We must identify and reduce barriers which keep women from beginning
      or continuing to @eastfeed their infants.

42. Everett Koop, M.D., Sc.D.
Surgeon General


REPORTY OF THE
SURGEON GENERAL'S WORKSHOP ON
BREASTFEEDING
& HUMAN LACTATION

Presented by the

US. DEPARTMENT OF HEALTH & HUMAN SE&ES
PubkHeaiihservice

Health Resources and services Administmtbn
Bureau of Health Care Dekery and Assistance
Dh4skx of Maternal and Chw Health

h cooperation with
The Uriversilv of Rochester Mediial Center

June 11th and 12th. 1964

DHHS Publication No. HRS-D-MC 84-2


The Surgeon General's Workshop on Breastfeeding and Human Lactation
         was supported by grants from
       The Daisy Marquis Jones Foundation
          Medella, Incorporated
                Parke-Davis

The Division of Maternal and Child Health-Public Health Service
    U.S. Department of Health and Human Services

This Report was edited by the Editorial Department of The National
Center for Education in Maternal and Child Health: Anthony Waddell,
            Director of Publications.

The original drawing on the cover was done by Bob tinge of Rochester, N.Y. Cover
design courtesy of the Publications Office and photos courtesy of the Medical Photo/
     Illustrations Unit, University of Rochester Medical Center.


PREFACE

The Surgeon General's Workshop on Breastfeeding and Human
Lactation represents a milestone in our continuing efforts to improve the
health of our nation's mothers and infants. Research fmdings have docu-
mented the benefits of human milk and lactation for babies and mothers.
One of the. "Health. Promotion/Disease Prevention Objectives for the
Nation" is that by the year 1990, the proportion of women who breast-
feed their babies should be increased to 75% at hospital discharge and
35% at 6 months of age.

The last decade has seen a steady increase in breastfeeding, predomi-
nantly among middle- and upper-income, educated, white women. We
need to identify and reduce the barriers that interfere with breastfeeding,
especially in those population groups with low prevalence of breastfeed-
ing-among women who are minority, low income, and less educated.
  The Workshop has provided an opportunity
  o to review progress of past efforts, in both public and private sec-
   tors, to promote breastfeeding;

  o to assess the state of the art related to factors that enhance and
   those that inhibit breastfeeding and human lactation;
  o to determine remaining challenges;
  o to develop strategies and recommendations in order to facilitate
   progress toward achieving the 1990 Objective.
Building on the model of the Healthy Mothers/Healthy Babies Coa-
lition, this Workshop involved the participation of representatives of
major professional and voluntary organizations. These organizations
working in the public and private sectors will play a major role in the
dissemination and implementation of the national recommendations.
The strategies developed at this Workshop will result in promotion
of sound infant feeding practices and in informed decisions by more
women about breastfeeding their babies.

C. Everett Koop, M.D., Sc.D.
Surgeon General

. . .
111


PLANNING COMMITTEE

Planning Committee for the Surgeon General's Workshop
on Breastfeeding and Human Lactation

WORKSHOP
CHAIRPERSON

WORKSHOP
CO-CHAIRPERSON

Ruth A. Lawrence, M.D., F.A.A.P.
Department of Pediatrics
University of Rochester Medical
Center

Henry A. Thiede, M.D., F.A.C.O.G.
Department of Obstetrics and
Gynecology

University of Rochester Medical
Center

WORKSHOP DIRECTOR

M. Elizabeth Brannon, M.S., R.D.
Division of Maternal and Child Health
U.S. Department of Health and Human
Services

COMMITTEE MEMBERS

Organizational Representatives

Jeanne F. Arnold, M.D., F.A.A.F.P.
American Academy of Family

Physicians

Richard H. Aubry, M.D., F.A.C.O.G.
American College of Obstetricians and

Gynecologists

Betty Ann Countryman, R.N:, MN.
La Leche League International

Judith A. Flanagan, C.N.M., M.S.
American College of Nurse-Midwives

Fred Holmes, M.D., F.A.A.P.
American Academy of Pediatrics

iv


Mary Hughes, Ph.D.
March of Dimes Birth Defects
Foundation

Jennifer R. Niebyl, M.D., F.A.C.O.G.
American College of Obstetricians and

Gynecologists

Julie Norris, R.N.
American Hospital Association

Judy Perkin, Dr.P.H., R.D.
The American Dietetic Association

Nancy Whitley, C.N.M.
Nurses Association of the American
College of Obstetricians and
Gynecologists

Federal Representatives

Joyce 0. Arango, M.P.H., R.D.
U.S. Department of Agriculture

Thor&n A. Fjellstedt, Ph.D.
National Institutes of Health

Vince L. Hutchins, M.D., M.P.H.,
F.A.A.P.

Health Resources and Services
Administration

Patricia Keamey, R.D,, M.S.
The White House

Michael McGinnis, M.D.
Office of the Assistant Secretary for
Health

Univemity of Rochester Representatives

Bernard B. Keele, Jr., Ph.D.
Office of Public Affairs

Paul Lamb&e
Continuing Professional Education

Milton B. Lederman, Ph.D.
Office of Public Affairs

V


WORKSHOP PROGRAM

June l&19%4

MO am. - 12:oo noon

Presiding

Welcome

Introduction of the Surgeon General

8:x) a.m.
Keynote Address

850 km.

Humin Lactation as a physiologic
Pmcess

93 a.m.

the Unique Values of Human Mi

940 a.m.

Bra&feeding Patterns in the United
StZ%tCS

$55 am.

opening menery session
The Strong Auditorium
University of Rochester

Elizabeth Brannon, MS.. RD.
Nutrition Specialist

Division of hlatemal and Child Health
United States Department of Health and Human Services

Robert Sproull, Ph.D.
P&dent

University of Rochester

Frank Young, M.D., PkD.
Vii President for Health Affairs
Dean, School of Medicine and Dentistry
University of Rochester

Ruth A. Lawrence, M.D.
ASSO&XC Professor, Departments of Pediatrics and Gbstetrics

and Gynecology

University of Rochester

Henry A. T&de, M.D.
Chairmen, Deprtment of Gbstetrics and Gynecology
University of Rochester

Michael h&Gin& M.D.
Deputy Assistant Secretary for Health
Disease Prevention and Health Promotion
United Statr, Department of Health and Human Services

C. Everett Koop, M.D., Sc.D.
Surgean Genertd

Ruth A. Lawrence, M.D.

Cutbcrto Garza M.D., Ph.D.
-iate Director, USDA Children's Nutrition Research
zent of Pediitrics
Baylor College of Medicine

Gilbert Martinez, M.B.A.
Director of Marketing Research
Ross~Labomtorics

Nutrition Break

vi


955 a.m.

IO:25 a.m.

The Cultural Context of Breastfeeding
in the United States

Nutrition Break

1050 a.m.
Successful Approaches to Promote
Breastfeeding

State-wide Approach

City-wide Approach

Hospital-based Approach

1 I A0 a.m.
Guidelines for Work Groups

12:15 p.m. - 1:45 p.m,

Audiovisual Presentation
"Outside My Mom"

`I& Lay Volunteer in the
Mother-to-Mother Program of
La Leche League

23Xl p.m. - 430 p.m.

Susan Scrimshaw, Ph.D.
Asaociite Professor of Public Health
Divlalon of Population, Family and International Health
University of Caliiomip. Los Angeles

Henry A. Thiede, M.D., Moderator

Jerianne Heimendinger, D.Sc., M.P.H.
Director of Nutrition Services
Rhode Island Department of Health

Linda Randolph, M.D., M.P.H.
Director, Oftke of Public Health
New York State Department of Health

John E. Alden, M.S., C.N.M.
Indian Health Service
Poplar, Montana

Audrey Naylor, M.D., Dr.P.H.
Co-Director, San Diego Lactation Program
Mercy Hospital and Medical Center

Martin Nacman. D.S.W.
Director, Social Work Divison, Strong Memorial Hospital
Professor, Department of Health Services
University of Rochester

Luncheon

Bridge Lounge and May Room
Wilson Commons

Vince L. Hutchins, M.D.. M.P.H.
Director, Division of Maternal and Child Health
United States Department 4 Health and Human Services

Rabbi Judea B. Miller
Temple B'rith Kodesh

March of Dimes Birth Defects Foundation

Viola Lumon

Founding Member, La Leche League International

Work Groups
Medical Education Building

vii


7:oO p.m.

Master of Ceremonies

Invocation

Speaker
Breastfeeding: New York State's
Infant Health Strategy

June 12, lwlrl

7~45 a.m.

8:30 a.m. - It:45 a.m.

12:oO noon - 1:45 p.m,

Invocation

Speaker
Breastfeeding and the Medii

2:W p.m. - 4~00 p.m,

Presiding

Reports from Work Groups

3a4lO p.m.

3:15 p.m.

Summary of Recommendations and
Presentation to the Surgmn General

Response of the Surgeon General

Closing Remarks

Reception and Dinner
Memorial Art Gallery and Cutler Union
Prince Street Campus

Richard Collins, M.D.
Avon, New York

Charles T. Lavery. C.S.B.
Chancellor, St. John Fisher College

David Axelrod, M.D.
Commissioner, New York State Department of Health

Continental Breakfast
Medical Education Wing

Work Groups

Luncheon
Helen Wood Hall

Robert E. Hoekelman, M.D.
Chairman, Department of Pediatrics
University of Rochester

Chaplain Thomas Herb& M.Div., M.Ed.
Strong Memorial Hospital

Robert Bazell
NBC Network

Closing Plenary Session
First Floor Auditorium
Medical Education Wing

Vince L. Hutchins, M.D., M.P.H.

Open Discussion

Ruth A. Lawrence, M.D.

C. Everett Koop, M.D., Sc.D.

Frank Young, M.D., Ph.D.

. . .
Vlll


CONTENTS

INTRODUCTION ..................................................................................

SURGEON GENERALS KEYNOTE ADDRESS.. ........................
EXCERPTS FROM PRESENTATIONS
    Human Lactation as a Physiologic Process.. .............................
  The Unique Values of Human Milk ...........................................
    Trends in Breastfeeding in the United States ............................
  The Cultural Context of Breastfeeding in the United States ....
  Successful Approaches to Promote Breastfeeding
      State-wide Approach ........................................................
     City-wide Approach .........................................................
      Rural-community Approach ............................................
     Hospital-based Approach .................................................
  Breastfeeding: New York State's Infant Health Strategy .........
  The Lay Volunteer in the Mother-to-Mother Program
    of La Leche League .................................................................
   Breastfeeding and the Media ................................. ..+ ..................
   Reflection on Breastfeeding ........................................................

WORK GROUP RECOMMENDATIONS ........................................

SUMMARY OF WORKSHOP RECOMMENDATIONS.. ..............
RESPONSE OF THE SURGEON GENERAL ................................

CLOSING REMARKS ..........................................................................

APPENDICES
   A-Participants.. ...........................................................................
   B-Facilitators and Recorders ....................................................
  C-Key Elements for Promotion of Breastfeeding in the
        Continuum of Maternal and Infant Health Care.. ..........

    D-Selected Readings .................................................................

1

3

9
14
18
23

30
36
39
41
52

55
58
61

63

75

77

81

82
89

90
92

ix

447-700 0 - 84 - 2


     1

Doctor Beverly Winikoff feeds her daughter, Lindsay.


INTRODUCTION

Breastfeeding is believed to provide substantive advantages to both
the mother and the infant. The mother's choice to breastfeed is most
likely based upon the family's knowledge of breastfeeding and their per-
ception of the environment in which the infant will be fed. Certain bar-
riers at home, work, or school, or in the health care delivery system or
the community can negatively influence both a woman's decision to
breastfeed and her breastfeeding experience. The promotion of
breastfeeding, a national priority, can be achieved through changing
community views.

Knowledge and acceptance of breastfeeding by the general public
are influenced by not only the media but also cultural and ethnic back-
ground, community attitudes, family patterns, and formal education. The
community attitude to be fostered is that breastfeeding is a normal part
of everyday life. A positive attitude toward breastfeeding must be pro-
moted in future parents; public officials and employers must be encour-
aged to remove barriers to breastfeeding; the health care system must
review its policies and procedures to insure that they facilitate
breastfeeding; multi-media approaches to specific target audiences must
be developed; the education of health professionals on the physiology of
lactation and the management of breastfeeding for optimal infant health
must be enhanced.

Excellent models of support in initiation and continuation of
breastfeeding exist. These models need to be shared for application in a
variety of settings. To assess the current status of breastfeeding in the
United States and to develop strategies to facilitate breastfeeding, Dr.
Koop convened the Third Surgeon General's Workshop at the Univer-
sity of Rochester, June 11-12, 1984. The Workshop on Breastfeeding and
Human Lactation brought together from a wide range of disciplines and
settings health professionals who serve different ethnic and cultural
groups throughout the nation. One hundred invited participants included
representatives of professional and lay organizations, local, state and fed-
eral governments, industry, and volunteer groups.

  Speakers at the opening session discussed the physiology and proc-
ess of human lactation, the composition of human milk, trends in
breastfeeding, socio-anthropologic factors, and successful approaches for
promoting breastfeeding. The roles of the lay volunteer and of the media
in the promotion of breastfeeding were highlighted. Participants con-
vened in work groups to consider key issues such as the decision to
breastfeed, socio-cultural influences and determinants of infant feeding
practices, support services for mothers who breastfeed, roles and respon-
sibilities of the health care system in promoting breastfeeding, vocational

1


supports and barriers to breastfeeding, educating health professionals and
the public about breastfeeding,  and research needs related to
breastfeeding and human lactation. Excerpts from presentations and rec-
ommendations of the work groups are included in this Report.

Presenting the findings and recommendations of the Workshop to
the Surgeon General, Workshop Chairperson Ruth Lawrence, M.D.,
synthesized the deliberations of the participants in her summary. The
Surgeon General accepted the report, commented on the general topics,
and stated that this Report of the Workshop would be prepared for
widespread dissemination.

2


KEYNOTE ADDRESS

C. Everett Koop, M.D., Sc.D.
Surgeon General and Deputy Assistant Secretary for Health

In 1978 the World Health Organization set for itself a goal of health
for all by the year 2000. Now this is a tall order, and many of the lesser
developed countries-those with limited resources-will have trouble in
meeting that goal. Other countries, with help from some of the more de-
veloped countries in the western world, will succeed in at least improv-
ing health for all in their countries by the year 2ooO only to see those
gains slip as support is subsequently withdrawn.

The United States is a signatory to "health for all" by the year 2000,
but we in this country had previously set ourselves a series of objectives
to be realized not by the year 2000, but by 1990. These are largely con-
tained in a publication called Healrhy People, the Surgeon General's
Report on Health Promotion and Disease Prevention. This volume was
subsequently supplemented by Objectives for the Nation Among the na-
tional objectives for the United States by the year 1990 is the topic of
this Workshop. This objective states: "The proportion of women who
breastfeed their babies at hospital discharge should be increased to 75%,
and the percentage of those still breastfeeding at 6 months of age should
be increased to 35%." In 1978, when this objective was chosen, the pro-
portion was 45% at hospital discharge and 21% at 6 months of age. His-
torically the federal government has not been idle in the promotion of
breastfeeding. During the years 1946-47 Dr. Katherine Bain of the Chil-
dren's Bureau conducted the first nationwide survey on the incidence of
breastfeeding in hospitals in the United States. This report was published
in Pediatrics in September 1948.

A symposium on human lactation was held at George Washington
University in October 1976 and was co-sponsored by the Public Health
Service, the March of Dimes, and George Washington University. The
proceedings of that symposium were widely disseminated in public
health circles. In 1978, an annotated bibliography on breastfeeding, sup-
ported by the Public Health Service, was published by the National
Academy of Sciences. Then in 1983, a nationwide video-teleconference
on improving nutrition of mothers and babies was co-sponsored by the
Department of Health and Human Services and the United States De-
partment of Agriculture. "Breastfeeding and Human Lactation" was one
of two major topics presented during this 3-hour program viewed at 125
sites coast-to-coast. The program presented an update of new research
findings with special emphasis on practical application. Edited videotapes
of the teleconference are now being disseminated. The Public Health

3


Service has not been idle in current activities. Breastfeeding promotion is
one of the thrusts of the Healthy Mothers/Healthy Babies Coalition. A
breastfeeding kit for professionals is now being produced in collaboration
with several professional organizations, voluntary associations, the De-
partment of Health and Human Services, and the United States Depart-
ment of Agriculture. The National Natality Survey of the National
Center for Health Statistics provides an ongoing surveillance and report-
ing mechanism on educational factors associated with breastfeeding.

But let us return for a moment to objectives for the nation. The cur-
rent roles of the federal government in promoting breastfeeding to meet
the already mentioned 1990 national objective include the following:
  o establishing and promulgating policy;
  o offering professional consultation and technical assistance to
    providers;
  o supporting professional training;
  o conducting research;
  o implementing service delivery; and
  o sponsoring public education.
Let me highlight some of these points. In reference to policy on nu-
trition, the guidelines and policies issued by recognized professional or-
ganizations such as the American Academy of Pediatrics, the American
College of Obstetricians and Gynecologists, the American Academy of
Family Physicians, the National Academy of Sciences, and the Associa-
tion of State and Territorial Health Officials are used by the Public
Health Service in formulating policies and recommendations in maternal
and child nutrition.

  Professional consultation and technical assistance on maternal nutri-
tion, lactation, and infant nutrition are made available through guidance
materials and technical references developed in concert with professional
organizations. For example, recommendations on breastfeeding and other
information on infant feeding are addressed in the Pediatric Nutrition
Handbook published by the American Academy of Pediatrics with the
support of the Division of Maternal and Child Health. An example of a
more recently developed technical reference is Guide to Breasfeeding the
Infant with PKU.

Another federal role is the support of professional training.
Breastfeeding is included in the curriculum of graduate training pro-
grams in public health nutrition and in the maternal and child health cur-
riculum for physicians, nurses, social workers, and other health-care pro-
viders. For example, over the last 10 years, 200 public health nutritionists
have received Title V/Maternal and Child Health support, and 107 nutri-
tionists have received National Health Service Corps scholarships for
training leading to a master's degree.

  As in ah of these endeavors, research and study form the basis for
policy and practice. In government, the National Institutes of Health
plays a major role in breastfeeding research efforts. A revival of interest
in the composition of human milk and the special functions of its many
components has been stimulated by the necessity of devising proper nu-
trient therapy for premature, growth-retarded, and immunologically

4


compromised babies. The National Institute of Child Health and Human
Development has stimulated studies of immunologic and nutrient compo-
sition, as well as perhaps undefined components and possible contami-
nants of coiostrum and human milk obtained from mothers delivering
babies at various gestational ages. In addition, in response to the recom-
mendations from workshops held by the Division of Maternal and Child
Health, in both 1975 and 1976, the National Institute of Child Health and
Human Development is supporting applied studies of human milk-bank-
ing in order to develop techniques of collecting, storing, and distributing
human milk and colostrum for use- in clinical situations. Currently tech-
niques are being developed to combat viral contamination without de-
stroying immunologically active cells or denaturing proteins that possess
antimicrobial activities. The eventual isolation of special immunologic
and nutrient components of human milk which could assist in the care of
premature and growth-retarded babies will be the hoped-for outcome of
such research. As a matter of fact, a workshop was held in September
1982 on human-milk banking in order to provide further stimulation for
this expanding research. The report will be available this summer. The
National Institute of Allergy and Infectious Diseases is studying the role
of breastmilk as a defense against enteric infections. The National Insti-
tute of Environmental Health Sciences is conducting a longitudinal study
of 900 children in. North Carolina to see if childhood morbidity is attrib-
utable to DDT and PCBs in breastmilk.
  In response to the controversy over the International Code of Mar-
keting of Breastmilk Substitutes, two task forces were established by the
Assistant Secretary for Health in November 1981. A Public Health Serv-
ice Task Force on the assessment of scientific evidence relating to prob-
lems of infant feeding, both in domestic and international context, was
chaired by the then-Director of the Centers for Disease Control, Dr.
William Foege. These findings will be published as a supplement to Pedi-
atrics in October 1984. I chaired the other task force on domestic activi-
ties, and the findings have been incorporated into a report that I made to
the World Health Assembly last month in Geneva.
  Education, perhaps the most important aspect of all, should not
really be left until the last. Educational materials on nutrition for use in
counseling parents and other caregivers of children in community health
education programs have been developed by the Public Health Service.
Maternal and Child Health funds are frequently used by the states to dis-
seminate educational materials. An example of this is Breastfeeding, a
publication developed in 1979 and aimed at parents-to-be and new par-
ents. Other federal agencies such as the United States Department of
Agriculture, voluntary groups such as La Leche League, and practition-
ers as well as parents had the opportunity to review the material in draft
and make suggestions. Thus, the publication is as practical and useful as


possible. To date, over 60,000 copies of the publication have been
distributed nationwide.

  Now you might wonder why we are having this Surgeon General's
Workshop on Breastfeeding and Human Lactation. Although the number
of breastfed infants has grown in recent years, the increase has not been
as great in the highest risk groups. The number of women who start to
breastfeed has increased, but many of them do not continue breastfeeding
beyond the first few weeks of their infant's life. We know that
breastfeeding gives babies complete nutrition plus immunologic benefits
to launch them on a healthy life. Breastfeeding also provides its particu-
lar benefits at a low cost. We must therefore identify and reduce those
barriers which keep women from initiating or continuing to breastfeed
their infants. And it is now time to consider what needs to be done. You
have already heard a little bit of why we chose the University of Roch-
ester, but let me expand on that. The University of Rochester School of
Medicine and Dentistry was selected because of its active and unique ef-
forts in the support of breastfeeding. Along with the School of Arts and
Sciences and the School of Nursing, the School of Medicine and Den-
tistry has developed a cluster for the interdisciplinary study of the phys-
iologic, psychologic, sociologic, and anthropologic aspects of human lac-
tation. Dr. Ruth Lawrence, Associate Professor of Pediatrics and of Ob-
stetrics and Gynecology, is the workshop chairperson and a nationally
recognized authority on breastfeeding. She is the author of the primary
text on the subject entitled Breastfeeding: A Guide for the Medical Profes-
sion. The University of Rochester has a strong Obstetrics and Gynecol-
ogy Department whose chairman is Dr. Henry Thiede. He is co-chair-
person of this workshop. Dr. Thiede, in his prior position as the Chair-
man of OB/GYN at the University of Mississippi, was instrumental in
the creation of the certified nurse/midwifery training program.

