenda
Lisi, Joan McGill, and Janine Schooley, who reviewed and critiqued the first
draft of the report, providing generous input and helpful suggestions. Most
importantly, we thank the respondents to our questionnaire, who provided us
with the program descriptions which constitute the body of this report.

Finally, we would like to acknowledge Rochelle Mayer, Director of the
National Center for Education in Maternal and Child Health, for supporting
our efforts to complete this project, as well as NCEMCH's publication staff,
particularly Chris Rigaux and Robin Landis.


TABLE OF CONTENTS

PREFACE

ACKNOWLEDGMENTS

LIST OF FIGURES AND TABLES

LIST OF ACRONYMS

EXECUTIVE SUMMARY

INTR~Du~~~ON
Background
Methodology
Description of Sample
Organization of This Report
TRENDS IN BREASTFEEDING RATES AND LEGISLATIVE
AND SOCIAL CHANGES, 1985-1990
Breastfeeding Rates
Federal Legislation and Policy
Societal Trends

PROFESSIONAL EDUCATION
Activities Reported

   Education

  Task Forces and Committees
  Policies and Regulations
   Professional Consultation and Technical Assistance
Barriers to Breastfeeding
Suggestions for Future Activities
PUBLIC EDUCATION
Activities Reported
  Hard-to-Reach Populations
  Media Campaigns and Social Marketing Approaches
   School-Based Curricula

. . .
111

V

  X

xi

xii

xvii

xvii
. . .
xv111

xix

xxi

1

1

2

6

8

8

8

12

14

14

17

18

19

19

19

21

24

vii


Barriers to Breastfeeding
Suggestions for Future Activities
SUPPORT IN THE HEALTH CARE SYSTEM
Activities Reported
  Policies, Standards, and Protocols
  Hospital-Community Liaisons
  Laws and Regulations
  Training Peer Counselors
Barriers to Breastfeeding
Suggestions for Future Activities
SUPPORT SERVICES IN THE COMMUNI~

Activities Reported
  Client Education and Followup Services
  Support Groups
  Telephone Hotlines
Barriers to Breastfeeding
Suggestions for Future Activities
SUPPORT IN THE WORKPLACE

Activities Reported

   Education

  Breastfeeding Facilities and Practices in
  Respondents' Workplaces

   Policies and Guidelines

  Surveys and Assessments of Need
  Breast Pump Loan Programs
  Model/Demonstration Programs
Barriers to Breastfeeding
Suggestions for Future Activities
RESEARCH
Activities Reported
   Research on Social and Behavioral Factors

  Program Evaluation
  Nutritional and Physiological Research
Suggestions for Future Activities

25

26

27

27

27

30

30

31

31
32

33

33

33

34

36

37

37

38

38

38

39

41

41

42

42

43

43

44

44

44

45

46

47

. . .
VI11


DATA COLLECTION

Definitions of Breastfeeding

Data Collection Activities

REFERENCES

APPENDIXES

A: Statement of Surgeon General C. Everett Koop
for the Subcommittee on Nutrition,
Senate Committee on Agriculture, Nutrition,
and Forestry on June 15, 1989
B: Second Followup Report Questionnaire
C: List of Questionnaire Respondents
D: Respondents Reporting Breastfeeding Promotion Activities
E: List of Resources

F: Healthy People 2000 National Health Promotion
and Disease Prevention Objectives: Breastfeeding Objective
G: Wellstart Resource Teams for Lactation
Management Education

H: National Association of WIC Directors
Guidelines for Breastfeeding Promotion
1: Innocenti Declaration

J: WHO/UNICEF Ten Steps to Successful Breast-feeding
and Checklist for Evaluating the Adequacy of Support for
Breast-feeding in Maternity Hospitals, Wards, and Clinics
K: Research on Human Lactation and Breastfeeding
Supported by the National Institutes of Health,
U.S. Department of Health and Human Services
L: Research on Human Lactation and Breastfeeding
Supported by the U.S. Department of Agriculture
SUBJECT INDEX

48

48

48

54

57

57

58

62

72

79

94

96

98

106

108

112

115

117

ix


LIST OF FIGURES AND TABLES

FIGURE l-Geographic distribution of survey respondents .............................. xix

FIGURE 2-Survey respondents by agency/organization type ............................ .

FIGURE L&--Percentage of women breastfeeding, 1971-1989, all races.. .............. .2

FIGURE e-Percentage of women breastfeeding, 1989, by education ................. .3

FIGURE S-Schema for breastfeeding definition ................................................. 49

FIGURE 6-Breastfeeding data collection activities reported by
respondents ....................................................................................................... .50
TABLE l-Percentage of respondents reporting activities related to the
recommendations from the 1984 Surgeon General's workshop ....................... xii

TABLE 2-Breastfeeding of infants born to ever-married mothers
15-44 years of age, according to selected characteristics
of mother, 1981 to 1987 ..................................................................................... .4

TABLE 3-Professional education related barriers to initiation and
continuation of breastfeeding.. ......................................................................... .17

TABLE 4-Programs targeted to specific populations ........................................ .20

TABLE S-Public education related barriers to initiation and
continuation of breastfeeding.. .......................................................................... 25

TABLE 6-Client education and followup services ............................................. 33

TABLE 7-Community support services barriers to initiation and
continuation of breastfeeding ............................................................................ 37

TABLE g-Respondents who reported provision of breastfeeding
facilities and/or implementation of practices to support breastfeeding
in their workplace.. ............................................................................................ .40


LIST OF ACRONYMS

BLS-Bureau of Labor Statistics
BNA-Bureau of National Affairs
CDC-Centers for Disease Control
CSFP-Commodity Supplemental Food Program
DHHS-United States Department of Health and Human Services
FNS-Food and Nutrition Service, United States Department of Agriculture
ICNM-Interagency Committee on Nutrition Monitoring
IOM--Institute of Medicine

IHS-Indian Health Service, United States Department of Health and Human
Services

MCHB-Maternal and Child Health Bureau, United States Department of
Health and Human Services

NAACOG-Organization for Obstetrics, Gynecologic, and Neonatal Nurses
NAWD-National Association of WIC Directors
NCEMCH-National Center for Education in Maternal and Child Health
NCHS-National Center for Health Statistics, United States Department of
Health and Human Services

PHS-Public Health Service, United States Department of Health and Human
Services
SPRANS-Special Projects of Regional and National Significance, Maternal and
Child Health Bureau

UNICEFUnited Nations Children's Fund
USAID-United States Agency for International Development, United States
Department of State
USDA-United States Department of Agriculture
WHO-World Health Organization
WIG-Special Supplemental Food Program for Women, Infants, and Children

xi


EXECUTIVE SUMMARY

This report is intended to serve as a resource and reference for planning
future breastfeeding promotion programs and for improving existing programs.
Information for this report was identified through a national survey of
programs, organizations, and agencies serving mothers and children.
Respondents provided information on their breastfeeding promotion activities
(related to the six recommendations of the 1984 Surgeon General's workshop),
described their data collection efforts, identified barriers that are keeping
women from breastfeeding, and made suggestions for future breastfeeding
promotion activities.

There have been a number of legislative, policy, and social changes since the
Report of the Surgeon General's Workshop on Breastfeeding and Human Lactation
and the first followup report were published in 1984 and 1985, respectively.
The 1989 Child Nutrition and WIC Reauthorization Act mandated a number of
important changes designed to promote breastfeeding among WIC
participants, as well as earmarked $8 million for breastfeeding promotion. The
Title V Maternal and Child Health Program has increased its breastfeeding
promotion activities related to services, training, and research in support of
the breastfeeding national health objective. Also, the increasing number of
women participating in the labor force and the marketing of infant formula
directly to the public have made breastfeeding promotion efforts even more
crucial as the Nation works toward achieving the year 2000 national
breastfeeding objective.

A variety of breastfeeding promotion activities have been implemented at
the national, State, and local levels over the past 5 years. Table 1 summarizes

Table 1 -Percent of respondents reporting activities related to the recommendations
from the 1984 Surgeon General's Workshop

Recommendation

Percentage of respondents reporting
       (Iv=1 13)

Professional Education                  88% (100)
Support Services in the Community           74% (84)
Support rn the Health Care System            73O/6 (83)
Public Education                    58% (66)
Research                         47% (53)
Support in the Workplace                 44% (50)

xii


the breastfeeding promotion activities reported by respondents, organized
according to the six recommendations from the Surgeon General's workshop.
Reported activities, barriers to breastfeeding and suggestions for future
activities for each recommendation are summarized below, followed by a
summary of data collection activities reported by respondents.

ACTIVITIES RELATED TO THE RECOMMENDATIONS OF THE
SURGEON GENERAL'S WORKSHOP

Professional Education

Professional education was the most frequently reported activity. Education
of public health clinic staff was the most common professional education
activity. Many respondents felt that lack of support or encouragement from
physicians, nurses, hospital staff, and other health professionals continues to
be a barrier that keeps women from beginning or continuing to breastfeed.
Professional education was also the activity most frequently mentioned by
respondents who made suggestions for future breastfeeding promotion efforts.
In addition to continuing education efforts, respondents suggested including
questions regarding breastfeeding and lactation on credentialing exams and
expanding preservice breastfeeding education for all health professionals.

Public Education

Public education activities were reported by slightly more than half of
survey respondents. A variety of hard-to-reach populations were targeted,
including low-income women, minorities, adolescents, and migrant workers.

An increased awareness of the potential and use of the media, especially
radio and television, seems to have developed over the past 5 years among
health professionals involved in breastfeeding promotion. Several States have
designated a breastfeeding promotion day, week, or month. Sophisticated
media campaigns and social marketing strategies are being utilized, and one
promotion project contracted with an advertising firm to develop promotional
materials designed to appeal to its target audience. In addition, two States have
initiated letter writing campaigns designed to influence the way in which
television shows portray infant feeding.

More attention is being paid to the marketing of infant formula, both via
distribution of free formula and coupons upon hospital discharge and via mail
and direct advertising to the public. Advertising of formula to the public
became an issue in 1989 with the entry of new brands of formula. Health care
professionals have expressed their concern that this practice will negatively
impact on breastfeeding rates and infant health.

The attitudes of women toward breastfeeding, as well as the attitudes of
women's families and friends and of society in general, were seen by many
respondents as being barriers to breastfeeding. Beliefs that breastfeeding would
severely restrict a woman's lifestyle and embarrassment about breastfeeding
were commonly cited by respondents as impediments to breastfeeding that
could be overcome by public education efforts. Suggestions for future

.
x111


breastfeeding promotion activities related to public education focused on
implementing media campaigns which emphasize the idea that breastfeeding
is the normative mode of infant feeding.

Support in the Health Care System

The majority of respondents reported being involved in activities designed
to strengthen support for breastfeeding in the health care system, mostly by
developing and advocating for the implementation of policies and protocols to
promote and support breastfeeding at hospitals, public health clinics, and
other health care sites. The WIG Reauthorization Act of 1989, which
established a number of requirements regarding breastfeeding promotion in
the WIC program, was a particularly important development and has the
potential to make a large impact on breastfeeding support for low-income
women.

When discussing barriers to breastfeeding in the health care system,
respondents focused mainly on hospital policies and procedures, such as
separation of mother and infant and glucose water feeding. Respondents were
also concerned about distribution of free formula at hospitals and clinics.
Recommendations for future breastfeeding promotion activities in this area
included coordinating services and developing and advocating for hospital
policy guidelines that support breastfeeding.

Support Services in the Community

Activities related to providing support services in the community were
reported by a majority of respondents. Most respondents reported providing
client education and individual counseling of clients and families, while
slightly less than half reported providing followup services. Peer support groups
and telephone hotlines seem to be increasingly popular support services.

Barriers to breastfeeding related to the lack of support services in the
community were focused on the lack of knowledge about breastfeeding among
women, lack of support from family and friends, and lack of postpartum
support services. Recommendations for future breastfeeding promotion
activities in this area included sponsoring peer support groups and training
peer counselors, providing telephone hotlines, and providing postpartum
followup for new mothers via home visits or phone calls.

Support in the Workplace

Of the six recommendations of the Surgeon General's workshop, activities
related to the recommendation to increase support for breastfeeding in the
workplace were the least frequently reported. Among those who did report
such activities, employee education was the most frequently cited, and
employer education the least. Many respondents reported providing facilities
in their own workplace for women to breastfeed or express their milk.
Although breastfeeding promotion activities related to the workplace were
the least frequently reported, the most frequently mentioned barrier to

xiv


breastfeeding was the need of many women to return to work or school soon
after giving birth and the lack of flexible schedules, maternity leave, and
facilities for pumping and storing breastmilk. Workplace-related activities were
also the least frequently mentioned among respondents who made suggestions
for future breastfeeding promotion activities. This suggests that, while
problems relating to the workplace are perceived by health professionals as
important barriers to breastfeeding, many are unsure of what action, if any,
they can undertake to reduce these barriers. Several respondents reported
conducting surveys or assessments of workplace policies and the needs of
breastfeeding working women, and it may be that activities to promote and
support breastfeeding for working women will increase once organizations
have obtained more data on the problem.

Research

Considerable research on various aspects of breastfeeding has been
conducted by universities and publicly and privately funded research
institutions. Most of the research reported was related to social and behavioral
factors that affect infant feeding decisions, and to evaluation or monitoring of
breastfeeding promotion programs. This is probably due in part to the fact that
a large number of the respondents represent State health agencies, with fewer
respondents from universities, where physiological and nutrition research is
usually conducted. It may also be reflective of the increasing emphasis on
social marketing approaches to breastfeeding promotion, and on the
importance of women's attitudes and beliefs about infant feeding.

Research was not mentioned in response to the survey questions on barriers
to breastfeeding and on suggested future breastfeeding promotion activities. It
may be that many respondents do not think of research as a breastfeeding
"promotion" activity.

Data Collection Activities

Data collection on breastfeeding incidence and duration is crucial for
monitoring the Nation's progress toward achieving the year 2000 national
breastfeeding objective, and for evaluating breastfeeding promotion programs.
Other than the Ross Laboratories Mothers Survey, however, there is no
frequent continuing source of data on national breastfeeding rates. The current
data collection efforts at the national level are directed at particular segments
of the population or at particular geographic areas, or are infrequently done.

Comparable data are not collected at the State or local levels, since many
definitions of breastfeeding are utilized. Lack of a nationally recognized
common definition of breastfeeding seriously hinders efforts to assess the
incidence and duration of breastfeeding in the United States. It remains to be
seen to what extent the development and use of a standard definition of
breastfeeding in all breastfeeding promotion efforts will occur.

Much progress has been made in developing, implementing, and
disseminating breastfeeding promotion ideas, activities, and programs since the
Surgeon General's Workshop on Breastfeeding and Human Lactation in 1984.

xv


By identifying six main areas (professional education, public education, the
health care system, community support services, the workplace, and research)
in which promotion efforts were needed, the workshop provided a framework
for the discussion and implementation of breastfeeding promotion activities
nationwide. The 1985 followup report served to document and disseminate
information about efforts to promote breastfeeding by implementing
recommendations from the workshop. It is hoped that this second followup
report will expand the information provided in the first followup report and
prove useful to the many individuals, organizations, and agencies across the
country working to achieve the year 2000 national breastfeeding objective.

xvi


INTRODUCTION

BACKGROUND

The Surgeon General's Workshop on Breastfeeding and Human Lactation-
held in Rochester, New York, on June 11-12, 1984-was convened by the
Maternal and Child Health Bureau (MCHB), U.S. Department of Health and
Human Services (DHHS), to assess the current status of breastfeeding in the
IJnited States and to develop strategies to facilitate reaching the 1990
breastfeeding health objective for the Nation. Invited workshop participants
included representatives of professional and lay organizations; local, State, and
Federal government; industry; and volunteer groups; as well as health
professionals from a wide range of disciplines and settings serving different
ethnic, cultural, and income groups.

At the workshop, workgroups were charged with identifying and prioritizing
issues related to breastfeeding and human lactation and then developing
recommendations and specific strategies to address them. These
recommendations-published in 1984 in the Report of the Surgeon General's
Workshop on Breastfeeding and Human Lactation-were organized into six areas:
professional education, public education, the health care system, support
services, the world of work, and research.

In 1985 the Followup Report: The Surgeon General's Workshop on Breastfeeding
and Human Lactation was published to describe efforts emanating from the
Surgeon General's workshop and to continue the dissemination of information
related to breastfeeding promotion activities and accomplishments. The
information in that report was collected from participants in the 1984 Surgeon
General's workshop, State directors of maternal and child health, members of
the Healthy Mothers, Healthy Babies coalition, and regional nutrition staff of
the U.S. Department of Health and Human Services.

Significant activity designed to promote breastfeeding has continued since
the publication of the 1985 followup report. In order to maintain the
momentum toward achieving the Healthy People 2000 breastfeeding health
objective for the Nation-to increase to at least 75 percent the proportion of
mothers who breastfeed their babies in the early postpartum period and to at
least 50 percent the proportion who continue breastfeeding until their babies
are 5 to 6 months old-the Maternal and Child Health Bureau requested that
the National Center for Education in Maternal and Child Health (NCEMCH)
develop a new report to identify recent breastfeeding promotion activities
related to the 1984 Surgeon General's workshop. The intent of this Second

xvii


Followup Report: The Surgeon General's Workshop on Breastfeeding and Human
Lactation is to provide information on the range of breastfeeding promotion
activities that have taken place since the publication of the first followup
report. It is hoped that this report will stimulate interest, serve as a resource for
the planning of future breastfeeding promotion efforts, and increase support
from all who can have an impact on breastfeeding decisions and opportunities.
The ultimate goal is to reinforce a continuing commitment to the promotion
and protection of breastfeeding and the improvement of maternal and child
health.

METHODOLOGY

The National Center for Education in Maternal and Child Health, in
consultation with Maternal and Child Health Bureau staff, developed and pilot
tested a questionnaire designed to gather descriptive information on
breastfeeding promotion activities related to the six recommendations of the
1984 Surgeon General's workshop. The questionnaire, reprinted in appendix B
on page 58, was not designed to gather quantitative data for a statistical
analysis of the prevalence or type of breastfeeding promotion activities, but to
collect descriptive information on as many breastfeeding promotion programs
as possible.

In August 1990 the questionnaire was sent to 55.5 individuals, organizations,
and agencies that are involved in breastfeeding, nutrition, and maternal and
child health. An attempt was made to be as inclusive as possible in order to
obtain responses from a variety of agencies and organizations at the national,
State, and local levels across the entire United States.

Questionnaires were sent to all State maternal and child health (MCH)
directors; State public health nutrition directors; regional program consultants
in MCH; DHHS regional nutrition consultants; University Affiliated Program
nutritionists; members of the Association of Teachers of Maternal and Child
Health; members of the Association of Faculties of Graduate Programs in Public
Health Nutrition; chairpersons of State Healthy Mothers, Healthy Babies
coalitions; executive directors of professional organizations of physicians,
nurses, dietitians, and other health professionals; directors of Federal health
agencies; presidents of private and nonprofit research, consumer, and service
organizations; and other individuals and organizations with an interest in
maternal and child health. All recipients were encouraged to share copies of
the questionnaire with other organizations they knew to be involved in
breastfeeding promotion; in this way questionnaires were received by some
local community organizations. In addition, breastfeeding promotion
programs or activities known to NCEMCH staff or MCHB personnel but not
represented in the original set of survey responses were contacted by phone,
and the questionnaire was administered.

. . .
xv111


DESCRIPTION OF SAMPLE

Of the 555 questionnaires sent, 111 completed questionnaires were returned
(a response rate of 20 percent). Ten of the responding organizations reported
that they had not been involved in any breastfeeding promotion activities in
the last 5 years; therefore their questionnaires were discarded. Twelve
additional breastfeeding promotion programs were contacted by telephone and
questionnaires were administered. Thus the total number of programs
describing breastfeeding promotion activities is 113.

Type of Respondents

The geographic distribution of the respondents to the survey is describqd in
figure 1. Forty-five States, plus the District of Columbia and the Federated
States of Micronesia, were represented in the survey. The States with the

Figure 1 -Geographic distribution of survey respondents
                                Number of completed
                                  questionnaires received
                                          from the States
           : z - i-2
                                                  -.___
    s

highest number of respondents were California, Colorado, and New York.
States in Public Health Service (PHS) Region VIII (Colorado, Montana, North
Dakota, South Dakota, Utah, and Wyoming) are somewhat overrepresented,
probably due to the fact that copies of the questionnaire were distributed by
the PHS regional nutrition consultant at a Region VIII breastfeeding promotion
meeting.

The types of agencies and organizations which responded to the
questionnaire are indicated in figure 2. The highest number of responses (45)
came from State health agencies. Some State health agencies submitted
separate surveys for their WIC and MCH programs, some submitted one
questionnaire for the entire health department, and some completed a
questionnaire only for the WIC program or only for the MCH program. In

xix


Figure 2-Survey respondents by agency/organization type

           Institution of higher learning
        Voluntary, professional nonprofit organization

   Local health agency
Community health center
Federal health agency

Private organization

Other Federal agency

0    5    10    15    20    25    30   35    40   45
I     I      I      I      I      I      I      I
            Percentage

cases where two questionnaires were received from a single State health agency
and both appeared to describe the same program, the questionnaires were
combined. In all, responses were received from State health agencies in 40
States.

Funding Sources

Respondents who indicated that they had been involved in breastfeeding
promotion were asked to describe the sources of funding for these efforts, and
85 percent (96/113) did so. Seventy-three percent (82/113) said they received
Federal or State government funds. The Special Supplemental Food Program for
Women, Infants, and Children (WIC), USDA, and the Title V Maternal and
Child Health Program, DHHS, were the most commonly cited sources of
government funds. Other sources of government funds mentioned were State
governments; the National Institutes of Health and the Indian Health Service,
DHHS; and the U.S. Agency for International Development (USAID). Twenty
percent (23/113) of respondents mentioned receiving support from
nongovernment sources, such as universities, hospitals, private foundations,
membership fees, and patient fees.

Collaboration

Seventy-seven percent (87/l 13) of respondents reported collaborating with
other agencies or organizations in their breastfeeding promotion efforts. The
most frequently cited type of agencies with which respondents collaborated
were State and local health departments, including the WIC program. Other

xx


organizations mentioned were (in order of frequency): La Leche League;
universities and medical schools; hospitals; Healthy Mothers, Healthy Babies
coalitions; professional organizations; State coalitions or task forces on
breastfeeding, nutrition, or maternal and child health; the Maternal and Child
Health Bureau, DHHS; State and local chapters of the March of Dimes;
community health clinics; private lactation consultants; and the Indian Health
Service, DHHS.

In summary, the information presented in the following chapters is based
on a geographically diverse sample of agencies and organizations-largely State
health agencies; institutions of higher learning; and voluntary, professional,
and nonprofit organizations. The majority of respondents used some
government funds to support breastfeeding promotion, most commonly WIC
and Title V funds. A significant proportion reported collaborating with a
variety of government and nongovernment organizations in their
breastfeeding promotion efforts.

ORGANIZATION OF THIS REPORT

National trends in breastfeeding incidence and duration from 1985 to 1990
are discussed in the first chapter (see page 1). Legislative and social changes
which may affect women's infant feeding decisions are also addressed in this
chapter. The next six chapters describe the breastfeeding promotion efforts
reported by the respondents. This part of the report is intended to present a
descriptive overview of current breastfeeding promotion efforts, not a statistical
analysis of the prevalence or type of such efforts. It was not possible to describe
all reported activities and programs, but an effort was made to present a
representative sample of activities. As in the 1985 followup report, the reported
breastfeeding promotion activities are organized according to the six
recommendations from the original 1984 workshop: professional education,
public education, the health care system, community support services, the
workplace, and research. These chapters also include sections on barriers to
breastfeeding and suggestions for future breastfeeding promotion activities.
Finally, the last chapter describes respondents' data collection activities related
to breastfeeding (see page 48).

Appendixes provide detailed information about the questionnaire and
respondents, publications, national and international guidelines and policy
statements, research projects supported by Federal agencies, and lactation
management education resources.

xxi


  TRENDS IN BREASTFEEDING RATES AND
LEGISLATIVE AND SOCIAL CHANGES, 1985-l 990

This chapter presents the national trends in breastfeeding incidence and duration
over the past 5 years, and gives a brief overview of some of the legislative and social
changes that have occurred since the first followup report that may have had an
impact on breastfeeding rates in the United States.

BREASTFEEDING RATES

One of the few available sources of national statistics on breastfeeding
incidence and duration in the 1980s is the Ross Laboratories Mothers Survey,
which was mailed to a sample of women derived from a list which represented
85 percent of all new mothers in the United States (IOM 1991). Mothers were
surveyed when their infants were 6 months of age, and were asked to recall the
method of infant feeding in the hospital and during each of the first 6 months
of life (Ryan and Martinez 1989). Concern has been expressed that the survey
may overestimate breastfeeding rates among black, low-income, and low
socioeconomic status women due to sampling bias and response bias (IOM
1991). In addition, data available from the Mothers Survey do not indicate
whether a breastfed infant is exclusively or only partially breastfed. In spite of
these limitations, the Institute of Medicine's Subcommittee on Nutrition
During Lactation feels that the Ross Laboratories data are the best national data
currently available (IOM 1991); thus, the following information on
breastfeeding rates is based on data collected by Ross Laboratories, as reported
in Institute of Medicine and DHHS publications.