Now, let us turn our attention to what will be going on here for the
next two days. The luncheon speaker today will highlight the role of the
lay volunteer in the mother-to-mother program of the La Leche League.
On Tuesday, Bob Bazell, Health and Science Correspondent for NBC,
will discuss the use of media in promoting breastfeeding. Speakers this
morning will give us an update on the state of the art and the state of
science on the physiology of breastfeeding, the unique values of human
milk, current trends, and cultural factors related to breastfeeding. This
introduction will provide background for the discussions to follow in the ,
work groups. Models of successful approaches will also be presented this
morning, in order that they become part of our knowledge base. This
afternoon and continuing through tomorrow morning, participants will
convene in 8 work groups to consider and make recommendations on
key issues, such as:

6


  o the decision to breastfeed;
  o so&cultural influences and determinants of infant feeding
   practices;
  G support services needed for initiation and continuation of
   breastfeeding;
  o roles and responsibilities of the health-care system in promoting
   breastfeeding;
  o overcoming barriers to breastfeeding in the world of work,
  o educating health professionals and the public about
   breastfeeding; and
  o research needs in breastfeeding and human lactation.
My charge to the participants of this Workshop is to report the fol-
lowing: which efforts have been successful, which need better applica-
tion, what else do we need to know, and what of the above will better
promote breastfeeding among high-risk groups in order to realize greater
benefits? Now this charge, as I stated earlier, is a tall order, but I know
that you will do this, I know that you will do it well, and I will be here
tomorrow afternoon to receive your report.
  Thank you very much.


EXCERPTS FROM PRESENTATIONS

HUMAN LACTATION AS A PHYSIOLOGIC
  PROCESS

Ruth A. Lawrence, M.D.

Lactation is the physiologic completion of the reproductive cycle.
The breast, the body, and the psyche are prepared for lactation during
pregnancy. The newborn infant is prepared to suckle at the breast at
birth.

Growth of the mammary gland is a gradual process that starts
during puberty under the influence of the sex steroids. The embryonic
buds which developed initially in the fetus and have been quiescent since
birth are stimulated by estrogen to proliferate and to become multilay-
ered. Buds and papillae are formed. The lobuloalveolar development and
ductal proliferation depend on the intact pituitary gland.

There are three major stages of activity: I) mammogenesis-mam-
mary growth, which begins embryonically and culminates during preg-
nancy, 2) lactogenesis-the initiation of milk secretion, which begins in
pregnancy and increases at delivery, 3) galactopoeisis-maintenance of
established lactation, which begins a few days postpartum and continues
as long as there is stimulus.

The embryonic breast begins its preparation at puberty when the hy-
pophyseal-ovarian-uterine cycle is established. Fifteen to 20 primitive
ducts arborize extensively and form a compound tubuloalveolar gland. A
relatively inactive stage continues through adult life until pregnancy ini-
tiates the proliferative stage. Spectacular ductal growth begins in re-
sponse to luteal and placental hormones. There is true hyperplasia, but in
an orderly fashion, as one alveolus does not overrun another. (Figure I)

The hormones-placental lactogen, prolactin, and chorionic gonado-
tropin-contribute to the acceleration of growth. At this stage one can
observe the complex interaction of the many hormones that function in
the development of both the fetus and the breasts during pregnancy. Es-
trogen stimulates ductular sprouting, and progesterone stimulates lobular
formation. There is a delicate balance of prolactin inhibiting factor in the
hypothalamus and prolactin production in the adenohypophysis as the
presecretory phase progresses in the second trimester to a secretory
phase. In this phase, material resembling colostrum is seen in the alveoli
stimulated by placental lactogen.

A mother delivering a previable infant at 16-weeks gestation will se-
crete colostrum. As early as 24 weeks, lipid droplets can be seen in the

9


     A          8          C          D          E
Figure 1. Female breast from infancy to lactation with corresponding cross section and
duct structure. A, B, and C, Gradual development of well-differentiated ductular and pe-
ripheral lobular-alveolar system. D, Ductular sprouting and intensified peripheral lobular-
alveolar development in pregnancy. Glandular luminal cells begin actively synthesizing
milk fat and proteins near term; only small amounts are released into lumen. E, With post-
partum withdrawal of luteal and placental sex steroids and placental lactogen, prolactin is
able to induce full secretory activity of alveolar cells and release of milk into alveoli and
smaller ducts.

alveolar cells. The composition of the secretion is fairly consistent from
16-17 weeks right up to the time of delivery.

With the delivery of the placenta, the source of hormones is lost
abruptly and the plasma levels begin to fall. Placental lactogen is gone
within hours, progesterone within 2-3 days, estrogen reaches basal levels
within 5-6 days, but prolactin levels depend upon the amount of suck-
ling. In the non-nursing mother, prolactin drops to prepregnant levels in
about 14 days. Observation of nursing mothers with retained placenta in-
dicates that lactation is suppressed until the placental fragments are re-
moved. This supression is similar to the lack of milk secretion seen in
mothers experiencing an intrauterine death. Evidence strongly suggests
that it is loss of the placental progesterone with the decline in plasma
progesterone which triggers galactogenesis, or milk production.

The necessity for adequate levels of prolactin for lactation to begin
in humans has been demonstrated. The exact role of prolactin in ade-

10


quate milk production, however, continues under investigation. In the
first week postpartum, the high levels of prolactin are only slightly aug-
mented by nursing. In the second stage, from 2 weeks to 2 months, base-
line levels of prolactin are 2-3 times normal, and increase to 10-20 times
normal with suckling. The third phase begins at about 3 months and lasts
to weaning. Prolactin levels are almost normal, and no rise is seen with
suckling, even though milk production continues.

  The role of other hormones such as insulin and thyroxine in
mammogenesis, lactogenesis, and galactogenesis is well established, but
the definition of their roles does not have universal agreement. The
breast does not function in isolation, but in synchrony and balance with
the maternal endocrine system.

The process of milk synthesis is complex. There is a marked alter-
ation of the maternal metabolism with a redistribution of the blood
supply and an increased demand for nutrients. The mammary blood
flow, cardiac output, and milk secretion are suckling-dependent. These
changes in turn trigger the hypothalamus to release prolactin to act on
the mammary cells. Milk is iso-osmolar with plasma in all species. Al-
though milks of different species vary tremendously, each is physio-
logic for the growth demands of that species.
The biosynthesis of milk involves a cellular site where the metabolic
processes occur. Milk is secreted by apocrine and merocrine mechanisms.
Protein and fat are synthesized de novo; lactose is synthesized from glu-
cose; ions and water diffuse across the membrane so that primary alveo-
lar milk is diluted to plasma isotonicity by water extracted from extracel-
lular fluid.

While the glands prepare for full lactation, other structures of the
breast prepare as well. The areolae increase in prominence with the de-
velopment and activity of the glands of Morgagni which provide a secre-
tion to lubricate and protect the nipple and areolae during suckling.
Some of the zealous rituals recommended to mothers during pregnancy
(such as scrubbing, buffing, and stretching these tissues) actually interfere
with nature's process.

During pregnancy, the body stores nutrients that are intended for
the manufacturing of milk in the postpartum period. Eight to 10 pounds
of added weight (neither fetus, placenta, uterus, or fluid) are carefully
stored for future nutrient and energy needs. The body stores reflect the
cumulative dietary intake of prepregnancy and pregnancy coupled with
the short-term dietary variation to ensure daily sources of both macro-
and micronutrients. Thus the daily nourishment provided through the
milk is consistent and balanced. Temporary deficiencies of diet are com-
pensated by body stores.

Lactation also influences the return to prepregnant state for the
mother. Getting back "in shape" is facilitated by utilizing the extra
weight of pregnancy for milk production. Thus, breastfeeding women
return to baseline weight more quickly.

The direct effect of the oxytocin released on stimulus of suckling
not only contracts the myoepithelial cells for milk ejection but also con-
tracts the uterus for faster physiologic involution and increased tone.

11


  In most anticipated normal pregnancies, a woman finds that the hor-
monal milieu triggers latent maternal instincts leading to anticipation of
holding the infant closely to the breast and providing continued nourish-
ment. Parenthood potentially provides the opportunity for psychologic
growth from the egocentricity of adolescence to an adult self-concept in
which the mother cares for and nourishes this new being.

  The mind, however, is not controlled by body function alone. Many
societal, community, family, and individual forces influence attitudes and
feelings about breastfeeding. If a woman rejects her own mother as a
model, other life experiences prevail. There are other psychodynamic
issues and social trends that may lead to negative decisions about
breastfeeding.

In the meanwhile, the fetus is simultaneously undergoing develop-
ment. The infant is prepared to suckle shortly after birth. The newborn
already has been making sucking motions in utero. Part of the balance of
the amount of amniotic fluid depends upon the fetus sucking and swal-
lowing fluid in utero. Until birth, the infant has not had to synchronize
this action with breathing, but as Tizzard showed in England some years

Hypothalamus

Figure 2. Diagrammatical outline of ejection reflex arc. When infant suckles breast, he stim-
ulates mechanoreceptors in nipple and areola that send stimulus along nerve pathways to
hypothalamus, which stimulates the posterior pituitary to release oxytocin. It is carried via
bloodstream to breast and uterus. Oxytocin stimulates myoepithelial cells in breast to con-
tract and eject milk from alveolus. Prolactin is responsible for milk production in alveolus.
It is secreted by anterior pituitary gland in response to suckling. Stress such as pain and
anxiety can inhibit let-down reflex. The sight or cry of infant can stimulate it.

Figures by permission of C. K Mosby Cotipany.

12


ago, suckling at the breast is compatible with continuous breathing com-
pared to the suck-swallow-breathe pattern of the infant while bottle feed-
ing. The infant also has a rooting reflex that helps him turn to grasp the
nipple. The normal newborn infant adapts to breastfeeding readily.
When the infant grasps the nipple and areola, the sucking stimulates
the nerve fibers in the nipple and these, in turn, stimulate the afferent
nerve fibers via the spinal cord to the mesencephalon and the
hypothalamus in the maternal brain and trigger the pituitary to release
two hormones-prolactin and oxytocin. (Figure 2) The prolactin stimu-
lates the synthesis and secretion of milk itself. The oxytocin rapidly
causes the ejection of milk from alveoli and smaller ducts into larger lac-
tiferous ducts and sinuses by stimulating the myoepithelial cells to con-
tract. The myoepithelial cells (or basket cells) are wrapped about the
ducts, and when they contract, milk is ejected. Milk ejection involves
both neural and endocrine stimulation and response. A neural afferent
pathway and an endocrine efferent pathway are required, but this stimu-
lus is triggered predominantly by touch and not by pressure of a full
milk gland. This response may be inhibited by pain or stress.
  Breastfeeding is not a reflex; it is a learned process. In our present
culture, many women have never witnessed an infant at the breast. When
a woman is called upon to nurSe her own infant, much of her success
depends on a learning process. Successful lactation depends on proper in-
formation. As increased numbers of women breastfeed, we need more
knowledge to help those who have difficulty in lactating. Another phys-
iologic effect of lactation-important, though it receives little notice-is
the suppression of ovulation and of menses. There is a temporal differ-
ence in the return of menses and ovulation among women who fully lac-
tate, who partially lactate, and who have either discontinued breastfeed-
ing or never began. The nonlactating woman ovulates within 4-6 weeks
of delivery; the lactating woman does not ovulate for 4 months or more.
This effect plays a role in general population statistics.
  Finally, as we look at all the physiologic processes, the interaction
of the breast with the mother's other bodily functions, we see that breast-
feeding is an art-one based on the science of lactation. We need to con-
tinue our explorations, for as Aristotle would have it: "There is a reason
behind all these things in nature."

13


THE UNIQUE VALUES OF HUMAN MILK

Cutberto Garza, M.D., Ph.D.

Introduction

  Recommendations of human milk as the ideal nutrient source for
term infants are common. These endorsements and the growing clinical
interest in its use have prompted a remarkable increase in studies of
human milk. The results of such investigations have underscored the dual
roles played by its constituents: 1) the classic role that is associated with
most nutrients, i.e., the provision of enzymatic cofactors or substrates for
energy or structural components and 2) a more complex role that is the
performance of functions complementing the developing abilities of ma-
turing infants. For example, proteins provide amino acids for growth, but
they occur in the form of polypeptides that aid in digestion, host defense,
and other functions. Lipids provide a major source of energy, but some
also have antiviral properties that may impart protection to the develop-
ing infant. In addition, this nutrient class provides fat-soluble vitamins
and essential fatty acids that are important structural membrane compo-
nents, especially in the nervous system. Carbohydrates provide a signifi-
cant portion of the energy in milk and also enhance mineral absorption,
i.e., calcium; modulate the growth of bacteria, i.e., bifidus factor; and
possibly act to prevent the attachment of selected bacteria to
retropharyngeal and other epithelial cells found in respiratory and gas-
trointestinal surfaces exposed to environmental pathogens.

Milk Intake of Breastfed Infants

The unique pattern of constituents in human milk and the feeding
practices inherent to breastfeeding appear to result in distinctive levels of
milk intake between breast- and formula-fed infants. Recent data indicate
that the intake of breastfed infants reaches a plateau at approximately 733
g/day through the first 4 months of lactation. Therefore, on a body
weight basis, the energy intake falls from approximately 110 to 70 kcal/
kg by the fourth month. These intakes are substantially below those of
formula-fed infants and below levels currently recommended for this age
group by the National Research Council.

Despite these differences between recommended amounts and ob-
served intakes, exclusively breastfed infants appear to grow well. Never-
theless, the possibility that human milk may become limiting by the
fourth month for most infants has been suggested. Current measurements
of the intakes of infants whose diets are supplemented ad libitum with
solids, however, do not support this view. Results of these recent studies
indicate that when the diet of the exclusively breastfed infant is comple-
mented with solid foods, intakes remain at approximately 70 k&/kg, and
infants continue to grow well.

14


These findings raise interesting points for discussion. They suggest
that a child's energy intake is dependent upon the mode of feeding. It is
not clear if the differences in intake between formula- and breastfed in-
fants represent a more active "gate-keeping" role by mothers of formula-
fed infants or represent sound physiologic responses to different nutrient
sources.. Formula-fed infants may require "more" food to attain approxi-
mately the same endpoint as their human-milk-fed counterparts. Human
milk is a highly complex mixture with a nutrient balance that may pro-
mote a level of metabolic efficiency unattainable by the formula-fed
infant. Yet, if we compare present estimates of the quantities of energy
required for growth and maintenance by the Cmonth-old infant, it ap
pears that the exclusively breastfed infant would have no energy avail-
able for activity. Are the metabolic economies recruited to achieve the
apparent high level of efftciency in the breastfed infant accomplished by
more conservative uses of energy for growth and maintenance, or are
these efficiencies accomplished by a significant curtailment in activity?
Are the same levels of efftciency possible under hostile environments? If
the energy consumed by bottle-fed infants represents a true excess, are
there any positive or negative short-term or long-term consequences?
These observations pose questions of significance to the general health of
all infants.

Functional Components: An Example-Secretory IgA

The issues raised by the differences between energy and protein in-
takes of formula- and human-milk-fed infants are interrelated with the in
vivo roles of milk components with demonstrated functional potentials.
Of these components, those with protective functions have been exam-
ined most actively. Secretory IgA (SIgA) is the predominant immuno-
globulin in human milk and is thought to represent one of its key protec-
tive agents.

Specific SIgA antibodies are found against a wide array of bacterial
and viral organisms. This protein has the ability to adhere to mucosal
surfaces and prevent the subsequent attachment, and possibly the inva-
sion, of specific infectious agents. Significant data exist indicating that
the appearance of these specific antibodies in milk is a response to envi-
ronmental challenges. Specific antibodies have been observed in the first
few weeks of lactation and are known to persist through 2 years of lacta-
tion. Observations made during weaning suggest that these antibodies
persist through the period of decreased suckling stimulation.

  The presence in human milk of SIgA antibodies which act against
potential pathogens in the maternal environment provides for "environ-
mentally specific" milk. The mechanism by which these antibodies, di-
rected against gastrointestinal and respiratory pathogens, appear in
human milk has been difficult to identify. In contrast to the gastrointesti-
nal and respiratory tracts, where such SIgA is abundant, direct contact
with such antigens is unlikely to occur in breast tissue. Experimental data
suggest that immune  cells  travel from  gastrointestinal   and
respiratory-associated immune tissues to multiple mucosal surfaces, in-

15


eluding breast tissue, and thereby effect the same specific immunity to all
mucosal surfaces. During lactation, the "homing" of these cells to the
breast appears to be activated by hormonal profiles which exist only in
lactating women. The concept of a gastrointestinal-respiratory-mammary
immune circulation provides an explanation of the means by which anti-
gen stimulation at distant sites results in the local production of specific
SIgA antibodies in milk.

This is one example of a protein with a great degree of specificity.
There are other proteins that have more general, potentially protective
functions. It is important to emphasize that carbohydrates and fats also
have functions which may contribute to the high level of metabolic efft-
ciency apparently characteristic of the breastfed infant.

Significance of Functional Components

Although the potential roles of specific antibodies, nonspecific
immunologic factors, and other functional components may be extrapo-
lated from laboratory studies, a definitive demonstration of their signifi-
cance in free-living populations has been much more problematic. For
example, differences in morbidity between bottle- and breastfed infants
often are difftcult to interpret because of confounding environmental and
demographic variables. Factors such as the degree of preventable con-
tamination of artificial formulas, the number of caretakers with whom
the child has contact, the behavioral characteristics of the caretaker-in-
cluding sanitation practices and other mothering skills, the number of po-
tential disease-carrying contacts, etc.- are difficult to control unless ap-
propriate data are collected and sufficiently large numbers of subjects are
recruited. Research designs must account for the "unidirectional" flow of
infants from one feeding category to another. A breastfed infant may
become exclusively bottle-fed for many reasons. An exclusively bottle-
fed infant, however, is unlikely to become exclusively breastfed. Al-
though most studies that compare morbidity among children fed human
milk or synthetic formula have not controlled adequately for all of the
confounding factors, most studies from developed and developing coun-
tries have reported significantly fewer illnesses in breastfed infants. A
few have found no differences, but there are no reports of increased
morbidity among the human-milk-fed groups. Differences in morbidity
between feeding groups have been demonstrated more consistently, how-
ever, in developing countries than in developed countries. Whereas avail-
able data are not conclusive, they generally support the theory that
human milk provides components that complement a developing immune
system in the infant. Although it is not known whether these comple-
mentary components participate in the improved development of active
immunoprotective abilities, they may serve as substitutes until the infant
matures sufficiently to mount an active immune response. Whether or
not the protective effects of human milk components are made real or
potential by environmental conditions, such benefits are available only if
the infant is breastfed.

16


Conclusion

Knowledge of the apparent differences between the ad libitum in-
takes of breast- and formula-fed infants, changes in the composition of
human milk as lactation progresses, and responses of immunologic fac-
tors in human milk which effect environmentally specific protection con-
tribute to the consensus that feeding human milk to infants is beneficial.
The implementation of this consensus requires the identification of bar-
riers that impede successful lactation. The consensus that recommends
human milk also poses a significant opportunity to private and public
health services to aid in the implementation of a practice which pro-
motes health and fosters greater individual responsibility for health.

17


TRENDS IN BREASTFEEDING IN
  THE UNITED STATES

Gilbert A. Martinez, M.B.A.

In 1971 the incidence of breastfeeding declined to its lowest level-
25%. Since then, breastfeeding has increased to 61.9% in 1982 and has
declined marginally to 61.4% in 1983. (Figure 1)

The duration of breastfeeding similarly declined in 1971 to its lowest
level of 9% of women who breastfed 3 months or longer. Since then,
breastfeeding for at least 3 months has increased to 40% of women
giving birth in 1983.

Between 1978 and 1983 breastfeeding increased from 47% to 61%
nationally, with substantial variation among socio-demographic groups.
The highest incidence of breastfeeding occurs among well-educated, rela-
tively affluent, somewhat older women living in the Western part of the
country. Conversely, the lowest proportion of women breastfeeding is
among mothers under 20 years of age, grade-school educated, lower
income, black, and living in the East South Central part of the country-
Kentucky, Tennessee, Alabama, and Mississippi. (Figure 2; Table 1)

The proportion of women breastfeeding their infants at 5 and 6
months of age increased from about 20% in 1978 to 27% in 1983. The

96
70

60

50

40

30

FIGURE l- Incidence of Breastfeeding U&A.
% of Infants Breastfed by Year 1970.1983

- In-Hospital (Ross)     /-

r

L- Government

01      I      I      I      I      I      I      I      I      t      I
70 71 72 73 74   '75 76-77 '78-79 '80-81  '82 '83

Savs: Ram bbombxks Naticd Mothas Survey
   Nati!mal Survey Family Growth, NCHS

18


FIGURE 2. MS3 Incidence of Bread-g by US. Census Regions

@@ h than 58.4    m 58.4 - 61.4
ffjJ&Q 61.4 - 75.0      m Above 75.0

Source: Ross Laboratoti National Mothers Survey

same differences by socioeconomic groups previously mentioned prevail
at 5 and 6 months of age.

The most rapid percentage increases in the incidence of breastfeed-
ing between 1978 and 1983 occurred among women with the least educa-
tion, employed full-time, multiparous, and in the West South Central
area-Arkansas, Louisiana, Oklahoma, and Texas. The least rapid per-
centage growth occurred among mothers under 20 years of age, the
well-educated, the unemployed, and those with lower incomes.
The proportion of black women who breastfed their infants in 1978
is unavailable. Hendershot reported 17% of black women breastfed their
infants in 1975. For the 2-year period of 1978-1979, 24% of black infants
were breastfed. In 1983 that figure had increased to 32%. (Figure 3)
The proportion of black women who breastfed their infants in 1983
for 3 months or more was 20%, and was less than half of the 42% of
white women who breastfed for 3 months or more.
Among black women, as among the whole country, the lowest inci-
dence of breastfeeding occurs among young, less educated, low-income
women, and, as is true among all women, the highest incidence of
breastfeeding occurs among those Blacks with the most education and
income. (Table 2)

The proportion (54%) of Hispanic women who breastfed their in-
fants in 1983 is less than the national rate.

19


FIGURE 3- Incidence of Bred&ding USA.
9% of Infants Breaded by Race 197043

  White (Government)
r
r Black (Government)

White

70   71   72   73   74

Souras: Ros Laboratories National Mothers Survey
   National Survey Family Growth. NCHS

75   `76-77  78-79  `80-81   `82   `83

Rank

1
2
3
4
5
;
8
9
10
11
12
13

14
15
16
17
18
19

20

TABLE l- Breastfeeding by Demographics: 1983

Characteristic

Percent
breastfed 1

College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pacific.. ....................................................................................
Momltain .................................................................................
> S25,OOO income.. ...................................................................
30 to 34 years of age.. ............................................................
25 to 29 years of age.. ............................................................
Primiparous .............................................................................
$15,000 to $24,999 income.. ...................................................
White .......................................................................................
West North Central.. ..............................................................
Not Employed ........................................................................
New England.. ........................................................................
$10,000 to $14,999 income.. ...................................................
National.. .................................................................................
Employed.. ..............................................................................
35+ years of age.. ..................................................................
East North Central.. ...............................................................
Multiparous.. ...........................................................................
West South Central.. ..............................................................
20 to 24 years of age ..............................................................