Breastfeeding rates in the United States, which declined in the 1950s and
196Os, began rising in the 1970s (IOM 1991) and reached a peak in 1982, with
62.0 percent of mothers initiating breastfeeding, and 30.0 percent continuing
to breastfeed at 6 months postpartum (see figure 3) (DHHS 1990a). Since 1982
there has been a continuous decline in both initiation and duration rates. In
1985, 58.0 percent of mothers initiated breastfeeding and 22.1 percent were
still breastfeeding at 6 months postpartum. By 1989 rates had fallen to 52.2
percent and 19.6 percent respectively (DHHS 1990a). Thus, between 1985 and
1989, the proportion of mothers who initiated breastfeeding fell by 10.0
percent and the proportion still breastfeeding at 6 months postpartum fell by
11.3 percent.

Rates of breastfeeding vary among geographic, racial, economic, and social
groups. Rates are highest among women who are white, married, and/or live in
the Western United States, and rates are lowest among women who are black,
single, and/or live in the Southeastern United States (IOM 1991, DHHS 1990a).

1


Figure 3--Percentage of women breastfeeding, 1977-l 989, all races

70

60

  50

g
3  40
&
2
2  30


  20



  10



   0

1971

II I I IllI II III II/I I

1989

In hospital

3 months

5-6 months

Source: Ross Laboratories, as reported in: Office of Maternal and Child Health, Public Health Service, U.S.
Department of Health and Human Services. (1990). Chrld Health USA `90. Washington, DC: US.
Department of Health and Human Services.

Breastfeeding incidence and duration rates are positively associated with
maternal age, maternal education, and family income (IOM 1991) (see figure 4
and table 2).

FEDERAL LEGISLATION AND POLICY

National Health Objectives

In the publications Healthy People (DHEW 1979) and Promoting
Health/Preverltir?g Disease: Objectives for the Nrztiorz (DHHS 1980), the U.S.
Department of Health and Human Services first set forth a series of national
health objectives, to be met by the year 1990. Included in these objectives was
a goal for breastfeeding: "By 1990, the proportion of women who breastfeed
their babies at hospital discharge should be increased to 75 percent and 35
percent at six months of age" (DHHS 1980, p. 75). These national health
objectives have been updated and revised for the 199Os, and are published in
Healthy People 2000: Ndorinl Health Promotiorl cud Disease Prevention Objectives.
Included in the Maternal and Infant Health priority area is a breastfeeding
objective: "To increase to at least 75 percent the proportion of mothers who
breastfeed their babies in the early postpartum period and to at least 50 percent
the proportion who continue breastfeeding until their babies are 5 to 6 months
old" (DHHS 1990b, p. 111). (This objective is also included in the Nutrition
priority area.) Low-income, black, Hispanic, and American Indian/Alaska

2


Figure 4-Percentage of women breastfeeding, 1989, by education

80

60

& 50
3
5 40
2
2
    30


    20


    10


    0

31
-

-

-

College         Noncollege

42.1

W in hospital
E 3 months
IJ 6 months

Source: Ross Laboratories, as reported in: Office of Maternal and Child Health, Public Health Service,
U.S. Department of Health and Human Services. (1990). Child Health USA `90. Washington, DC:
U.S. Department of Health and Human Services.

Native women are mentioned as special target populations (the full text of the
objective is reprinted in appendix F, beginning on page 94).

Title V MCH Program

The Maternal and Child Health Bureau (MCHB) has provided continuing
leadership in a nationwide initiative to improve breastfeeding rates. The
bureau's longstanding policy in support of breastfeeding is illustrated by a
number of efforts, leading up to the 1984 Surgeon General's workshop.

In 1976 the Office for Maternal and Child Health (OMCH-a precursor to
MCHB), in collaboration with the George Washington University and the
March of Dimes Birth Defects Foundation, cosponsored a symposium on
human lactation. Following that, OMCH provided funds to the National
Academy of Sciences to develop an annotated bibliography on breastfeeding,
published in 1978. Because there were few booklets directed to parents-to-be
on the subject of breastfeeding in the 197Os, OMCH published Brrustfeedirq in
1979. OMCH also provided leadership in 1983 for organizing a subcommittee
on breastfeeding promotion within the Healthy Mothers, Healthy Babies
coalition. One of the first projects was the development of a resource packet for
professionals to improve breastfeeding promotion at the community level.

OMCH initiated and directed the 1984 Surgeon General's Workshop on
Breastfeeding and Human Lactation. Since the workshop, MCHB has
intensified its support and program development in breastfeeding promotion
and continues to have the lead role in the U.S. Department of Health and

3


Table 2--Breastfeeding of infants born to ever-married mothers 7 5-#4 years of age,
according to selected characteristics of mother, 198 1 to I9870

Percentage breastfeeding    Percentage breastfeeding
      at all            at 3 months or more


1981-83     1984-87       1981-83    1984-87

Total


Race
White
Black

58.20       59.00        39.00      33.80



62.00      62.10        41.90      35.70
30.30      30.20         17.70      16.20

Education
Less than 12 years
12 years
13 or more
years

30.10      30.70        12.00      16.00
54.00      50.90        31.90      25.70
71 so       73.30        54.60      45.20

Geographic region
Northeast
Northcentral
South
West

65.70       70.50         51.10      44.50
58.10      53.70        38.50      28.30
47.40       47.90         26.90      25.10
73.10       77.20        51.70      48.30

Source: National Center for Health Statistics, Centers for Disease Control. Notional survey of fomity growth.
(1988). Hyattsville, MD: National Center for Health Statistics.

Human Services for breastfeeding promotion. Numerous efforts affirm the
bureau's continued policy of support for breastfeeding.

Breastfeeding promotion is a priority area for MCH special projects of
regional and national significance (SPRANS). MCHB has funded 10
demonstration projects to increase the incidence and duration of breastfeeding
among different target populations, particularly low-income and minority
groups and working women. A catalog of products developed through these
projects has been published. Currently, MCHB is funding 10 Implementation
Incentive Grants designed to assist States to incorporate approaches with
demonstrated efficacy for increasing the incidence and duration of
breastfeeding into permanent systems of care.

Training of health professionals in the management of breastfeeding is
another priority. MCHB continuing education training projects at the
University of Hawaii and the University of California at San Diego have
provided training to health professionals throughout the Nation and in the
U.S.-related Pacific Islands. A team consisting of a physician, nurse, and
nutritionist from each of the 10 Public Health Service regions received
intensive training from the Wellstart/San Diego Lactation Program, and each of

4


the teams then conducted continuing education conferences in its own region.
Because of a concern that health professionals entering practice need
knowledge and skills related to lactation support, a meeting of representatives
of boards that accredit educational programs and certify individual
practitioners in pediatrics, obstetrics, family medicine, nursing, nurse
midwifery, and dietetics was convened. Participants identified a need for a
curriculum to assure that new professionals entering practice have expertise in
the management and support of lactation and breastfeeding. Under the
leadership of the MCHB training program at the University of California at San
Diego, a scientifically based lactation management education curriculum has
been developed for health professionals and is currently being field tested and
revised. A method for preparing and certifying faculty to teach the curriculum
will also be recommended.

To complement professional education, MCHB has provided technical
assistance and consultation for health professionals in regard to clinical
management of lactation in special circumstances related to maternal or infant
problems. This is done through the Study Group on Human Lactation at the
University of Rochester.

Increasing interest in the interactions of breastfeeding/lactation and
maternal and infant health prompted MCHB to request that the Institute of
Medicine make this issue a major part of a study of maternal nutrition. The
Committee on Nutritional Status During Pregnancy and Lactation was
convened in 1987 and provided direction and oversight of this study. The
report, Nut&ion During Lactation, the first comprehensive review of this subject,
presents the latest findings on the science of lactation and should serve not
only as a useful reference but also as an aid in formulating guidelines for
clinical application. The report also highlights gaps in knowledge and
recommends future research directions.

In summary, the policy of the Federal MCH program to promote
breastfeeding is being implemented through a range of activities and services at
the national, State, and local levels.

Legislative Changes in the WIG program

In 1986 the Tennessee Department of Health and Environment was awarded
a special projects of regional and national significance (SPRANS) grant from
MCHB for a breastfeeding promotion project targeted at low-income women.
Based on this SPRANS project's experience with breastfeeding promotion in the
USDA's Special Supplemental Food Program for Women, Infants, and Children
(WIC), the American Public Health Association awarded a mini grant to the
Tennessee SPRANS project director for the formation of the National
Committee to Improve Breastfeeding Promotion Strategies in the WIC
program. As a result of the National Committee's efforts, eight new provisions
were included in the WIG Reauthorization Act of 1989 (Public Law 101-147).
This legislation also earmarked $8 million specifically for breastfeeding
promotion. The new regulations resulting from this legislation require State
WIC programs to:

5


1. Develop a plan to promote and support breastfeeding and to coordinate
operations with local programs for breastfeeding promotion;
2. Designate a breastfeeding promotion coordinator;
3. Train local agency staff responsible for providing breastfeeding promotion
and support;

4. Authorize the use of administrative funds to purchase breastfeeding aids
(such as breast pumps and nursing supplementers);
5. Evaluate breastfeeding promotion efforts annually, and include views of
participants as part of the evaluation;
6. Develop a policy that creates a positive clinic environment which
endorses breastfeeding as the preferred method of infant feeding; and
7. Provide breastfeeding promotion materials in languages other than
English (Federal Register 1990).

In addition, the new regulations proposed a standard definition of
breastfeeding for the WIC program (breastfeeding means "the practice of
feeding a mother's breastmilk to her infant[s] on the average of at least once
per day") and set forth guidelines for breastfeeding promotion and support
standards and evaluation (Federal Register 1990). The NAWD Committee on
Breastfeeding Promotion played a key role in developing guidelines for
implementation of the new regulations (see appendix H beginning on page 98).

National Child Care Legislation

In October 1990, the U.S. Congress enacted child care legislation as part of
Public Law 101-508, the Omnibus Budget Reconciliation Act of 1990 (U.S.
Congress 1991). In accordance with this legislation, regulations addressing
health and safety standards for day care facilities are being prepared. These
regulations, which will include provisions on nutrition and breastfeeding, are
being adapted from standards developed by the American Public Health
Association and the American Academy of Pediatrics through a SPRANS grant
from the Maternal and Child Health Bureau, DHHS.

SOCIETAL TRENDS

Women's Labor Force Participation

Women have moved into the labor force in unprecedented numbers in
recent decades, and mothers of infants and toddlers have been the fastest
growing segment of the labor force in recent years (Bureau of National Affairs
1986). According to the Bureau of Labor Statistics, 66.6% of women with
children under age 18, and 54.5% of women with children under age 3, are in
the labor force (BLS 1991).


Maternity Benefits

As the labor market has tightened in recent years and women have become
an increasingly important part of the labor force, some employers have been
paying more attention to family-related benefits such as day care and parental
leave as a way to attract and retain employees. Between 1982 and 1988, the
number of employers offering systematic child care or parental assistance as
part of their benefits package rose from 600 to 3,500 (Hewlett 1990). This is
still a fairly small number, however. A 1989 survey conducted by the American
Public Health Association's Clearinghouse on Infant Feeding and Maternal
Nutrition found that only 150 onsite day care facilities exist in all corporations
of the United States (APHA 1989). In addition, it is unclear to what extent
such parental assistance and day care benefits include provision of time and
facilities for breastfeeding or milk expression during the workday. One study of
workplace policies supportive of breastfeeding concluded that there was little
evidence that the American workplace had yet responded to the needs of
workers with young infants (Moore and Jansa 1987). Nevertheless, business
and industry seem to be increasingly aware of the importance of these issues.

Advertising of Infant Formula

Until 1988, infant formula companies in the United States marketed their
products to health professionals only and refrained from advertising formula
directly to consumers. In 1989, however, both the Carnation Company and
Gerber Products began advertising new formulas directly to the public through
television commercials and print ads (Oksi 1989), as well as through direct
mailings to mothers and by providing coupons on grocery store register
receipts targeted to purchases by new mothers. Health professionals have
expressed concern that this practice will negatively impact breastfeeding rates
and infant health (Huffman 1990, Siler 1990).

In summary, with the exception of the women's labor force participation
rate, which has been rising for many years, all of the legislative and social
changes described above are fairly recent, and their influence on breastfeeding
incidence and duration rates is impossible to assess at this point. Certainly,
changes in Federal policy, legislation, and regulations and the advent of infant
formula advertising directly to the public have the potential to make major
impacts on breastfeeding rates, albeit in opposite directions. The relationship
between maternal employment and breastfeeding rates is also difficult to
assess, although it has been suggested by some studies that full-time
employment may have more of a negative effect on breastfeeding duration
rates than on initiation rates (Ryan and Martinez 1989, Gielen et al. 1991).
Further study and monitoring of breastfeeding rates will be needed to assess
the impact of these changes.


PROFESSIONAL EDUCATION

    Recommendation:
Improve Professional Education in
Human Lactation and Breastfeeding

ACTIVITIES REPORTED

In calling for the improvement of professional education in breastfeeding,
the 1984 Surgeon General's Workshop on Breastfeeding and Human Lactation
stated: "It is imperative for all health care professionals to receive adequate
didactic and clinical training in lactation and breastfeeding and to develop
skills in patient education and the management of breastfeeding" (DHHS 1984,
p. 67).  This recommendation has received considerable attention since the
1985 followup report. Among respondents to our survey, 88 percent (100/113)
indicated that they engage in some professional education activities related to
breastfeeding. Seventy-seven percent (87/l 13) provide education to public
health clinic staff, 60 percent (68/113) to hospital staff, 47 percent (53/113) to
private practitioners, and 11 percent (12/113) to students in schools of
medicine, nursing, social work, and public health. Other professionals and
paraprofessionals reported to receive training were childbirth educators,
lactation counselors, and researchers. Professional education activities include
providing education, establishing task forces and committees, issuing policies
and regulations, and providing professional consultation and technical
assistance.

Education

Continuing education activities for health professionals-via conferences,
workshops, seminars, and classes-were the most common type of activity
reported. Fifty percent (57/113) of the respondents reported planning or
participating in activities related to continuing education in breastfeeding and
human lactation. A brief description of selected activities follows.

National Activities

The following programs provide training in breastfeeding and human
lactation to health professionals from across the Nation.
The Food and Nutrition Service (FNS), USDA, and the Maternal and Child
Health Bureau, DHHS, have jointly supported several continuing education
efforts in lactation management for health care providers. In fiscal year 1990,
FNS and MCHB supported three regional conferences for WIC and MCH staff
and other direct care providers. These conferences were conducted by Wellstart
(described below). In fiscal year 1991 FNS funded three additional regional

8


conferences through grants to WlC State agencies, and it will continue to fund
conferences as interest dictates. A total of 585 multidisciplinary health
professionals from 31 States participated in the first 3 conferences, which were
held in Columbus, Ohio; Atlanta, Georgia; and Rapid City, South Dakota.

The Maternal and Child Health Bureau has continued to support the
education of health professionals through grants to graduate training programs
m public health nutrition and maternal and child health, and breastfeeding
education is an integral part of these programs. Since the Surgeon General's
workshop in 1984, the bureau has awarded training grants focused on
breastfeeding to the University of Hawaii, the University of California at San
Diego/Wellstart, and the University of Rochester. These training projects are
described later in this section. For additional information on these projects, see
Breastfeeding: Abstracts of Active Projects FY 1989, and Of/ice of Maternal and
Child Health Projects FY 1990: An Annotated Listing (cited in the Community
Support Services section of appendix E).

In 1987 the University of California at San Diego and Wellstart (a private,
nonprofit organization), with support from a SPRANS training grant from
MCHB, undertook a 2-year project to provide lactation management education
throughout the United States. The goal of the project was to prepare 10
regional multidisciplinary teams of MCH professionals to function as
education, training, and program development specialists in lactation
management. These regional resource teams would then provide inservice and
continuing education programs for other MCH staff, as well as assist with
designing and reviewing existing and future breastfeeding promotion projects
and proposals within their home States and regions. The Wellstart project
consisted of two phases: The primary phase, in which intensive didactic and
clinical education was provided in San Diego for ten regional multidisciplinary
teams of MCH professionals; and the secondary phase, in which these regional
lactation management teams planned and conducted 10 education seminars
for MCH professionals throughout the Nation with the involvement of
Wellstart faculty. The 10 jurisdictions which participated in this project are
Maine, the Virgin Islands, Maryland, Georgia, Illinois, Oklahoma, Kansas,
Montana, California, and Oregon. A newsletter, Lactation Management:
Continuing Education Project Alumni News, has been distributed to enhance
networking and information sharing and to keep regional teams up to date on
the progress of the project and participant accomplishments. Several of these
teams continue to be quite active and to be utilized for education and training
both within and outside their regions. (Wellstart teams are listed in appendix
G, see page 96). In addition, Wellstart has developed a proposed Lactation
Management Education Curriculum, which is currently being tested and
revised. In addition to its domestic activities, Wellstart provides continuing
education in breastfeeding promotion, support, and management to health
professionals in many countries through funding provided by the United States
Agency for International Development (USAID). Training has been provided to
health professionals in Asia, Africa, Latin America, and Europe.

The American Academy of Pediatrics held a conference in March 1991 in
San Diego that featured a 6-hour workshop on breastfeeding and human

9


lactation developed and provided by Wellstart faculty. Topics included
problem-solving strategies, nutritional risk assessment, jaundice, slow weight
gain, insufficient milk syndrome, AIDS, and drugs.

La Leche League International continues to hold its annual Physician's
Seminars and Lactation Consultant Workshops.. The Physician's Seminar, a 2-
day intensive seminar which covers the latest breastfeeding research and
features a faculty of experts in the fields of lactation and family health care, is
accredited by the American Medical Association, the American College of
Obstetricians and Gynecologists, the American Academy of Pediatrics, and the
American Academy of Family Practitioners. The Lactation Consultant
Workshop is an advanced course for lactation specialists on current
breastfeeding information, skills, and tools they need to assist breastfeeding
women with prenatal and postnatal situations. Registration at the 1990
Physician's Seminar and Lactation Consultant Workshop was up significantly
from 1989 registration rates.

The University of California at Los Angeles Extension's Division of Nursing
offers two breastfeeding courses. The Lactation Educator Training Program is
intended to prepare health professionals and other interested people to be
lactation educators either in private practice or as part of their clinical
employment. Emphasis is placed on maximizing professional use of scientific
data and understanding problems of clinical management, and the course
includes clinical consultation and community observation as well as written
work and lectures. The Lactation Consultant Training Program, which builds
on the Lactation Educator Training Program, prepares health professionals to
serve as lactation consultants. The didactic portion of this program includes
four 2-l/2-day sessions spaced over 8 months and held at UCLA. Additional
requirements are an apprenticeship with a faculty member in Los Angeles and
a preceptorship and community observation in the student's local area.

The Lactation Program at Presbyterian-St. Luke's Medical Center in Denver,
Colorado, provides a variety of professional education services, including a l-
to 2-week internship program on breastfeeding management for nurses, an
annual conference for health professionals, and a telephone consultation
service.

The Maternal and Infant Care Project at the Grady Memorial Hospital in
Atlanta, Georgia (a Wellstart regional resource team), offers a l-week lactation
management practicum designed to give health professionals, particularly WIC
program staff, the skills needed to plan and develop a breastfeeding program.
The practicum includes lectures as well as clinical experience in the delivery
room, on maternity floors, and at a breastfeeding clinic.

State and Local Activities

Most of the reported education activities occurred at the State level, and, as
the examples outlined below demonstrate, they ranged from incorporating
information about breastfeeding into existing educational activities to
developing special projects devoted solely to the improvement of professional
education in breastfeeding and human lactation.

10


During 1990, the Hawaii Department of Health implemented a
breastfeeding training program in which seven teams were trained in
breastfeeding management and promotion, and training materials were
developed and adapted. The teams and materials were then utilized to provide
inservice training and technical assistance to clinic prenatal care providers,
hospital staff, and private care providers. The project also provided a
breastfeeding library for use by the teams, as well as a breastfeeding
information, referral, and consultation service.

The University of Hawaii School of Public Health, through a SPRANS grant
from MCHB, conducted a continuing education project from 1987 to 1990 for
health personnel in the U.S.-related Pacific Islands. Three physician-nurse
resource teams participated in intensive training at the Wellstart San Diego
Lactation Program. These resource teams then developed breastfeeding
promotion and training plans, and participated with MCH and Wellstart
faculty in subsequent training of teams from each of the nine U.S.-related
Pacific Island jurisdictions.

The Kentucky Department of Health Services, through a SPRANS grant from
MCHB, has provided inservice training on breastfeeding promotion and
lactation management to over 1,000 health professionals throughout central
and eastern Kentucky using the Best Start training program. Breastfeeding
resource manuals have been distributed to every public health agency in the
State. Resolutions supporting health professionals' active education and
promotion of breastfeeding submitted on behalf of Kentucky's Best Start
program were passed by the Kentucky Medical Association.

The New Mexico Department of Health administered a project to make
appropriate, consistent lactation training available to health care providers in
New Mexico. Activities included training the nutrition education coordinator
of the WIC program, developing an g-hour curriculum, and holding eight
regional training conferences throughout the State.

The North Carolina WIC program awarded approximately 28 scholarships to
public health practitioners throughout North Carolina to attend the UCLA
Breastfeeding Educator Program, the Grady Hospital practicum in lactation
management, and/or the Wesley Long Community Hospital Breastfeeding
Educator Program.

The Triad Lactation Center at Wesley Long Community Hospital in
Greensboro, North Carolina, sponsors a 3-day intensive program designed to
provide education and skills training for health professionals who work with
mothers and infants in a variety of health care settings. Maternal-child nurses,
physicians, nutritionists, WIC staff, and childbirth educators are invited to
attend these programs, which are offered five times each year. The curriculum
includes 2 days of classroom workshops on breastfeeding management and
techniques and 1 clinical observation day at the hospital.

The Division of Maternal and Child Health of the Ohio Department of
Health incorporates breastfeeding into all of its continuing education activities.
These activities include an annual 2-day conference for staff from local health
clinics at which they share information on programs and ideas; a State-level
conference for clinic nutrition staff, usually held every year; and periodic small

11


regional workshops for local clinic staff on topics of current interest.

The Oklahoma State Department of Health, the Oklahoma Healthy Mothers,
Healthy Babies coalition, and the PHS Region VI (Arkansas, Louisiana, New
Mexico, Oklahoma, and Texas) Wellstart Resource Team for Lactation
Management Education sponsored a conference entitled "Breast Investment:
Networking for Successful Lactation Management and Support in Region VI" in
March 1989. This conference was intended to expand the knowledge and skills
of MCH Title V staff in the five-State region and promote community
awareness and support for lactation.

The Texas Department of Health, in conjunction with the Austin Healthy
Mothers, Healthy Babies coalition and the local March of Dimes chapter,
sponsored a conference entitled "Breastfeeding Update for Physicians" in
September 1989. The aim of the conference was to provide physicians with the
current scientific basis for promoting breastfeeding and with the skills
necessary to apply the science in clinical practice.

Texas Children's Hospital-in conjunction with Baylor College of Medicine,
Ben Taub Hospital, USDA, and the Children's Nutrition Research Center-
provides a 2-hour session on breastfeeding for interns during their neonatology
rotations at a county hospital. In addition, a 2-hour lecture/demonstration on
lactation is offered to Baylor medical students in the nutrition elective during
their first year of medical school, and 2 hours of lecture/demonstration are
given to all third-year medical students. Texas Children's Hospital also provides
a series of applied nutrition conferences for physicians, nurses, dietitians, and
lactation consultants working with expectant and new mothers. These
seminars feature clinical applications of research in lactation and in infant and
maternal nutrition.

The West Virginia WIC program, in cooperation with the Family Resource
Center, Charleston Area Medical Center, is sponsoring a 2-day conference on
breastfeeding using the Wellstart San Diego Lactation Program staff. This
program is partially funded by a SPRANS grant from MCHB and by the West
Virginia Bureau of Public Health, Division of Nutrition Services, WIC program.

Task Forces and Committees

Task forces and committees provide a means to bring together individuals as
a group for the purpose of accomplishing a common objective. Several
organizations at the national, State, and local levels have utilized breastfeeding
task forces or committees to work toward improving professional education,
along with other activities to promote breastfeeding. Respondents who
reported task force or committee activities related to professional education as
an objective are listed below. Task forces and committees involved in activities
other than professional education are listed in the fourth chapter, Support in
the Health Care System (see page 27).

National Activities

The goal of the Healthy Mothers, Healthy Babies Subcommittee on
Breastfeeding Promotion is to encourage collaborative efforts involving the

12


public and private sectors in the promotion of breastfeeding and in working
toward achieving the breastfeeding objective for the Nation. The objectives of
this collaboration have been to assess and monitor breastfeeding promotion
efforts, to exchange information, to share production of materials, and to
disseminate information and materials. The target audiences have been health
providers, hospitals, pregnant and lactating women and their families, and the
general public. This subcommittee has approximately 40 members with
representation from a variety of Federal agencies and professional
organizations, as well as state and local level organizations. Among many other
activities, the subcommittee has developed a breastfeeding promotion packet
which was disseminated to 4,000 leaders in State health agencies and
professional organizations.

The Committee on Nutrition of the American Academy of Pediatrics is an
appointed committee which studies policies and practices related to pediatric
nutrition and makes recommendations based on its findings. The committee
has produced policy statements on breastfeeding and has disseminated
information on breastfeeding to health professionals. Its Pecfiatric- Nutritio,z
Hardbook includes a chapter on breastfeeding.

State and Local Activities

Colorado has formed a statewide Colorado Breastfeeding Task Force under
the leadership of the Colorado Department of Health. The group is comprised
of approximately 35 interdisciplinary volunteers, including physicians, nurses,
dietitians, lactation consultants, midwives, and members of breastfeeding
mother-to-mother support groups. Activities of the task force include providing
breastfeeding education to hospital staff, community health professionals,
obstetricians, family practitioners, pediatricians, and residents statewide. Day
care providers and employees will also receive training.

In 1987, the Illinois Department of Public Health established a statewide
Breastfeeding Promotion Task Force. One objective of the task force has been to
develop and disseminate professional education materials on breastfeeding.
Activities have included presentations promoting breastfeeding at annual State
public health-related meetings, statewide breastfeeding promotion workshops
and seminars, lectures at medical and nursing schools, revision of the State's
Lactation Counselor's Manual, and distribution of a newsletter.

In February 1990, the Maine Department of Human Services participated in
forming a statewide task force on breastfeeding, which includes representatives
from hospitals, physicians' offices, public health programs, and lay support
groups. The task force plans to produce a newsletter, compile a resource list for
health professionals, and provide training to a variety of health professionals,
including nurses, WIC staff, and childbirth educators.

The Montgomery County (Maryland) Breastfeeding Coalition, among other
activities, provides continuing education for health professionals. Participants
in this broad-based coalition include representatives from health maintenance
organizations, five local hospitals, the local WIC program and health
department, and several private, nonprofit organizations, as well as individual

13


health professionals such as childbirth educators and nutritionists from the
community.

The Model Standards Breastfeeding Task Force in St. Louis, Missouri, is
planning a project that will provide education on breastfeeding to maternal
and infant nurses and ancillary hospital staff at three area hospitals with a high
WIC client population. An evaluation component will assess attitudinal and
behavioral changes in the hospital staff, as well as the impact of the education
program on WIG breastfeeding mothers discharged from the three hospitals.

Policies and Regulations

Both national and State level agencies have issued policies and regulations
designed to increase the incidence and duration of breastfeeding through the
improvement of professional education. Respondents who reported enacting or
issuing policies or regulations which specifically address professional education
are described below

One requirement of the WIC reauthorization legislation is that State WlC
agencies must provide training in breastfeeding promotion and support to staff
members of local agencies who are responsible for counseling WIC
participants. During May and June of 1990, the Center on Budget and Policy
Priorities contacted WIC directors, nutrition coordinators, and breastfeeding
promotion coordinators from all the States and the District of Columbia in
order to determine each State's plan for promoting breastfeeding within the
WIC program. They reported that 33 States have conducted or are planning
statewide workshops, conferences, or training sessions in order to meet the
law's training requirement.

Policy and position statements related to breastfeeding and improvement of
professional education developed by many professional organizations remain
in effect. These include issuances from the American Academy of Pediatrics,
the National Association of Pediatric Nurse Associates and Practitioners, and
the American Public Health Association. In addition, the American Dietetic
Association published a position paper addressing breastfeeding and
professional education in 1986, and the National Association of WIC Directors
issued a position paper in 1989 on breastfeeding promotion in the WIC
program. (NAWD's position paper became the basis for NAWD's Guidelines for
Breastfeeding Promotion in the WIC Program, which is reprinted in appendix H).
Citations for these documents can be found in the Policy Statements section of
appendix E.

Several State agencies (the Pennsylvania Department of Health, the
Oklahoma Department of Health, and the Illinois Department of Health) have
issued position papers or policy statements that support breastfeeding
promotion and call for improvement in professional education.

Professional Consultation and Technical Assistance

In order to assist health care providers in improving their skills and
knowledge in breastfeeding management, some agencies have developed
technical assistance and consultation services related to professional education.

14


Some of these services, at the national, State, and local levels, are described
below.

National Activities

The Maternal and Child Health Bureau, DHHS, provides technical assistance
and professional education related to breastfeeding and human lactation to
State MCH and nutrition staff and to SPRANS grantees through its nutrition
consultants in the Central MCHB Office and in the 10 PHS Regional Offices.
These MCHB nutrition consultants assess national and regional needs for
professional education and work with educational institutions and other
agencies which respond to this need; help mobilize personnel and funding
resources for workshops and seminars; participate in national and regional
meetings for professional health personnel to promote breastfeeding; and
advise and assist with the development and dissemination of technical
assistance materials related to breastfeeding.

The Nutrition and Technical Service Division, Food and Nutrition Service
(FNS), USDA, provides technical assistance to its WIC and child nutrition
programs. FNS has produced and reprinted technical assistance materials in
order to help State and local agency staff promote breastfeeding (these
materials are listed in the Support Services in the Community section of
appendix E, beginning on page 87).

The Food and Nutrition Information Center (FNIC) at the USDA's National
Agricultural Library responds to inquiries and provides information,
publications, and audiovisual materials on many nutrition-related topics,
including breastfeeding. FNIC provides unlimited free service to the staff of
Federal and State Government agencies; school district and elementary and
secondary school personnel; Nutrition Education and Training Programs; the
Special Supplemental Food Program for Women, Infants, and Children; the
Commodity Supplemental Food Program; food distribution programs on
Indian reservations; child care food programs; U.S. libraries; and other
organizations receiving USDA funds or commodities.

The Subcommittee on Nutrition During Lactation of the Committee on
Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board,
Institute of Medicine, National Academy of Sciences, is an expert
subcommittee charged with evaluating and documenting current scientific
evidence on lactation and proposing nutrition recommendations for lactating
women. This expert committee, supported by a SPRANS grant from MCHB,
issued the report Nutrition During Lactation in February 1991. This report
examines methods for assessing the nutritional status of lactating women;
discusses the composition of human milk; explores how maternal health can
be influenced by lactation; reviews ways to meet the nutrient needs of lactating
women; reports links between the nutrition of the mother and the nutrition
and growth of the nursing infant; and presents the subcommittee's
recommendations and conclusions. The purpose of this report is to provide a
state-of-the-art reference for health care providers to aid in formulating
guidelines for clinical applications in the United States. Dissemination of

15


findings is through presentations by subcommittee members to professional
meetings; nationwide distribution of this report and a summary of this report
through the National Maternal and Child Health Clearinghouse; news releases;
and making the report widely available as an NAS publication.

The National Center for Education in Maternal and Child Health is a
national resource center (funded through a cooperative agreement with
MCHB) which provides information services, educational materials, and
technical assistance to organizations, agencies, and individuals with maternal
and child health interests. The reference collection contains Title V and other
maternal and child health programmatic materials (including breastfeeding
materials) not readily available elsewhere. NCEMCH has produced and
distributed several publications on Title V breastfeeding programs, including
Breastfeeding: Abstracts of Active Projects FY 1989, and Breastfeeding: Catalog of
Products.

The Lactation Study Center at the University of Rochester Medical Center,
funded through a SPRANS training grant from MCHB, maintains a data base
offering physicians free information on issues critical to the success of lactation
and breastfeeding, such as medications and substances. The bibliographic data
bank, which is constantly updated, provides immediate access to the latest
published references and may be searched by author or subject. Entries are
regularly updated and include clinically applicable comments and literature
references.

The American Public Health Association's Clearinghouse on Infant Feeding
and Maternal Nutrition, funded by USAID, was established in 1979 to support
efforts in developing countries to improve the nutrition and health of women
and children. The clearinghouse has developed a library of more than 9,000
books, documents, and educational materials reflecting information needs in
the field concerning breastfeeding promotion, weaning practices, and maternal
health. The data base also contains materials on a number of related subjects
including legislation and policies, education, food production, training, and
primary health care. The services and resources of the clearinghouse are mainly
geared toward issues relevant to developing countries.

La Leche League International operates a Center for Breastfeeding
Information which provides health professionals, researchers, breastfeeding
counselors, and medical students with a reliable source for breastfeeding
information through its collection of professional research articles on
breastfeeding.

Best Start, a program promoting breastfeeding among economically
disadvantaged women in the United States, has established the Best Start
National Resource Center. The center serves as a clearinghouse for
breastfeeding-related materials, including patient education materials and
professional and peer counselor training materials and curricula. The center
also provides technical assistance and training on breastfeeding promotion
techniques, program development strategies, program evaluation, social
marketing research, and materials development and testing (with an emphasis
on materials for low-literacy and minority populations). The center also has a
toll-free phone line for inquiries from health professionals.

16


State and Local Activities

The Arkansas Best Start project, with support from a SPRANS grant, has
established a Breastfeeding Promotion Center that provides technical assistance
to health professionals. Current information on medications and breastfeeding
is maintained at the center through a cooperative agreement with a clinical
pharmacologist.

The Children's Nutrition Research Center in Texas-in cooperation with
Baylor College of Medicine, Texas Children's Hospital, St. Luke's Episcopal
Hospital, Methodist Hospital, and the MacGregor Clinics-has been providing
a telephone counseling service for health professionals on breastfeeding
management problems in the Houston area for the last 8 years.

BARRIERS TO BREASTFEEDING

Of the 84 respondents who listed barriers to breastfeeding, 51 percent
(13184) mentioned professional education issues when discussing barriers that
keep women from beginning or continuing to breastfeed (see table 3).

Table 3-Professional education related barriers to initiation and continuation of
breastfeeding

Barriers

Percent of Respondents
     (N=84)

Lack of support or encouragement from physicians,
nurses, hospital staff, or other health professionals

32% (27)

Inaccurate or inappropriate advice from physicians
and other health care personnel

17% (14)

General lack of education among health professionals
about breastfeeding and lactation management

10% (8)

Lack of access of women to health professionals trained
in lactation management

5% (4)

17


SUWES'IIONS FOR FUTURE ACTIVITIES

Forty-three percent (49/l 13) of respondents mentioned professional
education in their recommendations for future breastfeeding promotion
efforts. Suggestions included the following:

o Continue and expand continuing breastfeeding and lactation
management education of health care providers (physicians, nurses,
nutritionists, public health workers, day care workers, hospital
administrators, and the like). Education should include information on the
importance of breastfeeding for infant and maternal health in order to
overcome the negative attitudes about or indifference to breastfeeding
among some health professionals.

o Include questions on breastfeeding and human lactation on national
boards and other credentialing examinations.

o Expand preservice breastfeeding training in schools of medicine, nursing,
dietetics, public health, and other related fields.

18


PUBLIC EDUCATION

        Recommendation:
Develop public education and promotional efforts

ACTIVITIES REPORTED

The 1984 Surgeon General's workshop cited the lack of information
available to the public about breastfeeding, as well as the sometimes incorrect
or confusing nature of the available information , as reasons for recommending
public education efforts. This recommendation has received considerable
attention from our respondents: 58 percent (66/113) indicated that they
engage in some public education activities related to breastfeeding. Public
education activities reported include implementing programs for hard-to-reach
populations, conducting media campaigns and using social marketing
approaches, and developing school-based curricula.

Hard-to-Reach Populations

The breastfeeding promotion efforts of many of the respondents focused in
whole or in part on various groups that could be designated as hard to reach:
42 percent (48/l 13) of respondents reported serving hard-to-reach populations.
The population most frequently targeted (by 24 percent [27/113] of
respondents) was low-income women (women participating in the WIC
program or other low-income women). Some other hard-to-reach populations
include adolescents, migrant workers, and minorities (see table 4). (The hard-
to-reach populations served by 10 percent [11/113] of respondents were not
specified). Examples of some of the programs for hard-to-reach populations
conducted at Federal, State, and local levels are described below.

National Initiatives

The Maternal and Child Health Bureau, DHHS, has designated breastfeeding
promotion for hard-to-reach populations as a priority area for special projects
of regional and national significance. Two of these projects, one in North
Carolina (targeted toward migrants) and one in South Carolina (targeted
toward low-income women and black women), are described later in this
section. Other SPRANS-funded breastfeeding projects are targeted toward low-
income women and Hispanic women.

The Indian Health Service (IHS), DHHS, reports that breastfeeding
promotion is an integral part of all of its programs, including public education.
In collaboration with USDA, MCHB, and Wellstart, IHS helped organize and
host a conference in September 1990 in Rapid City, South Dakota, which
focused on the promotion of breastfeeding among the American Indian
population.

19


Table 4-Programs targeted to specific populations

Population

Respondent

Minorities (unspecified)

La Leche League International
Franklin Park, IL
Missouri Department of Health
/efferson City, MO
New jersey Department of Health
Trenton, Nj

Blacks

American Indians

Pennsylvania Department of Health
Harrisburg, PA

Indian Health Service
Rockville, MD
North Dakota Health Department
Bismark, ND
South Dakota Health Department
Rapid City, SD

Non-English speakers

Nevada WIC Program
Carson City, NV

University of Illinois School of Public Health
Chicago, IL

Bilingua//bicu/tura/    Massachusetts Department of Public Health
groups          Boston, MA
          Rhode Island WIC Program
            Providence, RI

Adolescents

Low-literacy groups

Homeless families

Migrant workers

Pennsylvania Department of Health
Harrisburg, PA
Massachusetts Department of Public Health
Boston, MA
Pueblo Community Health Center
Pueblo, CO

Nevada WIC Program
Carson City, NV

New Hampshire Department of Health and Human Services
Concord, NH

University of North Carolina School of Public Health
Chapel Hill, NC
Montana Migrant Council
Billings, MT


Stute and Local Initiatives

The Division of Nutritional Sciences at Cornell University, through the
Expanded Food and Nutrition Education Program (EFNEP), provides
information on nutrition to low-income families throughout New York State.
Program participants who are pregnant learn about both breastfeeding and
bottlefeeding. For women who decide to breastfeed, additional information is
provided on the composition of breastmilk, the basic physiology of lactation,
and potential problems and how to prevent and treat them. A set of
educational pamphlets, Busies of Breostfeeding: A Mother's Guide, available in
both Spanish and English, has been developed for use with this population.

The University of North Carolina's School of Public Health implemented a
SPRANS project which included promoting breastfeeding at a migrant health
center in North Carolina. Strategies for promoting breastfeeding as a feeding
method particularly suited to the migrant lifestyle were identified and
implemented. Layettes donated by local churches were used to encourage
attendance of prenatal patients at a class on breastfeeding. Women planning to
breastfeed were given cards to alert the delivering hospital of their intention,
and hospitals were provided with bilingual flipcharts to use in communicating
with non-English-speaking patients.

The goal of the South Carolina Department of Health and Environmental
Control SPRANS project, A Statewide Action Plan to Promote Breastfeeding,
was to increase the number of low-income women and black women who
breastfeed. Information provided by focus groups was used to help develop
messages and promotional materials which would dispel mistaken beliefs about
breastfeeding among low-income women and black women. Posters were
developed which illustrate the cost savings of breastfeeding and show that
breastfeeding in public can be done modestly, without exposing the breast.

Media Campaigns and Social Marketing Approaches

Effective use of the media-print, radio, and television-has become
increasingly important in breastfeeding promotion efforts. Respondents
reported working to implement breastfeeding promotion media campaigns,
attempting to influence portrayals of infant feeding in popular films and
television shows, and responding to recent moves by formula companies to
market infant formula directly to the public.

National Initiatives

At the suggestion of the American Academy of Pediatrics, the U.S.
Department of Agriculture's Food and Nutrition Service hosted a meeting in
June 1990 to explore how government and private health interests, including
professional and nonprofit organizations, could work together to promote
breastfeeding. A major recommendation from this meeting was that USDA, in
coordination with the participating organizations, sponsor a national
campaign to promote the concept that breastfeeding is the optimum choice of
infant feeding for both mother and baby. This Breastfeeding Promotion

21


Consortium met again in February 1991 and reviewed a USDA proposal for the
design and implementation of such a breastfeeding promotion campaign. Plans
are also under way by the consortium to conduct a secondary campaign
directed toward health care providers, policymakers, employers, and other
community groups.

La Leche League International (LLLI) headquarters staff monitor and provide
timely responses to misinformation that appears in the media. LLLI also
advertises in magazines targeted at new parents.

State and Local Initiatives

The Best Start Program is a joint effort by public health officials in PHS
Region IV (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina,
South Carolina, and Tennessee) to implement a comprehensive campaign of
breastfeeding promotion based on the techniques of social marketing. The goal
is to bring vital information on breastfeeding to young, less privileged mothers
in the Southeast. In 1987 and 1988, consumer research was conducted in
Florida, Georgia, Kentucky, North Carolina, South Carolina, and Tennessee.
Research results were used to develop general program strategies and to
identify educational materials needed to reach economically disadvantaged
women, particularly those participating in the WIC program. Materials-
including TV and radio spots, a motivational videotape for patients, a training
videotape, a curriculum on use of the materials for public health professionals,
and motivational education materials for mothers-were developed to be
utilized in a media campaign, and the eight Southeastern States have now
begun to implement this campaign. The Kentucky Department of Human
Resources, for example, has funded four local promotion projects based on Best
Start materials and approaches, and Best Start television public service
announcements are being aired throughout central and eastern Kentucky.
Tennessee, Arkansas, West Virginia, Louisiana, North Carolina, and South
Carolina, as well as numerous States outside the Southeastern region, have
begun utilizing the Best Start materials in their breastfeeding promotion
activities.

The Colorado Breastfeeding Task Force worked to have the Governor
proclaim an annual Breastfeeding Awareness Week in May. Articles in two
major newspapers, spots on TV and radio stations, and a conference for over
200 health professionals were part of the 1991 effort.

The overall goal of the Indiana State Board of Health's SPRANS breastfeeding
promotion program was to improve the health of infants in the State. One
activity conducted was the initiation of a breastfeeding public awareness
campaign. The materials used were developed by a marketing agency and
included four television public service announcements, three posters, a
brochure, and a promotional video. The slogan for the campaign was
"Breastfeeding . . . for all the right reasons." The issues on which the campaign
focused were the health benefits, cost savings, and convenience of
breastfeeding, and the mother's ability to return to prepregnancy shape more
quickly. To kick off the campaign, activities such as public forums, displays at

22


shopping malls, and television appearances were held across the State.
Newspaper articles appeared in numerous cities. Specialty items including
buttons, balloons, bumper stickers, and banners boasted the campaign's slogan
and toll-free information phone number. Public opinion surveys were
completed at the beginning and end of the project in an effort to assess the
public awareness campaign. The campaign's methods and materials have been
used as a model by other States.

The Oregon WIC Coordinators Association (OWCA), in conjunction with
the Oregon WIC program, requested and was granted a governor's
proclamation to designate August 1989 as Breastfeeding Promotion Month.
OWCA received endorsements for the proclamation from a large array of
organizations, including the Oregon Chapter of Obstetricians and
Gynecologists, the Oregon Public Health Association, the Oregon Dietetic
Association, and the Oregon Nurse-Midwife Association. In support of this
campaign, the Oregon WIC program adapted promotional materials from the
Indiana State Board of Health's breastfeeding promotion project (described
above). Posters were sent to local WIC and maternal and child health
programs, physicians, and interested organizations; public service
announcements were sent to television stations.

In 1990, the Governor of Tennessee proclaimed March to be Nutrition
Month, with special emphasis on breastfeeding promotion. This proclamation
coincided with the launching of the Tennessee Best Start breastfeeding
promotion campaign.

The Texas Department of Health instituted a letter writing campaign to
change the way television portrays infant feeding so that breastfeeding is
depicted as the norm. When a pregnant woman or infant is featured on a
television program, a letter is written to the producers of the show encouraging
them to introduce positive references to breastfeeding. Letters are also written
if the show mentioned breastfeeding specifically, expressing support if the
reference was positive and concern if the reference was negative or if bottle
feeding was depicted as the norm. In addition, breastfeeding media campaign
television monitoring forms were distributed across the United States, and
letters have been written to actors and actresses who have either recently had a
child, who play a character who has recently had a child, or who are known to
be supportive of breastfeeding. The New Mexico Health and Environment
Department reported that their Breastfeeding Task Force has joined Texas'
letter writing campaign.

Response to Direct Consumer Advertising of Infant Formula

As discussed in the first chapter, two infant formula companies have
recently begun advertising their products directly to consumers via television
commercials and print advertisements, and health professionals have expressed
concern that this practice will negatively affect breastfeeding rates and infant
health. Many professional health organizations have issued policy statements
or resolutions condemning the direct advertising of infant formula to the
public, including: the American Medical Association, the American Dietetic

23


Association, the American Academy of Pediatrics, the American Academy of
Family Physicians, the Ambulatory Pediatric Association, and the Federation of
Pediatric Organizations.

In June 1989, the Federation of Pediatric Organizations, composed of seven
national pediatric groups-the Ambulatory Pediatric Association, American
Academy of Pediatrics, the American Board of Pediatrics, the American
Pediatric Society, the Association of Medical School Pediatric Department
Chairmen, the Association of Pediatric Program Directors, and the Society for
Pediatric Research-sent a letter to all of the major infant formula companies
expressing concern about the effects of initiatives to advertise infant formulas
directly to consumers, and announcing endorsement of the American Academy
of Pediatric's 1988 policy statement in support of breastfeeding and in
opposition to direct marketing of infant formulas to the lay public.

Also in June 1989, MCHB sent a packet of information on the direct
marketing of infant formula to all State MCH directors. The packet included a
statement by the Surgeon General before the Subcommittee on Nutrition of the
Senate Committee on Agriculture, Nutrition, and Forestry (reprinted as
appendix A, on page 57) on the importance of breastfeeding, and a copy of the
letter sent to formula companies by the Federation of Pediatric Organizations.

In September 1989, the executive board of the American Academy of
Pediatrics approved a new policy statement opposing direct advertising of
infant formula to the public. The policy states: "If an infant formula company
advertises its formula directly to the public, then the Academy will, as soon as
practical but in no event later than a year from the date on which the direct
advertising commences, terminate support of the Academy programs by that
company . . . If a company does not currently provide support for Academy
programs, then the .4cademy will not solicit or accept funding from such
company for any ongoing or future programs." This policy was published in
Pediatrics and received national news coverage.

In March 1991 the U.S. Senate Committee on Agriculture, Nutrition, and
Forestry and the Subcommittee on Antitrust, Monopolies, and Business Rights
held a joint hearing on the direct consumer advertising of infant formula. The
American Academy of Pediatrics, the Center on Budget and Policy Priorities,
Dr. Ruth Lawrence of the University of Rochester Medical Center, and others
presented testimony on the potential negative impact this practice can have on
breastfeeding rates.

School-Based Curricula

Integration of breastfeeding information into existing secondary school
curricula and educational programs, one of the strategies suggested at the 1984
workshop, was reported by a small number of respondents: 7 percent (8/113)
reported the development of school-based curricula as a method of public
education and promotion of breastfeeding. Two respondents described their
programs.

The Colorado Department of Health, through its new SPRANS breastfeeding
promotion project, plans to implement a previously developed high school
curriculum on breastfeeding in five schools in the State.

24


The Community Nutrition Resource Center (formerly Renewable
Technologies, Inc.) in Montana received a SPRANS grant for the project A
Model Approach to. Development of Breastfeeding as a Subspecialty Integrated
with Private Sector Maternal/Infant Health Care. As part of this project, several
in-class presentations on breastfeeding were made to second, fourth, and fifth
graders. In addition, information- on breastfeeding may be incorporated into
the health education curriculum the State of Montana is currently developing.

BARRIERSTO BREASTFEEDING

Of respondents listing barriers to breastfeeding, 44 percent (37/84)
mentioned barriers to breastfeeding which are related to public education (see
tab!e 5).

Table S-Public education related barriers to initiation and continuation of
breastfeeding

Barriers

Percentage of Respondents
    v-4

Women's attitudes

Modesty, embarrassment

Interference/incompatibility with lifestyle;
loss of independence

Lack of confidence in ability to breastfeed

Concern that supply of milk is inadequate for baby

Lack of desire, motivation

42% (35)

37% (31)


23% (19)

110/b(9)

10% (8)

Concern with figure

Had problem breastfeeding a previous baby

Have negative misconceptions about breastfeeding

Societal attitudes

7% (6)

6% (5)

6% (5)

Breastfeeding is not accepted as the norm;
general lack of societal support for breastfeeding

35% (29)

25


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


accompanying the minimum data set that States will collect for the 1992
biennial report. According to a survey of WIC programs in 48 States and 11
American Indian nations and territories conducted by NAWD in early 1991, 31
programs plan to report breastfeeding incidence data and 26 plan to report
breastfeeding duration data to FNS for the 1992 biennial report. In past WIC
program national data collection efforts, the definition of breastfeeding varied
by State, which complicated efforts to collect and compare data. The adoption
of the standard breastfeeding definition required by the WIC Reauthorization
Act, however, should remedy this situation.

The Pregnancy Nutrition Surveillance System (PNSS), supported by the
Division of Nutrition, Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, monitors nutrition-related problems
and behavioral risk factors associated with low birthweight among high-risk
prenatal populations. Simple key indicators of pregnancy nutritional status,
behavioral risk factors, and birth outcome are monitored using clinical data
from a population of low-income, high-risk pregnant women who participate
in publicly funded prenatal nutrition and food assistance programs in
participating States. Breastfeeding data are also collected.

The National Survey of Family Growth, conducted by the Centers for
Disease Control, was conducted in 1973-74, 1976, 1982, and 1988. Interviews
were conducted with a sample of women 15-44 years of age, and information
was collected on fertility, family planning, and breastfeeding practices.

The Pediatric Nutrition Surveillance System (PedNSS), also sponsored by the
Division of Nutrition, Center for Chronic Disease Prevention and Health
Promotion, monitors simple key indicators of nutritional status among low-
income, high-risk infants and children, especially those O-5 years of age, who
participate in publicly funded health, nutrition, and food assistance programs
in 36 States, the District of Columbia, and the Navajo Nation. The measures
used include anthropometry, birthweight, and hematology. Information is also
collected on infant feeding practices.