78
78
77
71
67
::
64
64
63
62
61
61
zi
60
59
58
58
57

Percent of
bi*E i 3

33
16
6
32
16
ii
26
80
8
65
5
I5

35
5
18
57
13
33


Rank

20
21
22
23
;:
26
27
28
29

Characteristic

Percent
breastfed r

South Atlantic. .........................................................................
Hispanic ...................................................................................
High School Education .........................................................
Middle Atlantic ......................................................................
East south central .................................................................
<5 lbs. 8 oz. biiweight .......................................................
< $10,000 income ....................................................................
<20 years of age.. ..................................................................
Grade School Education .......................................................
Black ........................................................................................

57
54
54
52
49
46
44
43
41
32

I

15
15
63
13
7
7
26
15
4
16

sources:

r Ross Laboratories' Mothers' Survey.
z Advance Report of Fii Natality Statistics, 198 1.
s Population Characteristics, Series P20, No. 386, April 1984 (women 18-44 years of age).

TABLE 2- Breastfeeding by Demographics among Blacks: 1983

Rank            Characteristic

1
2
3
4
5
6
7
8
9
10
11
12
13
14

15
16
17
18
19
20
21
22
23
24
25
26

Pacific ........................................................................            9      16
Mountain ...................................................................            1       6
>S25,ooO income.. .....................................................    56      13      32
College.. .....................................................................    55      22      33
New England ............................................................    54       2       5
Sl5,OOO to $24,999 income.. .....................................    45      18      26
Employed ..................................................................    41      33      35
35+ years of age ......................................................    41       4       5
West North Central.. ................................................    38               8
30 to 34 years of age ................................................    38   1:      16
25 to 29 years of age ................................................    38       24      31
Primiparous ...............................................................    38      40      43
East North Central.. .................................................    36       17      18
Middle Atlantic.. .......................................................    33      15      13
Nation01 .....................................................................    32
SlO,OOO to 814,999 income.. .....................................    31       13      15
West South Central ..................................................    31       14      13
20 to 24 years of age ................................................    30      35      33
Multiparous ...............................................................    29      61      57
(5 lbs. 8 oz. birthweight.. ........................................    28       13       7
South Atlantic.. .........................................................    27      28      15
Not Employed ..........................................................    27       67      65
Grade School Education .........................................    27       5
High School Education.. ..........................................    23      73   6':
<$lO,tXlO income.. ....................................................    20       55      26
East South Central ...................................................    20       11       7
<20 years of age ......................................................    15       25      15

              Percent
Percent   Percent
breastfed 1  of black   of all

I         births 2 s  birthsaS

sourcea:

t Ross Laboratories Mothers' Survey.
* Advance Report of Final Nirtahty Statistics, 1981.
8 Population Characteristics, Series P20, No. 386, April 1984 (women 18 to 44 yeurs of
WI.

21


The decision to breastfeed is made by well over half the women
prior to pregnancy. In 1981, 55% of breastfeeding women had made that
decision before becoming pregnant and, in 1984, that number had in-
creased to 63%. An additional 14% of breastfeeders made the decision
during their first trimester, and, by the time of delivery, 98% of breast-
feeding women had made their decision. In two prospective studies
asking women what they intended to feed their infants and subsequently
contacting them after the infant was born, 96% had implemented their
prenatal decision to breastfeed.

In summary, both the incidence and duration of breastfeeding in-
creased significantly among all segments of society from 1971 to 1982.
These gains did not continue in 1983, with the incidence dipping slightly
from 61.9% of mothers in 1982 to 61.4% in 1983. The figure remains a
function of socio-demographic variables: older, well-educated, relatively
affluent women living in the Western United States are more likely to
breastfeed; younger, less well-educated, black women in the East South
Central United States have the lowest incidence of breastfeeding. Contin-
ued gains will need to come from this latter group. Since the decision to
breastfeed is made by more than half of women before pregnancy, three
groups-the black, the young, and the poorly educated-need to be
reached early if they are to be influenced to breastfeed.

22


THE CULTURAL CONTEXT OF BREASTFEEDING
  IN THE UNITED STATES

Susan C.M. Scrimshaw, Ph.D.

Breastfeeding, Etknicity, and Socioeconomic Status

Research on breastfeeding in the U.S. reflects two biases frequently
found in medical and public health literature. First, ethnicity, and some-
times even socioeconomic status are not even mentioned in many reports.
Second, reports mentioning ethnicity and socioeconomic status often
focus on incidence without discussing correlates such as attitudes, reasons
for the observed behaviors, and the influence of sociocultural background.

The ethnic groups frequently discussed in the U.S.-Asians, Blacks,
Latinos, and Native Americans-are each in fact a complex set of dis-
tinct "sub-groups," with varying degrees of acculturation and levels of
socioeconomic status. For example, Latinos include major subgroupings
of Cubans, Puerto Ricans, Mexicans, and Mexican Americans with small-
er numbers of Dominicans, Salvadorans, Guatemalans, and many more
people from Central and South America and the Caribbean. Some La-
tinos, especially from the Caribbean and circum-Caribbean areas, are
Black and reflect influences of African cultures. While few studies make
comparisons between subcultures in relation to breastfeeding, important
differences exist. For example, in her report on feeding practices among
Anglos, Cubans, and Puerto Ricans in Dade County, Florida, Bryant re-
ports that most Puerto Ricans think breastfeeding is better for babies, but
almost half the Cuban women think bottle feeding is better.

Blacks, frequently thought of as one culture in this country, not only
divide into obvious groups like Haitians and Panamanian Blacks, but
vary in terms of parts of the country and rural or urban residence. A
rural southern Black and an urban western Black are as different from
each other as their White counterparts from the same region. Individuals
in each subcultural group are proud of their heritage; they resent being
lumped with others they perceive as dissimilar. Unfortunately, most of
the literature that does discuss breastfeeding and ethnicity does not make
these subcultural distinctions.

  Many of these variations are reduced when socioeconomic and edu-
cational statuses are considered. Baranowski et al. showed bimodal edu-
cational relationships to breastfeeding in a tri-ethnic population. Both the
least and the most educated were more likely to breastfeed. Middle- and
upper-class women are now more likely to breastfeed, although research
comparing middle- and upper-class women with lower-class women
within ethnic minority groups is conspicuous by its absence. Studies such
as Baranowski's which compared low socioeconomic status Anglo-Ameri-
cans, Black Americans, and Mexican Americans show significant differ-
ences between ethnic groups. It should be noted that Baranowski et al.
do not distinguish between Mexicans and Mexican Americans, although

23


they report that some of their Mexican American sample were inter-
viewed in English and some in Spanish.

Higher educational attainment is also correlated with breastfeeding.
Again, the effect of education within ethnic groups and subgroups has
not been adequately documented.

Frequency and Duration of Breastfeeding by Ethnic@

The data on frequency and duration of breastfeeding by ethnicity
vary greatly by region and by ethnic group. There is relatively little in-
formation on Asian populations, and even less on Native American popu-
lations. Breastfeeding in all populations declined from the beginning of
this century until the early 197Os, and Blacks may have experienced the
greatest decline. Prior to 1960, the majority of Blacks and Latinos
breastfed their first babies, and nursed longer than Whites.

The trend began to reverse in the early 197Os, but this change ap-
pears to be occurring more quickly in White than in Latino, Asian, or
Black populations. Current figures for Latinos on breastfeeding at dis-
charge from the hospital range from 18% in Upper New York State to
60% in Northern California and 74% in Southern California. Asians are
poorly represented in the literature, but Samuels reports that 67% of the
Asians in her Northern California HMO population were breastfeeding
at hospital discharge. The proportion of Blacks breastfeeding at hospital
discharge ranges from 20% in Hartford to 26% in Chicago and 52% in
Northern California. These discrepancies illustrate regional and perhaps
also rural/urban variations, but probably reflect subcultural and socio-
economic variations as well.

An example of probable variations according to socioeconomic
status is that the Blacks studied by Samuels were participants in a Kaiser
HMO as an employment benefit. Their socioeconomic status is probably
higher than that of the inner-city Blacks studied by Mohrer. The 74%
figure for Latinos in Southern California is from our project, which
looked at a population of 5 18 women, 96% Mexican in origin, 4% Mexi-
can in descent. The relatively recent Mexican origin of most of these
women probably accounts for the very high rate, and illust~:es the im-
portance of being able to distinguish between subcultures.

Duration of breastfeeding also varies, but drops off sharply after the
fust two or three months. According to Martinez and Nalezienski, in
1978 47% of all U.S. women were breastfeeding at hospital discharge,
35% were breastfeeding at two months postpartum, and 20% were
breastfeeding at six months postpartum. In one of the two Southern Cali-
fornia hospitals we studied, 86% of the Latinos (primarily Mexican)
planned to breastfeed as of their in-hospital postpartum interview, but by
the six-week postpartum visit, only 43% were still breastfeeding. On the
other hand, a greater proportion of Whites breastfed and did so longer.

24


Barriers to Breastfeeding

UNDERLYING FACTORS

Few of the underlying factors associated with bottle-feeding rather
than breastfeeding can be directly related to ethnicity, but relate instead
to socioeconomic status or are reported by women in all ethnic groups.
Cultural values, however, are likely to influence how these factors are
interpreted by women. These factors include: general perceptions of the
value of breastfeeding (mostly positive), the baby's father's feelings,
embarrassment at the exposure of the breasts, concerns about interfer-
ence with sexuality, questions about mother's temperament and suitability
for breastfeeding, anxieties about the mother's ability to produce high
quality and sufftcient milk, perception of bottles as convenient, percep-
tion of breastfeeding as old-fashioned, concerns about breastfeeding ruin-
ing the figure, and work intentions.

  In addition to socioeconomic and educational status, marital status
provides another underlying factor. Several studies show that married
women are more likely to breastfeed. The proportion of married women
giving birth varies by ethnicity, as do socioeconomic status and educa-
tional level.

One factor identified by Bryant is the husband's role. She found that
husbands were more often against breastfeeding in the Cuban and Puerto
Rican families she studied, and that Anglo husbands varied from beiig
very supportive to indifferent and sometimes negative. The husbands in
both Latin0 groups were concerned about exposure of the breasts, inter-
ference with sexual activity, and the perceived "old-fashioned" nature of
breastfeeding. This finding may appear to contradict the previously men-
tioned finding that married women are more likely to breastfeed, but
other factors such as the need to work and social isolation may influence
single women.

One perception often found in Latin0 populations is that of "bad
milk" due to maternal stress or tendency to have a temper. Mexicans,
Hondurans, Puerto Ricans, and Cubans have all described concern that
maternal anger and stress would produce bad milk, which would make
the baby sick. This concern was cited as a reason not to initiate lactation.

Another interethnic difference identified by Baranowski is the role
of the support person. The male partner was the most important breast-
feeding support person for the Anglo woman, the woman's mother was
most important to Latinos, and a close friend was most important to
Blacks. In this study, it was asserted that the woman's mother actually
had a negative effect on Anglo women.

Despite these interethnic differences, one major underlying obstacle
to breastfeeding in all groups is the woman's need to work postpartum.
While many women never even initiate breastfeeding because of postpar-
tum work plans, others simply stop sooner in order to return to work. In
our sample of 518 Mexican women, significantly fewer women planned
to breastfeed if they intended to return to work soon. The proportion
breastfeeding increased with a later return to work. The highest propor-

25


tion planning to breastfeed did not have any immediate plans to return to
work. Women were more likely to return to work soon if they did not
have economic support from the baby's father and if they were neither
married nor planning to be. Duration of breastfeeding was also influ-
enced by work plans, the variable most predictive of breastfeeding dura-
tion. Factors such as educational level and social support did not predict
intended duration.

  Embarrassment at feeding in public is more difficult to address than
some of the other obstacles, particularly since women are occasionally
arrested for indecent exposure while breastfeeding. In this society,
women are often told to go to the restroom to breastfeed, where (implic-
itly) excretory acts belong.

Influences During Pregnancy

During pregnancy, family and friends may discuss breastfeeding
with the woman, and their influence is reflected in some of the data al-
ready described. At this point, the health care providers enter, and can
either encourage or discourage breastfeeding by their attitudes and by
the information conveyed to the pregnant women. Some studies mention
that women did not breastfeed because "it did not occur to them." Many
others fmd that hospitals and clinics encouraging breastfeeding report a
higher incidence. An intervention study at Roosevelt Hospital in New
York revealed that prior to the onset of a prenatal breastfeeding
education program, only 11% of a large Hispanic patient population in-
tended to breastfeed. At the time of the evaluation of the program, 40%
intended to breastfeed, and the majority (70%) followed through with
their intentions.

Hospital-Based Influences: Delivery and the Early Postpartum Period

  Regardless of ethnicity of the mother, the hospital experience
strongly influences both initiation and duration of breastfeeding. Obsta-
cles reported in the literature include: medications given during labor
and delivery, delivery complications, cesarean section, baby complica-
tions, lack of early mother-infant contact and opportunity to nurse, use
of stilbesterol for the suppression of lactation, offering water and formula
to the breastfed newborn, restricting maternal access to the baby, re-
stricting feedings to every 4 hours, lack of support for overcoming en-
gorgement, sore nipples, not giving nursing mothers enough food or
liquid, not allowing mothers access to supportive family members during
hospital stay, and encouraging breastfeeding mothers to give babies for-
mula after nursing to "fill them up."

  Postpartum contact was associated with breastfeeding duration. Hos-
pitals differ significantly in the location and timing of the first attempt to
breastfeed, with some encouraging nursing in the delivery or recovery
room, some in the mother's room, and some not providing the opportu-

26


nity for nursing at the time of the postpartum interview (approximately
24 hours postpartum for normal births, 48 hours for cesarean sections).

  Staff attitudes and behaviors are also important. Several researchers
point out the different constituencies of nurses. Maternity nurses focus on
the mother, and can be either more likely to encourage breastfeeding or
may ignore the concept of a mother-baby dyad and focus solely on the
mother. Pediatric nurses focus on babies and may be more likely to give
babies bottles even when they are supposed to be breastfed. Nurses
sometimes encourage the mother to give bottles after breastfeeding. This
practice serves to undermine the mother's confidence in her milk, and
may influence her milk production as well. Duthie demonstrated that
breastfeeding success was significantly associated with not feeding babies
sterile water after nursing.

Physicians' attitudes toward and knowledge of breastfeeding also
need to be addressed. Hollen found that more pediatricians (58%) than
obstetricians (38%) thought breastfeeding was important. Among the
nearly 200 physicians he studied, only 22% had children who had been
breastfed. Halpern et al. also found that pediatricians indifferent to
breastfeeding had significantly fewer nursing mothers in their patient
populations than pediatricians favoring breastfeeding. Similarly, Acosta-
Johnson comments that the barriers to breastfeeding are not so much the
women's desires, but the organization of maternity services.

  We also found that most deviations from "normal" recovery inter-
fered with breastfeeding. Cesarean patients had a harder time getting
access to their infants, women with fever or on medication were not per-
mitted to nurse, and baby complications such as elevated bilirubin levels
were cited as reasons not to nurse. Clearly, good research is needed on
the validity of these and other medical practices, and staff must be taught
to encourage breastfeeding rather than to discourage it. Figure 1 outlines
encouraging and discouraging hospital practices. Hospital practices and
health care provider attitudes can be discouraging to women in all ethnic
groups, but cultural norms can influence factors such as assertiveness, at-
titudes toward medical authority, and feelings of autonomy. For some
women, language can create an additional barrier.

Conclusions and Recommendations

The research on breastfeeding attitudes and behavior is inconsistent,
particularly in its attention to variations between ethnic "subgroups" and
in socioeconomic and educational level variations within ethnic groups
and subgroups. Nevertheless, a great deal is known about attitudes
toward breastfeeding, barriers, and the reasons for not initiating breast-
feeding or for early discontinuance. Many of these reasons, such as the
need to work and hospital practices, present problems for women from
all ethnic groups, although cultural values and institutions will influence
the way these barriers are managed. Attitudinal research and research on
incidence remain important, but are of greater value when combined
with research aimed at reducing hospital barriers and developing and
testing high quality intervention programs.

27


Cultural norms guide decisions about breastfeeding and influence
support for breastfeeding. Cultural attitudes must be taken into account
in the design of intervention programs. Despite the importance of ethnic-
ity, education, and socioeconomic status, other factors need serious atten-

FIGURE l- Hospital Practices Which
Influence Breastfeeding Initiation

o baby put to breast immediately in delivery room

e
d     o baby not taken from mother after delivery       o staff sensitivity to cultural norms
8                                and expectations of woman
u
-z    o woman helped by staff to suckle baby in recov-
.I!
R       ery room
2    o rooming-in, staff help with baby care in room;
      not only in nursery

     o staff initiates discussion re: woman's intention to   o appropriate language skills of
8      breastfeed pre- and intrapartum             staff, teaching how to handle
`G
s                                breast engorgement and nipple
`c'                                  problem
i    o staff encourages & reinforces breastfeeding im-    o staff's own skills & comfort re:
3      mediately on labor and delivery            art of breastfeeding and time to
3                                      teach woman on one-to-one basis
>z

o staff discusses use of breast pump & realities of
separation from baby re: breastfeeding

o pictures of woman breastfeeding

8                     o literature on breastfeeding in understandable terms
`S
8 .-
8     o staff (doctors as well as nurses) give reinforce-
2     ment for breastfeeding (respect; smiles; aHirma-
s      tion)
2     o nurse (or any attendant) making mother comfort-
g      able and helping to arrange baby at breast for
8      nursing

z   o woman sees others breastfeeding in hospital,      o closed circuit TV show in hospi.
                               tal on breastfeeding

    o if breastfeeding not immediorely successful, staff
z      continues to be supportive
t
.g
&    o previous success with breastfeeding experience in
d      hospital

28


tion: postpartum participation in the work force; general U.S. attitudes
about breastfeeding in public; hospital practices; and health care provid-
ers' knowledge, attitudes, and behaviors. These areas must be addressed
in order to facilitate breastfeeding for women in all ethnic groups.

9 mother-infant separation at birth

o scheduled feedings regardless of
mother's breastfeeding wishes        o mother-infant housed on sepa-
                      rate floors in postpartum period

o mother separated from baby due
to bilirubin problem

o no rooming-in policy

o staff instructs woman "to get
good night's rest and miss the
feed"

o woman told to "take it easy,"
"get your rest" impres-
sion that breastfeeding is effort-
ful/tiring

o strict times allotted for breast-
feeding regardless of mother/
baby's feeding "cycle"

* woman told she doesn't "do it
right," staff interrupts her ef-
forts; corrects her re: positions,
etc.

o pictures of woman bottle-feeding

* woman given infant formula kit
& infant food literature

o stafT interrupts her breastfeeding
session for lab tests, etc.

o woman doesn't see others breast-
feeding

o sees official-looking nurses au-
thoritatively caring for babies
by bottle-feeding (leads to
woman's insecurities re: own ca-
pability of care)

o previous failure with breastfeed-
ing experience in hospital

29


SUCCESSFUL APPROACHES TO
  PROMOTE BREASTFEEDING

A State-Wide Breastfeeding Program: Rhode Island

Jerianne Heimendinger, DSc., M.P.H.

Information Provided

  If you want to encourage the practice of breastfeeding in a state,
where do you begin? Who is the target audience? Do you approach the
pregnant woman most likely or least likely to breastfeed? Teenagers
before they become pregnant? Grandmothers? Physicians? Nurses? Hus-
bands? All of the above? And what message do you deliver?

  Where to begin? With commitment to the effort-a top-level deci-
sion to act. The impetus for action within the Rhode Island Department
of Health came from several sources. Top-level management decided
that there was sufficient evidence of the positive benefits of breastfeeding
to promote actively the practice as good preventive health care. The Di-
vision of Family Health had recently adopted the Office of Nutrition
Services and viewed breastfeeding as a part of the nutritional agenda of
maternal and child health. Of greater human interest, two administrators
within the Department had recently become fathers of breastfed babies
and experienced first-hand the realities of breastfeeding and the institu-
tional and community resistance to the practice.

  Finally, a 1981 press release from Ross Laboratories' survey cata-
lyzed action. The survey indicated that Rhode Island had the lowest in-
cidence of breastfed newborns in the U.S. The U.S. average reported
was 55%, and the rate for Rhode Island was 36%. Even if the data are
questionable, Meyer's report of surveys from 1946 to 1966 also indicated
low incidences for the state.

  The first obvious question was: Why were fewer mothers breast-
feeding in Rhode Island? No hard data were available to answer the
question, but a variety of cultural and economic elements were postu-
lated as answers.

  Rhode Island is a small, densely populated, urban industrial state
with a long history of working mothers. Currently, 50.4% of Rhode
Island women work, compared to 50.8% for New England and 47.8%
for the U.S. The industries in which many women work, such as jewelry
and other manufacturing and cottage industries, often lack time and
space flexibility to accommodate breastfeeding women. Consequently,
even grandmothers and great-grandmothers may not have breastfed;
thus, there is no legacy of breastfeeding practice or exposure. In this situ-
ation, health professionals become even more important as sources of in-
formation and support.

30


The state has assimilated several waves of immigrants over the past
thirty years, and these immigrants are eager to trade their breastfeeding
legacy for the more "American" practice of bottle feeding.

Physicians and hospital nurses did not actively encourage
breastfeeding. Hospital routines were not designed to incorporate
breastfeeding. Finally, hospital administrators did not encourage the
practice because formula companies finance many hospital educational
and social activities. Although these last few elements are not peculiar to
Rhode Island, they add substantially to bottle-feeding's entrenched status.

With some of these concepts in mind, the staff of the Health Depart-
ment organized a planning committee to develop a statewide breastfeed-
ing campaign. The committee represented physicians, nurses, nutrition-
ists, hospital administrators, media and public relations experts, nursing
mothers, and the La Leche League. A media consultant was employed
to help direct the committee's efforts.

The campaign's goal was to increase the incidence and duration of
breastfeeding by addressing 3 major target groups: professionals, patients,
and the larger community. The committee was correspondingly divided
into 3 subcommittees.

The Professional Education Subcommittee developed a strategy for
motivating professionals to encourage breastfeeding in their practices.
Public endorsement of the campaign was obtained from the local chap-
ters of the American Academy of Pediatrics, the American College of
Obstetricians and Gynecologists, the Perinatal Committee of the Medical
Society, the American Academy of Family Physicians, the Hospital AS-
sociation, and the La Leche League. The committee also developed edu-
cational materials and counseling standards for physicians, nurses, nutri-
tionists, and other hospital and health center personnel.

The Patient Education Subcommittee discussed the targeting of their
efforts and decided to address both the pregnant women in Rhode Island
who obtained care from private physicians and the prenatal population
served directly through the Department's programs, such as the maternal
and infant care projects and WIC.

The Community Education Subcommittee attempted to create a
more supportive atmosphere by educating the community at large about
the practice of breastfeeding. Specific target groups were fathers, grand-
mothers, aunts, uncles, brothers, and sisters. A function of this committee
was to address cultural and lifestyle issues through the media.

The campaign was officially inaugurated in April 1982 at a press
conference held at Women and Infants Hospital, the major maternity
hospital in the state. Easelback posters and brochures inviting requests
for additional information were mailed to obstetricians, gynecologists,
pediatricians, and general practice physicians. Brochures were also dis-
tributed to clinics, hospitals, Visiting Nurse Associations, and community
organizations statewide. Materials were also available in Portuguese,
Spanish, and Vietnamese. Local diaper services and maternity clothing
stores distributed brochures to customers.

Public service announcements of 10 and 30 seconds were developed
for use by major Rhode Island TV and radio stations. Through these an-

31

447-700 0 - 84 - 6


nouncements, the community was invited to call the Division of Family
Health or the Nutrition Hotline to request brochures and additional in-
formation. Special feature articles and editorials appeared in the Provi-
dence Journal and local town newspapers. Members of the Committee
discussed breastfeeding issues on radio and TV talk shows, some of
which were broadcast in Portuguese and Spanish.

A library of breastfeeding films and slide-tapes was established at
Women and Infants Hospital and made available to professional and
community organizations. A videotape was developed for patient educa-
tion within the hospital.

  Two audiotapes on why and how to breastfeed a baby were devel-
oped for Tel-Med, the community service which makes tape-recorded
health messages available to the community by phone. A breastfeeding
manual for mothers was made available, and a speaker's bureau was
organized.

The nutritionists in the WIC program made a concerted effort to
educate their clients and gave them reasonable expectations and anticipa-
tory guidance on such matters as breast engorgement and weight gain.
The nutritionists felt that factors which made breastfeeding difficult for
mothers were: the presence of other small children in the household;
lack of support from health professionals, family, and friends; anxiety
that the breastfed infant was not getting enough to eat; and the ready
availability of formula both from the WIC program itself and in the hos-
pital setting. Informed discussions about the latter issue led to a decision
by the administration of Women and Infants Hospital to establish a
policy of not offering formula packs to breastfeeding women.

  The message we delivered was: "When feeding your newborn, the
natural way is best . . . A popular `new' way to feed babies is sweeping
America . . . Breastfeeding is nature's own way of giving the best to
your baby . . . and it's something only you can give." Our messages ad-
dressed special attention to the issues of working, worrying about wheth-
er babies get enough to eat, and nutrition.

Information Collected

  While we were providing information, we were also collecting data.
Several small surveys done prior to the campaign indicated that the inci-
dence of breastfeeding ranged from 16% to 48%. I would like to share
some of the details of the survey done several months after the campaign
was underway.

  At the request of the Centers for Disease Control, the Division of
Family Health conducted a breastfeeding pilot survey (July/August
1982) designed to serve as a model for other states by providing a simple
instrument for sampling from birth certificates and assessing the inci-
dence of breastfeeding nationwide. Although the survey was not de-
signed as part of the breastfeeding campaign, it immediately followed the
major media blitz; its design and preliminary results are quite pertinent to
the issues of this Workshop.

32


To allow states flexibility, the survey was designed in 2 parts: a
simple one-page mail questionnaire and a telephone interview follow-up.
The mail survey recorded data on the incidence and duration of
breastfeeding, other food supplements given to breastfed infants, birth
weight, and the mother's participation or lack of participation in WIC or
Food Stamp programs. The survey also identified whether the mother
was given formula by a hospital and whether she was willing to be con-
tacted by telephone. Information obtained on this questionnaire could be
linked with demographic information available on the birth certificate. It
was thus unnecessary to ask respondents any socio-demographic
information.

The reverse side of the mail survey contained an explanatory letter
from the Health Department with a name and number to contact if the
recipient had any questions. In addition, the letter contained short notes
in Spanish and Portuguese. The notes requested non-English speaking re-
cipients to secure help in translating the survey. The purpose of the
letter was to assure people of the legitimacy and confidentiality of the
survey and to attempt to address the problem of language barriers. En-
closed with the survey was a stamped self-addressed envelope.

The second part of the survey was the telephone interview in which
data were obtained on the reasons a mother chose to breastfeed or
bottle-feed, why she stopped breastfeeding, what types and amounts of
food were fed, at what ages various solids were introduced, and what
the weight of the child was. The telephone interview also provided an
opportunity to verify the mail-survey questions, such as participation in
WIG.

A representative data sample of infants 3 months of age was ob-
tained from 2 sources: 1) a list of April births as recorded by the Divi-
sion of Vital Statistics and 2) lists of WIC infants born in April and of
women known or expected to deliver in April. Two major factors af-
fected the choice of sampling sources and the sampling process. First, it
was not possible to obtain a truly representative sample because state
confidentiality laws prohibited inclusion of births of unwed mothers in
the vital statistics sample. Secondly, the WIC program was interested in
obtaining information on the feeding practices of its clients. By sampling
from its participant list, we were able to obtain some information on
unwed mothers-a fact that we think enhances the value of our survey.

A few pertinent points from the preliminary results follow. Women
were very eager to talk to us. In fact, 70% of them indicated they would
not mind being contacted. Both breastfeeding and bottle-feeding mothers
seemed pleased that someone was still interested in them so long after
delivery. Even women without telephones provided us with numbers of
family and friends through whom they could be contacted. The conclu-
sion we draw is that women with infants 3 to 4 months of age provide
an informative sample population, They are not only eager to talk, but
they are likely still to be breastfeeding, carefully measuring the amounts
of other foods given their infants, and knowledgeable about the reasons
behind their behaviors.

Preliminary analysis indicates that 52% of the total sample of 283

33


women breastfed at least once; 37% of the sample were still
breastfeeding at 3 months of age. Of the WlC sample of 123 women,
40% breastfed at some point; 21% were still breastfeeding at 3 months of
age. Comparable figures for the vital statistics sample of 160 women
were 62% and 49%. Although these rates may be a little high (respond-
ents tended to be the better educated women of higher socioeconomic
status), it is unlikely that even our adjusted rates could be as low as the
Ross Survey indicates. Although we would like to think our campaign
has had an impact on the incidence and duration of breastfeeding, we
cannot draw that conclusion from this survey at this time.

  Most surveys on breastfeeding behavior have been limited to legiti-
mate births. Seventeen percent of the infants in our sample were born to
unwed mothers. Since the prevalence of single mothers is increasing, we
were happy to be able to include a few in our sample. We look forward
to further analysis of the data on this cohort.

  Finally, we plan to delineate the following reasons given for breast-
feeding: health-healthier for the baby; intrinsic reasons such as bonding;
extrinsic ones such as encouragement by physicians, relatives, or friends;
and practical ones such as ease and economy. Preliminary anlaysis shows
that choices were made in the order of: health, health and closeness,
health and practical considerations, and health and extrinsic encourage-
ment. Thus, the initial decision to breastfeed by women in our sample
was based on concerns about the health and well-being of the child. In-
terestingly, even in Rhode Island, returning to work was not the most
important reason given for stopping breastfeeding; anxiety about whether
the baby was getting enough to eat was the major concern.

  In summary, we think the simple mail survey linked to vital statistics
records is a quick and inexpensive means for states to use to estimate the
incidence of breastfeeding. Sampling from programs such as WIC can
provide information about the characteristics and infant-feeding behav-
iors of single mothers, a growing portion of the population. Preliminary
analysis indicates that in our sample, health and nurturing factors are the
most important determinants of the choice to breastfeed. We still think,
however, that creating a supportive environment is a priority.

  We think we were correct in our ambition to address all target
groups-professionals, patients, and the community at large. We did the
best job of communicating with health professionals, largely-I sup-
pose-because we are used to talking to ourselves. The key groups of
professionals to enlist are: 1) professionals who interact with women
prior to or early in their pregnancies-obstetricians, gynecologists, nutri-
tionists, and childbirth educators and 2) professionals whose support is
crucial in initiating the actual practice of breastfeeding-hospital nurses
and pediatricians.

  As for the patient population, we would target the subgroups mo.st
likely to adopt breastfeeding who tend to be the better educated women
of higher social status. Social norms etablished by higher status groups
are eventually adopted by lower income groups. Thus a small amount of
effort on the margin can reap large benefits in terms of increased num-

34


bers of women in a social group who not only lend support to eacu
other but ultimately influence other social groups.

However, it is also important to address the needs of lower income
groups. Is it cost effective for us in public health to address the popula-
tions most accessible, or should we aggressively seek out the population
hardest to reach? The groups most accessible to us are those involved in
public programs on the basis of low income or medical or nutritional
need; within these groups are subgroups more likely to breastfeed. For
example, it is more productive to target married older women than
unwed teenagers.

The most difficult population for us to reach is low-income women
who are not eligible for our services, work in low-wage jobs, and re-
ceive services from private physicians. For this population, we suggest
focusing on strategies addressed to the health-care providers and the
work place.

The consumers we would target are husbands and grandmothers,
since they form the major support around the breastfeeding mother. If
we had this campaign to do again, we might hire an advertising agency
to do a better job of reaching the community through the media.

We have been pleased that our campaign produced some good mate-
rials and initiatives. We have suffered, however, from not providing ade-
quately for continuity of our efforts. A coordinator, committed to main-
taining the momentum of this effort, needs to be designated within the
Health Department. This initiative, along with others, has suffered from
the funding and staffing constraints common in state governments in the
past several years.

On the more positive side, some residuals of our efforts are im-
proved inservice education programs for nurses in the maternity hospi-
tals and improved educational materials for both professionals and preg-
nant women. We have also given people broader access to information
through the Nutrition Hotline. In addition, the Department has strength-
ened its emphasis on breastfeeding through its request for proposal proc-
ess, which it uses for contracting direct services. Three nutrition-related
innovative projects were recently funded. The purpose of one of these is
to develop breastfeeding support groups for low-income women. Finally,
we hope the ideas generated in this Workshop will re-energize and redi-
rect our efforts to finalize the analysis of our survey and to continue to
create a more supportive environment for breastfeeding among women
in Rhode Island.

35


City-wide Approach: New York

Linda Randolph, M.D., M.P.H.

  New York City has a high proportion of both ethnic minorities and
the poor. In 1980, the White population in New York City was 36.5%,
the Black population 30.8%, those of Hispanic origin 27.9%, and the
Native American-Asian 3.6%. Twenty-seven percent of the New York
City population were below the poverty line in 1980 compared to the
New York State percentage with 16% and the U.S. with 13%. In 1970,
19.5% of all children under 18 years of age in New York City lived with
a female head of household. By 1980 the percentage had grown to
30.9%. The city's poor increased by 10% between 1969 and 1982. In
1982, the New York City Department of Health conducted a survey of
infant feeding practices in municipal, voluntary, and private hospitals.
According to this survey, 15.1% of infants discharged from municipal
hospitals were breastfed compared to 37.7% discharged from private
hospitals and compared to the overall U.S. rate of in-hospital breastfeed-
ing of 57.6% in 1981. In the survey of the New York City Health De-
partment Child Health Stations, 3% to 6% of babies were breastfed
during the period of 1980-1982.

  In January 1982, the Steering Committee to Promote Breastfeeding
in New York City was formed, with the goal of instituting a comprehen-
sive program to increase the breastfeeding rate of women, with specific
emphasis on low-income women. The Committee is sponsored by the
New York State Department of Health, and I have been its chairperson
for the last two years. The State Health Department's Bureau of Mater-
nal and Child Health has had breastfeeding promotion as one of its goals,
and this effort in New York City has reflected a local implementation of
that goal.

  Originally, 25 individuals were called together from medical and
public health schools, city and state health departments, voluntary and
research organizations, foundations, and maternity service providers to
discuss methods of procedure. Based upon the copious literature avail-
able and the considerable experience of the various members, the com-
mittee developed a comprehensive program to address the barriers to
successful breastfeeding. The Steering Committee's total agenda is built
around 6 coordinated programs, each administered by a task group. Each
group targets a barrier to breastfeeding and works simultaneously to
achieve the overall program goal. A multidisciplinary membership on the
committee has evolved as interests increased throughout the 5 boroughs
of the city. Today it consists of over 40 active members, including pedia-
tricians, obstetricians, nutritionists, nurses, nurse-midwives, public health
administrators, social workers, a lawyer, legislative aides, a journalist,
health educators, a foundation representative, and public health students.

36


  A brief description of the 6 task groups and their activities to date
follows. The first task group is concerned with research and surveys.
The intent is not so much to conduct research, but rather to identify ex-
isting material to be used by all of the other task groups. Six research
background papers are being developed to assess the following areas re-
lating to breastfeeding: 1) trends and patterns of infant feeding practices
by socioeconomic and ethnic groups; 2) factors influencing the pattern
and incidence of breastfeeding-especially cultural and social influences
(this background paper will also analyze the role of existing health serv-
ices such as prenatal, maternity, and postpartum care, and WIC);
3) the impact of the media and business interests in breastfeeding practices
with particular emphasis on the media effects on different ethnic
groups; 4) examination of the impact of government, legislation, reim-
bursement patterns, maternity leave, child-care facilities, government and
business support networks available for the lactating mother; 5) the eco-
nomic value of breastfeeding as it relates to cost of formula versus the
increased cost of providing a lactating mother with an enriched diet; and
6) the influence of alcohol, smoking, and drugs on mother's milk.
The professional education task group, our second group, has devel-
oped a slide presentation to be used for grand rounds in the city's hospi-
tals. The slides are designed to address lack of knowledge of both
breastfeeding physiology and techniques. Since many pediatricians, ob-
stetricians, and even some nurses have never during their training seen a
baby being breastfed, they will not necessarily be as informed as they
should be in order to provide assistance to a lactating woman. Members
of the Steering Committee will be available to conduct the rounds on
request of hospitals, and we are beginning to receive those requests.
The third group looks at hospital practices. It addresses barriers of
facility design, rigid feeding schedules, supplemental feeding, gift packs,
and lack of information on the part of hospital support staff. Guidelines
for changes in hospital practices in order to encourage breastfeeding and
to create an atmosphere of acceptance at the site of delivery have been
prepared with participation of representatives of the Health and Hospital
Corporation and the voluntary hospital sector.
One task of the fourth group, the pre- and postnatal care group, has
been the development of a handbook for promoting breastfeeding in am-
bulatory-care facililities. The handbook was done in conjunction with
our Office of Health Promotion in the New York State Health Depart-
ment. In addition, a project developed by a member of the Steering
Committee and endorsed by it is the Bronx-based Lactation Consultation
Team. This project has received federal MCH funding. It is designed to
provide a team of health professionals to institutions for breastfeeding
consultation in the Bronx. The entire health care system in the borough
will be affected.
  The fifth task group is concerned with public policy and legislation;
it has been monitoring existing legislation and assisting in the develop-
ment of new policy and legislative efforts related to the promotion of
breastfeeding in both the city and the state. The major emphasis has been
the analysis of trends in labor force participation rates among mothers of


children under 3. Existing legislation, maternity benefits, and employer
policies have not adequately addressed the difficulties faced by pregnant
working women or by those wanting to breastfeed while maintaining
their job. A background paper presenting an overview of these trends is
in draft form, and it gives an analysis of maternity benefits, including
health insurance and maternity leave. The paper also discusses the poten-
tial benefits unions and employers might derive from promotion of pre-
natal care and breastfeeding. In addition, 2 sets of sample guides have
been drafted to provide recommendations for the development of prena-
tal care and breastfeeding promotion programs at the worksite. A third
paper will analyze maternity benefit packages and provide recommenda-
tions of strategies for change. During 1984, this group also plans to im-
plement a continuing education program for occupational health nurses.

  The Public Information Group has developed a 3-tiered program to
counter the perception of breastfeeding as aberrant behavior. The first
level is a blanketing of the city with visual images of breastfeeding, in-
cluding a subway poster campaign, TV public service announcements,
and engagements for Steering Committee members on talk shows. The
second level is individualized support, information, and referrals pro-
vided by counselors to callers on an information line. Data will be col-
lected and follow-up on a sample of those calls will be conducted. The
third level is written information mailed to callers, community groups,
and lay health advocates.

One interesting phenomenon about the Steering Committee is that
we have learned how to make a little money go a long way. The funding
for the committee projects has come from very small contributions from
the New York State Department of Health, the New York City Depart-
ment of Health, the Columbia University School of Public Health-
Center for Population and Family Health, the Health Education Fund,
the New York Community Trust, and the Division of Maternal and
Child Health-DHHS. All of the organizations represented on the com-
mittee allowed staff to provide significant amounts of time for task group
efforts and for Steering Committee meetings which we held approxi-
mately every 2 months for the past 2% years.

  Recently we saw the end of a long gestation. The Committee con-
ducted for approximately 200 persons an invitational workshop wherein
the materials that had been developed by the task groups were presented,
shared, and discussed. We were fortunate to have Dr. Lawrence as our
keynote speaker and Jane Brody, the personal-health columnist for the
New York Times, to provide some of her personal insights on the breast-
feeding of twins.

Where do we go from here? The public information campaign will
be launched in the early fall. Further dissemination of materials and com-
pletion of an evaluation design and its implementation are on the agenda.
Concomitantly, the State Health Department is revising its hospital code
in order to facilitate maternity patients' ability to breastfeed.
  In conclusion then, I think the Steering Committee in New York
City is an example of government and the public and private sectors
working together with professional organizations, voluntary organiza-

38


tions, and individuals to try to put together a comprehensive, interre-
lated, multidisciplinary approach to promotion of breastfeeding. We have
just gotten off the ground, and I hope to have another forum at a later
date to let you know what our impact has been.

Breastfeeding Promotion in
Three Rural Indigent Populations

John E. Alden, M.S., C.N.M.

Breastfeeding in an Indigent Rural County in Florida

Jackson County, Florida is predominantly rural and has a population
of approximately 40,000. The two largest communities contain 12,000
and 5,000 persons. About 30% of families in this agriculture-based econ-
omy have annual incomes below levels established for federal assistance
programs. Approximately one-quarter of the county residents are Blacks,
and the remainder are Caucasians of English-speaking origin. The indi-
gent population is primarily Black.

Many families in this poor rural society are comprised of younger
mothers raising children in their mothers' (or parents') homes, as in a ma-
triarchal society. Young mothers receive considerable child-care support
from their mothers, grandmothers, and sisters.

Until the past decade, breastfeeding has been commonly practiced.
Supplementation has been usual even during the first few months, but
bottle-feeding from birth appears to have become common with the
availability of formula through assistance programs such as WIC. Most
young women now having children were breastfed as infants.

Breastfeeding Promotion Project

In 1979 a focused effort to promote breastfeeding among the low
income rural population began. The program was coordinated by the pri-
mary care provider (a nurse-midwife) with the special assistance of the
public health nutritionist and support of the clinic and hospital nursing
staffs. The project consisted primarily of modification of patient-teaching

39

447-700 0 - 84 - 7


practices during the prenatal period and of patient management during
the intrapartum and postpartum periods.

  The project was conducted through the county health department in
the context of a maternity-care program for low-income families. Ap-
proximately 20% of mothers delivering in the community hospital re-
ceived their obstetrical care through the Low Income Clinic Program.

Data Collection

  The basic means of data collection was to have mothers and infants
return to the clinic frequently "to see how you and the baby are doing."
It was not difficult to get them to return at least once a week during the
first month and subsequently at least monthly. During these visits, the
infant was generally weighed and perfunctorily examined. The mother
was questioned about feeding and supplementation, her well-being, and
the baby's activity. Either the woman was encouraged to show how the
baby fed or the baby was "tested" with a bottle or finger to evaluate the
sucking pattern. By this means, the evaluators could be reasonably sure
that the baby was being predominantly breastfed. Women's statements
about feeding were generally consistent with the babies' responses. For
the purpose of this study, the infant was no longer considered to be
breastfed if he/she received more than 8 ounces of supplemental feeding
a day (for the first week, 4 ounces).

  Data collection at each visit included the number of weeks through
which the woman continued to breastfeed predominantly and some anec-
dotal information (comments, reasons for stopping, problems, etc.). Data
were updated with each contact.

  If the woman did not return to the clinic, attempts were made to
contact her by telephone, public health nurses, or relatives. If satisfac-
tory contact could not be made, she was assumed to have discontinued
breastfeeding.

Discussion of the Project

  Initiation of Breastfeeding. Figure I presents data for the percentage
of women initiating breastfeeding. Shown are rates for women who re-
ceived maternity care through the public low-income clinic and by pri-
vate physicians. During the 6-month period before the project began,
breastfeeding rates for the two groups were similar. During the term of
the project, the percentage of women initiating breastfeeding among the
low income clinic (project participants) more than doubled. The increase
in breastfeeding by other women in the community occurred after the
project began providing breastfeeding education to prepared childbirth
groups, nurses groups, and the community at large.

  The first increase during January-June 1979 over the control period
(July-December 1978) appeared to occur after a more consistent encour-
agement to breastfeed. The increases after July 1979 occurred as a more
well-developed teaching program, distribution of selected written materi-
als, and use of films were adopted.

40


FIGURE I- Percentage of Women hitiathg Breastfeedmg of Newborns Delivered
    by Private Physicians vs. Those Cared for in Low Income Clinic
       (Community Hospital - July 78 through June 80)

Low Income Clinic

Private Medical Practice

N=l2 N=80     N=20 N=75

N=42 N=ll6

N=40 N=l02

July-Dee 1978     Jan-June 1979

July-Dee 1979

Jan-April 1980

Over the term of the project, a progressive improvement in the du-
ration of breastfeeding was observed at all intervals. During the control
period, half of the women initiating breastfeeding discontinued the prac-
tice during the first week, with none continuing through 16 weeks.
During the last 6 months, almost half of the study participants breastfed
through 16 weeks. (Table I)

  Of 23 women known to discontinue breastfeeding between 4 and 16
weeks during 1979, only 5 did so upon returning to work or school. The
majority expressed dissatisfaction with breastfeeding or the demands it
placed on their lives.

  The most easily discernible difference between women who contin-
ued breastfeeding and those who did not was their family situation. Not
surprisingly, most of the women who continued were those in stable
marital relationships. Few women who were single, divorced, or in peri-
ods of marital conflict continued. Returning to work or school was a
more frequent (though not universal) occurrence among single mothers.

Subjective Evaluation of Influencing Factors

Prenatal Instruction. Of all factors considered in promoting selection
of breastfeeding, unhurried discussion of infant feeding appeared most
productive for this group. Many women seemed to want to breastfeed

41


but were inhibited by stories they had heard or anxieties they were
harboring.

The primary-care provider is generally a person with whom the
woman is developing a trust relationship and seems the ideal person to
provide counsel on breastfeeding. Additionally, during prenatal care
visits, the woman is a captive audience. Prenatal care should include,

Table I

Percentage of Women Continuing to Breastfeed through Selected Intervals
             After Delivery

(Low-Income Clinic-July 1978 through June 1980)

Duration

July-    January-
December    June

1978      1979

July-
December
1979

January-
June
1980

1 week               50        62        81       88
W=)                6        10        34       35

4 weeks              33        62        79       75
(N=)                4        10        33       30

8 weeks              25        44       63       68
@=I               3        7       26       27

12 weeks              8        38       38       56
(N=)                1         6        16       22

16 weeks               0        25        36       48
W=)                0         4       15       19

whenever possible, the woman's significant others. Most husbands reti-
cent about breastfeeding usually responded readily to open discussion.
This form of breastfeeding education also encouraged the woman to feel
free to call the care provider if problems were encountered.