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a cooperative
effort between the Centers for Disease Control and the following 7 State Health
Departments: Alaska, District of Columbia, Indiana, Maine, Michigan,
Oklahoma, and West Virginia. The goal of PRAMS is to conduct State-specific,
population-based surveillance of selected maternal behaviors, including infant
feeding practices, that occur during pregnancy and the child's early infancy.
Data are collected monthly from a sample of mothers (drawn from birth
certificate information) who are contacted by mail and by telephone.

The National Health and Nutrition Examination Survey III (NHANES III) is
being conducted by the Centers for Disease Control from 1988 to 1994.
NHANES III is an interview and examination survey of the civilian
noninstitutionalized population ages 2 months and older. A wide variety of
nutrition information is being collected, including information on
breastfeeding.

The National Maternal and Infant Health Survey (NMIHS) was conducted by
the National Center for Health Statistics, DHHS, from 1988 to 1990. The
purpose of NMIHS is to collect nationally representative data covering natality

51


and fetal and infant mortality. Approximately 60,000 mothers, hospitals, and
providers of prenatal care were contacted via mailed questionnaires and
interviews, which will be linked with vital records. A longitudinal followup of
mothers was conducted in 1990, which involved recontacting mothers and
sometimes their medical providers as well in order to obtain updated health
histories. Mothers were questioned about infant feeding practices and
recommendations they received regarding infant feeding. Hospitals were asked
what the primary method of feeding was while the infant was in the hospital,
and what the infant's major source of nutrition was up to the fourth month of
life.

The Food and Drug Administration conducted the Survey of Infant Feeding
Patterns in 1989, obtaining detailed information about feeding practices during
the first 12 months of life, including information on transitions between breast
and bottle feeding, introduction of cow's milk, type and timing of introduction
of solid foods, and important sources of information used for guidance about
infant feeding practices.

From 1984 to 1986, the National Institute of Child Health and Human
Development conducted the Prospective Survey of Infant Feeding Practices
Among Primipara among black and white urban primipara living in
Washington, DC, in order to measure the incidence and duration of
breastfeeding and identify the correlates of incidence and duration of
breastfeeding.

As mentioned in the first chapter, Ross Laboratories conducts a survey
which contacts mothers when their infants are 6 months of age, and asks them
to recall their method of infant feeding in the hospital and during each of the
first 6 months.of life. These data contain information on the incidence of
breastfeeding at, delivery and at 6 months postpartum for women of various
social, economic, educational, and ethnic backgrounds, The data from this
survey have been used as the basis-for setting the parameters of the 1990 and
the year 2000 breastfeeding objectives for the Nation.

State Data Collection Activities

The 1991 survey of WIC programs in 48 States and 11 American Indian
nations and territories conducted by NAWD found that 46 WIe programs
currently collect breastfeeding incidence data, and 15 more plan to do so in the
future. In addition, 41 programs currently collect breastfeeding duration data,
and 17 more plan to do so in the future. Forty-three of the programs reported
using the standard national definition, and, of the 15 that used other
definitions, 12 plan to change to the national definition in the future. At the
present time, however, it is difficult to compare some of the current and past
data on breastfeeding rates in the. WIC program due to the varying definitions
of breastfeeding and calculatiori formulas used by each State. In many States,
rates reflect the percentage of all postpartum wqmen who are breastfeeding.
Other States measure the rate of bieastheding using the percentage of women
previously enrolled-as pregnant women who return for certification as
breastfeeding mothers.

The Iowa WIG program is currently in the.process of developing a new data

52


management system. When complete, the system will allow collection of the
following data: breastfeeding incidence; breastfeeding duration; duration of
breastfeeding of infants not currently breastfed; introduction of other milk
besides breastmilk; number of infants being breastfed at their postpartum
visits; and sociodemographic data on the mother.

The Maine Breastfeeding Surveillance System, begun in 1983 and automated
in 1986, monitors the incidence of breastfeeding at hospital discharge; using
information collected on standard newborn metabolic disorders screening
forms. Annual reports are generated which show incidence by county, hospital,
size of hospital, individual physician, and physician specialty.

In summary, with the exception of the Ross Laboratories Mothers Survey, all
of the data collection activities described above have very specific target
populations as well as varying methods for collecting data on breastfeeding.
This makes comparison of rates across programs or among different
surveillance systems very difficult. Until a national uniform data collection
system to assess breastfeeding rates of all births is in place, many organizations
working in breastfeeding promotion will continue to utilize the Ross
Laboratories Mothers Survey to compare breastfeeding rates in the general
population to rates in their own study, program, or jurisdiction. It is
encouraging to see the number of breastfeeding incidence and duration data
collection activities reported by respondents. However, to adequately monitor
progress toward the year 2000 breastfeeding objective for the Nation, a
uniform system for collecting data on all mothers and infants in the United
States will need to be put into place.

53


REFERENCES

American Public Health Association Clearinghouse on Infant Feeding and
Matema1 Nutrition. (1989). Government legislation and policies to support
breastfeeding, improve maternal and infant nutrition, and implement a code of
marketing of breastmilk substitutes. Washington, DC: American Public Health
Association CIearinghouse on Infant Feeding and Maternal Nutrition.

Bureau of Labor Statistics. (1991, March). Current PopuZation Survey.
Washington, DC: Bureau of Labor Statistics.

Bureau of National Affairs. (1986). Work and family: A changing dynamic.
Washington, DC: Bureau of National Affairs.

U.S. Congress. (1991, January). "Public Law 101-508: Omnibus Budget
Reconciliation Act of 1990." Congressional and Administrative News, lolst
Congress, 2nd Session, 10.

Department of Health, Education and Welfare. (1979). HeaZthy people: The
Surgeon General's report on health promotion and disease prevention.
Washington, DC: Department of Health, Education and Welfare.

Department of Health and Human Services. (1980). Promoting health,
preventing disease: Objectives for the Nation. Roc%Ile, MD: Department of
Health and Human Services.

Department of Health and Human Services. (1984). Report of the Surgeon
General's Workshop on Breastfeeding and Human Lactation. [DHHS PubIication
No. HRS-D-MC 84-2.1 Rockville, MD: Health Resources and Services
Administration.

Department of Health and Human Services. (1985). Followup report: The
Surgeon General's Workshop on Breastfeeding and Human Lactation. ~HHS
Publication NO. HRS-D-MC 85-2.1 Rockville, MD: Health Resources and
Services Administration.

Department of Health and Human Services. (1990a). Child health USA `90.
[DHHS Publication NO. HRS-M-CH 90-l.] Rockville, MD: Health Resources
and Services Administration.

Department of Health and Human Services. (1990b). Healthy people 2000:
National health promotion and disease prevention objectives. [DHHS Publication
No. (DHS) 91-50213.1 Washington, DC: U.S. Government Printing Office.

54


Federal Register. (1990). "Special Supplemental Food Program for Women,
Infants, and Children (WIC): Nonfunding mandates of the Child Nutrition
and WIC Reauthorization Act of 1989." Federal Register, 55(131), 2803348.

Gielen, A. C., Faden, R. R., O'Campo, P., Brown, H., Paige, D. M. (1991).
"Maternal employment during the early postpartum period: Effects on
initiation and continuation of breast-feeding." Pediatrics, 87(3), 298-305.

Hewlett, S. A. (1990). "The feminization of the work force." New Perspectives
Quurterly, 7(l), 13-15.

Huffman, S. L. (1990). Should infant firmuZa be marketed to the public?
Bethesda, MD: Center to Prevent Childhood Malnutrition.

Institute of Medicine. (1991). N&&ion during lactation. Washington, DC:
National Academy Press.

Interagency Committee on Nutrition Monitoring. (1989). Nutition monitoring
in the United States: The directory of Federal nutrition monitoring activities.
Hyattsville, MD: National Center for Health Statistics.

Moore, J. F., and Jansa, N. (1987). "A survey of policies and practices in
support of breastfeeding mothers in the workplace." Birth, 14(4), 191-S.
Oski, F. A. (1989). "Heating up the bottle battle." 7'he Nation, 249,683-84.
Ryan, A. S., and Martinez, G. A. (1989). "Breast-feeding and the working
mother: A profile." Pediutics, 83(4): 524-31.
Siler, J. (1990, 9 April ). "The furor over formula is coming to a boil." Business
Week, 3153: 52-53.

55


APPENDIX A

STATEMENT OF SURGEON GENERAL C. EVERY KOOP FOR THE SUBCOMM~+E
ON NunWION, SENATE CoMMrrr~r oN AGR~~~LTME, NLITRITION, AND FORESTRY
             or4 JUNE 15, 1989

Breastfeeding should be actively promoted in all maternal and child health
programs. Health experts worldwide agree that breastfeeding is the optimal
way to nurture infants and should be practiced whenever possible. I use the
term "nurture" deliberately since it means "to feed and care for during
growth." Another term for breastfeeding is "nurse" which means "to look after
carefully" as well as "to suckle." Breastfeeding is, therefore, recommended not
only as a method of feeding but also as a caring relationship.
In fact, lactation is the primary feature that sets us mammals apart from the
rest of the animal kingdom. Human milk, as the unique species-specific source
of infant nutrition, not only allows birth to occur at an early stage of
development, but also requires a time of intense maternal-infant interaction to
facilitate early behavioral development.

Breastfeeding offers many important benefits for mothers, babies, and also
for society. In summary, for mothers it affords protection against hemorrhage
and quicker recovery from childbirth, stronger bonding with the baby, and
relaxation while nursing. For infants, breastfeeding provides optimal nutrition
for normal growth and development; protection against disease, especially ear
infections and gastrointestinal distress; and decreased risk of allergies.
Breastfeeding also has benefits for society through stronger family bonds,
women's fulfillment of their aspirations for motherhood and increased self-
esteem, and decreased health care costs for infants.
Lactation is an integral stage of the reproductive cycle. The body prepares
for lactation throughout pregnancy, and lactation automatically occurs soon
after the baby is born.

There is abundant evidence that human milk is designed to enhance
optimally the growth, development, and well-being of the infant. A mother's
milk provides the best protection for her infant against specific infections.
This cannot be duplicated in infant formula.

These benefits are meaningless unless women breastfeed. The rates of
breastfeeding have been slowly declining since 1982, and breastfeeding rates in
lower socioeconomic groups remain much lower than in more affluent PUPS.
Therefore, infants who could benefit most from the immrmologic advantages
of human milk are least likely to receive this protection.

A decisive way to promote child health in the United States in the next
decade will be to implement effective breastfeeding promotion programs SO
that the unique and important benefits of breastfeeding can he made available
to protect health, nourish, and optimally develop infants in all segments of our
society.

57


       APPENDIX B
SECOND FOLLOWUP REPORT QUESTIONNAIRE

Please answer the following questions about your
   breastfeeding promotion efforts.

1. Name
Title
Address
Telephone number

2. Agency/organization name
Check the box which best describes your agency:
  Cl Federal Health Agency
  El Other Federal Agency
  Cl State Health Agency
  Cl Local Health Agency
  0 Voluntary, Professional, or Nonprofit Organization
  0 Institution of Higher Learning
  Cl Private Practice
  Cl Other; please specify:

3. Does your agency/organization receive Title V support? 0 yes or Cl no
If yes, please describe

4. Has your agency/organization been involved in the past 5 years in
breastfeedlng promotion efforts aimed at achieving the breastfeeding
objectives for the Nation? 0 yes or 0 no
If yes, please continue the questionnaire.

5. Please describe how your breastfeeding promotion efforts are funded.

6. Does your breastfeedlng promotion effort involve collaboration with
other agencies or organizations? Cl yes or O no
If yes, please list all agencies and organizations involved

58


7. Check all activities included in your.breastfeeding promotion efforts.

Professional education in human lactation and breastfeeding
Cl Hospital staff
Cl Public health clinic staff
0 Private practitioners
Cl Other (please specify):

Public education and other breastfeeding promotional efforts
Cl Media campaigns

Cl School-based curricula
Cl Hard-to-reach populations; please specify:
Cl Other (please specify):

Strengthening of support for breastfeeding in the health care system
Cl Promoting coordinated breastfeeding policies and practices in the
    continuum of maternal and infant health
0 Establishing hospital-community liaisons
O Training peer counselors
Cl Other (please specify):

Building support for breastfeeding in the workplace
0 Employee education
0 Employer education
Cl Encouraging provision of facilities for pumping and
    storing breastmilk
0 Provision of facilities in your own agency/organization to
   allow employees to pump and store breastmilk
  Cl Day care policies and practices
  _! Maternity leave polices and practices
  Cl Other (please specify):
0 Establishing workplace polices and practices

Development of support services in the communi~
0 Telephone hotlines
0 Support groups (professional or peer)
0 Individual counseling of clients and famiies
0 Followup services related to breastfeediig management
0 Client education

Cl Prenatal breastfeeding education
O Inhospital counseling
0 Postdischarge education
0 Other (please specify):

59


&sea& on human lactation and breastkeding
0 Physiological (Le., bn%tmilk composition)
Cl Social/behavioral
El Nutritional
0 Economic

Cl Programmatic (i.e., management, financing, needs assessment, cost-
  benefit analysis, etc., of breastfeeding programs)
O other (please specify):

8. Please provide a basic description of each of your breastfeedlng promotion
efforts (items identifled ln question 7) or attach copies of proposals or
reports which describe your programs.

Please include information on:
o ??????????o?
o Programdesign
o  Length of program
o `Ifipe of staff involved (i.e., physicians, nurses, health educators,
    dietitians)
o Target audience
o Participating agencies

9. Please describe any data you collect on the incidence and duration of
breastfeeding. Please include the defmition(s) of breastfeeding used in
your data collection.

10. Please describe (or provide copies of) the results of any evaluation of your
breastfeeding promotion efforts.

11. Describe the key or essential elements that made these breastfeeding
promotion efforts work.

12. Please list any materials generated as a result of these efforts (manuals,
policy guidelines, education materials, videotapes, training curricula,
conference proceedings, fhxal reports, etc.) Please include information on
each publication's availability and price, as well as a contact address and
phone number. If possible, please enclose a copy of each of these
  materials for NCEMCH's Reference Collection.

13. In your experience, what barriers keep women from beginning to
  breastfeed? How can these barriers be overcome?

14. In your experience, what barriers keep women from continuing to
  breastfeed? How can these barriers be overcome?

60


15. What suggestions or ideas do you have for future
breastfeeding promotion efforts?
     o  At the national level:
     o  At the State level:
     o  At the agency/local level:

    Please return this questionnaire to:
        Breastfeeding Project
National Center for Education in Maternal and Child Health
        38th and R Streets, N.W.
       Washington, DC 20057

61


     &PE!`4DlX c
LIST OF QUESTIONNAIRE RESPONDENTS

The ~liowing is a list of all questionm&e responcientr. Organizations of a national
scope and Federal agencies are listed first, in alphabetical order by agency or
orgrmization name. State and local organizations are then listed, in alphabetical order
b,VStade?liWlt?.

NATIONAL oJIGmnATloNs AND FEDERAL
AlxNcuu

American Academy of Pediatrics
Joe M. Sanders, Jr., M.D.
Associate Executive Director
141 Northwest Point Boulevard
EIk Grove ViIIage, IL 60009-0927
(800) 433-9016

American Conege of Obstetricians and
Gynecologistr
Shirley A. Shelton
Associate Director, CIinicaI Practice
409 12th street, S.W.
Washington, DC 20024
(202) 863-2502

AmericanDietetic Association
Cheryl Co&n, MS., R.D.
Administrator, Alliance Program
216 West Jackson Boulevard, Suite 700
Chicago, IL 60606-6995
(312) 899-0040, Rxt. 4778

AInelk!an HospitaI Association
Bruce McPherson
Group Vice President
840 North Lake Shore Drive
Chicago, IL 60611
(312) 2806000

American Public Health Association
Clearinghouse on Infant Feeding and
Matemzd Nutrition
1015 15th Street, N.W.
Washington, DC 20005
(202) 789-5600

Center to Prevent Childhood
MdllUtdtiOll
Barbara L. Bershon, PhD.
U.S. Projects Manager
7200 Wisconsin Avenue, Suite 204
Bethesda, MD 20814
(301) 9865777

Food and Nutrition Board
(Institute of Medicine)
Carol West Suitor
Study Director
2101 Constitution Avenue, N.W.
IOM 2137, Room 301
Washington, DC 20418
(202) 3341917

Food and Nutrition
Information Center,
National Agricultural Library
U.S. Department of Agricukure
10301 Baltimore Boulevard, Room 304
BeItsviIIe, MD 20705-235 1
(301) 5045719

Food and Nutrition Service
Supplerr~eutal Food Programs Division
U.S. Department of Agriculture
Ronald J. Vogel
Director
3101 Park Center Drive, Suite 1017
Alexandria, VA 22302
(703) 305-2746

Healthy Mothers, He&by Babies
National Coalition, Subcommittee on
Breastfeeding Promotion
Brenda Lisi

3101 Park Center Drive, Room 609
Alexandria, VA 22302
(703) 305-2554

lndian Health Service
U.S. Department of Health and Human
services
Yvonne Jackson, Ph.D., R.D.
Chief, Nutrition and Dietetics Section
5600 Fishers Lane
Rockville, MD 28057
(301) 443-1114

62


Institute for Reproductive HeaIth
Georgetown University Medical Center
Department of Obstetrics and Gynecology,
3 PHC
3800 Reservoir Road, N.W.
Washington, DC 20057
(202) 687-1392

La Lecbe League International
Betty Wagner
Fxecutive Director
9616 Minneapolis Avenue
P.O. Box 1209
Franklin Park, IL 60131-8209
(708) 455-7730

Matemal and Child Health Bureau
Health Resources and Service
Admihtration
U.S. Department of Health and Human
SMViCeS
M. Elizabeth Brannon, MS., R.D.
Director, MCH Training
Parklawn Building, Room 9-12
5600 Fishers Lane
Rockvilie, MD 20857
(301) 443-2190

National Association of WTC Direcl
Kathy A. Dugas
Chair, Breastfeeding Promotion
committee
c/o Mississippi WIG Program
2423 North State Street
Underwood Annex Room R214
Jackson, MS 39215
(601) 960-7842

National Center for Education in
Maternal and Child Health
Carolyn Sharbaugh, M.S., R.D.
Director, Nutrition Programs
38th and R Streets, N.W.
Washington, DC 20057
(202) 625-8400

National Center for Health Statistics
U.S. Department of Health and Human
StVViCS
Paul J. Placek, Ph.D.
Chief, Followback Survey Branch
Division of Vital Statistics
6525 Belaest Road
Presidential Building, Room 840
Hyattsville, MD 28782
(301) 4367464

United States Agency for Internatonal
DeveIopment
Sue Anthony
Office of Nutrition Servfces
SA-18, Room 413
Washington, DC 20523-1808
(703) 875-4035

STATE AND LOCAL AGENCIES AND
OR-TIONS

Mtrlam J. Gaines
Nutrition Services Administrator
Alabama Department of Public Health
434 Monroe S@eet
Montgomery, AL 36130
(205) 242-5673

Arizona
Sheryl Lee, M.P.H., R.D.
Chief, Office of Nutrition services
Arizona Department of Health Services
1740 West Adams
Phoenix, AZ 85007
(602) 5421886

Becky Melland-Buckley, M.S., R.D.
Division Director
Pima County Health Department
WIG Program
Community Nutrition Division
1121 North RI Dorado Place, R200
Tucson, AZ 85713
(602) 296-6207

Susan Trombley, RN.C., LB.C.LC.
Lactation Coordinator
University Medical Center
Deparhnent of Nursing-OB/GYN
1501 North Campbell
Tucson, AZ 85724
(602) 694-5712

Arkansas
Carole Gamer
Director, Nutrition Services
Arkansas Department of Health
4815 West Markham, Slot 21
LittIe Rock, AR 722053867
(501) 6612324

63


wIC Project Director
~arneda County Health Care Services

499 5th Street, Room 304
Oakland, CA 94607
(415) 2682548

KathrynG.Dewey
Associate Professor
z;;;f ~tlition
      califomia at Davis
Davis, CA 95616
(916) 752-1992

Of&a Dhige

Associate Frokssor
Division of Maternai and child Health
Graduate School of public Health

San Diego State University
6505 AIvarado Road, W205
San Diego, CA 92120
(619) 5942795

Joyce M. Houston
public Health Nutritionist
Humboldt County Health Department
529 I street
Eureka, CA 95501
(707) 445-6205

Audrey Naylor, M.D.
president and Codhector
Wellstart
P.O. Box 87549
San Diego, CA 92138
(619) 295-5192

Sandra Apgar Steffes, RN., MS.
Course Coordinator, Lactation programs
Univerrity of CaIifornia at Los Angeles
Fxtension/HeaIth Sciences
loo995 Le Conte Avenue, Room 614
Los Angeles, CA 90024
(213) 825-9187

Colorado
Stephanie Buffetti, R.N., B.S.N.
Fund Development Manager
Community Health Centers, Inc.
2828 International CircIe
Colorado Springs, CO 80910
(719) 6306440

Chris Hunt

perinataI Frogram Manager
Katy Baer
WIG Program Manager
Valley-Wide Health Services, Inc
204 Carson Avenue
Alanma, CO 81101
(719) 589-5161

Lynn Wand
Director of Community Nutrition
Denver Department of He&h and
Hospitals
Nutrition Frogram
777 Bannock street
Denver, CO 80204
(303) 893-7197

Pam Leite
Fresbyterian-St. Luke's Medical Center
Lactation program
501East19tbAvenue
Denver, CO 80203
(303) 869-1881

Joan McGill, M.D., RD.
Chief Nutritionist
Colorado Department of Health
Nutrition Services
4210 East 1 lth Avenue
Denver, CO 80220
(303) 331-8380

Jose E. Ortega
Administrator
La CIinica de1 VaIIe, Inc.
P.O. Box 870
Rocky Ford, CO 81067
(719) 2547626

Barbara Skinder
F%inatal Coordinator
Pueblo Community Health Center
230 Colorado Avenue
pueblo, CO 81004
(719) 5438711

COMeCtiCUt
Ruth Gitchell, MS., RD.
Nutrition Consuhant
CoMecticut Department of Health
SC?lViCeS
150 Washington Street
Hartford, CT 06106
(203) 566-1159

64


District of Columbia
Vergie Hughes, RN., I.B.C.L.C.
Nursing Coordinator
Georgetown University Hospital
3800 Reservoir Road, N.W.
Washington, DC 20007
(202) 7846455

LiIia E. Parekh, R.D.
WIC Coordinator
Children's Hospital
Children's National Medical Center
2220 11th Street, N.W.
Washington, DC 20009
(202) 745-5597

Federated States of Micronesia
h-thy Nena
Health Education Supervisor
Kosrae Department of Health Services
P.O. Box 127
Kosrae, FSM 96944
(691) 370-3199

Florida
Carol Bryant

Hawaii
Loretta J. Fuddy, A.C.S.W., M.P.H.
Acting program Administrator
Maternal and Child Health Branch
Hawaii Department of Health
741-A Sunset Avenue
Honolulu, HI 96816
(808) 737-8229

GigIiola Baruffi, M.D., M.P.H.
Project Director
Infant Feeding and Growth
U.S.-Related PachIc Islands
University of Hawaii School of Public
Health
1960 East-West Road
Honolulu, HI 96822
(808) 9568832

MeIissa Nikaido
Nutrition Education Coordinator
WIG Program
Ala Moana Health Center
591 Ala Moana Boulevard, Suite 233
Honolulu, HI 96813
(808) 548~6559,548-5300

Executive Director
Best Start
3500 East Fletcher, Suite 106
Tampa, FL 33609
(813) 9744867

lIIbOiS
Robyn Gabel
Director
IIIinois Maternal and Child Health
Coalition

Deborah Eibeck, M.S., R.D.
Chief, WIC and Nutrition Services
Florida Department of Health

   3411 West Diversey, Suite 5
   Chicago, IL 60647
- (312) 3848828

and Rehabihtative Services
1317 Winewood Boulevard
Building 1, Room 200
Tallahassee, FL 32399-0700
(904) 488-8985

Judy Perkin

Program Diiector
CC Dietetics, University of FIorida
Box J-184 JHMHC
Gainesville, FL 32610
(904) 3924078 .

Georgia

Beth S. Everett, M.P.H., R.D.