Considerable effort was made toward deftning the breast as a nutri-
tive organ rather than as a sexual one. A successful technique was to
take time during the prenatal physical exam to "explore" with the
woman the anatomy of the breast in relation to infant feeding.

Most women appreciated films about breastfeeding. "Promotional
films" were shown prior to delivery and "how-to" films were reserved
for after delivery when breastfeeding was started. Within this lower
socioeconomic group, written material was of less value; many did not
read it.

Hospital Management. The primary-care provider may insure that
hospital management of the mother and infant promotes breastfeeding.
Most important aspects (not commonly practiced by hospital maternity
departments) are early and frequent (demand) feedings, avoidance of sup-
plementation, and avoidance of mother-infant separation. During the hos-
pital stay, "hospital rounds" were generally made twice each day, ideally
when the infant was with the mother. During these visits, previous

42


teaching was reinforced, and anticipatory guidance and encouragemenr
were provided.

Post-Hospital Management. Women were given appointments for a
follow-up visit within a few days of hospital discharge. This early visit
provided early problem intervention for many women. Of women breast-
feeding at one week, 91% continued through at least one month (during
the last year of this study). Most breastfeeding problems developed in the
first few days at home.

Although formula companies provided free formula samples upon
discharge from the hospital, these samples were not distributed to
breastfeeding mothers. Sterile water was provided for "emergency"
supplementation until professional assistance could be obtained.

Community Follow-Up Two Years After Discontinuance of
Breastfeeding Project

As demonstrated in Table II, the discontinuance of the special
breastfeeding promotion project was accompanied by a prompt decline
in the number of women initiating breastfeeding. Within 2 years, breast-
feeding initiation rates were similar to pre-project levels. Careful analysis
of this observation was not possible.

          Table II
Percentage of Women Initiating Breastfeeding
(Community Hospital-l 978 through 1982)

1978           1979           1980           1981           1982

43%           50%           60%           48%          46%

(Breastfeeding Promotion Project)

Breastfeeding Promotion on the Papago Indian Reservation (Arizona)

The Papago Reservation's community is a rather closed, traditional
Indian society. The reservation population is approximately 10,000 per-
sons, with very few non-tribal members. The largest community contains
3,000 persons, and the nearest large non-Indian community (Tucson) is
60 miles distant. The native language is used in commerce. Many prob-
lems common to Indian reservations exist, including high infant morbidi-
ty and mortality and other nutrition-related problems-probably originat-
ing in alteration of traditional dietary practices.

Elements of the Papago Breastfeeding Education Project

In 1981, the U.S. Department of Agriculture granted funding for a
breastfeeding demonstration project on the Papago Reservation. The

43


project functioned with the assistance of an advisory board made up of
representatives of the Indian Health Service, WIC, tribal programs,
Meals for Millions Foundation, and other interested individuals. Overall
function and administration of the project was local and native.

The project developed high quality audiovisual aids to increase
community awareness and understanding of breastfeeding. The theme of
this material focused on breastfeeding as "the Papago Way." Native lay
women were recruited, trained, and paid as "breastfeeding helpers," both
to assist the new mother and infant directly and to act as liaison for her
with other services. A free nursery for breastfeeding babies was estab-
lished in a location central to school and major work places so that new
mothers could, with the cooperation of employers, feed their infants
during the day. The project also sought to develop rapport with and im-
prove services from the health-care system.

Outcome

As noted in Table III, a marked increase in breastfeeding initiation
was occurring in the time immediately preceding the grant funding of
the project. This change occurred as individual program efforts devel-
oped and became coordinated.                                     . .

        Table III
Breastfeeding Initiation and Duration
(Papago Reservation-1979 through 1983)

Percentage of New Mothers
  Initiating Breastfeeding

1979    6/81    7/81-6/82    4/83-9/83

23      44        59          49

Percentage Breastfeeding at
        6 weeks
       4 months

Percentage Utilizing
Formula Supplementation
  (Age: Birth to 4 months)

50          48
33         42

21         37

Summary of Papago Breastfeeding Project

With this multi-level approach, improvements in breastfeeding initi-
ation and duration were noted. While the percentage of mothers initiat-
ing breastfeeding has decreased somewhat following the ending of the
USDA grant-funded program, the percentage of infants breastfeeding
during the first months of life remains similar to that during the program.
Formula supplementation during breastfeeding has increased. The factors
contributing to the apparent post-project declines are not fully under-

44


stood; however, decreased direct support of the breastfeeding mother
may be an influential factor.

Breastfeeding on the Fort Peck Indian Reservation (Montana)

Description of Reservation

Unlike the Papago Indian Reservation, the Fort Peck Indian Reser-
vation is not homogeneous. The reservation population is approximately
12,000; the largest community has fewer than 4,000 persons. The reserva-
tion is the assigned home of two unrelated and, historically, sometimes
antagonistic tribes. The reservation was opened to homesteading in 1911,
and currently, less than one-half of the residents are tribal members.
Intermarriage with non-Indians and members of other Indian tribes is
common. The native languages are used infrequently and are generally
unfamiliar to younger tribal members.

Largely agriculture-based, the local economy is augmented by oil
production, federal-agency salaries, and tribal light industry (receiving
minority-preference federal contracts). Unemployment is relatively high.
Women of child-bearing years comprise a substantial portion of the work
force.

  The health-care needs are met by both the Indian Health Service
and private medical practices. Two small hospitals have limited services;
referral and transport to outside specialists and facilities are common.

The Recent Practice of Breastfeeding

As anticipated from the rapid assimilation into a non-Indian society,
many traditional ways have been lost. Cultural and family disruptions
have brought about major changes in child-care practices, including
mothering and feeding of infants. Breastfeeding has been infrequent for
two generations. Traditional family ties have been altered, and women
are increasingly dependent on their male partners for breastfeeding sup-
port. Native male attitudes toward breastfeeding as well as other aspects
of child care reflect the relatively greater role alteration of the aboriginal
male produced by assimilation. Many males are strongly opposed to
breastfeeding.

Breastfeeding Promotion on the Fort Peck Indian Reservation

  It is the policy of the Indian Health Service to encourage
breastfeeding. The tribal WIC program reaches almost all pregnant
women (WIC reaches approximately 80% of eligible families in Mon-
tana). Few Indian families have contact with prepared childbirth pro-
grams, nor is there an active breastfeeding mother support group (such
as La Leche League). Almost all pregnant women receive some prenatal
care, although often less than optimal. Approximately 60% of pregnant
women receive maternity care from one provider (the author), who pro-

45


vides prenatal, inpatient obstetrical, and postpartum care. A limited
amount of commercially produced written material is available.

During the course of prenatal care, breastfeeding is discussed at least
twice, literature is distributed, and a short film is shown. The pregnant
women are encouraged to talk with other women who they know have
breastfed. The WIC program staff tells all pregnant women that breast-
feeding is best for the baby and encourages them "at least to try." The
outpatient nursing staff encourages breastfeeding. The inpatient nursing
staff is generally supportive, and the inpatient hospital routine is general-
ly conducive to breastfeeding. The infant is usually allowed only sterile
water as a supplement, and formula samples are not sent home with the
mother. Post-hospital discharge follow-up is within two or three days
and generally one week later. Telephone or personal consultation is
always available.

Montana rates of breastfeeding initiation fit the general characteris-
tics of urban vs. rural, educational, and economic patterns. With promo-
tional efforts, the Fort Peck Reservation-among those served by the
Poplar Community Hospital/Indian Health Service (PCH/IHS) pro-
gram-has a percentage initiating and continuing breastfeeding among
the highest in the state, even with the previously mentioned negative fac-
tors.

Summary

Results of breastfeeding promotion efforts in these three rural areas
indicate potential for success in increasing both initiation and duration of
breastfeeding. Data available following the ending of the promotion
projects suggest that infant-feeding practices will tend to revert to prac-
tices similar to those before promotion.

Two programs (Florida and Arizona) were among populations less
affected by cultural change-where breastfeeding was recently practiced
and where indigenous support was present. In the Montana community
(Fort Peck Indian Reservation- PCH/IHS), both of these factors are
lacking, and breastfeeding promotion has made slower progress.

  Breastfeeding mothers in rural areas encounter several problems.
Often these women lack frequent contact with other new mothers, and
thus basic information and peer support are less available than in urban
areas. The media (audiovisual and written) are limited and not always in
accord with the culture. While many breastfeeding promotion efforts
take place outside of the formal health-care system, groups such as La
Leche League and prepared childbirth programs are less frequently
available in rural areas. Although some assert that the free infant formula
available through the WIC program acts as a disincentive, WIC program
personnel actively encourage breastfeeding. When promotional efforts
address these rural problems, the incidence of breastfeeding can dramati-
cally increase.

46


The San Diego Lactation Program: A Teaching Hospital-
Based Resource to Promote Breastfeeding

Audrey J. Naylor, M.D., Dr.P.H.

  The transformation of maternal blood into milk and successful deliv-
ery of this complex nutritional and immunologic substance in the correct
quantity and quality to assure infant growth and development, though
"natural," is not simple. As with other complex physiologic functions
and behaviors, both lactation and breastfeeding are at risk for a variety
of problems which can and often do lead to early weaning. This risk can
be greatly reduced when perinatal health care professionals understand
the complexities of breast function and suckling and when they are
trained to apply this understanding to the clinical management of breast-
feeding.

During the past 30 years, while other areas of medical and nursing
education underwent vast revisions in response to medical advances, at-
tention to lactation and breastfeeding declined. Obstetrics taught students
how to inhibit lactation and speed the postpartum involution of the
breast, while pediatrics concentrated on the fine points of providing in-
fants with an artificial formula. The breast became a topic discussed pri-
marily in pathology classes and surgical clerkships. Students and house
officers were taught details about how to eliminate its basic function
either temporarily or permanently, but learned little about how to en-
courage and enhance its normal processes, or how to prevent, diagnose,
or treat deviations from normal function.

During the past 5 to 10 years, the basic science information provided
for students of the health professions about lactation and breast milk
has significantly increased; however, instruction regarding clinical eval-
uation and management of breast function is rare. Many perinatal health
care providers enter practice unprepared to assist the nursing mother and
often give advice and carry out procedures leading to breastfeeding
problems and failures.

The San Diego Lactation Program

Until September 1977, training programs available at the University
of California, San Diego Medical Center (UCSDMC), and Mercy Hospi-
tal and Medical Center, an academically affiliated teaching hospital, were
typically deficient in this area. While 50% to 65% of new mothers were
initiating nursing, less than half continued beyond 8 to 10 weeks. To pro-
mote breastfeeding while simultaneously providing appropriate clinical
teaching opportunities, the San Diego Lactation Program was launched.

The Lactation Program was designed with multi-departmental guid-
ance. The consortium of departments contributing to the early planning
included Reproductive Medicine (OB/GYN), Pediatrics, and Community
and Family Medicine, as well as Nursing and Social Service. Within a
short time, the Program developed its own distinct identity and now
functions independently and essentially like other academic subspecialty

47


services within the teaching-hospital setting. In July 1983, the Program's
base of operations was moved to nearby Mercy Hospital and Medical
Center. Both the UCSDMC and Mercy Hospital are now used as teach-
ing resources.

The core service and teaching team has always included a board-
certified member of the pediatric faculty, a certified pediatric nurse prac-
titioner, and a part-time nutritionist. A faculty obstetrician and a medical
social worker are readily available on a consultation basis. Direction for
the Program is jointly provided by the pediatrician and the pediatric
nurse practitioner. Both have become full-time, highly skilled
subspecialists.

Six distinct components of the Program are definable: 1) prenatal
guidance; 2) skilled immediate postpartum assistance; 3) 24-hour tele-
phone consultation service; 4) evaluation of lactation progress and prob-
lem-solving in a special Lactation Clinic; 5) Intensive Care Nursery
consultation; and 6) provision of educational programs for community
doctors and nurses. Each component offers an opportunity for clinical
experiences for health professional trainees.

Prenatal Guidance

Prenatal guidance provides the basic foundation for successful lacta-
tion. As one of the initial and essential steps in developing the Program,
several hours of inservice education regarding all aspects of lactation and
breastfeeding were provided for both professionals and non-professionals
on the clinic staff.

Following this training, the clinic staff actively recommended
breastfeeding as the preferred feeding method for infants. In addition,
breast examinations were more carefully performed, sound preparation
explained, and non-commercial patient-education materials provided.
Lactation became an even more significant aspect of the nutritional
counseling. A 2-hour class for expectant parents in the prenatal education
series reviewed the advantages of human milk and breastfeeding and
clarified the anatomy and physiology of lactation. In addition, basic
issues of the techniques of nursing were covered in this series.

Postpartum Assistance

Regardless of the extent and quality of prenatal service, lactation
and breastfeeding may not progress well if the postpartum care is poorly
managed. The Lactation Program also provided the nurses from the
postpartum and nursery units with a review of the reasons for breastfeed-
ing, anatomy and physiology, and sound techniques to encourage normal
lactation physiology. Following the training, procedures were gradually
instituted which allowed normal newborns to nurse within the first 30
minutes after delivery, and on demand thereafter. Rooming-in became
the usual, rather than unusual, arrangement. Routine use of formula,
water, bottles, pacifiers, and nipple shields was discontinued. In addition,
rather than being discharged with an inappropriate sample pack of infant

48


formula with its implicit message of doubt, all nursing families began to
receive a discharge "gift" of careful counseling and the number to call
the Lactation Program's telephone consultation service or Helpline.

Telephone Consultation Service

The telephone consultation service is an essential component of the
Program; in spite of good preparation, skilled postpartum help, and thor-
ough counseling at discharge, nursing problems arise from time to time.
Rapid solutions are often needed if infant well-being is to be maintained
and breastfeeding continued. The 24-hour telephone service is available
to any breastfeeding family, regardless of their source of medical care.
Program staff members answer questions, solve acute nursing problems,
see mother-infant couples if needed, and provide a significant, always-
available support system in response to about 130 calls per month. Com-
munity health professionals also seek consultation via this service.

The Lactation Clinic

While students and house officers have opportunities to observe and
participate in all of the preceding facets of the Program as they rotate
through their clinical assignments, the fourth component, the Lactation
Clinic, is the Program's major teaching resource.

Breastfeeding mother-infant couples are given appointments to be
seen in the Clinic within 7 days of hospital discharge and whenever
problems occur. Forty to fifty patients are seen each week. Lactation
progress is evaluated by use of a specially designed history and thorough
infant examination. Maternal breast examinations are routinely done,
breastfeeding carefully observed, and both maternal and infant weight
changes documented. Advice and treatment are given as needed, and ap-
propriate nutrition for successful lactation is discussed. Social service
intervention is offered whenever indicated.

Medical and nurse practitioner students as well as residents in pedi-
atrics and obstetrics all rotate through this service. Each assigned trainee
receives 16 hours of clinical instruction from the Program's experienced
staff.

Students and residents gain an appreciation for the complex physiol-
ogy of lactation, the multi-determined and learned nature of successful
breastfeeding, the biologic partnership of a mother-infant couple, and the
family's influence on nursing. They become comfortable with maternal
breast examinations and lean the importance of carefully observing nurs-
ing technique. They acquire physiologically sound methods of prevent-
ing and treating common breastfeeding problems, such as let-down inhi-
bition, engorgement, nipple abrasion, clogged ducts, and mastitis. They
are taught about the causes and treatment of nipple confusion and abnor-
mal suckling patterns and learn how to approach the diagnosis and treat-
ment of slow-weight gain and reluctant nursers without immediately rec-
ommending weaning or supplementing.

The Lactation Clinic component of the Program is not designed as a
high-volume experience. Teaching and demonstrating the important de-

49


tails of normal breastfeeding take time. In addition, the psychophysto-
logic sensitivity of lactation does not always respond well if a mother
feels rushed. If there are problems, solutions are frequently found only
when careful attention is paid to feeding techniques, maternal feelings,
activities and nutrition, other aspects of general health, and family adjust-
ments and interrelationships. Rarely are such solutions quickly found, es-
pecially in the teaching setting. However, long-range gain for both fami-
lies and trainees is well worth the initial extra time invested.

Intensive Care Nursery Consultation

Breastmilk is the preferred nutrient for most of the preterm and
critically ill infants admitted to the intensive care nurseries of both hospi-
tals used by the Program. Nursing staffs of these units have been taught
how to instruct parents about techniques necessary for the development
and maintenance of lactation, effective methods of pumping and express-
ing milk, proper breast care, and maternal nutrition. Instruction is also
given in safe methods of storage and transport of milk. When the infant
is sufficiently developed and well enough to begin nursing, parents are
assisted in retraining the baby to breastfeed. The Lactation Program staff
members consult on complex problems.

Community Education

The impact of the Lactation Program as a training resource for
health professionals has been extended beyond the students and postgrad-
uate trainees served by UCSDMC and Mercy Hospital. Physicians and
nurses throughout the local, national, and international community have
increased their awareness of the importance of breastfeeding during the
past decade. Many of these health-care providers have recognized the
need for a better understanding of the basic physiology of lactation and
for current information on successful management of breastfeeding. The
Lactation Program staff has responded to increasingly frequent requests
for training from such professionals. At the Program's home base in San
Diego, one- or two-day workshops are provided for large groups from
time to time. Additionally, intensive professional certification courses in-
volving 40 hours of carefully supervised clinical experiences, combined
with 40 hours of seminars and didactic classes, are offered to small
groups of physicians and/or nurses from perinatal specialities. Teaching
conferences and consultations are also provided, on invitation, for hospi-
tals and other health-care institutions across the United States, and have
reached several thousand health care professionals.

In August 1983, the Program extended its influence to developing
countries where the American model of separate postpartum and nursery
care as well as routine use of artificial feeding is common in teaching
hospitals. To date, 8 physician-nurse teams (19 trainees) have completed
4 weeks of intensive lactation management training in San Diego and are
now launching clinical training programs and lactation clinics in their
own teaching hospitals in Kenya, Thailand, Indonesia, the Philippines,

50


Guatemala, and Costa Rica. The San Diego Lactation Program 1s proua
to be participating in this American export.

Summary and Conclusions

This report has described rhe San Diego Lactation Program, a
teaching-hospital-based program in operation since September 1977. The
Program functions as an academic subspecialty and is co-directed by a
pediatrician and a pediatric nurse practitioner. Though important serv-
ices are provided for breastfeeding families, the Lactation Program is pri-
marily a teaching resource for health care students and postgraduate
trainees from the perinatally oriented disciplines.

If breastfeeding is to be seriously promoted in this country and if
infants of families from all walks of life are to receive the many benefits
of human milk and breastfeeding, then skilled services from knowledge-
able health professionals are essential. In order to assure the availability
of such professionals, clinical learning opportunities concerning lactation
and breastfeeding must become an unquestioned, standard unit of medical
and nursing education and of postgraduate training in the perinatal
specialties.

Because of the complexity of both the physiology of mother and
infant and their interactive behavior, such clinical training deserves the
same degree of attention, support, and careful direction as given to any
other complex subspecialty. It should be under the direction of knowl-
edgeable and experienced medical faculty with primary training in one of
the perinatal specialties. Teaching-hospital-based lactation programs such
as this can provide ideal clinical learning opportunities for health profes-
sionals and can add a major contribution to the successful promotion of
breastfeeding for all infants and mothers.

51


BREASTFEEDING: NEW YORK STATE'S
INFANT HEALTH STRATEGY

David Axelrod, M.D.

  I bring greetings from Governor Cuomo and his wife, Matilda, both
of whom are very interested in the subject of maternal and child health.
The Governor is a strong proponent of initiatives to improve the health
of infants, children, and lactating women, as exemplified by his successful
support of the addition of $15 million to this year's budget for nutritional
assistance to high-risk populations, many of whom are young mothers
and their children. Mrs. Cuomo has been a tireless worker on behalf of
child health programs in both the public and voluntary sectors.

  Our society needs to do more to promote child health, particularly
among the poor, the racial minorities, and adolescent mothers. Ours is a
time and an environment that seems to have turned its back on the needs
of children. We need greater understanding in the White House, in Con-
gress, and in statehouses throughout this country that the future of our
nation is dependent on the physical health and development of our chil-
dren. Their needs cannot be made to wait.

  I believe a nation which fails to commit itself to protect the health
and development of its children and the women who bear them is a
nation flirting with social disaster, a nation which has no sense of destiny
in weighing the true determinants of national strength and purpose. It is
neither cliche-ridden nor simplistic to say that children are our most pre-
cious national resource. And it is time we directed our national and local
resources in such a way to prove that we are truly committed to serve
the future of our country.

  Our best defense as a nation lies not in weaponry, but in a strong,
healthy, and resilient society, which we cannot have unless we do a
better job of bearing, rearing, and educating our young. And so we
cannot do, unless we address the problem of unwanted adolescent preg-
nancy, unless we recognize that many mothers, their unborn fetuses, and
their newborn infants are being inadequately nourished; and unless we
recognize that, despite all our scientific advances, we still have a long
way to go to achieve our goals in reducing perinatal mortality and
morbidity.

  Seventy years ago, one of every ten infants born in this country died
before age one. Last year, the infant mortality rate in the U.S. was the
lowest ever achieved-just over one death per 100 live births. But,
before letting out a loud cheer to celebrate this accomplishment, we
should not forget that the infant mortality rate of Rlacks is almost twice
that of Whites in our country. In some ghetto areas, the infant mortality
rate is equivalent to that of some Third World countries.

  Nearly two-thirds of the infants who die before their first birthday
have one thing in common, low birthweight, which makes them more
susceptible to disease and developmental defects. All too commonly, low

52


birthweight babies are born to immature, poorly nourished, unwed ado-
lescent mothers. These mothers and their children, if they survive their
common ordeal, usually end up on the welfare rolls, with little prospect
of ever leading independent lives.

  I cite these issues because I believe they are critical to our common
goal of encouraging more mothers to breastfeed their young. A glance at
the data on breastfeeding rates gives a rosy picture-between 1971 and
1981, the percentage of postpartum women discharged from U.S. hospi-
tals who were breastfeeding their children increased more than twofold,
from about 25% to over 57%. Indeed, a survey of breastfeeding prac-
tices by mothers discharged from hospitals in most areas of New York
State mirrors the national experience. Here in Rochester, for example,
60% of the maternity patients at Strong Memorial Hospital reportedly
breastfeed their infants.

But it is when we look to hospitals serving poor, minority clientele
that we discover a different picture. In these hospitals, the hospitals of
the Health and Hospitals Corporation in New York City, hospitals serv-
ing the Crown Point and Bedford-Stuyvesant neighborhoods of Brook-
lyn, and hospitals in Harlem or the South Bronx, one discovers that the
percentage of mothers breastfeeding their infants is more likely to be
10% or 15%. In the case of the Harlem Hospital Center, only 5% of
mothers breastfeed.

Our misbegotten marriage with medical technology is not always
consistent with our goals for more breastfeeding mothers. Let me point
out that some of our leading medical centers are not doing an adequate
job of promoting breastfeeding practices for mothers who come under
their care. Their statistics in this regard are little better than those of the
public hospitals in New York City.

Obviously, we need to do more than simply encourage and educate
mothers to breastfeed their young; we need to inculcate belief in the ad-
vantages of breastfeeding among our doctors, nurses, and hospital admin-
istrators.

While we are still gathering evidence for the population being
served by the federal WIC program, early returns are not encouraging.
Only about 15% of this high-risk population are breastfeeders. This evi-
dence suggests failure to reach the audience that stands to benefit the
most from breastfeeding their young.

We in New York State have decided to do something to remedy
this gap in our infant health strategy. We have discovered that despite
extensive documentation of the physical and psychological benefits of
breastfeeding for both mothers and infants, health-care providers in New
York State are not being appropriately informative or helpful to those
who stand to gain the most from breastfeeding. Indeed, if anything, the
approach in many hospitals has been to encourage artificial feeding
methods at the expense of breastfeeding promotion.

  In order to turn this situation around, we in the State Health De-
partment, in addition to supporting model legislation to require hospitals
to inform patients properly of the infant feeding options available to

53


them-including breastfeeding-have drafted new regulations governing
the responsibilities of hospitals with respect to maternity patients who
wish to breastfeed their infants. We anticipate that these regulations will
be adopted later this month by the State Hospital Review and Planning
Council. *

Under these proposed new regulations, hospitals will be required to
provide instruction and assistance to each maternity patient who either
chooses to breastfeed or is undecided about the feeding method for her
infant. Each hospital with a maternity service will be required to desig-
nate at least one person who is thoroughly trained in breastfeeding physi-
ology and management to be responsible for presentation of an effective
breastfeeding instruction program. Among the other policies and proce-
dures that the hospitals will be required to carry out are:
  1. prohibition of the application of standing orders for antilactation
    drugs;

2. positioning of the infant for breastfeeding immediately following
delivery, unless contraindicated;

3. provision for the infant to be fed on demand;
4. restriction of supplemental feedings to those indicated by the
medical condition of the infant or the mother; and
5. restriction of distribution of discharge packs of infant formula to
an individual order by the attending physician or at the request
of the mother.

The education program, which is to be presented as soon after ad-
mission as possible, must include information on:
  1. the nutritional and physiological aspects of human milk;
  2. lactation, including care of breasts, frequency of feeding, prob-
   lems associated with breastfeeding;

3. dietary requirements for breastfeeding;
4. sanitary procedures to follow in collecting and storing human
milk; and

  5. sources for advice available to the mother following discharge.
  In order to facilitate implementation of these new regulations, we in
the Health Department intend to develop a curriculum to enhance the
skills and knowledge of maternity staffs in those hospitals that do not
currently have supportive programs for breastfeeding mothers.
These regulations also call for the modification of existing standards
that emphasize procedures and allocation of space for hospital prepara-
tion of infant formulas and for the deletion of regulations that require
bacteriologic monitoring of the feeding unit associated with prepackaged,
presterilized, commercially-prepared formulas. Hospitals should realize
some cost savings as a result of these two changes.
We believe these proposed regulations are indicative of our commit-
ment to increase the number of mothers who provide their infants with
the immunologic, bonding, and other benefits associated with breastfeeding.
We look upon these regulations as an integral part of our strategy to
improve maternal and child health in New York State and to continue

* These regulations were adopted in June 1984.

54


our progress in reducing infant mortality and developmental disability. In
a state where the chief executive has tied his entire political philosophy
to the concept of Family, we are sworn to the belief that nothing is more
essential to the promotion of close ties between mother and child than
breastfeeding.

THE LAY VOLUNTEER IN THE MOTHER-TO-
MOTHER PROGRAM OF LA LECHE LEAGUE

Viola Lennon

One of the most interesting aspects of La Leche League is we never
meant to found it. We were all busy young mothers in 1956 and never
dreamed of starting a worldwide organization. None of us had the vision
to see an organization now in 44 countries, having 14,000 qualified lead-
ers in these 27 years.

It all started with a phone call from an old friend, Edwina Froeh-
lich-a person who was a great help to me with breastfeeding of my
children. She invited me to a meeting to discuss breastfeeding and moth-
ering. If she had not mentioned mothering, I would never have accepted
her invitation. I had little trouble with breastfeeding, thanks to the sup-
port and information she had given me. However, mothering interested
me. I wasn't sure just what it really meant.

In our first meeting we shared our ideas about breastfeeding, its im-
portance, some of the problems in getting started with lactation, and our
real joys in the breastfeeding relationship.

One meeting led to others and mothers came. They wanted to know
more about breastfeeding and mothering, and we soon found we had
started reviving the lost art of breastfeeding. When we grew into too
large a group, we broke into several groups. Soon, I was leading a meet-
ing in Chicago.

We then developed an outline for our organization and started to
write a short version of what would eventually be The Womanly Art of

55


Breastfeeding, I remember not being very enthusiastic about writing a
book. Who needs a book?

When an article appeared in the Readers Dig& entitled "They
Teach the Joys of Breastfeeding," we received hundreds of letters. I was
called and asked to answer a few letters and agreed. Soon we were re-
ceiving letters by the stack.

In time, I remember one of the husbands suggesting a national con-
ference. Imagine having mothers and babies travel to a convention! The
idea seemed radical to me, but it happened. Eight hundred people ar-
rived for the conference.

We continued to grow because we had uncovered a natural need. I
will always believe that most mothers want what is best for their chil-
dren, and they knew intuitively breastfeeding was best and would lead
them most quickly to a discovery of mothering and all it entails. We had
the help of several doctors and other professionals who made sugges-
tions;stimulated our thinking, and lent us their expertise. Just as at these
meetings, we need each other-professionals and mothers-to give each
mother the solid base she will need.

The discussion in this Workshop about the indecent exposure issue
reminds me of an incident that happened to one of my daughters. The
girls have earned some of their college expenses by waitressing. One day,
one of the other waitresses approached my daughter with the statement,
"You will never guess what the lady in station 17 is doing."
My daughter knew what the woman was doing. The waitress con-
tinued, "Wouldn't you think she would nurse the baby in the bathroom?'
My daughter confided to me that years ago she would have said nothing.
In those early days the children had problems describing their mother's
involvement. Now, breastfeeding has come out of the closet, and my
daughter responded, "No one else in this restaurant is eating lunch in the
bathroom."

Now back to the story. We just kept on growing and soon we had a
few State meetings and a State Coordinator. Then Canada and New Zea-
land joined us, and we changed to areas.

The usual followed-starting to employ a few people, setting up an
offXal offlice, writing a constitution. Many of you in the voluntary
sector know the steps.

We started out as a breastfeeding support system. Like all of you
who have your vision focused on the ultimate health and happiness of
families, we made startling discoveries. Breastfeeding is important. A
positive birthing experience adds immeasurable support to a mother's
confidence, but she needs all this and more to complete her education as
a parent for the lifelong job of raising a family. We together must give
parents this belief in themselves. That whole process is what La Leche
League is all about.

La Leche League is a much broader oganization than we, the found-
ers, first anticipated. La Leche League is first a breastfeeding information
and support network, usually based on the mother-to-mother approach.
La Leche League is really the only organization that speaks to the
needs of the baby and is a spokesperson for the baby.
La Leche League International is a witness to the importance of

56


motherhood, a model for mothering. LLLI is also a comfortable place to
grow in mothering. The mother who becomes attentive to the real needs
of her infant and is sensitive to the rhythm of a little body soon learns
real discipline is loving guidance. The mother who sees growth in her
infant through her own milk soon begins to take a real interest in her
own and her family's diet.

La Leche League International is becoming a worldwide resource
for minority, employed, and professional mothers.

The ingenuity displayed by employed mothers will always fascinate
me. Their determination to breastfeed makes me pause in respectful ad-
miration. They come home for lunch for two. They pump their milk on
coffee breaks. By prior arrangement, some mothers bring their babies to
work.

The WIC program and La Leche League are cooperating in offer-
ing breastfeeding information and support to the clinic mother. We had
often wondered if our mother-to-mother approach and our materials
would work for this group of mothers. Happily it does work, if our lead-
ers develop a real sensitivity to cultural differences in any group. In Chi-
cago we have had several seminars on Black culture to sharpen our own
insights. We also offer many of our materials in Spanish. In the Watts
district in California, our inner city program is thriving and our member-
ship has real interest in other cultures.

For the pregnant professional, we are planning a series of lectures
on breastfeeding complete with a package of information and an appro-
priate charge. This scheme is a departure from our meeting series, but
we realize that some women will not attend a La Leche League Series
meeting. We are not locked into any one format. Our philosophy is para-
mount. The eighties present new life-styles, and we mean to be as sup-
portive as possible-always depending on you good professionals for
guidance and cooperation.

We need you, but you need us. When a new mother is confronted
by a crying, seemingly unmanageable infant, she doesn't need a diagram
of the construction of the breast. She needs an experienced nursing
mother. When there is a medical problem, the diagram may point to the
solution, and a doctor's experience is vital. We never give medical
advice.

The following story is true and says what we really are. One day an
overwrought and tired new mother called me. She was haying problems
with breastfeeding. Since she lived close by, I suggested that she drop in.
She did-and started asking questions. Martin Lennon was 3 months old
and behaving just his age. I nursed him and we talked. I put him on my
lap, then I put him on a blanket on the floor as I made some coffee. Fi-
nally I noticed my visitor was not paying any attention to my answers.
She was watching and finally blurted out, "Do you think that child is
normal?" Remember, this was my son! I said "yes" and she seemed to
smile and relax. "I guess I don't have any problems. I just didn't know!"
There it is: La Leche League.

57


BREASTFEEDING AND THE MEDIA

Robert Bazell, NBC News

  After I was asked to speak at this conference of distinguished par-
ticipants, I read a press release that said I would be talking about what
television is doing to promote breastfeeding. I then went to our comput-
er to see what NBC News has done on the subject of breastfeeding. In
researching the 7#years since tape has replaced film as the primary video
storage element, I found that NBC News had done 7 pieces on breast-
feeding, 3 of them in a period of a few days in 1981. Using these pieces
as a framework, I would like to talk about how news is made, and why
something becomes newsworthy. Breastfeeding, although it involves cru-
cial health issues, is unfortunately "old hat." It is not news. It is true that
the news media certainly stresses educating the public, but we in the
media don't always function as if that were our primary role.

  Let me enumerate the NBC News stories on breastfeeding in chron-
ological order. The first was aired on June 8, 1977. There was a report
of a Senate hearing in which some environmentalists showed that toxic
substances had been found in human milk. How will such a story be
treated? We must remember that the network evening news program is
22 minutes and 40 seconds long after the commercials. Frequently a
story is sandwiched between a commercial touting a headache remedy
and another selling a hemorrhoid remedy, and conveying health informa-
tion in that perspective is difficult. Furthermore, a typical story on the
evening news is 90 seconds long, including the sound bites (the 15-18
second quotation from the subject of the story) as well as the 1 l/s min-
utes of reporter's commentary. This amount of space/time doesn't allow
for much of a balanced perspective on two sides of a complicated issue.
There is usually time for only one impression to be conveyed in this
visual medium, and in the story in point, probably the one idea that came
across was that there was something dangerous in mother's milk. The
public takes away the idea that there is something to worry about.

  Why did we do that story? It was startling, and therefore it was
news-and viewers paid attention. Breastfeeding was suddenly suspected
as potentially harmful to children; thus it became newsworthy.

The decisions concerning news content are made by relatively few
people and almost all of them are men. Certain subjects simply evoke
squeamishness. A story on the benefits of breastfeeding unfortunately
seems to be considered by some as unfit material for the evening news.
The subject is a visual one, and showing a picture of a woman nursing
her baby, no matter how tastefully done, makes some people nervous.
Those who decide what will be shown seem to prefer to do a story on
another health topic-almost any other.

The second story aired by NBC in this 7-year period was in January
1978. Jane Pauley on the "Today Show" interviewed Dr. Jean Lockhart
of the American Academy of Pediatrics. The Academy had just come

58


out with a recommendation strongly in favor of breastfeeding. The pre-
sentation was a one-on-one interview and did not involve showing pic-
tures. This type of presentation, 4 to 6 minutes long, does give more of
an opportunity for questions and answers and explanations. I believe
such a format is better for conveying information, and I am surprised
that there have not been more presentations of this kind. There is the
conviction that health issues are important, and breastfeeding is certainly
one of these issues. This interview also reinforced the concept of the
voice of authority. The physician or the medical organization will make
US pay attention to an issue-in this case, breastfeeding. When the Amer-
ican Academy of Pediatrics highlights an issue, people listen. Even SO,
the press and the public are ambivalent toward physicians and the medi-
cal establishment as authority figures. On one hand, we look to them as
experts with all knowledge; on the other, there is enormous skepticism
running through the country. In this context, breastfeeding, or the return
to breastfeeding, first started as a popular movement and then received
the establishment's blessing through scientific research. There are both
the popular and the establishment currents at work, and we in the media
always wonder which current we should swim with.

  The next story to appear on NBC was on the nightly news on Janu-
ary 26, 1979, and I am sure it is familiar to you. Linda Eaton, a fire fight-
er in Iowa City, was dismissed from the fire department because she in-
sisted on the right to nurse her baby in the firehouse. Now a story like
this one gets on the news because it's quirky, and in fact it does raise
some very crucial issues like the questions of breastfeeding and women
working and women's rights. Even though this case was regarded as bi-
zarre, it could have been a focus to discuss those issues. I think that one
of the reasons it got so much attention was that she was a tire fighter. If
she had been a secretary and had been tired for insisting on bringing her
child to the offrce, there would have been a small paragraph in a news-
paper someplace. It was only because she was a tire fighter, a job which
obviously is commonly male, that the story received so much attention.
That is the reason some stories become news. I hope that some people
go beyond seeing it as more than just a weird story about a woman in a
firehouse, and see the real issue. But certainly when I look back over the
way the scripts were written, or even the way newspapers (which have
much more space) treated it, I don't think it was treated in a way to
bring out the substantive issue.

The next time that a story about breastfeeding appeared on NBC
was two years later in May 1981. There were three itories in a period of
a few days. Officials in the Agency for International Development
threatened to resign because the Reagan administration did not support
the World Health Organization's infant formula code. Television news
sed the issue very quickly and then just dismissed it. If I am listing the
tits of television, this is the area where we fail the most. Middle-class
>men and men who make decisions about breastfeeding don't need a
tgthy discussion on the "Today Show." If they are educated or if they
111 consult their doctors for the right information, they will get the in-
rmation. But the issue of infant formula sales in Third-World countries

59


and formula promotion in poverty areas of the United States is a crucial
news issue, and it is one that has been almost ignored by both newspa-
pers and television. It only came up in this one instance because two men
threatened to resign. It happened, and then it was just forgotten. There
was never an in-depth report. There was never a "why is it so impor-
tant?' The reasons are astounding in terms of the implications for nutri-
tion, the implications for birth control in those countries, and all those
things which you know so well. We should have done 20 news stories or
documentaries about breastfeeding, because the issue really matters. But
it was not done. We did not cover it because American television would
much rather cover a story about the sex life of gorillas.

The last story on the -list illustrates another reason why things get
on the air. On December 6, 1982, in Boston, 150 women donated breast-
milk to save the life of an infant whose mother couldn't produce enough.
That's wonderful! That is a nice heartwarming story, and got on the air
for that reason . . . not because it instructs people about anything, not
because it informs us about the issues, but because it is a "Gee whiz,
aren't those people nice" story.

There you have the limitation of our coverage. I think it should be
different.

One of the fascinating things on the subject of breastfeeding is its
lack of media history. I always associate breastfeeding with bricking up
the fireplace. After World War II, many people bricked up their fire-
places because why in the world would you want to have a fireplace in
your living room anymore with all the new technology? Who would
want to see an old-fashioned thing burning? Now we are rediscovering
that it is a good thing.

60


REFLECTION ON BREASTFEEDING

Rabbi Judea B. Miller

Some participants asked if there were any references in the Bible to
nursing and lactation. I want to point out that aside from the most obvi-
ous bonding and nurturing references to the mother mentioned in one
portion of the service, Moses is described as a nursing father. He carried
Israel through the desert like a nursing father. And when I see the young
fathers today holding their children and sharing in the nurturing and
raising of children (as in my generation they did not do), I can under-
stand what was meant by Moses as a nursing father.

In Jewish tradition, a woman is not ordained (according to our Or-
thodox brethren), not because she is unworthy of ordination, but just the
opposite. There is a hierarchy of values, and from those mitzvot or com-
mandments that have to do with time and place, a woman is automatical-
ly exempt. She can take them on, but she is exempt from the responsibil-
ity of fulfilling them. Because of a higher order of priorities, her res?on-
sibility is to be available to nurse and nurture the chi!dren. Of Lourse,
women don't nurse children all their lives. After they finish their nursing
responsibilities, they can become rabbis or priests, or anything else they
care to be.

A Jewish child, like every other, is introduced to the world with a
whack. That is quite an introduction, but at least we grow up knowing
that there are loving, nurturing arms and breasts to receive us into a
world that is sympathetic and hospitable. Let me recall to those of YOU
who know Hebrew that one of the words for God in the Bible is El
Shaddat The word shaddai has the same root as shaddayim, which means
breasts. God is compared to a nurturing, nourishing mother, taking care
of believer and unbeliever alike.

One last thought is that according to the laws of kashrut, you shall
not boil the kid in its mother's milk. And from that law, the rabbinical
tradition builds up our whole system separating milk from meat. The
thought behind it is not merely one of taboo, but (long before the days
of Freudian psychology) one of symbolism and of metaphor. It seems in-
sensitive and brutal to eat flesh and then immediately to drink milk that
was given out of love. The giving of the milk is the height of human
compassion. In Jewish thinking the highest. order of priorities for a
woman and for a man, like the nurturing father Moses, is the care and
nurture of the young. God could not be everywhere. That is why God
created mothers; that is why God created parents.

61



WORK GROUP
  RECOMMENDATIONS

NTRODUCTION TO WORK GROUPS

  Each interdisciplinary work group of approximately 12 persons was
tssigned to examine in detail one of 8 specific issues related to human
actation and breastfeeding. Each work group included participants with
;pecial knowledge of the issue being addressed as well as participants
with unique perspectives on the issue by virtue of their discipline, work
jetting, cultural and ethnic orientation, and organizational affiliation.
Each work group had as its core a nurse/nurse-midwife, a nutritionist/
dietitian, a pediatrician, and an obstetrician. Each work group focused on
B different topic that was well delineated. The tasks of the work groups
were to identify issues, prioritize and discuss them, and then to generate
recommendations and develop strategies to address them.
Although the broad scope of information and the range of views
and perspectives exchanged in the work groups cannot be covered ade-
quately in this document, some of the more urgent issues, needs, and
strategies are synthesized and presented in capsule form. To provide a
convenient framework for follow-up discussion and action, the delibera-
tions and recommendations were categorized into common themes and
are reported under the following 6 headings:
   1. World of Work
  2. Public Education
   3. Professional Education
  4. Health-Care System
  5. Support Services
   6. Research

CATEGORY 1: WORLD OF WORK

  A national breastfeeding promotion initiative directed to all those who
influence the breastfeeding decisions and opportunities of women involved
in school, job training, professional education, and employment is needed.

63


DEFINITION OF THE ISSUE

Many barriers currently exist at work and school which can nega-
tively influence a woman's decision to breastfeed and/or her breastfeed-
ing experience. These barriers include:

o Lack of information on the part of the lay public (including
women themselves), employers, health providers, and other sup-
port persons to whom the mother may turn for assistance and/or
advice.

o Logistic elements such as how, when, how often, and where to
nurse her baby or to empty her breasts when separated from the
baby and to store milk for later use.

o A social, psychological, and political climate which significantly
separates the worlds of work and home and their related roles.
The .working breastfeeding mother often receives negative mes-
sages about her efforts, specifically, that she is attempting to
combine mutually incompatible roles and threatening the deci-
sions others have made to keep the worlds of work and home
separate and unrelated to one another.

In addition, adequate data necessary to direct effective promotional
efforts to working women and to those who influence them are not
available. Also lacking are the appropriate support systems, e.g., prenatal
care, paid maternity leave, and flexible work arrangements, which are es-
sential for the success of programs designed to promote breastfeeding by
working mothers.

SUGGESTED STRATEGIES

1. Develop a Public Health Service initiative which would help to
insure the rights of all mothers to make and implement an informed
choice about infant feeding. This effort should be targeted (but not
limited) to employers, unions, educational institutions, health care
providers, and social service agencies. Particular attention should be
directed to employers of certain job categories, e.g., domestic
employees, in which minority and low-income women are often
over-represented. The initiative should include at least the following:
  a. Development and distribution of informational packets for
  prospective breastfeeding mothers, major employer groups,
  health professionals, and agencies serving women and infants.
   These packets should specifically address logistical and support
   elements relating to employment/school and breastfeeding.
  b. Collection and dissemination of current information about
   existing programs for employed breastfeeding mothers.
  c. Allocation of funds for:

o data collection on populations potentially affected;
o studies of employed breastfeeding women;

64


   o evaluation of program components;
   o projects to demonstrate how to facilitate breastfeeding for
    working women, including some with emphasis on minority
      and low-income women.
   d. Exploration of legislation related to federal, state, and local tax
   incentives for those who successfully implement breastfeeding
   programs in work/school settings.
2. Examine institutional policies which interfere with culturally appro-
priate choices of infant feeding in work/school and other institutional
settings.

3. Encourage the development and/or accessibility of appropriate
support services in the world of work, e.g., prenatal care, social and
nutritional services, paid maternity leave, child care, and alternate
types of work arrangements such as flexitime and job sharing.

CATEGORY 2: PUBLIC EDUCATION

Public education and promotional efforts should be undertaken
through the education system and the media. Such efforts should recognize
the diversity of the audience; should target various wxxnic, cultural, and
ethnic groups; and should be coordinated with professional education.

DEFINITION OF THE ISSUE

  Information and education about lactation and breastfeeding as a
normal process, a part of everyday life, and the preferred method of
infant feeding are not universally available. In those instances where edu-
cational programs do exist, they frequently lack sensitivity to cultural
differences, life styles, and socioeconomic levels. Often messages and in-
formation about breastfeeding and lactation conveyed to women, fami-
lies, care providers, community officials, and the public are conflicting
and not based on fact. The resulting confusion often leads to the perpet-
uation of myths, attitudes, laws/regulations, and other barriers which
impact negatively on the initiation and/or continuation of breastfeeding.

65


SUGGESTED STRATEGIES

1. Issue to the national media a Surgeon General's public policy
message emphasizing the positive aspects of breastfeeding and re-
porting the annual progress made toward the 1990 national ob-
jective related to breastfeeding.

2. Develop, implement, and evaluate a public-education campaign
to encourage the development of attitudes and behaviors which
support breastfeeding. Such a campaign should target women of
child-bearing age, their supporters, and the community at large,
with highest priority given to lower-income/less-educated
women. Important elements include:
   a.  An on-going media campaign which utilizes public service
   announcements, features, display ads, posters, printed mate-
   rials, and role modeling to portray breastfeeding as a com-
   munity norm and a part of everyday life.

b.  A mechanism to exchange and share educational materials
developed in various parts of the country.