Stephen E. Saunders, M.D., M.P.H.
Chief, Division of Family Health
IIIinois Department of Public Health
535 West Jefferson
Springfield, IL 62761
(217) 782-2736

AquiIes J. Solnero, M.D.
Professor
University of IlIinois
School of Public Health
2035 West Taylor
Chicago, IL 60612
(312) 281-1871

Chief Nutritionist
Maternal and Infant Care Project       Merryjo Ware, M.P.H., R.D.
                       Nutrition Services Coordinator
Grady Memorial Hospital
80 Butler Street             IIIinois Department of Public Health
                        Division of Health Assessment and
Atlanta, GA 30335
(404) 589-4932               Screening
                    100 West Randolph
                    Chicago, IL 60601
                     (312) 814-5126

65


Indiana

Indiana WIG Program
hdiana State Roard of Health
1330 west Michigan street
P-0. Box 1964
Indianapolis, IN 46206
(317) 633-0849

Nancy B. Meade
Nutrition Consdtant
lndiana State Board of Health
Maternal and Child Health JXvision
1330 West Michigan Street
P.O. Box 1964
Indianapolis, IN 462061964
(3 17) 6330656

IOWil
Connie Betterley, MS., R.D.
Chief, Bureau of Nutrition and
Health Promotion
Brenda Dobson
WIG Nutrition Services Coordinator
Iowa Department of Public Health
3rd Flooi, Lucas Building
Des Moines. IA 503190075
(515) 281-7097,281-7769

iiEEf-
Director of Training in Nutrition
Children's Rehabilitation Unit
University Affiliated Programs
university of Kansas
39th and Rainbow Boulevard
Kansas City, KS 66103
(913) 5885745

Kermlcky
Patricia Nlcol, M.D., M.P.H.
Director, Division of Maternal and Child
Health
Cabinet fox Human Resources
Kentucky Department of Health Services
275 F&t Main street
Rankfort, KY 406210001
(502) 564-4830

Louisiana
Betty Oseid, M.D.
Depmment of Pediatrics
l.mMana State University Medical Center
1542 Tulane Avenue
New Orleans, LA 70112
(504) 568-6123

Maine
Judythe GatcheR
Nutrition Consultant
me Department of Human Services
Division of Maternal and Child Health
15 1 Capitol Street, State House Station #l 1
Augusta, ME 04333
(207) 289-3311

Maryland
Mary T. Goodwin
Chief Nutritionist
Montgomery County Health Department
100 Maryland Avenue
Rockville, MD 20850
(301) 217-1701

Ruth Faden, Ph.D.
Project Director
Determinants of Infant Feeding:
Breast vs. Bottle
Johns Hopkins School of Hygiene and
Public Health
615 North Wolfe Street
Baltimore, MD 21205
(301) 955-6498

Massachusetts
Jan Kallio, MS., R.D.
State WIG Nutrition Coordinator
Ruth Palombo, MS., RD.
Director, Office of Nutrition
Massachusetts Department of Public
Health
150 Tremont Street, Third Floor
Boston, MA 02111
(617) 727-6876

Michigan

Susan L. Hoshield, R.N.C., B.S.N.
Regional Perinatal Coordinator
Northern Michigan Hospitals
416 Connable Street
Petoskey, MI 49770
(616) 348-4819

Alwin K. Peterson
Acting Director, WIC Division
Michigan Department of Public Health
3423 North Logan, Box 30195
Lansing, MI 48909
(5 17) 335-8979

66


h4imlesota
Mary Johnson
Nutrition Consultant
wlc Program
Minnesota Department of Health
717 Delaware Street, S.E.
P.O. Box 9441
Minneapolis, MN 55440
(612) 623-5400

h4ississippi
Agnes Hinton, R.D., MS.
Director, Nutrition Services
Mississippi State Department of Health
P.O. Box 1700
Jackson, MS 39215-1700
(601) 960-7476

MiSSOuri
Bradley E. Applebaum
Regional Medical Consultant
U.S. Public Health Service
601 East 12th Street, Room 501
Kansas City, MO 64106
(816) 4262924

Loma Wilson
Director
Division of Maternal, Child,
and Family Health
Missouri Department of Health
1730 East Elm Street
Jefferson City, MO 65101
(314) 7516174

Montana
Rita J. Bradley, RD.
Community Nutrition Resource Center
(formerly Renewable Ttiologies)
P.O. Box 4511
Butte, MT 59702
(406) 723-6387

June Luptak, R.D.
Deering Community Health Center
123 South 27th Street
Billings, MT 59101
(406) 256-6821

Maria Stephens
Executive Director
Montana Migrant Council, Inc.
1148 First Avenue North
Biilings, MT 59101
(406) 2483149

Nebraska
Sue Medinger
Director, Nutrition Division
Nebraska Department of Health
P.O. Box 95007
Lincoln,NE 68509
(402) 471-2781

Nevada
Beverly Donahue
Nutrition F&cation Coordinator
Nevada WIG Program
505 East King Street, Room 205
Carson City, NV 89511
(702) 687-4797

New Hampshire
Lisa Ferriero
WIG Nutrition Consultant
Bureau of WIG Nutrition Services
New Hampshire Division of
Public Health Services
6 Hazen Drive, Health and Welfare
Bllilding
Concord, NH 03301
(603) 271-4546

Chris Shannon
Nutrition Consultant
Bureau of Maternal and Child Health
New Hampshire Division of
Public Health Services
6 Hazen Drive
Concord, NH 03301-6527
(603) 271-4541

New J-Y
Geraldine Franklin, M.S., R.D.
Public Health Consultant (Nutritionist)
Sandra Ottenberg, R.N.C., B.S.N.   _,.
Health Care Service Evaluator
New Jersey Department of Health
Division of Community Health Services
CN 364
.Trenton, NJ 086250364
(201) 292-9560,292-5616

New Mexico
Victoria Panill
MCH Nutritionist
Sharon Porter
WIG Nutrition Education Coordinator
New Mexico Health and Environment
Department
Public Health Division
Santa Fe, NM 87503
(SOS) 8272355, 827-2486

67


New York
Cutberto Garza
Director and Professor
Division of Nutritional Sciences
Cornell University
127 Savage Hall
Ithaca. NY 14853
(607) 255-2228

Barbara H. J. Gordon, Ph.D.
Associate Professor/Program Diior
City University of New York Hunter
College
Nutrition and Food Science Program
425 East 25th street
New York, NY 10010
(212) 481-7570

Ruth A. Lawrence, M.D.
Project Director
University of Rochester
School of Medicine and Dentistry
Department of Pediatrics, Box 777
601 Elmwood Avenue
Rochester, NY 14642
(716) 275-0088,275-4354

Sally Ann Lederman
Associate Professor
Clinical Public Health and Nutrition
Columbia University School of Public
Health
Center for Population and Family Health
60 Haven Avenue
New York, NY 10032
(212) 3056960

Elisabeth Luder, Ph.D.
Associate Director
Pedfatric Puhnonary Center
Mount Sinai School of Medicine
New York, NY 10029
(212) 241-7788

Christine M. Olson
Associate Professor
Cornell Cooperative Extension
Division of Nutrition Sciences
Room 376, MVR Hall
Ithaca, NY 14853
(607) 255-2142

68

Wilma E. Waithe
MCI-I Nutrition Coordinator
New York State Department of Health
Bureau of Nutrition
Room 859
E.S.P. Coming Tower Building
Albany, NY 12237
(518) 4748459

North Carolina
Janice Somers Lebeuf, M.P.H.
Nutrition Consultant
WIG Section
Division of Maternal and Child Health
North Carolina Department of
Environmental Health and Natural
Resources
P.O. Box 27687
Raleigh, NC 2761 l-7687
(919) 733-2973

Elizabeth Watkins, D.Sc.
Professor
University of North Carolina
School of Public Health
Department of Maternal and Child Health
315 Pittsboro Street
CB 87400
Chapel Hill, NC 27599
(919) 966-5979

North Dakota
Jean Tracy
Nutritionist
North Dakota Health Department
Bismark, ND 58505
(701) 2242493

Ohio
Lindsey K. Grossman, Ph.D.
Project Director
Breastfeeding Promotion in a Low-Income
Urban Population
Ohio State University
Research Foundation
1314 Kinnear Road
Columbus, OH 43210
(614) 293-8034

Ruth Shrock
Administrative Staff Nutrition Consultant
Division of Maternal and Child Health
Ohio Department of Health
246 North High Street
Columbus, OH 43215
(614) 466-8932


olcIahoma
AnneRoberts

State Coordinator
Oklahoma Healthy Mothers,
Healthy Babies

c/o Oklahoma Institute for Child
Advocacy
4030 North Lincoln, #208
Oklahoma City, OK 73152
(405) 4248014

Carok Waldvogel
MCH Consultant
Oklahoma State Department Of Health
100 Northeast 10th Street, P.O. Box 53551
Oklahoma City, OK 73152
(405) 271-6617

Mary Kay DiL.oreto, MS., R.D.
Nutrition Consultant
Oregon Department of Human Resources
Health Division
P.O. Box 231

Portland, OR 97207
(503) 229-5691

Pam Hellings, R.N., Ph.D., C.P.N.P.
Associate Professor, Family Nursing
Oregon Health Sciences University--EJSN
3181 Southwest Sam Jackson Park Road
Portland, OR 97201-3098 r
(503) 4948382

Pennsylvania

Evelyn S. Bouden, M.D.
Director
Division of Maternal and Child Health
Pennsylvania Department of Health
Room 725, H 61 W Building
P-0. Box 90

Harrisburg, PA 17108
(717) 787-7443

Biiye June Eichelberger, RD., M.P.H.
State Nutrition Director
Pennsylvania Department of Health
P.O. Box 90
Room 1003, Health and Welfare Building
Hanisburg, PA 17108
(717) 787-6967

National Child Nutrition Project
Philadelphia, PA
Contact the National Center fix Education in
Maternal and Child Health, Wrdngton,
DC, for more infinmation. See page 63.

Rhode Island
Cathleen Mdligott, MS., RD.
State WIG Nutritton Coordinator
Rhode Island Department of Health
Three Capitol Hill
Providence, RI 02908
(401) 277-3940

south carolhla
Robert H. Buchanan, Jr.
Project Director, Statewide Action Plan to
Promote Breastfeeding
South Carolina Department of Health and
Environxnental Control
Division of Children's Health
2600 Bull Street
Columbia, SC 29201
(803) 734-4610

South Dakota
Linda Marchand
District Nutrition Supervisor
South Dakota Department of Health
Nut&ion Services
725 North LaCrosse
Rapid City, SD 57701
(605) 394-2526

Randi Oviatt, RN.
Community Health Nurse
South Dakota Department of Health
1306 North Main
Spearfish, SD 57783
(605) 347-4587

Nancy Spyker
State Nutritionist
South Dakota Department of Health
Nutritional Services
717 Fifth Street
Spearfish, SD 57783
(605) 642-6391

TeMeSSee
Betsy Haughton
Associate professor, Nutrition and Food
Sciences
College of Human Ecology
University of Tennessee
Knoxville, TN 379961900
(615) 9745445

69


Minda Iaaw, MS., RD.
Director, Breas&edmg Promotion
and Support Programs
Maternal and Child Health Section
Tennessee Department of Health
and Environment
CZ-233 Cordell Hull Building
Nashvlile, TN 372475225
(615) 741-7218

TuraS
M. T. DiFkrante, M.P.H., R.D., LD.
Chief of Nutrition Services
City of Houston Department of Health
and Human Services
8000 North Stadium Drive
Houston, TX 77054
(713) 7949292

Judy Hopkinson, Ph.D.
Research Assistant Professor
Children's Nutrition Research Center
1100 Bates
Houston, TX 77030
(713) 798-7008

Barbara Keir
Director, Public Health Nutrition
Texas Department of Health
Community and Rural Health
1100 West 49th Street
Austin, TX 787563199
(512) 458-7785

David K Rassm, Ph.D.
Professor, Department of Pediatrics
Child Health Center, C3T16
University of Texas Medical Branch
Galveston, TX 77550
(409) 761-1139

E Greenhall
Perinatal Care Coordinator
Salt Lake Communi~ Health Centers
C/O Redwood Community Health Center
3060 Lester street
West Valley City, UT 84119
(801) 973-9483

Marianne Michael.% MS.
Breastfeeding Promotion Coordinator
Utah Department of Health, WIG Program
262 West 300 North
Provo, UT 84601
(801) 373-5339

Esther Satterfield
Executive Director
weber Community Health Center, Inc.
670 28th Street
Ogden, UT 84403
(801) 393-5355

Vermont
Penny Rieley
WIC Nutrition Coordinator
Vermont Department of Health-Local
Health
1193 North Avenue
P.O. Box 70
Burlington, VT 05402
(802) 863-7333

Washington

Maxine D. Hayes, M.D., M.P.H.
MCH Director
Washington Department of Health
and Socfal Services
Division of Parent/Child Health Services
MS: LC-1lA

Olympia, WA 98504
(206) 753-7021

Jane Mitchell Rees, M.S., R.D.
Director, Nutrition Services and Education
Division of Adolescent Medicine
University of Washington, CDMRC WJ-10
Seattle, WA 98195
(206) 685-1266

Bonnie Worthington-Roberts
Professor, Nutrition Sciences
Child Development and
Mental Retardation Center
University of Washington, DL 10
Seattle, WA 98195
(206) 543-l 730

West Virginia
Denise Ferris
Director
West Virginia WIG Program
Bureau of Public Health
West Virginia Department of Health
and Human Resources
1411 Virginia Street, Past
P.O. Box 69004
Charleston, WV 25301
(304) 348-0030

70


Wyoming
Deborah Barnes and Margie Sewell
Laramie County WIG Program
1122 Logan Avenue
Cheyenne, WY 82001
(307) 638-1630

Lois Pine, R.N., M.S.
Education Coordinator
Wyoming Department of Health
Family Health Services
Hathaway Building, Fourth floor
Cheyenne,WY 82002

71


APPENDIX D

RESPONDENTS REPORTING BREASTFEEDING PROMOTION ACTIVITIES

RESPONDENTS

Federal Agencies and National Organizations
American Academy of Pediatrics
American College of Obstetricians and Gynecologists
American Dietetic Association
American Hospital Association
APHA Clearinghouse on Infant Feeding and Maternal Nutrition
Center to Prevent Childhood Malnutrition
Food and Nutrition Board, institute of Medicine
Food and Nutrition information Center, USDA
Food and Nutrition Service, USDA
Indian Health Service, DHHS
institute for Reproductive Health
La Leche League International
Maternal and Child Health Bureau, DHHS
National Association of WIC Directors
National Center for Education in Maternal and Child Health
National Center for Health Statistics, DHHS
Subcommittee on Breastfeeding Promotion,

Healthy Mothers, Healthy Babies Coalition
U. 5. Agency for international Development
Alabama

Alabama Department of Public Health

.

.
-

.

9,13,21,24,40
10
14,23

16
28, 35,39
15,47
15
8,15, 21, 30, 39,40,4S, SO
19, 20, 40
4a,49
10, 11,20,22, 35, 37, 39.40
8,11,15, 19,24,28, 29, 35,42,46
14, 28, 31,51
! 16


Arizona

Arizona Department of Health Service-
Pima Countv Health

Alameda County Health Care Services Agency
Humboldt County Health Department
San Diego State University School of Public He;
University of California at Davis

University of California at Los Angeles Extensior
Wellstart

t:  Colorado Department of Health
Community Health Centers, Inc.
Denver Department of Health and Hospitals
La Clinica del Valle, Inc.                                 .
Pueblo Community Health Center
  Presbyterian-St. Lukes's Me&-al rnnta

Children's National

Best Start

Florida Department of Health and Rehabilitative Canri*ar         . - I
University of Florida

1

ii, 16, 22, 28, 30, 36,44


Y

Georgia
Grady Memorial Hnsnital
        .._ ..-. .-. _ ._-.
       -

Hawaii
Hawaii Department of Health,
Maternal and Child Health Branch
Hawaii WIC Proaram

University
Illinois

of Hawaii School I of Public Health                  .
                                         -
-

Illinois Department of Public Health,
Division of Family Health
Illinois Department of Public Health,
Division of Health Assessment and Screening
Illinois Maternal and Child Health Coalition

University

.


.

01 ' Illinois School of Public Health                   .
-

Indiana

Indiana State Board of Health,
Maternal and Child Health Division
Indiana State Board of Health,
WIC Program
Iowa
Iowa Department of Public Health/Iowa WIC Program

.



.

22,23,29,40,41,42

.


Kansas

Unit              .

University of Kansas Children's Rehabilitation
Kentuky
Kentucky Department of Health Services
Louisiana

Louisiana State University Medical Center
Maine

Maine Department of Human Services

.- . .

Marylana

Johns Hopkins School of Hygiene and Public Health
Montgomery County Health Department

Massachusetts

Massachusetts Department of Public Health
Michigan

Michigan Department of Public Health

Northern Michigan Hospitals
_ __

Minnesota

Minnesota Department of Health
Mississippi
Mississippi Department of Health
Missouri
Missouri Department of Health
__

Montana
Community Nutrition Resource Center
Deering Community Health Center
Montana Miqrant Council, Inc.
Nebraska
Nebraska Department of Health

Nevada
Nevada WIC Program

34


11,22

13.53

45
13,29

20

40

14,20, 34


2540


2440


31


20,40


New Hampshire
New Hampshire Division of Public Health Services,
Bureau of Maternal and Child Health
New Hampshire Division of Public Health Services,

Bureau of WIC Nutrition Services
_. _

-

New Jersey
New Jersey Department of Health
_. -- .

New MeXiCO

New Mexico Health and Environment Deoartment
New York

City University of New York Hunter College
Columbia University School of Public Health
Cornell Cooperative Extension
Cornell University

Mount Sinai School of Medicine Pediatric Pulmonary Center
New York State Department of Health
University of Rochester School of Medicine and Dentistry
North Carolina
North Carolina Department of Environmental Health and
Natural Resources

University of North Carolina School of Public Health
North Dakota

.



.

.

.

.
-




.

North Dakota Health Department


Ohio
Ohio Department of Health
Ohio State University Research Foundation
Oklahoma
Oklahoma Department of Health
Oklahoma Healthy Mothers, Healthy Babies
Oregon

Oregon Department of Human Resources
Oregon Health Sciences University
Pennsylvania

-

National Child Nutrition Project                            .
Pennsylvania Department of Health, General Nutrition Services      .
Pennsylvania Department of Health,
Division of Maternal and Child health

Rhode Island
Rhode Island Department of Health
South Carolina

South Carolina Department of Health and Environmental
South Dakota
South Dakota Department of Health
Tennessee
Tennessee Department of Health and Environment
University of Tennessee College of Human Ecology
Texas
Children's Nutrition Research Center
Houston Department of Health and Human Services
Texas Department of Health
Universitv of Texas Medical Branch

Control

.
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Utah
Salt Lake Community Health Centers

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46


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Vermont
Vermont Department of Health                            .
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(*`--L?-q+nm nanl+mdn+ -f ~~4th -4 cfirid c-,irar

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West Virginia
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-

Resourc :es

.

CITED


APPENDIX E
hST OF &SOURCES

7'he fi&wing list of resources (journal articles, manuals, pamphlets, videotapes,
etc.) was compiled porn information questionnaire respondents gave about materials
they have produced am#or are distributing, as well as from the Resouce Center af the
National Center fix Education in Maternal and Child Health. The list is organized
into the six main topic areas discussed in this report: professional education, public
education, support in the health care system, support in the community, support in
the workplace, and research. A brief paragraph at the beginning of each section
describes the types of materials listed in that section.

PROFESSIONALEDUCAITON

This section contains pmceedings of conferenes; newsletrers, curricula, textbooks,
and manuals for prof~ionals; and state-of-the-art reports.

Bradley, R. J. A model for improving breastfeeding practices and nutrition: A
practical guide for the health professional. (1990). Butte, MT: Community
Nutrition Resource Center.

Contact: Rita J. Bradley, Community Nutrition Resource Center, P.O. Box 4511,
Butte, MT 59702. (406) 782-2386. $25.00 for single copy, $22.00 each for 2-9
copies, $20.00 each for 10 or more copies, plus $4.95 shipping/handling.

DiLoreto, M. K., Murray, T., Mortell, T., and Hughes, J. A. Breastfeeding training
and resource guide for sttzfl Level 17 training module. (1990). portland, OR: WIC
Program, Oregon Health Division.
Contact: Oregon WIC and MCH Programs, Office of Health Services, Oregon
Health Division, P.O. Box 231, Portland, OR 97207. (503) 299-5691.

Florida Department of Health and Rehabilitative Services, WIC and Nutrition
Services. Florida's nufrition paraprofessional training guide: The breastfeeding
module. (1991). Tallahassee, FL:  WIC and Nutrition Services, Florida
Department of Health and Rehabilitative Services.
Contact: Mary Ann Patterson, WIC and Nutrition Services, Florida Department
of Health and Rehabilitative Services, 1317 Winewood Boulevard, Tallahassee,
FL 32399-0700. (904) 488-8985.

Hughes, V., and Owen, J. Self-learning packets: Initiating breastfeeding;
Difficulties breastfeeding mothers may encounter; Use of a breast pump and
breastmilk storage; and Breastfeeding ready reference. (1989). Washington, DC:
National Capital Lactation Center, Georgetown University Hospital.
Contact: National Capital Lactation Center, Georgetown University Hospital,
3800 Reservoir Road, N.W., Washington, DC 20057. (202) 784-6455. $10.00
each.

79


Illinois Department of Public Health, Nutrition Services Section, Breastfeeding
Promotion Task Force. Breustf&eding topics: A communication of the breastfeeding
promotion task force. (1989-1990). Springfield, IL: Breastfeeding Promotion
Task Force, Illinois Department of Public Health.
Contact: Merryjo Ware, M.P.H., R.D., Nutrition Services Coordinator, Division
of Health Assessment and Screening, Illinois Department of Public Health, 100
West Randolph, Suite 6-600, Chicago, IL 60601. (312) 814-5126.

Illinois Department of Public Health, Office of Health Services, Division of
Health Assessment and Screening, Nutrition Services Section. Lactutfon
counselor's manual (2nd edition). (1989). Springfield, IL: Nutrition Services
Section, Illinois Department of Public Health.
Contact: Merryjo Ware, M.P.H., R.D., Nutrition Services Coordinator, Division
of Health Assessment and Screening, Illinois Department of Public Health, 100
West Randolph, Suite 6-600, Chicago, IL 60601. (312) 814-5126. Available at
no charge within Illinois ; non Illinois residents can obtain a copy for loan
from NCEMCH.

Institute of Medicine. Nutrition during lactation. (1991). Washington, DC:
National Academy Press.
Contact: National Maternal and Child Health Clearinghouse, 38th and R
Streets, N.W., Washington, DC 20057. (202) 625-8400 or (703) 821-89515, ext.
254.

Naylor, A. J., Dixon, S., and Schooley, J. The lactation management continuing
education proje& A model for education/training in maternal and child health.
(1989). San Diego, CA: Wellstart.
Contact: Wellstart, P.O. Box 87549, San Diego, CA 92138. (619) 2955192.
Single copies available at no charge.

New Mexico Health and Environment Department. Curriculum and packet of
wticles for expanding lactation training statewide. (n.d.). Santa Fe, NM: New
Mexico Health and Environment Department.
Contact: Sharon Porter, R.D., WIG Breastfeeding Coordinator, Public Health
Division, New Mexico Health and Environment Department, Santa Fe, NM
87503. (SOS) 827-2486. Single copies available at no charge.

Rodriguez-Garcia, R., Schaefer, L. A., and Yunes, J. (Eds.). Lactation education fir
health professionals. (1990). Washington, DC: Pan American Health
Organization.
Contact: Institute for Reproductive Health, Georgetown University, 3800
Reservoir Road, N.W., Washington, DC 20007. (202) 687-1392. Available at
no charge for developing country organizations. For all others the book is
available at $10.00 per copy.

80


Steering Committee to Promote Breastfeeding in New York City.  The art und
sciqrce of breastfeeding. (1986). Washington, DC: National Center for
Education in Maternal and Child Health.

Contact: National Maternal and Child Health Clearinghouse, 38th and R
Streets, N.W., Washington, DC 20057. (202) 625-8410 or (703) 821-8955, ext.
254. $5.00 per manual and $50.00 per set of slides; make check payable to
National Center for Education in Maternal and Child HeaIth.

Taylor, M. M. Trur~~~lturul aspects of breastfeeding: U.S.A. (1985). Lactation
Cmmltant Series, unit 2. Garden City Park Avery Pubiishing Group.
Contact: Avery Publishing Group, 350 Thorens Avenue, Garden City Park, NY
11040. (516) 741-2155. $3.00 per copy; make check payable to Avery
Publishing Group, Inc.

Worthington-Roberts, B., and Williams, S. R. Nutrition in pregnancy and
hctution (4th edition). (1989). St. Louis, MO: C.V. Mosby Company.
Cor&zctz C-V. Mosby Company, 11830 Westiine Industrial Drive, Saint Louis,
MO 63146. (800) 3254177. $21.95 per copy plus $3.50 for shipping and
handling.  A 10% discount is available for order of 10 books or more.

PUBLICEDUCATION

This section is divided into three subsections: position and policy statements on
brea+Wing und marketing of infant finnukq promotional breu.s@eding materials
fOrpatients and thepublic; andguidelines fiw breastfeedingpromotion und edwation.

Policy and Position Statements

Ambulatory Pediatric Association. Resolution. (1989). McLean, VA:
Ambulatory Pediatric Association.
COntaCt: Ambulatory Pediatric Association, 6728 Old McLean Village Drive,
McLean, VA 22101. (703) 556-9222.

American Academy of FamUy Physicians. A&&&rg: lnfunt formula; and
Infant health: Breast feeding and infant nutrition. (1989). 1990-1991
Compendium of AAPP Positions on Selected Health Issues, pp. 5, 59. Kansas
City, MO: American Academy of Family Physicians.
contuct American Academy of Family Physicians, 8880 Ward Parkway, Kansas
City, MO 641142797. (816) 333-9700.

American Academy of Pediatrics. Policy on direct advertising to the public.
(1989). Elk Grove Village, IL: American Academy of Pediatrics.
Contact: American Academy of pediatrics, 141 Northwest Point Bouievani, EJk
Grove Village, IL 68009-0927. (800) 4339016.

American Academy of Pediatrics. PO&V swementbusedon~kforce~ *
promotion of breast-@ding. (1982). Pediubi~ 69(5): 654-61. FJk Grove WG
IL: American Academy of Pediatrics.

81


Contact: American Academy of Pediatrics, 141 Northwest Point Boulevard, EIk
Grove Viiage, IL 60009-0927. (800) 443-9016.

American Academy of Pediatrics. Recommended infant fmuh code of practice.
(n-d.). Elk Grove Village, IL: American Academy of Pediatrics.
Contact: American Academy of Pediatrics, 141 Northwest Point Boulevard, Eik
Grove Village, IL 60009-0927. (800) 433-9016.