C.  A coordinated effort of organizations concerned with pre-
natal care to achieve the universal provision of education
and counseling on breastfeeding and other goals of the
  public education campaign.
d.  Materials developed and tested for applicability to specific
  target groups.

3. Develop an educational campaign for public officials to identify
and address community attitudes and to remove and prevent
laws restricting the practice of breastfeeding in public (e.g.,
public nudity, indecent exposure). Organizations of elected offi-
cials (e.g., national associations of attorneys general) and legisla-
tors should be utilized.

4. Integrate breastfeeding information early and throughout the
educational system through a cooperative effort of State Depart-
ments of Health and State Departments of Education. Such an
effort should include:

a.  Development of model education curricula and materials;
b.  Integration of breastfeeding information into existing cur-
ricula for science, family life education, home economics,
  and health.

5. Use the Healthy Mothers/Healthy Babies Coalition as a clearing-
house for educational materials related to breastfeeding.
6. Encourage community support for breastfeeding by health-care
systems, businesses, religious organizations, volunteer organiza-
tions, and the media. These efforts should focus on:

a.  Removal of physical and attitudinal barriers to
breastfeeding, e.g., providing an appropriate place and fos-

66


   tering postive public attitudes by provision of educational
    materials;
  b.  Development of support systems to nurture nursing moth-
   ers such as support groups, telephone hotlines, and the uti-
   lization of existing community resources, e.g., churches, so-
    rorities, and ethnic community organizations.
7. Collect information and data to monitor changes in attitudes and
behavior related to breastfeeding.

CATEGORY 3: PROFESSIONAL EDUCATION

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.

DEFINITION OF THE ISSUE

Education of professionals in this important aspect of maternal and
child health care is too often inadequate, ineffective, and-in some situa-
tions-unavailable. A national plan for the education of professionals in
lactation and breastfeeding does not exist. Current concerns are related
to the following aspects and issues of educational programs:
  o The need for appropriate curricula which recognize the diversity
   of sociocultural and economic groups in the population as well
   as the roles/responsibilities of various health professionals;
  o The inadequate funding for the preparation of faculty to direct
   and provide training related to lactation and breastfeeding;
  o The unavailability of educational programs and resources, in-
   cluding faculty and funds, to support the education of practicing
   professionals;

o The lack of appropriate involvement of accreditation and
standard-setting bodies to assure the competence of health pro-
fessionals and others involved in education and counseling
related to lactation and breastfeeding.

67


SUGGESTED STRATEGIES

1. Charge the Healthy Mothers/Healthy Babies Coalition to estab-
lish an interdisciplinary sub-committee to develop strategies for
the education of professionals regarding lactation and breastfeed-
ing; provide the Coalition with the necessary funding and admin-
istrative support.

2. Encourage the federal Maternal and Child Health agency to pro-
vide leadership for education of professionals, including guide-
lines for curriculum, evaluation, and accreditation.
3. Encourage state, county, and municipal health departments to in-
clude breastfeeding and lactation in in-service training programs.
4. Encourage local health professional societies, universities, and
perinatal outreach programs to give priority to continuing edu-
cation regarding breastfeeding and lactation to practicing profes-
sionals.

5. Request the Department of Health and Human Services and
non-profit foundations to provide additional funding for pro-
grams for faculty development and for education of health pro-
fessionals in breastfeeding and lactation.
6. Include training modules on breastfeeding in curricula of health
care professional students (particularly in medicine, nursing, and
nutrition) to cover contemporary scientific knowledge, influence
of social factors, practical techniques, and roles in multi-chan-
neled promotion programs.

7. Stimulate national professional societies to educate their mem-
bers regarding breastfeeding and lactation through policy state-
ments, articles published in their journals, and continuing educa-
tion programs.

8. Encourage editorial boards of professional journals to accept for
publication appropriate articles dealing with scientific knowl-
edge, influence of social factors, and practical techniques regard-
ing breastfeeding and lactation.

9. Include questions on breastfeedingflactation on certification
exams for health professionals serving families in the perinatal
period, e.g., nurses, nurse-midwives, dietitians, nutritionists,
physicians.

10. Develop guidelines concerning training and accreditation of lay
lactation advisors in relation to selection criteria of trainees; de-
tails of practical and theoretical training; examination system;
  nomenclature.

11. Develop accreditation guidelines for health care facilities that
specifically include a requirement of staff education in lactation
and breastfeeding.

68


CATEGORY 4: HEALTH-CARE SYSTEM

The health-care system needs to be better informed and more clearly
supportive of lactation and breastfeeding.

DEFINITION OF THE ISSUE

  How best to support and encourage lactation and breastfeeding as
the natural and preferred method of infant feeding is a major overall
issue of the health-care system. Concern for lactation and the promotion
of breastfeeding are not always reflected in the practices of the health-
care team and in the policies of health-care institutions. 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 hospi-
tal settings. The current organization and delivery of maternal and child
health services and attitudes of health-care team members frequently
negate support for breastfeeding. The problem is compounded by the sig-
nificant numbers of health-care providers who are not adequately edu-
cated about the process and advantages of lactation in human reproduc-
tion and in infant health.

Achievement of the goal to increase the incidence and duration of
breastfeeding will require thorough education of all members of the
health-care team. The result should be a clearer recognition of support
for lactation and breastfeeding as an important and valuable component
of family-centered maternity/newborn care. Furthermore, the application
of this knowledge will require on the part of all members of the health-
care team a positive attitude, based upon the conviction that lactation has
specific and significant advantages for both mother and baby. According-
ly, all providers and facilities should adopt a posture of advocating lacta-
tion as the natural and preferred means of infant feeding. This attitude
should include institutional policies clearly supportive of lactation and
breastfeeding.

At the present time, some of the federal programs serving women
and children include disincentives to breastfeeding. The federal govern-
ment should address these barriers and become committed to the elimina-
tion or modification of such policies.

Elements important for the promotion' of breastfeeding in the vari-
ous phases and settings of health care are detailed in Appendix C.

SUGGESTED STRATEGIES

Recommendations and strategies are outlined according to the inter-
action of the individual with the various levels of the health-care system.

69


Narionaf Level

1. Assign the Division of Maternal and Child Health the responsi-
bility to determine national policy related to lactation and breast-
feeding and to convene periodically a national group to advise
on and monitor national policy on breastfeeding.

2. Improve the support for lactation in the Women, Infants, and
Children (WIC) Program, including the possible formation of
task forces at both federal and state levels to examine ways in
which WIC can develop incentives to promote breastfeeding,
eliminate existing disincentives, and increase the flexibility of the
program in certain aspects such as cultural foods.

3. Request professional organizations including the American HOS-
pita1 Association, the American College of Obstetricians and
Gynecologists, the American Academy of Pediatrics, the Ameri-
can Academy of Family Physicians, the American College of
Nurse-Midwives; the American Dietetic Association, the Ameri-
can Nurses Association, and others to develop policies and ac-
tivities which more clearly support breastfeeding.

4. Request the Joint Commission on Accreditation of Hospitals to
develop guidelines for hospital policies which will promote fully
informed choice about infant feeding and which will support a
mother's decision to breastfeed, e.g., rooming-in and feeding on
  demand.

5. Explore the potential for third-party coverage for lactation coun-
seling and breastfeeding support through the Health Care Fi-
nancing Administration, the National Association of Insurance
Carriers, and other appropriate groups/agencies.

State Level

6. State health departments working cooperatively with state pro-
fessional societies and voluntary agencies, regional perinatal pro-
grams, hospitals, and others should establish state task forces to
review state laws and regulations with a view to eliminating
laws/regulations which inhibit breastfeeding and make recom-
mendations regarding 1) policies, procedures, and standing
orders of hospitals and ambulatory settings; 2) implementation of
recommendations of this Surgeon General's Workshop; 3) staff
education; 4) continuing education; 5) education materials on
breastfeeding; 6) funds for support of demonstration projects;
and 7) incentives for women to initiate and continue breastfeed-
ing.

7. Encourage state health departments and regional perinatal cen-
ters to become resources for training and consultation and to
serve as models for the promotion and support of breastfeeding.

70


8. Develop a model for a continuum of postpartum care involving
immediate follow-up with integration of medical and social sup-
port to avoid the present fragmentation of services.

Regional Level

9. Encourage regional perinatal centers to become regional re-
sources for training and consultation regarding breastfeeding and
models for promotion and support of breastfeeding. These cen-
ters would relate to each hospital's breastfeeding coordinator,
stimulate and initiate research, provide centralized information
and referrals, and provide direct services to high-risk popula-
tions, as appropriate.

10. Make equipment and facilities of the regioanl perinatal centers
available for teaching purposes throughout the region.

Local Level

11. Encourage and assist hospitals to:
    a. Explore the development of facilities for parents of hospitalized
    infants;
   b. Designate breastfeeding coordinators to serve patient needs and
   to be the contact with regional lactation resources;
c. Provide materials, equipment, and facilities for rooming-in;
  d. Meet other needs of breastfeeding mothers;
e. Provide information about La Leche League and other such
    support groups;

f. Create special programs supportive of breastfeeding for high-
risk groups such as pregnant adolescents;
g. Recognize the marketing value of an effective lactation pro-
gram.

12. Organize in the community a continuum of postpartum care
which will facilitate immediate follow-up and referral, including
medical and support services, as the matrix for breastfeeding sup-
  port.

71


CATEGORY 5: SUPPORT SERVICES

  The successful initiation and continuation of breastfeeding will require
a broad spectrum of support services involving families, peers, care provid-
ers, employers, and community agencies and organiwrtions.

DEFINITION OF THE ISSUE

  It is essential to have a model of care which focuses on the strengths
of the family, respects the variations found within different cultural/
ethnic and economic groups as well as life styles, offers a continuum of
care for the mother and child throughout the reproductive cycle, and ef-
fectively utilizes community resources to support breastfeeding. Yet, far
too often, many of these attributes are missing. Even those mothers and
families who may have received appropriate education and counseling
for breastfeeding prior to and during hospitalization, do not always have
access to the follow-up support necessary to cope with problems and
questions frequently arising after discharge. Although health-care provid-
ers may do a good job of promoting an informed choice about infant
feeding, the important involvement and support throughout the process
by the family members, peers, employers, and community resources may
be lacking and unrecognized.

SUGGESTED STRATEGIES

1. Encourage cooperation and referral between breastfeeding sup-
port groups and providers of health and social services.
2. Provide for culturally appropriate peer-support groups who can
offer assistance and counseling for such lifestyle conflicts as
breastfeeding in public and/or while working.
3. Explore the availability of insurance coverage and other sources
of funding for support services and for materials and supplies to
facilitate breastfeeding, especially for mothers and infants with
special needs, e.g., infants in day care and mothers with chronic
illness.

4. Advocate for infant-care centers which provide breastfeeding fa-
cilities in the workplaces, schools, and other locations serving
"working women."

5. Develop support services in the community which help to nur-
ture nursing mothers, e.g., telephone hotlines, community or
public health nursing follow-up, and volunteers who are experi-
enced in breastfeeding.

6. Seek commitment from national voluntary organizations to stim-
ulate support for breastfeeding among their membership. Include

72


voluntary organizations which reach various cultural/ethnic
populations, economic groups, and women of different ages.
7. Collect information about successful models of support for initi-
ation and continuation of breastfeeding and disseminate this
knowledge nationwide through the Healthy Mothers/Healthy
Babies Coalition.

CATEGORY 6: RESEARCH

An intensified national research effort, including a broad range of re-
search studies, is needed to provide data on the benefits and contraindica-
tions of breastfeeding among women in the United States. Research is also
needed to evaluate strategies/interventions and to determine progress in
achieving goals related to the promotion of breastfeeding.

DEFINITION OF THE ISSUE

Basic studies, clinical studies, evaluation of information studies, and
prospective, longitudinal studies related to breastfeeding are all needed to
improve the information base, establish policy, improve and target strate-
gies, and assess program effectiveness. Areqs of concern which need to
be investigated are:

o Epidemiologic studies on the outcome of breastfeeding in com-
parison to other types of feeding among diverse groups of Amer-
ican women;

o Infant outcome with respect to morbidity, physical growth, and
both physical and behavioral development of the child;
* Physiology and pharmacology of the lactation process, including
better data on the medical contraindications to breastfeeding;
o Behavioral and social-scientific aspects of lactation in particular
segments of our society, including barriers to initiation and con-
tinuatiqn of breastfeeding, resistance of health care providers,
and need for-as well as effectiveness of-support services for
lactating mothers.

o Evaluation of strategies designed to motivate and foster a change
in breastfeeding behavior.

o Cost-benefit research which would provide a scientific basis for
development of national policy on breastfeeding.

73


SUGGESTED STRATEGIES

1. Develop a national data base on initiation and duration of lacta-
tion.

2. Initiate multi-center studies that focus on the physiologic, phar-
macologic, medical, psychosocial, and cultural aspects of breast-
feeding.

3. Encourage and support longitudinal and cross-sectional studies.
4. Improve coordination among federal agencies with responsibil-
ities for research relating to breastfeeding and among federal,
state, and local governments in order to provide a unified ap-
proach to research questions.

5. Request the Public Health Service, including the National Insti-
tutes of Health, as well as the U.S. Department of Agriculture,
to increase funding support for research related to breastfeeding.
6. Develop a multi-cultural task force responsible for collecting
available interdisciplinary research on cultural differences related
to lactation and breastfeeding and for disseminating research
findings to health care providers.

7. Establish a national clearinghouse on research findings, demon-
stration projects, and baseline data related to breastfeeding and
human lactation. '

8. Design and implement a national evaluation effort to determine
the degree to which strategies recommended at this Workshop
have been implemented and goals have been achieved.

74


SUMMARY OF WORKSHOP
RECOMMENDATIONS

Ruth A. Lawrence, M.D.

Common themes emerge from all the work groups. Many of the
groups made similar recommendations focusing on the same issues, but
perhaps from different perspectives.

The importance of endorsement of the positive aspects of breastfeed-
ing by federal agencies, professional organizations, and voluntary groups
ran throughout the reports. We need to insure an informed and free
choice for all women with regard to feeding their infants. In order to
remove or prevent the passage of laws detrimental to breastfeeding,
public officials should be educated about the normalcy of breastfeeding.
In other words, let us insure the right to breastfeed.

We need to establish breastfeeding as the community norm; in order
to accomplish this goal, we need universal education-early and continu-
ous. An unceasing effort should be directed to educating all segments of
society, levels of the education system, and cultural subgroups.

A professional information base should be determined and standards
established for training all health-care professionals. In addition, profes-
sional education for specific health-care areas should be developed in
order to train consultants within the health-care structure to understand
human lactation and to facilitate breastfeeding.

The health-care system should deal with breastfeeding issues within
the continuum of comprehensive perinatal care. Support for breastfeed-
ing families should be available from health-care facilities and from com-
munity-based resources.

With respect to employment, the opportunity should be available for
women to continue breastfeeding when working or when completing
their education or training.
All of these efforts should be sensitive to cultural values and should
be initiated and implemented with the involvement of members from the
targeted cultural groups.

With respect to research, the needs are great and the potential un-
limited. We need a national data base on the initiation and the duration
of lactation. Multicenter, longitudinal, and cross-sectional studies are
needed to investigate benefits and contraindications of breastfeeding and
to evaluate strategies and interventions to promote it. Interagency co-
ordination of projects would insure a unified approach to research ques-
tions and timely dissemination of research findings.

In summary, we need to continue to communicate among ourselves
and also to involve other colleagues to begin to implement these recom-
mendations in our own programs, regions, and states. We all stand ready
to assist the Surgeon General in this effort. We realize it cannot all be
done in Washington. Thus, it will be the responsibility of each of us to
initiate efforts from our own vantage points to enhance and magnify the
national effort to make breastfeeding the norm.

75


76


RESPONSE OF
THE SURGEON GENERAL

As previously noted, participants in this Surgeon General's Work-
shop were selected for their expertise and for representation of profes-
sional organizations, voluntary organizations, and government agencies
with an interest in breastfeeding. Diverse groups have joined together in
focusing on breastfeeding and human lactation-a topic considered as top
priority by the Office of the Surgeon General. The Recommendations
presented this afternoon become a national statement, synthesized and
promulgated by the Office of the Surgeon General with the active in-
volvement of the many organizations that you represent. This shared ap-
proach has been a major factor in the continuing success of the two pre-
vious workshops. The report of each has been a national, not a federal,
statement.

The first report, Report of the Surgeon Gene&s Workshnr, on nlater-
nal and Infant Health-published in January 1981-reviewed the status
of perinatal health at that time and outlined social strategies for improve-
ment. Professional and voluntary organizations and state and local gov-
ernments have utilized the report for policy and program initiation. The
report became the basis for the Healthy Mothers/Healthy Babies Coali-
tion and its subsequent activities.

The second report, Report of the Surgeon General5 Workshop on
Children With Handicaps and Their Families, was published in February
1983. From this report many ensuing activities serve as examples of the
effectiveness of this approach:

o The scope of the problem has been further defined by the Van-
derbilt Policy Study on Chronic Illness in Children;
o Standards for regionalized, comprehensive care are being devel-
oped through a diabetes project at Michigan State University
and a program of projects for juvenile rheumatoid arthritis
throughout the nation;

o Several efforts involving insurers from both the public and pri-
vate sectors to improve the financing of care for these children
has been ongoing since the Workshop. Professional organizations
have collaborated in this activity;
o Three projects in Illinois, Louisiana, and Maryland are focusing
on moving ventilator-dependent children from institutional set-
tings to home or home-like settings through the use of multidisci-
plinary teams;

o A network project for agencies serving disabled children is pro-
viding consultation, technical assistance, and resource sharing in
approximately 20 states.

We expect no less from the report of this Workshop.

77


Now, in response to your specific recommendations, please remem-
ber that the one hour between your presentations and my response is in-
sufficient to reply in the depth and breadth your efforts deserve.

Some of your recommendations are the responsibility of other cabi-
net departments; that doesn't mean we won't address them. Some recom-
mendations are impossible without legislation. While I will not ignore
these concerns, neither can I make any promises. Finally, it is inevitable
that some of your recommendations overlap those coming from other
groups.

  Several themes seem recurrent. One is the establishment of breast-
feeding as the norm. The issuance of the Workshop Report by the Sur-
geon General will, in effect, reply to this recommendation by providing
a basis for promotion by professional and voluntary organizations.

A second theme is universal education. We can and will encourage
formal education of professionals through curricula of health providers
via the Bureau of Health Professions and of the public through the
media: magazines, newspapers, radio, and TV.

We can and will encourage continuing education for health provid-
ers in practice. We will ask state Maternal and Child Health (MCH)
agencies to work with local chapters of professional organizations to ac-
complish this goal.

When it comes to education of public off'cials, I suggest that legisla-
tive and regulatory approaches and models like those in New York State
we heard about last night be made available to people in a position to do
something about the issue.

In reference to the workplace, the Division of Maternal and Child
Health and I will, through this Report and other means available to us,
emphasize the problems in the workplace and address the issue by every
avenue open to us through private industry and public employers. We
will inform them about the concerns raised by the Workshop partici-
pants. I will continue to enunciate in public addresses the challenges
facing employers and possible solutions. In the long run, legislation is
necessary to accomplish some of your goals. I promise that your concern
will be communicated.

We will attempt to develop a continuum of postpartum care which
involves immediate follow-up, and to encourage public health agencies
to adopt promotion and support of breastfeeding as standard practice.
We will continue to work with professional organizations (providers and
hospitals) to promote breastfeeding in the private sector.
  I am enthusiastic about the details enunciated in the recommenda-
tions. The best way I know to express your concerns is to transmit spe-
cific recommendations to the Assistant Secretary for Health and appro-
priate agencies and to ask for a response.

Please remember that mine is a quick response to a number of issues
with high priority in your work groups. My office and the MCH staff
will carefully consider your written and oral reports and attempt to
come up with a more detailed and appropriate response.
We are grateful for your participation in this Workshop and are

78


counting on your commitment to share your recommendations and to
nromote them within your organizations.
The Report will be sent to selected groups of those people able to
effect the recommended changes -for example, members of Congress,
staff members of appropriate House and Senate committees, and appro-
priate members of agencies and of the private sector. I give you my per-
sonal assurance that your suggestions and recommendations at this
Workshop will receive the attention of the Office of the Surgeon Gen-
eral. We will:

o Disseminate this Report widely;
o Follow through on your recommendations where possible-even

when they cross departmental lines;
o Keep you informed of the results of this Workshop;
o Be responsive to your concerns.

79


80


EXCERPT FROM
CLOSING REMARKS

Frank Young, M.D.

We at the University of Rochester are very proud of the contribu-
tions of Dr. Lawrence in the development of a lactation cluster and in
the subsequent plans for a Surgeon General's Workshop at this universi-
ty, As members of the university, it is our pleasure to participate in this
conference with other organizations and agencies devoted to Maternal
and Child Health. We appreciate the opportunity it has given us to learn,
and I have been pleased by the Workshop's focus on education. The edu-
cational experiments that have been suggested by this group will take
months, even years to accomplish. For myself, as a bacteriologist who
deals with a process of cellular division-a process occurring every 22
minutes-I recognize impatience. An experiment in bacteriology can be
accomplished in a few hours. The experiments and learning processes of
this conference will take far longer, and you-the participants-will be
able to show the required patience. I challenge you to continue your ef-
forts to see how public education, both in the media and in traditional
academic settings, will serve our very important objectives.

As a corollary to the educational aspect of this conference, you can
be proud of the Workshop's focus on the recognition that education must
be universally directed. As your deliberations reinforced, we are not
dealing with a particular segment of society. We are a diverse society
with many needs and contributions. In this diversity, we recognize the
partnership of the professional, the government, and the individual. You,
the participants of this conference, represent this partnership through
your varied backgrounds, agencies, and areas of expertise. You came to
the conference with the responsibility of honestly and soundly exploring
the topic of breastfeeding and human lactation, not to serve your own
egos, but to serve mankind. You have met your responsibility.

Madonna and Child
School of Burges
Flemish, 15th c.
colored drawing
Reproduced with permission from Memorial Art Gallery of the University of Rochester.