American Dietetic Association. Marketing of infant formulas (ADA timely
statement). (1989). Journal of the American Dietetic Association, 89(2): 268.
Chicago, IL: American Dietetic Association.
Contact: American Dietetic Association, 206 South LaSalle Street, Suite 1100,
Chicago, IL 60604-1003. (312) 899-0040.

American Dietetic Association. Position of the American Dietetic Association:
Promotion of breast feeding. (1986). Journal of the American Dietetic Assochation,
86(11): 1580-85. Chicago, IL: American Dietetic Association.
Contact: American Dietetic Association, 206 South LaSaiIe Street, Suite 1100,
Chicago, IL 60604-1003. (312) 899-0040.

American Medical Association. Direct udvertlsing of Rx drugs, durable medical
goods, and infmt fomulas to the public; Encouragement of breast-feeding by WIG
participants; Infant nutrition; and Breast-feeding. (1990). American Medical
Association Policy Compendium:  Current Policies of, the AMA House of
Delegates Through the 1989 Interim Meeting, pp. 23, 45, 50, 51. Chicago, IL:
American Medical Association.

Contact: American Medical Association, 515 North State Street, Chicago, IL
60610. (312) 464-5471.

American Public Health Association. APHA policy stutements: Infant feeding in
the United States. (1981). American Journal of Public Health, 71(2): 207-11.
Washington, DC: American Pubhc Health Association.
Contact: American Public Health Association, 1015 15th Street, N.W.,
Washington, DC 20005. (202) 789-5600.

National Association of Pediatric Nurse Associates and Practitioners. Policy
statement on breasftizeding. (1988). Cherry Hill, NJ: National Association of
Pediatric Nurse Associates and Practitioners.
Contact: National Association of Pediatric Nurse Associates and Practitioners,
1101 Kings Highway, North, Suite 206, Cherry Hill, NJ 08034. (609) 667-1773.

National Association of WlC Directors. Position of the National Association of
W7C Directors on breus@edingpromotion in the WIG program. (1989). Jackson,
MS: National Association of WlC Diiors.
Contact: Kathy Dugas, R-D., Chair, National Association of WIC Directors
B-g Promotion Committee, c/o Mississippi WIC Program, 2423 North
State Street, Underwood Annex Room 211, Jackson, MS 39215.

82


Oklahoma State Department of Health, Maternal and Child Health Services,
Nutrition Services. Oklahoma State Department of Health position on the
promotion of breastfeeding.  (n-d.). Oklahoma City, OK: Oklahoma State
Dep&mt?Ilt of Health.
Contact Maternal and Child Health Services, Nut&ion Division, Oklahoma
State Department Of Health, 1000 Northeast 10th Street, P.O. Box 53551,
Oklahoma City, OK 73152.

U.S. Department of Health and Human Services, Public Health Service. Healthy
people 2000: National health p?or?wtion and disease prevention objectives. (1991).
Washington, DC: Public Health Service, U.S. Department of Health and Human
services.

Contact: Superintendent of Documents, Government Printing Office,
Washington, DC 20402. (202) 783-3238. $31.00 for the report and $9.00 for
the sumrrmy (GPO# 017-001-00474-O).

Promotional Materials for Patients and the Public

Best Start. Best start: Breastfeeding for healthy mothers, healthy babies: Promotional
and educational materials catalog and order firm. (1991). Tampa, FL.z Best Start.
Contact: Best Start, 3500 E. Fletcher Avenue, Suite 308, Tampa, FL 33613.
(800) 277-4975. Available at no charge.

Healthy Mothers, Healthy Babies Coalition Subcommittee on Breastfeeding
Promotion. A selected bibliography of videotapes on breastfeeding. (1989).
Washington, DC: National Center for Education in Maternal and Child
Health.

Contact: Librarian, National Center for Education in Maternal and Child
Health, 38th and R Streets, N.W., Washington, DC 20057. (202) 625-8400.
Available for loan from the National Center for Education in Maternal and
Child Health.

Indiana State Board of Health, Indiana Breastfeeding Promotion Project.
Breastfeeding . . . for all the right reasons. (n.d.). Indianapolis, INz Indiana
Breastfeedlng Promotion Project, Indiana State Board of Health.
Contact: Nancy B. Meade, R.D., M.P.H., Nutritionist, Division of Matemal and
Child Health, Indiana State Board of Health, 1330 West Michigan Street, P.O.
Box 1964, Indianapolis, IN 46206-1964. (317) 633-0656. $6.00 for video;
$25.00 for pubic service announcements; other materials available at no
charge.

Massachusetts Department of Health, WIC Program. Thinking about
breastfeeding? (1985). Boston, MA: WIG Prom, Massachusetts Department
of Health.
Contact: Massachusetts WIG Office, 150 Tremont Sweet, Boston, MA 02111.
(617) 7276876. Single copies available at no charge.

83


North Carolina Department of Environment, Health, and Natural Resources,
Division of Maternal and Child Health, WIC Section. Breastfed babies . . . are
happy. (n.d.). Raleigh, NC: WIC Section, Division of Maternal and Child
Health, North Carolina Department of Environment, Health, and Natural
Resources.

Contact Division of Maternal and Child Health, WIG Section, Department of
Environment, Health, and Natural Resources, P.O. Box 27687, Raleigh, NC
27611-7687. Single copies available at no charge.

Ohio State University Breastfeeding Promotion Project. Mother and baby
breustfeeding. (1987). Columbus, OH: Ohio State Breastfeeding Promotion
Project.
Contact: Lindsey K. Grossman, M.D., Section of Ambulatory Pediatrics,
Children's Hospital, 700 Children's Drive, Columbus, OH 43235. (614) 460-
8478.

Pima County Health Department, Project BEST. Focw on the best (Fijese en lo
me@). (1989). Tucson, AZ: Project BEST, Pima County Health Department.
Contact: Becky Melland-Buckley, M.S., R.D., Manager, Community Nutrition
Division, Pima County Health Department, 1121 North El Dorado Place, E-200,
Tucson, AZ 85715. (602) 296-6207.

Rees, J., and Murphy, S. Outside my mom: The story of a breastfed baby. (n.d.).
Seattle, WA: Puget Sound Chapter, March of Dimes Birth Defects Foundation.
Contact: Supply Division, March of Dimes Birth Defects Foundation, 1275
Mamaroneck Avenue, White Plains, NY 10605. $15.00 for filmstrip, $25.00 for
slides.

South Carolina Department of Health and Environmental Control, and the
South Carolina Educational Television Network. Bre.as@eding: The very sweet
@?Ztig only mothers know. (1987). Columbia, SC: South Carolina Department
of Health and Environmental Control, and the South Carolina Educational
Television Network.

Contact: Jenny Kirksey, Division of WIG Services, South Carolina Department
of Health and Environmental Control, Box 101106, Columbia, SC 29211.
(803) 737-3840.

Guidelines for Bm ng Promotion and Education

BreasQeeclins promotion guide&ook. (1985). Philadelphia, PA: National Child
Nutrition Project.
Contact: Librarian, National Center for Education in Maternal and Child
Health, 38th and R Streets, N.W., Washington, DC 20057. (202) 625-8400.
Available for loan.

84


American Public Health Association. Government legislation and policies to
support bmzstfeediing, improve maternal and infant nut&ion, and implement a code
of marketing of breastmilk substitutes. (1986). Washington, DC: American
Public Health Association.

Contact: American Public Health Association, 1015 15th Street, N.W.,
Washington, DC 20005. (202) 789-5600.

Huffman, S. L. Breastfeeding policies in the U.S.: What can we learn from
developing counties. (199Oa). Bethesda, MD: Center to Prevent Childhood
Malnutrition.

Conract Center to Prevent Childhood Malnutrition, 7200 Wisconsin Avenue,
Suite 204, Bethesda, MD 20814. (301) 9865777.  $5.00 per copy plus $2.90
for shipping and handling.

Huffman, S. L. Should infant formula be marketed to the public? (1990b).
Bethesda, MD: Center to Prevent Childhood Malnutrition.
Contact: Center to Prevent Childhood Mahumition, 7200 Wisconsin Avenue,
Bethesda, MD 20814. (301) 9865777.

Lazarov, M. Breast-feeding promotion: A handbook for public health professionals.
(1986). Nashville, TN: Breastfeeding Promotion Task Force, Tennessee
Department of Health and Environment.
Contact: Tennessee Department of Health and Environment, Nutrition and
Supplemental Food Programs, 108 Ninth Avenue, North, Nashville, TN 37219-
5405. (615) 741-0265. $5.00 per copy.

SUPPoRTMTmHEALTHCARESYsTEh4

This section contains descriptions of health care-based programs; publications on
breastfeeding and the health care system; hospital policies and protocols fbr promoting
breastfeeding in the health care system; health care standards; publications on
training peer counselors; regulations for clinics; and surveys of hospital breastfeeding
protocols and practices.

Arizona Department of Health Services, Office of Nutrition Services. Hospital
breastfeeding education protocol. (n.d.). Phoenix, AZ: Office of Nutrition
Services, Arizona Department of Health Services.
Contact: Office of Nutrition Services, Arizona Department of Health Services,
1740 West Adams, Phoenix, AZ 85007. (602) 5421886.

Arizona Healthy Mothers, Healthy Babies Coalition. Arizona Healthy Mothers,
Healthy Babies Breas@eding Task Force model hospital poliq. (1988). Phoenix,
AZ: Arizona Department of Health Services.
Contact: Arizona Healthy Mothers, Healthy Babies Coalition, Arizona
Department of Health Services, Office of Nutrition Services, 1740 West Adams,
Room 208, Phoenix, AZ 85007. (602) 5421890.

85


Biondillo, N. Breast feeding your hospitalized infant. (1990). Houston, TX:
Children's Nutrition Research Center.
Contact: Office of Educational Resources, Texas Children's Hospital, 6621
Fannln, Houston, TX 77030. (713) 770-2040. $1.50 each for less than 50;
$1.00 each for 50 or more.

Breunlg, S., and Merwln, M. Model hospital policies and protocols to support
breastfeeding mothers: A training program for hospitaI staff. (1990). Gainesville,
FLz Florida Healthy Mothers, Healthy Babies and Florida Department of Health
and Rehabilitative Services, WIC Office.
Contact: Carol Brady, Executive Director, Florida Healthy Mothers, Healthy
Babies Coalition, 15 S.E. First Avenue, Suite A, Galnesvllle, FL 32601. (904)
392-5667. $50.00 per copy plus $10.00 postage and handling.

Center to Prevent Childhood Malnutrition. Analyses of Healthy Mothers,
Healthy Babies surveys of hospital practices related to breastfeeding: 1988 survey.
(n.d.). Bethesda, MD: Center to Prevent Childhood Malnutrition.
Contact: Healthy Mothers, Healthy Babies, 409 12th Street, S.W., Washington,
DC 200242188. (202) 8632458.

District of Columbia Department of Human Services, Commission of Public
Health, WIC State Agency. District of Columbia breastfkeding peer counselor
prognun: Training manual. (1990). Washington, DC: WlC State Agency, District
of Columbia Department of Human Services.
Contact: Ms. Judy Win, Manager, WIC State Agency, District of Columbia
Department of Human Services, 1660 L Street, N.W., Washington, DC 20036.
(202) 673-6746. $15.00.

Georgetown University Hospital, National Capital Lactation Center. Counseling
protocols, nursing care plans. (n.d.). Washington, DC: National Capital
Lactation Center, Georgetown University Hospital.
Contad: National Capital Lactation Center, Georgetown University Hospital,
3800 Reservoir Road, N.W., Washington, DC 20057. (202) 784-6455. $20.00.

Healthy Mothers, Healthy Babies Coalition. Response to breastfeeding survey:
Follow-up questionnaire and data. (n.d.). Washington, DC: Healthy Mothers,
Healthy Babies Coalition.
Contact: National Maternal and Child Health Clearinghouse, 38th and R
Streets, N.W., Washington, DC 20057. (202) 6258410 or (703) 821-8955, ext.
254. Available at no charge.

Labbok, M., and McDonald, M. (Eds.). Proceedings of the Interagenq Workshop
on Health Care Practices Related to Breas@eding. (1990). International Journal of
Gynecology and Obstetrics, 32(l). New York, NY: Elsevier Scientific Publishers.
Contact: Mhiam H. Labbok, Institute for Reproductive Health, Georgetown
University, 3800 Reservoir Road, N.W., Washington, DC 20057. (202) 687-
1392.

86


Levine, R. E., Huffman, S. L., and Labbok, M. Changing hospital practices to
promote breastfeeding: Financial considerations. (1990). Bethesda, MD Center to
Prevent Childhood Malnutrition.

Confaa Ruth E. Levine Ph.D., Center to Prevent Childhood Malnutrition,
7200 Wisconsin Avenue, Suite 204, Bethesda, MD 20814. (301) 986-5777.
Available for $5.00 plus $2.40 for postage and handling.

Tibbetts, E., and Cadwell, K. The health ed breastfeeding teaching box for in-
hospital use. (1985). Glenside, PA: Health Education Associates.
Contact Health Education Associates, Inc., 8 Jan Sebastian Way, Sandwich, MA
02563. (508) 8888044.

Wellstart. Model hospital breastfeeding policies for full-term normal newborn
infants. (1988). San Diego, CA: Weilstart.
Contact: Wellstart, P.O. Box 87549, San Diego, CA 92138. (619) 295-5192.

World Health Organization. Erotecting, promoting, and sqporting breast-f&ing
The special role of maternity services. (1989). Geneva, Switzerland: World
Health Organization.
Contact: WHO Publications Center USA, 49 Sheridan Avenue, Albany, NY
12210. (518) 436-9686. $5.40 per copy plus $3.00 postage and handling.

SUPPORT SERVICES IN THE COMMUNITY

This section is divided into two sub-sections: eaYucationa1 materials fir patients,
and materials fbr professionals. The materials for profecFionals include descriitions of
support groups, hotlines, and community-based programs such as WZC clinics, as well
as community resource lists.

Educational Materials for Patients

American Dietetic Association. Breast f&ding.+ Baby's best start (Dar el pechor El
mejor comienzo para su bebej (2nd edition). (1983). Chicago, IL: American
Dietetic Association.

Con&z& Publications Department, American Dietetic Association, 216 West
Jackson Boulevard, Suite 800, Chicago, IL 606066995. (800) 877-1600.

Community Nutrition Resource Center. Breastfkling: Practical information for
success series. (1990). Butte, MT: Community Nutrition Resource Center.
Contact Rita J. Bradley, Community Nutrition Resource Center, P.O. Box 4511,
Butte, MT 59702. (406) 782-2386. $6.50 per sample packet, quantity rates
available on request.

Crane, K., Levert, E., Manning, W., and Williamson, M. The natural thing to do.
(n-d.). Atlanta, GA: Kuona.
Contact: Division of Nutrition Services, Tennessee Department of Public
Health, Penthouse, TDPH State Office Building, Nashville, TN 37216. (615)
741-7218.

87


Harter, C., Grossman, L. Ii., and Kay, A. Help@ hints for the nursing mother.
(1986). Columbus, OH: Ohio State University Breastfeeding Promotion
Project.
Con&% Lindsey K. Grossman, M.D., Section of Ambulatory Pediatrics,
Children's Hospital, 700 Children's Drive, Columbus, OH 43235. (614) 460-
8478.

Health Education Associates. Publications catalog. (1989). Sandwich, MA:
Health Education Associates.

Contact: Health Education Associates, Inc., 8 Jan Sebastian Way, Sandwich, MA
02563. (508) 888-8044.

Iowa Department of Public Health, WIC Program. A guide to breast feeding.
(n.d.). Des Moines, IA: WIG Program, Iowa Department of Public Health.
Contact: Brenda Dobson, WIG Program, Iowa Department of Public Health,
Lucas State Office Building, 3rd Floor, Des Moines, IA 50319-0075. (515) 281-
7769.

La Leche League. Publications catalog. (n-d.) Franklin Park, IL: La Leche
League.
Contact: La Leche League Publications Department, 9616 Minneapolis Avenue,
Box 1209, Franklin Park, IL 60131-8209.

Massachusetts Department of Health, WIC Program. Breastfeeding: Getting
started. (1987). Boston, MA: WIG Program, Massachusetts Department of
Health.

Contact: Massachusetts WIG Office, 150 Tremont Street, Boston, MA 02111.
(617) 727-6876. Single copies available at no charge.

Massachusetts Department of Health, WIC Program. Breastfeeding your new
baby. (1986). Boston, MA: WIC Program, Massachusetts Department of
Health.

Contact: Massachusetts WIG Office, 150 Tremont Street, Boston, MA 02111.
(617) 727-6876. Single copies available at no charge.

OZeary, M. J. Breastfkding you preterm baby. (1989). Seattle, WA: Health
Sciences Center for Educational Resources, University of Washington.
Contact: Health Sciences Center for Educational Resources, Distribution
Center, SB-56, University of Washington, Seattle, WA 98195. (206) 545-1186.
$200.00 for complete package, $90.00 for individual videotape/handout
packages.

Olson, C., Kaplowitz, D., and Proctor, L. Basks of breastfeeding: A mother's
guide. (1983).
Contact: Dr. Cutberto Garza, Division of Nutritional Sciences, Cornell
University, 127 Savage Hall, Ithaca, NY 14853. (607) 252228. $2.50 for
review set of 1 Copy each; $14.50 for set of 10 copies of each pamphlet.

88


Pima County Health Department, Project BEST. Breastfeeding: Getting started
(Dar pecho: Corn0 ernpesur). (1989). Tucson, AZ: Project BEST, Pima County
Health Department.
Contact: Becky Melland-Buckley, M.S., R.D., Community Nutrition Division,
Pima County Health Department WIG Program, 1121 North El Dorado Place,
E200, Tucson, AZ 85713. (602) 2966207.

Seattle-King County Department of Public Health. Breastf?eding educational
materials. (1988). Seattle, WA: SeattleKing County Department of Public
Health.

Contact: Breastfeedmg Publications, Seattle-King County Department of Public
Health, 100 Prefontaine Avenue South, Suite 500, Seattle, WA 91804. (206)
S87-2792.

Texas Department of Health. You and your baby deserve the b& Breastfeeding . . .
The give of love. (1989). Austin, TX: WIC Bureau, Texas Department of Health.
Contact: Barbara Kerr, Director, Public Health Nutrition, Community and Rural
Health, Texas Department of Health, 1100 West 49th Street, Austin, TX 78756.
(512) 458-7785.

University Medical Center. Breast-feeding your baby in the first weeks (El aWe
pecho a su bebe durante las primeras semanas). (1990). Tucson, AZ: Project
BEST, Pima County Health Department.
Conrad: Becky Me&id-Buckley, MS., R-D., Community Nutrition Division,
Pima County Health Department WIC Program, 1121 North El Dorado Place,
E200, Tucson, AZ 85713.

Materials for Professionals

Arango, J. Promoting breas@edingz A guide to health prof2.wionals working in the
WK und CSFjwqmns. (1984). Atlanta, GA: Infant Formula Council.
Contact: Nutrition and Technical Services Division, Food and Nutrition Service,
U.S. Department of Agriculture, 3101 Park Center Drive, Room 607,
Alexandria, VA 22302. (703) 305-2585. Single copies available at no charge.
Health Education Associates. The health ed kit for preventing breastfeeding
problems and earZy failure. (1985). Glenside, PA: Health Education Asscxiates.
Contact: Health Education Associates, Inc., 8 Jan Sebastian Way, Suite 13,
Sandwich, MA 02563. (SOS) 8888044. 535.00.

Healthy Mothers, Healthy Babies Coalition Subcommittee on Breastfeeding
Promotion. List of selected state professional organizations and agency contacts for
the promotion of brear@eding. (n-d.). White Plains, NY: March of Dimes.
Contact: Healthy Mothers, Healthy Babies Coalition, 409 12th Street, S.W.,
Washington, DC 20024. (202) 638-0026.

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National Association of WIC Directors. Guidelines #3r breastfeedingpromotion in
the WCprogram. (1990). National Association of WIC Directors.
Contact Kathy A. Dugas, R.D., National Association of WIC Directors, c/o
Mississippi WIG Program, 2423 North State Street, Underwood Annex Room
21i, Jackson, MS 39215.

National Center for Education in Maternal and Child Health. Breastfkeding:
Abstracts of uctive projects supported by fhe Bureau of Maternal and Child Health
and Resources Development FY 1989. (1989). Washington, DC: National Center
for Education in Maternal and Child Health.
Contact: National Maternal and Child Health Clearinghouse, 38th and R
Streets., N-W., Washington, DC 20057. (202) 625-8410 or (703) 821-8955, ext.
254. Available at no charge.

National Center for Education in Maternal and Child Health. Breuslfeeding:
Catalog of products from projects supported by the Bureau of Maternal and Child
Health and Resources Development 1989. (1989). Washington, DC: National
Center for Education in Maternal and Child Health.
Contact: National Maternal and Child Health Clearinghouse, 38th and R
Streets, N.W., Washington, DC 20057. (202) 625-8410 or (703) 821-8955, ext.
254. Available at no charge.

Nutrition Council of Arizona. Electric breastpump rental locations. (1990).
Phoenix, AZ: Nutrition Council of Arizona.
Contar Offke of Nutrition Services, Arizona Department of Health Services,
1740 West Adams, Phoenix, AZ 85007. Single copies available at no charge.

Sanders, A., Romashko, T., Fleischman, H., Hopstock, P., and Willette, J. WIG
breastfeeding promotion study and demonstration: Phase ZV report.  (1990).
Alexandria, VA: Food and Nutrition Service, U.S. Department of Agriculture.
Contact: Office of Analysis and Evaluation, Food and Nutrition Service, U.S.
Department of Agriculture, 3101 Park Center Drive, Room 208, Alexandria, VA
22302. (703) 305-2585. Single copies available at no charge.

South Carolina Department of Health Environmental Control, Division of
Children's Health, Breastfeeding Promotion Project. Resources for physicians to
prwrote breas@eding. (1989). Columbia, SC: South Carolina Department of
Health and Environmental Control.
Conrclrt: Jenny Rirksey, Division of WIC Services, South Carolina Department
of Health and Environmental Control, Box 101106, Columbia, SC 29211.
(803) 737-3840. Notebook not available for distribution. Detailed table of
contents available at no charge.

90


Steel, A. Breastfkdingpromotion: Observations from a community-based mother-to-
mother supportproject fbr low-income women in rural Tennessee. (1990). Bethesda,
MD: Center to Prevent Childhood Malnutrition.
Contact: Center to Prevent Childhood Malnutrition, 7208 Wisconsin Avenue,
Suite 204, Bethesda, MD 20814. (301) 9865777.

U.S. Department of Agriculture, Food and Nutrition Section, National Advisory
Council on Maternal, Infant, and Fetal Nutrition. Biennial report on the Special
Supplemental Food Program for Women, Infants, and Children and on the
Commodity Supplemental Food Program. (1990). Alexandria, VA: Food and
Nutrition Service, U.S. Department of Agriculture.
Contact: Supplemental Food Programs Division, Food and Nutrition Service,
U.S. Department of Agriculture, 3101 Park Center Drive, Alexandria, VA
22302. (703) 305-2746. Single copies available at no charge, lilted quantities
available.

U.S. Department of Agriculture, Food and Nutrition Service. Promoting
breastfeeding in WZC: A compendium ofpractkal approaches. (1988). Alexandria,
VA: Nutrition and Technical Services Division, U.S. Department of Agriculture.
Contact: Nutrition and Technical Services Division, U.S. Department of
Agriculture, 3101 Park Center Drive, Room 609, Alexandria, VA 22303. (703)
3052585.

U.S. Department of Agriculture, National Agricultural Library, Food and
Nutrition Information Center and National Association of WIC Directors.
Nutrition education resource guide: An annotated bibliography of educational
materiab fir the WIG and CSF programs. (1991). Bibliographies and Literature
of Agriculture, Number 94. Beltsvilie, MD: Food and Nutrition Information
Center, U.S. Department of Agricuhure.
Contact: Food and Nutrition Service, Supplemental Food Programs Division,
U.S. Department of Agriculture, 3101 Park Center Drive, Alexandria, VA
22302. Single copy available at no charge.

SUPPORT IN THE WORKPJACE

This section encompasses any materials related to breastfkeding and employment,
including guidelines for breastfeeding working mothers and surveys of employers'
breastfeeding policies and bene/its.

Bradley, R. J. Breast@ding in the work place. (1990). Butte, MT? Community
Nutrition Resource Center.
Contact: Rita J. Bradey, R.D., Community Nutrition Resource Center, P-0. Box
4511, Butte, MT 59702. (406) 723-6387. $0.11 each for 1 to 99 copies, $0.10
each for 100 to 999 copies, $0.09 each for 1,000 or more copies, plus shipping
and handling.

91


Indiana State Board of Health, Indiana Breastfeeding Promotion Project. What
does your business have in common with II breastf-ed baby? (1989). Indianapolis,
INz Indiana Breastfeeding Promotion Project, Indiana State Board of Health.
contact Indiana State Board of Health, 1330 West Michigan Street, P.O. Box
1964, Indianapolis, IN 46206-1964. (317) 633-0656.

National Child Nutrition Project. Breastfkd infants and you: A manual for child
~u~poviders. (1988). Philadelphia, PA: National Child Nutrition Project.
Contuct: Librarian, National Center for Education in Maternal and Child
Health, 38th and R Streets, N.W., Washington, DC 20057. (202) 6258400.
Available for loan.