81


APPENDIX A

PARTICIPANTS

John E. Alden, C.N.M., MS.
Public Health Service
Indian Health Center
Poplar, MT 59255

Diane M. Anderson, M.S., R.D.
Rainbow Babies & Childrens Hospital
Department of Pediatrics, Room 706
2101 Adelbert Road
Cleveland, OH 44106

Joyce 0. Arango, M.P.H., R.D.
U.S. Department of Agriculture
3101 Center Drive, Room 609
Alexandria, VA 22302
U.S. Department of Agriculture

Jeanne F. Arnold, M.D.
St. Elizabeth Hospital
2209 Genesee Street
Utica, NY 13354
American Academy of Family Physicians

Maria Teresa Asquith
Institute for Medical Research
Mothers' Milk Bank
2260 Clove Drive
San Jose, CA 95128

Richard H. Aubry, M.D.
SUNY Upstate Medical Center
750 E. Adams Street
Syracuse, NY 13210
American College of OB/GYN

Kathleen G. Auerbach, Ph.D.
Department of Sociology
University of Nebraska Medical Center
42nd and Dewey Avenue
Omaha, NE 68105

Rosemary Barber-Madden, Ed.D.
Center for Population and Family Health

Cheryl Bittle, R.D., Ph.D.
Food 8r Nutrition Department
Oregon State University
Corvallis, OR 97331

Sara B. Bonam, R.D., M.S.
Bureau of Family Health
Kansas Department of Health and

Environment
Forbes Field, Building 740
Topeka, KS 66620
Association of State and Territorial Public Health
Nutrition Direc!ors

Elizabeth Brannon, M.S., R.D.
Department of Health & Human Services
Room 6-22 Parklawn Building
5600 Fishers Lane
Rockville, MD 20857

Elaine B. Bratic
Offtce of Public Affairs, OASH, PHS
200 Independence Avenue SW
721H Hubert H. Humphrey Building
Washington, DC 20201

Theodore M. Brown, Ph.D.
Department of History
University of Rochester
RR Lib 585
Rochester, NY 14627

Carol A. Bryant, Ph.D.
Lexington Fayette County Health Department
650 Newton Pike
Lexington, KY 40508

Elizabeth Burkett, R.N.C., M.S.N.
Department of OB/GYN
Duke University Medical Center
Box 3974
Durham, NC 27710

Columbia University, School of Public Health Anthony T. Carter, Ph.D.
60 Haven Avenue              Department of Anthropology
New York, NY 10032             University of Rochester
Association of Teachers of Maternal and Child  Harkness 334
Health                     Rochester, NY 14627

82


Solan Chao, M.D.
Department of OB/GYN
Harlem Hospital Center
506 Lenox Avenue
yew York, NY 10037

Rate Clancy, Ph.D.
Department of Human Nutrition
307 Slocum Hall
Syracuse University
Syracuse, NY 13210
Society for Nutrition Education

Elizabeth M. Cooper, C.N.M., M.S.
Department of OB/GYN
University of Rochester Medical Center
601 Elmwood Avenue, Box 668
Rochester, NY 14642

Betty Ann Countryman, R.N., M.N.
4140 E. 75th Street
Indianapolis, IN 46250
La Leche League International

Catherine Cowell, Ph.D.
Bureau of Nutrition
New York City Department of Health
93 Worth Street, Room 714
New York, NY 10013

Carole A. Davis, MS.
Human Nutrition Information Service
U.S. Department of Agriculture
Room 330, Building 307, BARC-East
Beltsville, MD 20705

Roselyn Payne Epps, M.D., M.P.H.
Department of Pediatrics & Child Health
Howard University College of Medicine
2041 Georgia Avenue NW
Washington, DC 20060

Ruth R. Faden, Ph.D., M.P.H.
The Johns Hopkins University
School of Hygiene & Public Health
615 N. Wolfe Street
Baltimore, MD 2 1205

Thorsten A. Fjellstedt, Ph.D.
Department of Health & Human Services
Room 7C-09 Landow Building
7910 Woodmont Avenue
Bethesda, MD 20505

Judith G. Flanagan, C.N.M., R.N., M.S.
U.C.S.F.G.H.
10001 Potrero
San Francisco, CA 941 IO
American Co&e of Nurse-Midwives

Gilbert B. Forbes, M.D.
Department of Pediatrics
University of Rochester Medical Center
601 Elmwood Avenue, Box 777
Rochester, NY 14642

Michele Forman, Ph.D., M.S.P.H.
Division of Nutrition
Centers for Disease Control
Building 3, Room SB48
Atlanta, GA 30333

Henry W. Foster, Jr., M.D.
Department of OB/GYN
Meharry Medical College
1005 D. B. Todd Boulevard
Nashville, TN 37208

Paul S. Frame, M.D.
Tri-County Family Medicine
Box 339
Red Jacket Street
Dansville, NY 14437

Karen L. Freeburn, R.D.
Migrant & Rural Community Health

Association
P.O. Box 130
Bangor, MI 49013

Ayala Gabriel, Ph.D.
Department of Anthropology
University of Rochester
Harkness Hall 324
Rochester, NY 14627

David Gagnon, M.P.H.
Women & Infants Hospital
50 Maude Street
Providence, RI 02908

Lawrence M. Gartner, M.D.
Wyier Children's Hospital
5825 S. Maryland Avenue
Chicago, IL 60637

Cutbero Garza, M.D., Ph.D.
Baylor College of Medicine
Department of Pediatrics
1 Baylor Plaza
Houston, TX 77030

Robert C. Gelardi
Suite 500-D
5775 Peachtree-Dunwoody Road
Atlanta, GA 30342
Infant Formula Council

83


Doris Haire
439 E. 51st Street
New York, NY 10022

Jerianne Heimendinger, D.Sc.
Division of Family Health
Department of Health
75 Davis Street, Room 302
Providence, RI 02908

William Heird, M.D.
Babies Hospital
1st Floor, Room 116 South
Department of Pediatrics
New York, NY 10032

David Heppel, M.D.
Division of Maternal & Child Health
5600 Fishers Lane, Room 6-22
Rockville, MD 20857

Jan L. Herr, M.D.
Kaiser Permanente
2200 O'Farrell Street
San Francisco, CA 94115
Residency Review Committee in OB/GYN

Frederick C. Holmes, M.D.
R.D. #l
Fairfax, VT 05454
American Academy of Pediatrics

Mary T. Horan, R.N.
HQ Department of Army
Offtce of the Surgeon General
HQDA (DASG PSP-D)
Pentagon, Room 2D529
Washington, DC 203 IO
Department of Defense

Kathryn Montgomery Hunter, Ph.D.
University of Rochester Medical Center
601 Elmwood Avenue, Box 644
Rochester, NY 14642

Vince L. Hutchins, M.D., M.P.H.
Department of Health & Human Services
Room 6-05 Parklawn Building
5600 Fishers Lane
Rockville. MD 20857

Bernard B. Keele, Ph.D.
Office of Public Affairs
University of Rochester Medical Center
601 Elmwood Avenue, Box 643
Rochester. NY 14642

John H. Kennell, M.D.
Rainbow Babies & Childrens Hospital
2101 Adelbert Road
Cleveland, OH 44106

C. Everett Koop, M.D., Sc.D.
Department of Health & Human Services
Room 716G HHH Building
2OOIndependence Avenue SW
Washington, DC 20201

Mary Grace Kovar, Dr.P.H.
National Center for Health Statistics
3700 East-West Highway, Room 2-58
Hyattsville, MD 20782

Gail Kowalski

Genesee Ecumenical Council
17 S. Fitzhugh Street
Rochester, NY 14614

Anthony H. Labrum, M.D.
Division of Psychosomatic OB/GYN
University of Rochester Medical Center
601 Elmwood Avenue, Box 668
Rochester, NY 14642

Paul J. Lambiase

Office of Continuing Professional Education
University Of Rochester Medical Center
601 Elmwood Avenue, Box 677
Rochester, NY 14642

Ruth A. Lawrence. M.D.
Department of Pediatrics-Neonatology
University of Rochester Medical Center
601 Elmwood Avenue, Box 651
Rochester, NY 14642

Morton A. Lebow, M.A.
American College of OB/GYN
600 Maryland Avenue SW
Washington, DC 20024

Milton B. Lederman, Ph.D.
Offrice of Public Affairs
University of Rochester Medical Center
601 Elmwood Avenue, Box 643
Rochester, NY 14642

Viola Lennon

5745 Newcastle Street
Chicago, IL 60631

Alice S. Linyear, M.D., M.P.H.
Bureau of Maternal & Child Health
State Department of Health
109 Governor Street
Richmond. VA 23219

Ruth E. Little, Sc.D.
Alcohol & Drug Abuse Institute
University of Washington NL-I5
Seattle. WA 98195

84


Vivian M. Littlefield, R.N., Ph.D.
School of Nursing
University of Rochester Medical Center
601 Elmwood Avenue, Box 619
Rochester, NY 14642

Gilbert A. Martinez, M.B.A.
Market Research
Ross Laboratories
625 Cleveland Avenue
Columbus, OH 43216

Elizabeth R. McAnamey, M.D.
Department of PCdiatriCS
University of Rochester Medical Center
601 Elmwood Avenue, Box 690
Rochester, NY 14642

Michael McGinnis, M.D.
Department of Health & Human Services
Room 2 132 Switzer Building
330 C Street SW
Washington, DC 20201
U.S. Department of Health and Human Services

Jeanne Meurer, C.N.M., M.S.
Birthing Program
College of Medicine
University of South Florida
Tampa, FL 33612

Solbritt Murphy, M.D.
Bureau of Maternal & Child Health
New York State Department of Health
ESP-Coming Tower
Albany, NY 12237

Anthony W. Myres, Ph.D.
Health & Welfare Canada
Jeanne Mance Building, Room 428
Tunney's Pasture
Ottawa, Ontario Canada KIA 184

Martin Nacman, M.S.W., D.S.W.
Social Work Division
University of Rochester Medical Center
601 Elmwood Avenue, Box 650
Rochester, NY 14642

Audrey Naylor, M.D., Dr.P.H.
San Diego Lactation Program
Mercy Hospital
4077 Fifth Avenue
San Diego, CA 92103

Marianne R. Neifert, M.D.
University of Colorado
Health Sciences Center-C-2 19
4200 E. 9th Avenue
Denver, CO 80262

Margaret C. Neville
University of Colorado School of Medicine
Department of Physiology C240
VCHSC
Denver, CO 80262

Jennifer R. Niebyl, M.D.
The Johns Hopkins Hospital
Harvey 108
Baltimore, MD 21205
American College of OWGYN

Joel L. Nitzkin, M.D., M.P.H., D.P.A.
Monroe County Health Department
111 Westfall Road-Caller 632
Rochester, NY 14692

Julie H. Norris, R.N.
St. Vincent's WelIness Center-Carmel
2001 W. 86th Street
Indianapolis, IN 46260
Amekan Hospital Association

Carolyn A. O'Neil, M.S., R.D.
Cable News Network
1050 Techwood Drive
Atlanta. GA 30318

Christine M. Olson, Ph.D., R.D.
Division of Nutritional Sciences
376 MVR
Cornell University
Ithaca, NY 14853
Society for Nutrition Education

Betty Oseid, M.D.
Department of Pediatrics
Louisiana State University Medical Center
1542 Tulane Avenue
New Orleans, LA 70124

Judy Perkin, Dr.P.H., R.D.
Deoartment of Health Education and Safety
RoLm 4, Florida GYM
University of Florida
Gainesville, FL 32611
The American Dietetic Association

Linda Randolph, M.D., M.P.H.
Office of Public Health
New York State Department of Health
Empire State Plaza
Albany, NY 12237

Dana Raphael, Ph.D.
The Human Lactation Center Ltd.
666 Sturges Highway
Westport, CT 06880

85


Herbert Ratner, M.D.
Child and Family Quarterly
244 Wesley Road
Oak Park, IL 60303

Nancy K. Rice, M.S.W.
Social Work Division
University of Rochester Medical Center
601 Elmwood Avenue, Box 650
Rochester, NY 14642

Walter J. Rogan, M.D., M.P.H.
Epidemiology Branch
National Institute of Environmental Health

Sciences

Mail Drop A3-02, P.O. Box 12233
Research Triangle Park, NC 27709

Jeanne Rose. M.S.
1711 Lake Shore Drive
Escanaba, Ml49829
International Childbirth Education Association

Ruth B. Rosenberg, J.D.
Nixon, Hargrave, Devens & Doyle
Lincoln First Tower
P.O. Box 1051
Rochester, NY 14603

Pearl W. Rubin
Daisy Marquis Jones Foundation
945 Crossroads Building
2 State Street

Rochester, NY 14614

Gardenia B. Ruff, M.S.W.
South Carolina Department of Health and

Environmental Control
Division of Maternal & Child Health
2600 Bull Street
Columbia, SC 29201

Sarah Samuels, Dr.P.H.
Institute for Health Policy Studies
University of California School of Medicine
565 CED

San Francisco. CA 94143

Susan Scrimshaw, Ph.D.
School of Public Health
University of California
Los Angeles, CA 90024

Donald L. Shapiro, M.D.
Neonatology Division
University of Rochester Medical Center
601 Elmwood Avenue, BOX 651
Rochester, NY 14642

Andrew Sorenson, Ph.D.
Division of Public Health
School of Health Sciences
University of Massachusetts
Amherst. MA 01003

Marilyn G. Stephenson, M.S., R.D.
Office of Nutrition and Food Sciences
Center for Food Safety and Applied Nutrition
U.S. Food and Drug Administration
200 C Street SW

Washington, DC 20204

Mary Story, Ph.D., R.D.
Adolescent Health Program
Box 721 Mayo, 420 Delaware Street SE
University of Minnesota
Minneapolis, MN 55455

Robert C. Tatelbaum, M.D.
220 Alexander Street
Suite 707
Rochester, NY 14607
Rochester Academy of Medicine, OB/GYN
Section

Janet Taylor-Leahman, R.D., M.S.
Brownsville Community Health Clinic
2137 E. 22nd
Brownsville, TX 78520

Henry A. Thiede, M.D.
Chairman, Department of OB/GYN
University of Rochester Medical Center
601 Elmwood Avenue, Box 668
Rochester, NY 14642

Edith P. Thomas, Ph.D., R.D.
U.S. Department of Agriculture Extension

Service

Room 3443 South Building
14th & Independence Avenue SW
Washington, DC 20250

Jewel M. Thomas, M.Ed.
4504 N. Roseneath Drive
Houston, TX 77021
Alpha Kappa Alpha Sorority, Inc.

Edith Tibbetts, M&i.
Health Education Associates, Inc.
21 I S. Easton Road
Glenside, PA 19038

Terry Tobin, M.P.H., R.N.
Marquette University
Milwaukee, WI 53233

86


Joel Tolliver, M.P.H.
16 Rawhide Road
West Henrietta, NY 14586

Michael Weidner, M.B.A.
Highland Hospital
South Avenue at Bellevue Drive
Rochester, NY 14620

Francine Rae White, M.S.P.H.
1625 `I' Street, NW
Suite 420
Washington, DC 20006
National Association of Community Health
Centers

Nancy Whitley, C.N.M., R.N.
125 Pearl Street
Mt. Holly, NJ 08060
Nurses Association of the American College of

OB/GYN

Beverly Winikoff, M.D., M.P.H.
The Population Council
One Dag Hammarskjold Plaza
New York, NY 10017

Kenneth Wolfe
I10 Blackmore Road
Camillus, NY 13031
United States JA YCEES

Kenneth W. Woodward, M.D.
Xerox Corporation
800 Phillips Road
Building 208M
Webster, NY 14580

Bonnie Worthington-Roberts, Ph.D.
Child Development Center
University of Washington
CDMRC WJ-10
Seattle, WA 98195

John T. Wilson, M.D.
Louisiana State University Medical Center
P.O. Box 33932
Kings Highway
Shreveport, LA 71130

87


APPENDIX B

FACILITATORS

Marilyn J. Aten, Ph.D., R.N.
School of Nursing
University of Rochester Medical Center
601 Elmwood Avenue, Box HWH
Rochester, NY 14642

Susan MacKrell, Ph.D.
Education & Human Development
University of Rochester
Latimore 509

Rochester, NY 14627

Joel L. Nitzkin, M.D., M.P.H., D.P.A.
Monroe County Health Department
111 Westfall Road, Caller 632
Rochester, NY 14692

Betty Oppenheimer
Health Association of Rochester & Monroe

County

973 East Avenue
Rochester, NY 14607

Nancy K. Rice, M.S.W.
Social Work Division
University of Rochester Medical Center
601 Elmwood Avenue, Box 650
Rochester, NY 14642

Ruth Rockowitz, M.S.W., A.C.S.W.
Social Work Division
University of Rochester Medical Center
601 Elmwood Avenue, Box 650
Rochester, NY 14642

Doreen Smethurst, C.S.W., A.C.S.W.
Social Work Division
University of Rochester Medical Center
601 Elmwood Avenue, Box 650
Rochester, NY 14642

Andrew A. Sorensen, Ph.D.
University of Massachusetts-Amherst
106 Arnold House
Amherst, MA 01003

RECORDERS

Lizabeth Berkeley, M.P.H.
NYS Department of Health
Office of Public Health
Office for New York City Affairs
8-10 E. 40th Street
New York, NY 10016

Rosellen Bohlen, R.N.
202 Clovercrest Drive
Rochester, NY 14618

Myra Citrin, M.D.
Department of Pediatrics
University of Rochester Medical Center
601 Elmwood Avenue, Box 777
Rochester, NY 14642

Judy Gussler, Ph.D.
Ross Laboratories
625 Cleveland Avenue
Columbus, OH 43216

Joan Merzbach, M.S.W.
Social Work Division
University of Rochester Medical Center
601 Elmwood Avenue, Box 650
Rochester, NY 14642

Elizabeth Naumburg, M.D.
Family Medicine Program
885 South Avenue
Rochester, NY 14620

Marsha Nielson
Health Association of Rochester & Monroe
County
973 East Avenue
Rochester, NY 14607

Marie Stahl, R.N.
3616 Connecticut Avenue NW
Washington, DC 20007

89


APPENDIX C

KEY ELEMENTS FOR PROMOTION OF
BREASTFEEDING IN THE CONTINUUM OF
MATERNAL AND INFANT HEALTH CARE

1. Primary-care settings for women of childbearing age should have:
  o a supportive milieu for lactation
  o educational opportunities (including availability of literature, per-
   sonal counseling, and information about community resources)
   for learning about lactation and its advantages
  o ready response to requests for further information
  . continuity allowing for the exposure to and development over
   time of a positive attitude regarding lactation on the part of the
   recipient of care.

2. Prenatal-care settings should have:
  o a specific assessment at the first prenatal visit of the physical ca-
   pability and emotional predisposition to lactation. This assess-
   ment should include the potential role of the father of the child
   as well as other significant family members. An educational pro-
   gram about the advantages of and ways of preparing for lacta-
   tion should continue throughout the pregnancy.
  o resource personnel-such as nutritionists/dietitians, social work-
   ers, public health nurses, La Leche League members, childbirth
   education groups-for assistance in preparing for lactation
  o availability and utilization of culturally suitable patient-education
    materials

o an established mechanism for a predelivery visit to the newborn
care provider to insure initiation and maintenance of lactation
o a means of communicating to the in-hospital team the infant-
feeding plans developed during the prenatal course.

3. In-hospital settings should have:
  o a policy to determine the patient's infant-feeding plan on admis-
   sion or during labor

o a family-centered orientation to childbirth including the mini-
mum use of intrapartum medications and anesthesia
o a medical and nursing staff informed about and supportive of
ways to facilitate the initiation and continuation of breastfeeding
(including early mother-infant contact and ready access by the
mother to her baby throughout the hospital stay)

90


o the availability of individualized counseling and education by a
specially trained breastfeeding coordinator to facilitate lactation
for those planning to breastfeed and to counsel those who have
not yet decided about their method of infant feeding
o on-going inservice education about lactation and ways to support
it. This program should be conducted by the breastfeeding coor-
dinator for all relevant hospital staff.
o proper space and equipment for breastfeeding in the postpartum
and neonatal units. Attention should be given to the particular
needs of women breastfeeding babies with special problems.
o the elimination of hospital practices/policies which have the
effect of inhibiting the lactation process, e.g., rules separating
mother and baby

o the elimination of standing orders that inhibit lactation, e.g., lac-
tation suppressants, fixed feeding schedules, maternal medications
. discharge planning which includes referral to community agen-
cies to aid in the continuing support of the lactating mother.
This referral is especially important for patients discharged early.
o a policy to limit the distribution of packages of free formula at
discharge only to those mothers who are not lactating
o the development of policies to support lactation throughout the
hospital units (e.g., medicine, surgery, pediatrics, emergency
room, etc.)

o the provision of continued lactation support for those infants
who must remain in the hospital after the mother's discharge.

4. Postpartum ambulatory settings should have:
  o a capacity for telephone assistance to mothers experiencing prob-
   lems with breastfeeding

o a policy for telephone follow-up l-3 days after discharge
o a plan for an early follow-up visit (within first week after dis-
charge)

o the availability of lactation counseling as a means of preventing
or solving lactation problems
o access to lay support resources for the mother
o the presence of a supportive attitude by all staff
o a policy to encourage bringing the infant to postpartum appoint-
ments

o the availability of public/community-health nurse referral for
those having problems with lactation
o a mechanism for the smooth transition to pediatric care of the
infant, including good communication between obstetric and pe-
diatric care providers.

91


APPENDIX D

SELECTED READINGS

Baranowski T., Bee D.E., Rassin D.K., Richardson C.J., Brown J.P.,
Guenther N., and Nader P.R.: Social Support, Social Influence, Ethnic-
ity and the Breastfeeding Decision. Social Science and Medicine 17:1599-
161 1, 1983.

Cowie A.T., Forsyth LA., Hart I.C.: Hormonal Control of Lactation.
Berlin: Springer-Verlag, 1980.

Eckhardt K.W. and Hendershot G.E.: Analysis of the Reversal in Breast
Feeding Trends in the Early 1970s. Public Health Reports 99:410-414,
July-August 1984.

Ellis D.J.: Secondary School Students' Attitudes and Beliefs About
Breastfeeding. Journal of School Health 53:600-604, December 1983.

Gussler J. and Bryant C. (eds): Helping Mothers Breastfeed: Program
Strategies for Minority Communities. Health Action Paper No. 1, Lexing-
ton, KY: Lexington-Fayette County Health Department and University
of Kentucky Medical Behavioral Science Department, 1984.

Hally M.R., Bond J., Crowley J., Gregson B., Phillips P., and Russell I.:
What Influences a Mother's Choice of Infant Feeding Method? Nursing
Times 65-68: January 25, 1984.

Lawrence R.A.: Breastfeeding: A Guide for the Medical Profession. St.
Louis: C.V. Mosby Company, 1980 (2nd edition, 1984).

Martinez G.A. and Dodd D.A.: 1981 Milk Feeding Patterns in the
United States during the First 12 Months of Life. Pediatrics 71: 166-170,
February 1983.

Neville M.C. and Neifert M.R. (eds): Lactation: Physiology Nutrition, and
Breastfeeding. New York: Plenum Press, 1983.

Oseid B., Carter J., Sullivan J., and Braud S.: Promoting Breastfeeding in
Louisiana. Journal of the Louisiana State Medical Society,  4-6: December
1983.

Shand N. and Kosawa Y.: Breast-Feeding as Cultural or Personal Deci-
sion: Sources of Information and Actual Success in Japan and the United
States. Journal of Biosocial Science 16:65-80, 1984.

92


Van Esterik P. and Greiner T.: Breastfeeding and Women's Work: Con-
straints and Opportunities. Studies in Family Planning 12184-197, April
1981.

Vorherr H.: The Breast: Morphology, Physiology, and Lactation. New
York: Academic Press, Inc., 1974.

93

U.S. GOVE- PRINTING OF'FICE : 1984 0 - 447-700