National Child Nutrition Project. Breastfeeding and working patient education set.
(1988). Philadelphia, PA: National Child Nutrition Project.
Contact: Librarian, National Center for Education in Maternal and Child
Health, 38th and R Streets, N.W., Washington, DC 20057. (202) 6258400.
Available for loam

New Mexico Breastfeeding Task Force. Workplace recommendations for support of
brea.@eding. (n.d.). Santa Fe, NM: New Mexico Health and Environment
Department.
Contnct: Sharon Porter, R.D., WIC Breastfeeding Coordinator, New Mexico
Health and Environment Department, Santa Fe, NM 87503. (505) 827-2486.
Single copies available at no charge.

South Carolina Department of Health Environmental Control, Division of
Children's Health, Breastfeeding Promotion Project. Management of
breast@%iing A helping guide for the professional. (1989). Columbia, SC: South
Carolina Department of Health and Environmental Control.
Contact: Jenny Kirksey, Division of WIG Services, South Carolina Department
of Health and Environmental Control, Box 101106, Columbia, SC 29211.
(803) 737-3840.

RESEARCH

Baranowski, T., Rassin, D. K., Richardson, C. J., Brown, J. P., and Bee, D. E.
AWudes toward breast@ding. (1986). Baltimore, MD: Williams and Wilkins.
Contact: Tom Baranowski, Department of Preventive Medicine and
Community Health, University of Texas Medical Branch at Galveston, JZS,
Sheam Moody Plaza, Suite 7020, Galveston, TX 77550.

Bradley, R J. Analysis of the potential cost savings of breastfeeding: Medical
literature review and assessment. (n.d.). Butte, MT: Community Nutrition
Resource Center.
Contact: R&a J. Bradley, Community Nutrition Resource Center, P-0. Box 4511,
Butte, MT 59702. (406) 7236387. $8.00.

92


Krasovec, K. Schema and framework for breastfeeding definitions. (1990).
Washington, DC: Institute for International Studies in Natural Family
Planning.
Contact: Miriam Labbok, M.D., M.P.H., Institute for Reproductive Health,
Georgetown University School of Medicine, 3800 Reservoir Road, N.W.,
Washington, DC 20057. (202) 687-1392. Available at no charge.

Labbok, M. H., and Krasovec, K. Report of a meeting on breastfeding d$nitlons
held by the Interagency Group fbr Action on Breastfeeding, hosted by UNICEF, April
29, 1988. (n-d.). Institute Issues Report number 4. Washington, DC: Institute
for hrtemationai Studies in Natural Family Planning.
Confact: Miriam H. Labbok, M.D., M.P.H., Institute for Reproductive Health,
Georgetown University School of Medicine, 3800 Reservoir Road, N.W.,
Washington, DC 20057. (202) 687-1392. Available at no charge.

mdy, T., and Petrone, L. Determining statewide breastfeeaing rates and associated
factOn. (1988). Providence, RI: Rhode Island Department of Health.
Contact: Division of Nutrition Services, Rhode Island Department of Health, 75
Davis Street, Providence, RI 02908. (401) 277-2312. Available at no charge.

Rassln, D. K., Markides, K., Baran~~~ki, T., Richardson, C. J., and Winkier, B. A.
Acculturation and breastfeeding on the United States-Mexico border- (1990).
Clinical Research, 38(46A).
Contact: David K. Rassin, Department of Pediatrics, Division of Perinatal
Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX
77550. (409) 761-2815.

Rassin, D. K., Richardson, C. J., and Baranowski, T. Ethnic determinant Of
lactation in a population of mothers in the United States. (1986). Plenum
Publishing.
Contad: David K. Rassin, Ph.D., Department of Pediatrics, Division of Perinatal
Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX
77550. (409) 761-2815.

Ruder, Fin, and Rotman. Public at&&-s towurd breasweding: Healt%y Mothers,
HeaIthy Babies natiomvide survey. (1986). Washington, DC: Healthy Mothers,
Healthy Babies Coalition.
Contact: Healthy Mothers, Healthy Babies Coalition, 409 12th Street, SW.,
Room 523, Washington, DC 20024-2188. (202) 863-2458.

93


APPENDIX F:

HEALTHY PEOPLE 2000 NATIONAL HEALTH PROMOTION AND
DISEME PREVENTION OBJECTIVES: BREA~TFEEDING OBJECTIVE

14.9'  To increase to at least 75 percent the proportion of mothers who
   breastfeed their babies in the early postpartum period and to at least
   SO percent the proportion who continue breastfeeding until their
   babies are 5 to 6 months old. (Baseline: 54 percent at discharge from
   birth site and 21 percent at 5 to 6 months in 1988).

SPECIAL PoFWlAnoN TARGETS

Mothers Breast&ding Their Babies:

1988 Baseline  2000 Target

During Early Postpwtum Pefiod-
14.9a Low-income mothers
14.9b Black mothers
14.9c Hispanic mothers
14.94  American Indian/Alaska Native mothers

32%
25%
51%
47%

At Age S-6 Months-
14.9a  Low-income mothers
14.9b Black mothers
14.9c Hispanic mothers
14.9d  American Indian/Alaska Native mothers

9%
8%
16%
28%

75%
75%
75%
75%




50%
50%
50%
50%

atnefincdata~ ROSS Laboratories Mothers Survey; for American Indians and Alaska Natives, Pediatric
Nutrition Surveillance System, CDC.

Breastfeeding is the optimal way of nurturing full-term infants while
simultaneously benefitting the lactating mothers. The advantages of
breastfeeding range from biochemical, immunologic, enzymatic, and
endocrinologic to psychosocial, developmental, hygienic, and economic.
Human milk contains the ideal balance of nutrients, enzymes,
immunoglobulin, anti-infective and anti-inflammatory substances, hormones,
and growth factors. Further, breast milk changes to match the changing needs
of the infant. Breastfeeding provides a time of intense maternal-infant
interaction. Lactation also facilitates the physiologic return to the prepregnant
state for the mother while suppressing ovulation for many.

Although breastfeeding is strongly recommended, it is not appropriate for
babies whose mothers use drugs such as cocaine, PCP, or marijuana, take more
than minimal amounts of alcohol, or who receive certain therapeutic or
diagnostic agents such as radioactive elements and cancer chemotherapy.
Women who are HIV positive should also avoid breastfeeding.

94


Analysis of data from ROSS Laboratories Mothers Survey indicates that
breastfeeding rates continue to be highest among women who are older, well
educated, relatively affluent, and/or who live in the Western United States (71
percent at discharge from birth site and 31 percent at 5 to 6 months). Among
those least likely to breastfeed are women who are low-income, black, less than
age 20, and/or who live in the Southeastern United States. Low income and
black women should receive special attention because they have low rates of
breastfeeding and are a significant proportion of all new mothers
(approximately 25 percent and 17 percent, respectively).

An important barrier to achieving this objective is the general absence of
work policies and facilities that support lactating women. Given the large
percentage of mothers of young children who work outside the home, efforts
to increase breastfeeding should focus on convincing employers to provide
assistance such as extended maternity leave, part-time employment, provision
of facilities for pumping breast milk or breastfeeding, and onsite child care.
Another important barrier is portrayal of bottle rather that breastfeeding as the
norm in American society and the absence of breastfeeding incentives and
support for low-income women. Overcoming these barriers will require public
and professional education, improved support from health care providers and
employers, and the involvement of culturally sensitive social, religious, and
professional groups. The media can play an important role by more frequem$'
portraying breastfeeding as the norm.

-rhlsob@ztkdsoappearsasob~2.11In~.
Source: U.S. ~kpmmnt of Health and Human stfflnr ( 199o).fkamlypspplc#xwtNh&rrrd-
Prumotfon~~pmntiar o&jfws. m?is Pub- No. mm 9r-sMr3. w=meQ DC:
u-s. Govemment Fmlung omce.

95


              APPENDIX C
WELLSTART RESOURCE TEAMS H)R LACTATION MANAGEMENT EDUCATION

CdifOlllia
Mary E. O'Connor, M.D., M.P.H.
Division of General Academic Pediatrics
Rainbow Baby and Children's Hospital
2074 Abmgdon Road
Cleveland, OH 44186

Laura FinkIer, M.P.H., RD.
Project Coordinator
Highland General Hospital
Infant Feeding Project
1411 E. 31st Street
Oakland, CA 94602

Meg Zweiback, R.N., M.P.H., P.N.P.
Ass&ant Clinical Professor of Nursing
San Francisco General Hospital
1001 Potrero Avenue
San Francisco, CA 94110

-rgIa
George W. Bugg, M.D.
Emory University and CDC
Grady Memorial Hospitai
P-0. Box 26015
80 Butler street, S.E.
Atlanta, GA 303353801

Kimarie A. Bugg, R.N.
Breastfeeding CounseIor
Grady Memorial Hospital
P.O. Box 26015
80 Butler Street, SE.
Atlanta, GA 303353801

Beth Everett, M.P.H., R.D., L.D.
Vice President
Health Metrics Corporation
2302 Parklake hive, Suite 345
Atlanta, GA 30345

IllillOiS
DianaJ.Merteus, RN., C.N.M., M.P.H.
Maternity Nursing Consultant
Lois went of Public Health
53.5 West Jefferson
Sprin@ifM, U 62761

Doris J. McGuire, RD., M.S.
IIIinois Department of Public Health
Region IV Office
Cottonwood Road, I-270 67 159
Edwardsville, IL 62025

Suzanne Trupin, M.D.
OB/GYN
University of IIIinois School of Medicine
301 East Springfield Avenue
Champaign, IL 61820

M. Ahmad, M.D.
Raiser Permanente
6900 Squibb Road, Suite 201
Kansas City, KS 66202

Sara McCanunan, M.S, R.D.
Director, Training in Nutrition
University of Kansas Medical Center ChM
Rehabilitation Center
39th and Rainbow
Shawnee Mission, IZS 66103

Saliie Page-Goertz, R.N., C.N.M.
University of Kansas Medical
Center/Pediatrics
39th and Rainbow
Kansas City, KS 66103

Maine
Judy GatcheII, M.S., L.D.
Nut&ion Cons&ant
Division of Maternal and Child Health
15 1 Capitol Street, Station #l 1
Augusta, ME 04333

hhreen S. Savadove, M.D.
232 Saint John Street
Portland, ME 04102

Kathy Sutton, R.N., P.H.N.
Public Health Nurse II
Department of Human Services
117MainStreet
Mexico, ME 04257

96


Maryland

Fay A Sachs, R.D., M.P.H.
Chief, Nutritional Support Services
Baltimore City Department of HeaIth
9100 Franklin Square Drive
Bakhnore, MD 21237

Susan E. Brown Wii, RN., MS.
Clinical Nurse Spedahst Sinai Hospital
Belvedere at Greenspring
Baltimore, MD 21215

Linda L. Wright, M.D.
Special Assistant to the Director
National Institute for Child Health and
Human Development
Center for Research for Mothers
and Children
Executive Plaza North Building
Room 643

9OOORockvilIe Pike
Bethesda, MD 20892

Montana
James R. Feist, M.D.
Medical Associates, P.C.
7EastBeaII
Bozeman, MT 59715

Tien-Ha Ma, MA.
Nutrition Aide III
GaIlatin County HeaIth Department
Room 105 Courthouse
Bozeman, MT 59715

Stephanie Nelson
Pediatric Nurse Practitioner
GaIlatin County Heahh Department
Room 103 Courthouse
Bozeman, MT 59715

olclahonla

Donna J. Eckbart, RN., MS-N., C.P.N.P.
Maternal and Child Health Consultant
Oklahoma State Department of
Her&h/Pediatrics
1000 10th Street, N.E.
P.O. Box 53551

Oklahoma, OK 73152

Dianne Kittredge, M.D.
Assistant Professor of Pediatrics
Oklahoma Children's Memorial Hospital
940 13th Street, N.E., Room 3B700
Oklahoma City, OK 73104

Carol Paine-McGovern, M.P.H., R.D.
Nutrition Coordinator
Nutrition Division of Oklahoma State
Department of Health
P.O. Box 53551

Oklahoma City, OK 73152

Oregon

Pam HeIIings, Ph.D., P.N.P.
Associate Professor and Chairman for
Family Nursing
Oregon Health Sciences University
3181 Sam Jackson Park Road, SW. EJSN
Portland, OR 97201

Trida MorteII, RD.
Oregon Health Sciences University
Outpatient Nutrition; OP21
3181 Sam Jackson Park Road, S.W.
Portland, OR 97201

Mary Steinberg, M.D.
Assistant Professor of Pediatrics
Oregon Health Sciences University
Department of Pediatrics
3181 Sam Jackson Park Road, S.W.
Portland, OR 97201

virgiuIslaIlds
Chung Y. Kwon, M.D.
V.I. Government Health Department
P.O. Box 754, Cluistiansted
Charles Harwood Memorial Hospital
St. Croix, VI 00821-0754

Jeanette Hubbard Lewis
MCI-I Services
Knud Hanson HospitaI Complex
st. Thomas, VI oo801

h-ma Mastian, MS., R.D.
S-7A Peppertree Terrace, A15
  . .
ChnsMnsted
st. Croix, VI 00820

97


        APPENDIX H
NATIONAL ASSOCIATION OF WIC DIRECTORS
GIJIDEUNE~ FOR BREA.STFEEDING PROMOTION IN
      THE wit PROGRAM

The National Association of WIC Directors Committee on Breastfeeding
Promotion, with approval from the Board of Directors, has deve1ope.d these guidelines
to assist state and local agencies in initiating and/or strengthening existing
breastfeeding promotion and support programs.

GUIDELINE 1: Breastfeeding is enhanced when local agency WIc Staff
receive orientation and task-appropriate training on breastfeeding
promotion and support,

Suggestions for Implementation
1. It is important to develop orientation guidelines for new WIG employees
that address:

o clinic environment policies

o program goals and philosophy regarding breastfeeding
o task appropriate information

Rationale.- All new employees (support staff, paraprofessionals, and
professionals) must be famihar with program policies, goals, and philosophy
regarding breastfeeding. When all program staff project a positive attitude
about breastfeeding, clients will be more comfortable discussing their
breastfeeding questions and concerns. Clients will also be more likely to
i&late breastfeeding and breast-feed for longer duration.
2. It is important that the state agency develop guidelines for ongoing training
that address:

o culturally appropriate breastfeeding promotion strategies
o current breastfeeding management techniques to encourage and support
the breastfeeding mother and infant
o appropriate use of breastfeeding education materials
Rationale: Ongoing trainiig for staff providing breastfeeding education is
needed hecause information about breastfeeding management continues to
evolve. Addressing specific ethnic and culturally based needs fosters
appropriately targeted messages in print and audiovisual materials.
3. It is important that local agency staff participate in breastfeeding training
such as:

. conferences, workshops, and programs
o statewide and local events
o evfmi sponsored by other agencies and organizations

98


RationaZe: Local agencies' participation in breastfeeding training is essential
to successful implementation of breastfeeding promotion programs.

GUIDELINE 2: Breastfeeding is enhanced when policies are developed
that encourage a positive clinic environment and that endorse
breastfeeding as the preferred method of infant feeding.
Suggestions for Implementation

1. It is important to assure that relevant educational materials available to
participants portray breastfeeding as the preferred infant feeding method in a
manner that is culturally and aesthetically appropriate for the population
group. Consider:

o print and audiovisual materials free of formula product names
o office supplies such as cups, pens, and notepads free of formula product
names

Rationale: Use of materials with product names sends a mixed message to
clients and staff and might unconsciously put up barriers to breastfeeding.
2. It is important to establish a positive attitude toward breastfeeding in WIC
clinics.

Rationale: Health care workers should be careful not to communicate overt
or subtle endorsements of formula. Such messages may influence a mother's
decision about infant feeding or her breastfeeding pattern.
3. It is important that the local agency minimize the visibility of formula.
Consider storing supplies of formula out of view of participants.
Rationale: Formula in clear view of participants may influence a mother's
decision on infant feeding.

4. It is important that staff not accept formula from formula manufacturer
representatives for personal use.

Rationale: Acceptance of formula for personal use may influence staff to
endorse a particular product, either consciously or unconsciously.
5. It is important that the local agency try to provide a supportive environment
in which women feel comfortable breastfeeding their infants. Consider:

o chairswitharms

o a breastfeeding area away from entrance
Rationale: The clinic waiting area can be used advantageously to motivate
women to recognize breastfeeding as the "norm" rather than the exception.

99


GUIDELINE 3: Breastfeeding is enhanced when WIC agencies coordinate
with private and public health care systems, educational systems, and
community organizations providing care and support for women,
infants, and children.

Suggestions for Implementation
1. It is important to participate in coordination activities with appropriate
groups such as:

o networks or steering committees to exchange information and strategies
o professional health organizations to secure resources and expertise and
assure communication with health professionals serving pregnant and
breastfeeding women
o existing peer support groups to facilitate local exchange of breastfeeding
information across the state

Rationale: A collaborative approach to breastfeeding promotion can create a
strong supportive climate and help ensure more effective use of all available
resources.

2. It is important that the state agency disseminate appropriate policies such as
the NAWD position paper, Breastfeeding Promotion in the WIG Program, to
groups such as:

o American Academy of Pediatrics
o ???????* Academy of Family Physicians
o American College of Obstetricians and Gynecologists
o American Dietetic Association

o American Hospital Association
o Amerkm Nurses Association

o American Public Health Association
o Association of Pediatric Nurse Practitioners
o International Lactation Consultants Association
o American College of Nurse Midwives
o L.a Leche League International
o Maternal and Child Health Directors
o Medicaid Directors

o Indian Health Service
o National Association of Pediatric Nurse Associates and Practitioners
Ration&e: Serving as an adjunct to health care is a vital component of the
WIC program. Therefore, it is important that the program's health-related
policies be shared with appropriate health care programs and professional
organizations. Such interaction helps to encourage a strong cooperative
working relationship with the health community to accomplish mutual goals.

100


GIJIDELIN~Z 4: Breastfeeding is enhanced when positive breastfeeding
messages are incorporated in relevant educational activities, materials,
and outreach efforts.

sugj,p2dions for Implementation
1. It is important that positive breastfeeding messages are used in:
o participant orientation programs and materials
o printed and audiovisual materials for professional audiences
o printed, audiovisual, and display materials for potential clients
Rationale: Including positive breastfeeding messages promotes breastfeeding
as the preferred infant feeding choice and reinforces WE's position on
breastfeeding-

GUIDELINE 5: Breastfeeding is enhanced when activities are evaluated
on an annual basis.

Suggestions for Implementation
1. It is important that evaluation include measures of incidence and duration
such as:

o incorporation of data collection into current WIG systems
o sample surveys

o Center for Disease Control surveillance systems
o state surveillance systems
o birth certificate information

Rationale: Since few data are available, data collection will help identify and
direct further breastfeeding promotion efforts for this population.
Assessment of successful strategies will help agencies measure progress
toward meeting the health objectives for the Nation.
2. It is important that questions regarding breastfeeding attitudes and the WIG
program's breastfeeding support activities are included in the annual
participant survey.
Rationale:  Collecting data on breastfeeding attitudes and WIC-related
promotion activities about breastfeeding will help state and local agendes
design more effective breastfeeding promotion programs.
3. If more indepth information on the incidence and duration of breastfeeding
is desired, it is important that information be collected on at least the
following categories:
o exclusive breastfeeding
o patterns of combined breastfeeding and formula feeding (e.g., mostly
breastfeeding)

. equal parts breastfeeding and formula feeding

101


o mostly formula feeding
. exclusive formula feeding

Rationuk Collecting data on breastfeeding patterns gives a better picture of
WE's population. This will help States better focus their breastfeeding
promotion activities.

GUIDELINE 6:  Breastfeeding is enhanced when appropriate
breastfeeding education and support is offered to all pregnant WlC
participants.
Suggestions for Implementation

1. It is important that a breastfeeding protocol is established to:
o integrate breastfeeding promotion into the continuum of prenatal
nutrition education

. include an initial assessment of participant knowledge, concerns, and
attitudes related to breastfeeding

o provide breastfeeding education and support sessions to each prenatal
participant based on the above assessment
o define the roles of all staff in the promotion of breastfeeding
o define situations when breastfeeding is contraindicated
Rutionde: Making informed choices regarding the best method of infant
feeding is dependent on staff's abiity and efforts to address women's needs
and concerns throughout the prenatal period.
2. It is important to develop a mechanism to incorporate positive peer
influence into the prenatal period, such as:
o peer counselors

. an honor roll of successful breastfeeding WIG participants
o an opportunity to watch other WIG participants breastfeed
Rationale: Positive peer influence has been shown to be a factor in a
woman's decision to breastfeed.

3. It is important to include the participant's family and friends in
breastfeed@ education and support sessions.
RationaL?: Assistance and emotional support from family and friends are
helpful to a woman's initiation and continuation of breastfeeding.
0. It is important to encourage the mother to communicate her decision to
xeastfeed to appropriate hospital staff and physician.
~tionakr To overcome potential barriers due to hospital and physician
practices, women should be aware of the need to request the services that
will facilitate SUCC~SS~~~ breastfeeding; e.g., baby put to the breast within
first hour after delivery.


GUIDELINE 7: Breastfeeding is enhanced when policies allow
breastfeeding women to receive all WIC services regardless of their
breastfeeding patterns.
Suggestions for Implementation

1. It is important that eligible women who meet the definition of
breastfeeding" be certified to the extent that caseload management permits.
Rationale: Breastfeeding women are among the highest priority groups of
WIG participants.

2. It is important that breastfeeding women receive a food package consistent
with their nutritional needs.

Rationale: Breastfeeding women have the highest nutritional needs of any
category of women participants and should receive a food package to meet
those needs.

3. It is important that breastfeeding women receive support and assistance in
order to maintain or increase breastfeeding.
RathaJe: AlI breastfeeding women regardless of breastfeeding pattern need
ongoing support so that they feel positive about their breastfeeding
experience.

GUIDELINE 8: Breastfeeding is enhanced when policies allow
breastfeeding infants to receive a food package consistent with their
nutritional needs.

Suggestions for Implementation

1. It is important that the use of supplemental formula for breastfed infants be
minimized.

Rationale: Support that encourages breastfeeding is more effective than
offering more formula than the baby is currently using. Clear support which
continues to build confidence would include praise and encouragement for
her current level of breastfeeding.

2. It is important that vouchers are not issued to exclusively breastfed infants.
If a food instrument must be distributed to enroll the infant, consider printing
a positive breastfeeding message on the voucher.
Rationale: A blank voucher emphasizes that the breastfeeding dyad may not
be receiving as much food as the formula feeding dyad and makes the
mother feel as though she is missing out on some of the food available to
her. A voucher wlth even a smalI amount of formula on it sends a message
to the mother that she is expected to supplement. A positive breastfeeding
message will reinforce the importance of breastfeeding.

o Proposed definition: The practice of feeding a mother's breast milk to her infant(s) on the average
of at least once a day.

103


3. It is important to encourage the issuance of vouchers for powdered formula
to breastfeeding mothers who wish to supplement.
Rationale: Powdered formula can be prepared in as small a quantity as
needed. However, the minimum amount of the concentrated fluid formula
that can be prepared is 26 ounces. This amount must be used within 48
hours which could encourage more supplementation than originally
intended.

4. It is important that breastfeeding women receive information about the
potential impact of formula on lactation and breastfeeding before formula is
given,

Rationale: Breastfeeding mothers may not fully understand the impact
formula supplementation has on breast milk supply. This is especially
important during the first few critical weeks when the milk supply is beiig
established.

5. It is important that formula vouchers or samples be given only when
speciflcahy requested.

Rationale: Offering formula to a breastfeeding woman undermines her
confidence that she can breastfeed successfully, particuIarly in the first few
weeks. She aIso may find it difficult to refuse the free formula even though
she had not planned to use it.

GUIDELINE 9: Breastfeeding is enhanced when breastfeeding support
and assistance is provided throughout the postpartum period,
particularly at critical times when the mother is most likely to need
assistance.

Suggestions for Implementation

1. It is important to develop a plan to provide women with access to locally
available breastfeeding support programs, making sure support is available
early in the postpartum period and throughout lactation to:

o include professional support, such as management of lactation problems,
hotline contacts, and telephone counselors
o include peer support, such as peer counselors and resource mothers

RatiomJe: Professional support programs assist the mother experiencing
lactation problems to resolve questions and problems with lactation
management. Peer support programs use individuals who have successfully
breastfed an infant and who express a positive, enthusiastic viewpoint of
breastfeeding.

104


2. It is important to provide or identify education and support for
breastfeeding women in special situations. Consider:
o supporting working mothers, mothers returning to school, and
hospitalized mothers and infants

o offering support programs at times in keeping with the mother's schedule
Rationale: Breastfeeding mothers who are separated from their infants need
support programs which include situation-specific information and support.
3. It is important that postpartum contacts with breastfeeding women provide
positive reinforcement for the continuation of breastfeeding. Consider:
o using appropriate posters and messages placed In the clinic waiting and
nutrition education areas

o including a special breastfeeding message encouraging the continuation of
breastfeeding on food instruments
Rationale: Encouragement from professional staff and peers can provide
motivation to succeed at breastfeeding.
4. It is important to coordinate breastfeeding support with other health care
programs such as:
o Maternal and Child Health

o Family Planning
o Hospitals
o Indian Health Service

o Community health care providers
Rationale: Collaborative relationships result in consistent messages
supporting breastfeeding, more efflclent services, and decreased lactation
problems, and reach a larger number of women. These efforts will have a
more far-reaching effect as the incidence of breastfeeding increases.

105


   APPENDIX I
INNOCENTI ~~cwuTlor4

          INNOCFNTI DECLARATION
ON THE PROTECTION, PROMOTION AND SUPPORT OF BREASTFEEDING

RECOGNIZING THAT

Breastfeeding is a unique process that:
o provides ideal nutrition for infants and contributes to their healthy
growth and development;

o reduces incidence and severity of infectious diseases, thereby lowering
infant morbidity and mortality;

o contributes to women's health by reducing the risk of breast and ovaria~~
cancer, and by increasing the spacing between pregnancies;
o provides social and economic benefits to the family and the nation;
o provides women with a sense of satisfaction when successfully carried out;
and that

Recent research has found that:

o these benefits increase with increased exclusiveness1 of breastfeeding
during the first six months of life, and thereafter with increased duration Of
breastfeeding with complementary foods, and
o programme interventions can result in positive changes in breastfeeding
behaviour;

WE THEREFORE DECLARE THAT

As a global goal for optimal maternal and child health and nutrition, all
women should be enabled to practice exclusive breastfeeding and all infants
should be fed exclusively on breast milk from birth to 4-6 months of age.
Thereafter, children should continue to be breastfed, while receiving
appropriate and adequate complementary foods, for up to two years of age or
beyond. This child-feeding ideal is to be achieved by creating an appropriate
environment of awareness and support so that women can breastfeed in this
manner.

Attainment of the goal requires, in many countries, the reinforcement of a
"breastfeeding culture" and its vigorous defence against incursions of a "bottle-
feeding culture. n This requires commitment and advocacy for social
mobilization, utilizing to the full the prestige and authority of acknowledged
leaders of society in all walks of life.

Rfforts should be made to increase women's confidence in their ability to
breastfeed. Such empowerment involves the removal of constraints and
influences that manipulate perceptions and behaviour towards breastfeeding,
often by subtle and indirect means. This requires sensitivity, continued

' ~clusfve breastfeedlng means that no other drink or food is given to the infant the infant should
feedfcequentlyandforunrestdc&dpedod~.


vigilance, and a responsive and comprehensive communications strategy
involving all media and addressed to all levels of society. Furthermore,
obstacles to breastfeeding within the health system, the workplace and the
community must be eliminated.

Measures should be taken to ensure that women are adequately nourished
for their optimal health and that of their families. Furthermore, ensuring that
all women also have access to family planning information and services allows
them to sustain breastfeeding and avoid shortened birth intervals that may
compromise their health and nutritional status, and that of their children.
All governments should develop national breastfeeding policies and set
appropriate national targets for the 1990s. They should establish a national
system for monitoring the attainment of their targets, and they should develop
indicators such as the prevalence of exclusively breastfed infants at discharge
from maternity services, and the prevalence of exclmively breastfed infants at
four months of age.

National authorities are further urged to integrate their breastfeeding
policies into their overall health and development policies. In so doing they
should reinforce all actions that protect, promote, and support breastfeeding
within complementary programmes such as prenatal and perinatal care,
nutrition, family planning services, and prevention and treatment of common
maternal and childhood diseases. All healthcare staff should be trained in the
skills necessary to implement these breastfeeding policies.

OPERATIONAL TARGMS:

AM gowmments by the year 1995 should have:
o appointed a national breastfeeding coordinator of appropriate authori~,
and established a multlsectoral national breastfeeding committee composed
of representatives from relevant government departments,
nongovernmental organizations, and health professional associations;
o ensured that every facility providing maternity services fully practices alI
ten of the "Ten Steps to Successful Breastfeeding" set out in the joint
WHO/UNICEF statement Protecting, promoting and supportiw breast-f&i%:
the special role of ma&mity services;

o taken action to give effect to the principles and aim of all Articles of the
International Code of Marketing of Breast-milk Substitutes and subsequent
relevant World Health Assembly resolutions in their entirety; and
o enacted imaginative legislation protecting the breastfeeding rights of
working women and established means for its enforcement.

WE -0 CALL UPON INTERNJI~ION~ oRG~TIONS To:
o draw up action strategies for protecting, promoting, and supporting
breastfeeding, including global monitoring and evaluation of their
strategies;
o support national situation analyses and surveys and the development of
national goals and targets for action; and
o encourage and support national authorities in planning, implementin&
monitoring, and evaluating their breastfeeding policies

107


    WHO/UNICEF's TEN STEPS TO SUCCESSFUL DUST-FEEDING
AND CHECKLET FOR EVALUATING THE ADEQUACV OF SUPPORT FOR BREAST-FEEDING
      IN MATERNITY HOSPITALS, WARDS, AND CLINICS

TENSTWSTOSUCCESSFULBREAST-FEEDING
Every facility providing maternity services and care for newborn infM.s
should:

1. Have a written breast-feeding policy that is routinely communicated to all
health care staff.

2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management Of breast-
feeding.

4. Help mothers initiate breast-feeding within a half-hour of birth.
5. Show mothers how to breast-feed, and how to maintain lactation even if
they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless
medically indicated.

7. hXtiSe rooming-in-allow mothers and infants to remain together-24
hours a day.

8. Encourage breast-feeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to
breastfeeding infants.

10. Foster the establishment of breast-feeding support groups and refer mothers
to them on discharge from the hospital or clhric.

WHO/UNICEF's CHECKLIST MIR EVALUATING THE ADEQUACY 0~~uP~~
FOR BREAST-FEFDING IN MATERNITY Hosprr~~s, WARDS, AND CLINICS
The following check-list has been prepared for use by the competent

authorities in countries-health and nutrition policymakers; managers of
maternal and child health and family planning services; clinicians, midwives,
nursing personnel and other support staff in maternity services and facilities
for the care of newborn infants; health workers' organizations; and mothers'
SUPPOrt groups. It is intended to be a suggestive rather than exhaustive
inventory of the kinds of practical steps that can be taken within and through
materniry services to protect, promote and support breast-feeding, and should
be used in conjunction with the main text of the joint WHO/UNICEF
statement. Under ideal circumstan ces, the answer to all of the questions in the
check-list will be "Yes." A negative reply may in&cate an inappropriate practice
or routine that should be modified in accordance with the statement.


Policy

1. Does the health care facility have an explicit policy for protecting,
promoting and supporting breast-feeding
2. Is this policy communicated to those responsible for managing and
providing maternity services (for example in oral briefings when new staff are
employed; in manuals, guidelines and other written materials; or by
supervisory personnel)?

3. Is there a mechanism for evaluating the effectiveness of the breast-feeding
policy? For example:

o Are data collected on the prevalence of breast-feeding initiation and
breast-feeding at the time of discharge of mothers and their infants from the
health care facility?
o Is there a system for assessing related health care practices and training
and promotional materials, including those commonly used by antenatal
and postnatal services?

4. Are the cooperation and support of all interested parties, particularly health
care providers, breast-feeding counsellors and mothers' support groups, but
also the general public, sought in developing and implementing the health
care facility's breast-feeding policy.

Staff Training

5. Are all health care staff well aware of the importance and advantages of
breast-feeding and acquainted with the health care facilivs policy and services
to protect, promote and support breast-feeding?
6. Has the health care facility provided specialized training in lactation
management to specific staff members?

Structure and Functioning of Services
7. Do antenatal records indicate whether breast-feeding has been discussed
with a pregnant woman? Is it noted:
o Whether a woman has indicated her intention to breastfeed?

o Whether her breasts have been examined?
o Whether her breast-feeding history has been taken?
o How long and how often she has already breast-fed?
o Whether she previously encountered any problems and, if so, what kind?
o What type of help she received, if any, and from whom?
8. Is a mother's antenatal record available at the time of delivery?
o If not, is the information in point 7 nevertheless communicated to the
staff of the health care facility?


o Does a woman who has never breast-fed, or who has previouslj
encountered problems with breast-feeding, receive special attention and
support from the staff of the health care facility?
9. Does the health care facility take into account a woman's intention to
breast-feed when deciding on the use of a sedative, an analgesic or an
anaesthetic, if any, during labour and delivery?

o Are staff familiar with the effects of such medicaments on breast-feeding?
10. In general, are newborn infants:

o Shown to their mothers within 5 minutes after completion of the second
stage of labour?

o Shown/given to their mothers before silver nitrate or antibiotic drops are
administered prophylactically to the infants' eyes?
o Given to their mothers to hold and put to the breast within a half-hour of
completion of the second stage of labour, and allowed to remain with them
for at least one hour?

11. DNS the health care facility have a rooming-in policy? That is, do infants
remain with their mothers throughout their stay?

o Are mothers allowed to have their infants with them in their beds?

o If the infants stay in cots, are these placed close to the mothers' beds?
o If rooming-in applies only during daytime hours, are infants at least
brought frequently (every 3-4 hours) to their mothers at night?

12. Is it the health care facility's policy to restrict the giving of prelacteal feeds,
that is any food or drink other than breast milk, before breast-feeding has been
established?

Health Education

13. Are all expectant mothers advised on nutritional requirements during
pregnancy and lactation, and on the dangers associated with the use of drugs?
14. Are information and education on breast-feeding routinely provided to
pqwnt women during antenatal care?
1.5. Are staff members or counsellors who have specialteed training in lactation
mgeramt available full time to advise breast-feeding mothers during their
stay in the health care facility and in preparation for their discharge? Are
mothers inform&

o About the physiology of lactation and how to maintain it?
o How to prevent and manage common problems like breast engorgement
and sore or cracked nipples?
o Where to turn, for example to breast-feeding support groups, to deal with
these or ~wd PIoblems? @o breast-feeding support groups have access to
the health care fadllty?)

110


16. Are support and counselling on how to initiate and maintain breast-feeding
routinely provided for women who:
o Have undergone caesarean section?
o Have delivered prematurely?
o Have delivered low-birth-weight Infants?
o Have infants who are in special care for any reason?
17. Are breast-feeding mothers provided with printed materials that give
relevant guidance and Information?

Discharge

18. If "discharge packs" containing baby- and personal-care products are
provided to mothers when they leave the hospital or clinic, is it the policy of
the health care facility to ensure that they contain nothing that might interfere
with the successful initiation and establishment of breast-feeding, for example
feeding bottles and teats, pacifiers and infant formula?
19. Are mothers or other family members, as appropriate, of infants who are
not fed on breast milk given adequate instructions for the correct preparation
and feeding of breast-milk substitutes, and a warning against the health
hazards of incorrect preparation?

o Is it the policy of the health care facility not to give such instructions in
the presence of breast-feeding mothers?
20. Is every mother given an appointment for her first follow-up visit for
postnatal and infant care?

o Is she informed how to deal with any problems that may arise meanwhile
in relation to breast-feeding?

SnOrr World Health OrganfzatiOn. (1989). Bvh%tb& jmwnot&& and m br~a~t-@d@ 7%
spaid role ofmatcm~y suvka [a joint WHO/UNICEF statement]. Geneva, snrltzerland: World Health
organhtlm.

111


          APPENDIX K
RESEARCH ON HUMAN LKTATION AND BREASTFEEDING
SUPPORTED BY THE NATIONAL INSTITIJTES OF HEALTH,
U.S. DEPARTMENT OF HEALW AND HUMAN SERVICES*

Pms~omw 0F LACTATION

"Effect of Lactation on Bone," M. F. Sowers, University of Michigan, Ann Arbor, MI.
"Effects of Exercise on Lactation Performance in Humans," K. G. Dewey, University
of California, Davis, CA.

"Evaluation of Lactation Performance," K. J. Motil, Baylor College of Medicine,
Houston, TX.

"Human Mammary Cell Growth and Function in Defined Media," R. G. Ham,
University of Colorado at Boulder, Boulder, CO.
"Milk Production in Mothers of Preterm Infants: Single vs. Bilateral Pump," D.
Jurdi-Haldeman, Case Western Reserve University, Cleveland, OH.
"Novel Evaluation of Lactation Performance, u C. Garza, Cornell University at
Ithaca, Ithaca, NY.

"Nutrient Transfer into Human Milk," K. J. Motil, Baylor College of Medicine,
Houston, TX.

"Physiological Factor Affecting Human Lactation," M. C. Neville, University of
Colorado Health Sciences Center, Denver, CO.
"Prematurity and Lactation: Role of Prolactin," R. Ehrenkranz, Yale University, New
Haven, CT.

"The Effect of Smoking on Lactation," P. M. Kuhnert, Case Western Reserve
University, Cleveland, OH.

"Vitamin A Transport During Lactation," A. C. Ross, Medical College of
Pennsylvania, Philadelphia, PA.
"X-Ray StmcturaI Studies of Iactoferrin," E. N. Baker, Massey University,
Palmerston North, New Zealand.

"Alcohol Consumption, Lactation, and Breast Cancer Risk," R. MacMahon and P. A.
Newcomb, Harvard University, MA, and University of Wisconsin, Madison, WI.
"Antenatal Education and Women's Choice of Infant Feeding Method," M.
Franktin, Case Western Reserve University, Cleveland, OH.
"Effect of Lactation and Diet on Calcium Metabolism, ' B. L. Specker, Children's
Hospital Medical Center, Cincinnati, OH.

Sowcez Feded lhman Nutddon Reseamh and Information Management Syxtem, 1989.
o ~onhumanlactaUonami bms6dbg supported by the Maternal and Child Health
8~ Dmp through its SW prolens of r@mal and national significance (PRANS) program IS
-~~-~-pter(seepag&q.

112


"Levels of Dietary Intake for Various Nutrients," C. W. callaway, National Academy
of Sciences, Washington, DC.

"Maternal B-6 Deficiency," T. R. Guilarte, Johns Hopkins University, Baltimore, MD.
"Maternal Calorie Restriction on Breast Milk Production," L. B. Dusdieker,
University of Iowa, Iowa City, LA.

"Maternal Zinc Status During Lactation Growth of the Breast Fed infant," M. K.,
Hambridge, University of Colorado Health Sciences Center, Denver, CO.

.  "Sex Hormone Effects on Intestinal Calcium Absorption," M. L. Thomas, University
of Texas Medical Branch, Galveston, TX.
"Studies of 70 Zinc Absorption During Pregnancy and Lactation, ' M. K. Hambridge,
University of Colorado Health Sciences Center, Denver, CO.
"Zinc Absorption in Pregnant and Lactating Women," M. K. Hambridge, University
of Colorado Health Sciences Center, Denver, CO.

INFANT PIiYsI0mGY

"Amino Acid interrelations in Human Metabolic Disease," L. Sweetman, University
of California, San Diego, CA.

"Effects of Human Milk Associated Growth Modulators on Neuronal
Development," J. A. Sturman, Institute for Basic Research in Developmental
Disabilities, New York, NY.

"Maturation of Intestinal Host Defenses," A. W. Walker, Children's Hospital,
Boston, MA.

"Nutrition and Metabolism-Abetalipoprotetnemia," D. R. Illingworth, Oregon
Health Sciences University, Portland, OR.
"Vitamin A Transport System," D. E. Ong, Vanderbilt University, Nashville, TN.

INFANT NUTRITION ASPECTS

"Body Composition of Infants Fed Human Milk or Similac with Iron," W. J. Klish,
Baylor College of Medicine, Houston, TX.
"Effects of Perinatal Factors on Breast Feeding Outcomes," L. R. Cronenwett,
Dartmouth College, Hanover, NH.

"Epidemiology of Infant Feeding Dynamics," B. M. Popkin, University of North
Carolina, Chapel Hill, NC.

"Human Mii in Preterm Infants: Effects of Supplementation," E. E. Ziegler,
University of Iowa, Iowa City, LA.
"Human Requirement for Biotin," D. M. Mock, University of Iowa, Iowa City, LA.
"Human Zinc Deficiency," M. K. Hambridge, University of Colorado Health
Sciences Center, Denver, CO.
"Navajo Infant Feeding Project," A. L. Wright, University of Arizona, Tuscan, AZ.

113


"Role of Human Milk in Infant Nutrition and Health," L. K. Pickering, University of
Texas Health Sciences Center, Houston, TX.
`Selenium Nut&we of the Neonate," R. Ehrenkranz, Yale University, New Haven, CT.
"Vitamin D Requirement of Infants," B. W. Hollis, Medical University of South
Carolina, Charleston, SC.

"Zinc Absorption in Very Low Birth Weight Preterm Infants," M. K. Hambridge,
University of Colorado Health Sciences Center, Denver, CO.

cO?dPOSITlON OF HUMAN MILK

UHuman Milk BAL-!%ructure and Physiological Function," C. Wang, Oklahoma
Medical Research Foundation, Oklahoma City, OK.
"Human Milk Selenium Content and Distribution," M. F. Picciano, University Of
Illinois Urbana-Champaign, Champaign, IL.
"Milk Enzymes, Origin and Distribution," M. Hamosh, Georgetown University,
Washington, DC.

"Significance of Folate-Binding Proteins in Human Milk," A. C. Antony, Indiana
University-Purdue University, Indianapolis, IN.
"Sources of Human Milk Fat," K. J. Mot& Baylor College of Medicine, Houston, TX.

EFFECT OF ENVIRONMENTAL F.~PO~~RFS

"Human Exposure to Halogenated Aromatic Compounds," W. J. Rogan, National
  Institute of Environmental Health Sciences? (NIEHS), Research Triangle, NC.
"Meperldlne and Local Anesthetics in Breastmilk," E. H. Phillipson, Case Western
  Reserve University, Cleveland, OH.

IMMuN0LDG1cAL ASPECTS

"Image Analysis System: Role of Human Milk in Protection of Infant Against
  Diarrheal Disease," D. S. Newburg, Eunice Kennedy Shriver Center for
  Mental Retardation, Waltham, MA.

114


              APPENDIX L
~SEARCH ON HUMAN &TATlON AND ~RWTFEEDING SUPPORTEO
     BY THE U.S. DEPARTMENT OF AGRICUUIJRE

PHYSIOLOGY OF LxTATION

"Benefidal Effects of Human Milk on the Intestine of Infants," B. L. Nichols,
Baylor College of Medicine, Houston, TX.
`Effects of Nutritional Insuf&iency on Cellular Maturation and Function," B.
L. Nichols, Baylor College of Medicine, Houston, TX.
"Functional Role of Human Milk Proteins," W. Hutchens, Baylor College of
Medicine, Houston, TX.

"Protein Metabollsm in Lactating Women," B. L. Nichols, Baylor College of
Medicine, Houston, TX.

MATERNAL NUTRITION ASPECTS

"Amino Acid Needs for Reproduction and Growth," T. Davis and F. P. Hom,
Baylor College of Medicine, Houston, TX.
"Bioavailability of Vitamin B-6 and Interaction with Minerals," R. D. Reynolds,
Agricultural Research Service, Beltsville, MD.
"Dietary Lipid Requirements for Optimal Development and Health," D. Hachey
and F. P. Horn, Baylor College of Medicine, Houston, TX.
"Influence of Trace Element Nutriture on Physical Performance and Body
Composition," L. M. Klevay, Agricultural Research Service, Grand Fork, ND.
"Maternal and Dietary Determinants of Infant Selenium Nutrition," M. F.
Picciano, Human Resources/Family Studies, University of Illinois, Urbana, IL.
"Maternal and Infant Nutrition," C. Garza, Cornell University, Ithaca, NY.
"Maternal versus Infant Factors Related to Lactational Performance," K. G.
Dewey, Agricultural Experimental Station, University of California, Davis, CA.
"Metabolic Fate of Omega-3 and Omega-6 Polyunsaturated Fatty Acids," R 0.
Adlof, Northern Regional Research Center, Peoria, IL.
"The Role of Dietary Fat in the Production of Human Mii Fat," B. L. Nichols,
Baylor College of Medicine, Houston, TX.
"Vitamin A and Lactation," K. M. Rasmussen, Nutrition Sciences, Cornell
University, Ithaca, NY.
"Vitamin and Mineral Nutritional Assessment in Pregnancy and Lactation," A.
Kirksey, Agricultural Experimental Station, Purdue University, West Lafayette, IN-

Snmc Fedetal Human Nuaition Research and lnfmatfm MaMgaMnt system, 1989.


INFANT PHYsloLoGY

"Amino Acid Responses of Infants Fed Human Milk or Artificial Formulas,"
B. L. Nichols, Baylor College of Medicine, Houston, TX.
"Development of a Model for Assessing the Functional Significance of Feeding-
Human Milk," B. L. Nichols, Baylor College of Medicine, Houston, TX.
"Energy Contribution of Specific Food Components," F. P. Horn and P. L.
Klein, Baylor College of Medicine, Houston, TX.
"Energy Needs and Expenditure During Growth and Reproduction," W. P.
Sheng, Baylor College of Medicine, Houston, TX.
"Measurement of Energy Expenditure of Infants," B. L. Nichols, Baylor College
of Medicine, Houston, TX.

"Measurement of Human Energy Expenditure Using 2H2180 Labeled Water,"
B. L. Nichols, Baylor College of Medicine, Houston, TX.
"Proteolytic Degradation of Human Milk Lactoferrin in Infants," B. L.
bMerd& Agricultural Experimental Station, University of Callfomla, Davis, CA.
"Studies of Body Composition," B. L. Nichols, Baylor College of Medicine,
Houston, TX.

INFANT NUTRITION ASPECTS

"Bioavailability and Function of Minerals," C. M. Weaver, School of Consumer
and Family Science, Purdue University, West Lafayette, IN.
"Comparison of Nutrient Intake and Growth of Breast- Versus Formula-Fed
Infants," K. G. Dewey, Agricultural Experimental Station, University Of
California, Davis, CA.

"Determination of Nutrient Intake of Infants Receiving Human Milk and Solid
Foods," B. L. Nichols, Baylor College of Medicine, Houston, TX.
"Maternal and Infant Nutrition," C. Garza, Cornell University, Ithaca, NY.

t%i4POSITION OF HUMAN MILK
"Biotln in Human Milk," D. M. Mock, University of Iowa, Iowa City, IA.

HUMJWMILKBANKS

"Processing and Storage of Human Milk: Deaeration, Flexible Packaging, and
Rapid Heating Methods," R. R. Eitenrniller, Agricultural Experiment Station,
University of Georgia, Athens, GA.

116


     v

Sui3j~c-r INDEX

Adolescents 19,20

Arm-km Indian/Alaska Native women 2,15,19,31,51,52
Attitudes towards breastfeeding 14, l&23,25,29,31,39,44,46
Black women 1, 2, 4, 19,20, 21, 26, 52
Breast pumping 6, 7,34, 38, 39, 40,41, 42,43
Breastmilk 6, 1521, 25,34,38, 39,41, 42,43, 45,46,53
Breastfeeding Promotion consortium 21-22
Rreastfeediig rates l-2, 3, 4, 7,23, 24, 35,36,45, 47, SO, 52, 53
Child care 6-7, 13, 15, 39, 42,43
Child Nutrition and WIC Reauthorization Act of 1989 5,14,31,51
C~earinghouses/libraries/information centers 11,15,16
Collaboration 3,12,19

Commodity Supplemental Food Program 15,30
comxmulity support 33-37
Counseling, see also peer coumellng 16,33-37
Data bases 16, 48

Data collection 4&53
Definitions of breastfeeding 6,48,51,52
Duola 36
Education, continuing 4,8-12
Education, employer 38,43
Education, patient/client 33-34,36
Employment rates 6

Expanded Food and Nutrition Education Program 21
Family support 37
Focus groups 21,44
He&-hy people 2000: National Health PrOmOtiOn and DiiaSe ~&ion
Objectives 2
Healthy People 2000 ~reastfeeding Objective for the Nation 2,4% 52#53

117


Hispanic women 2,19,26,44,45
Homeless women 20
Hospitalized infants 34,42
Hotlines 30,33,36-37

Income l-2
Infant formula 7,21,23-24,29, 31,32,48
Infant health 5,7, 15, 18, 22, 23, 45, 46
I~ocenti Declaration 27
Legislation 2,5-7,14,16,27,3&31,43
Low-literacy 16,20

Low-income women 1, 2, 4,5, 19, 21, 22, 26, 28, 29, 35, 43, 44, 45, 51

Marital smus 3

Maternal age 2,4

Maternal education 2,3,4
Maternal health 5, 15, 16, 18,31, 46, 47
Maternity benefm 7,39-42,43
Migrant women 19,20,21
National Committee to Improve Breastfeeding Promotion Strategies in the MC
m!F-s
N;lcional Health and Nutrition Examination Survey III 51
National Maternal and Infant Health Survey 5 l-52
N;rtfonal Survey of Family Growth 51
Non-English qeakers 6,19,20,21
Nutritional needs 45-46
Omnibus Reconciliation Act of 1990 6
Parental leave 7

Pediatric Nutrition Surveillance System 5 1
pctrp 16,27,31, 34,35, 36, 37, 43, 45
physiokgv 21,44,46
hky statements 14,23-24,27,29,41
hptancy Nutrition Surveillance System 5 1
- Rwr Assessment Monitoring System 5 1
- infants 34,42
- swfcc announCements 22,23,25
- 6,7,14,27,30-31
IRaaa hboratorks Mothers Surve`v 1,2,3,52,53
W-35

118


self-esteem 35

Socioeconomic status 1,3,5
Spanish-language materials 21
Special Projects of Regional and National Significance 4,5,6,9,12,15,17,19,
21, 24, 25, 28, 29, 35, 42, 46
Special Supplemental Food Program for Women, Infants and Children WC)
5, 8-9, 11, 13, 14, 15, 19,22,23,28, 29,30,34,35,36, 37,42,45,46,50, 52
Support groups 33,34-36
Surgeon General's Workshop on Breastfeeding and Human Lactation 3,8,19,
24, 27,33,34, 38,44,48
Survey of Infant Feeding Patterns 52
Surveys/assessments 23, 28, 29, 30,38, 39,41-43,46, 48-53
Technical assistance 5, 11, 14-16
Urban women 35

Working women 4,6-7,29,38-43,45

119