The Surgeon General’s Call to Action
 to Support Breastfeeding
 

2011
 

U.S. Department of Health and Human Services
 

The Surgeon General’s Call to Action
 

to Support Breastfeeding
 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

U.S. Public Health Service 

Office of the Surgeon General 

Suggested Citation 

U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support 

Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the 

Surgeon General; 2011. 

This publication is available at http://www.surgeongeneral.gov. 
Table of Contents
 

Message from the Secretary, U.S. Department of Health and Human Services...........................iii
 

Action 3. Strengthen programs that provide mother-to-mother support 


Action 4. Use community-based organizations to promote and 


Foreword from the Surgeon General, U.S. Department of Health and Human Services............. v
 

The Importance of Breastfeeding ...................................................................................................1
 

Health Effects.............................................................................................................................1
 

Psychosocial Effects.....................................................................................................................3
 

Economic Effects........................................................................................................................3
 

Environmental Effects.................................................................................................................4
 

Endorsement of Breastfeeding as the Best Nutrition for Infants..................................................4
 

Federal Policy on Breastfeeding...................................................................................................5
 

Rates of Breastfeeding ....................................................................................................................6
 

Disparities in Breastfeeding Practices ..........................................................................................7
 

Barriers to Breastfeeding in the United States .............................................................................10
 

Lack of Knowledge...................................................................................................................10
 

Social Norms ............................................................................................................................11
 

Poor Family and Social Support................................................................................................12
 

Embarrassment .........................................................................................................................13
 

Lactation Problems...................................................................................................................13
 

Employment and Child Care....................................................................................................14 


Barriers Related to Health Services............................................................................................15
 

Breastfeeding from the Public Health Perspective.......................................................................16
 

Mothers and Their Families ......................................................................................................16
 

Communities............................................................................................................................18
 

Health Care..............................................................................................................................24
 

Employment.............................................................................................................................29
 

Research and Surveillance.........................................................................................................32
 

Public Health Infrastructure .....................................................................................................35
 

A Call to Action ............................................................................................................................37
 

Mothers and Their Families.....................................................................................................38
 

Action 1. Give mothers the support they need to breastfeed their babies...........................38
 

Action 2. Develop programs to educate fathers and grandmothers about breastfeeding.....39
 

Communities ...........................................................................................................................40
 

and peer counseling...........................................................................................40
 

support breastfeeding ........................................................................................41
 

i 
Action 5. Create a national campaign to promote breastfeeding........................................42
 

Action 6. Ensure that the marketing of infant formula is conducted in a way that 


Action 7. Ensure that maternity care practices throughout the United States are fully 


Action 8. Develop systems to guarantee continuity of skilled support for lactation 


Action 9. Provide education and training in breastfeeding for all health 


Action 10. Include basic support for breastfeeding as a standard of care for midwives, 


Action 11. Ensure access to services provided by International Board Certified 


Action 12. Identify and address obstacles to greater availability of safe banked donor 


minimizes its negative impacts on exclusive breastfeeding..................................43
 

Health Care .............................................................................................................................44
 

supportive of breastfeeding................................................................................44
 

between hospitals and health care settings in the community ............................45
 

professionals who care for women and children.................................................46
 

obstetricians, family physicians, nurse practitioners, and pediatricians...............47
 

Lactation Consultants .......................................................................................48
 

milk for fragile infants.......................................................................................49
 

Employment.............................................................................................................................50
 

Action 13. Work toward establishing paid maternity leave for all employed mothers ..........50
 

Action 14. Ensure that employers establish and maintain comprehensive, 


high-quality lactation support programs for their employees .............................51
 

Action 15. Expand the use of programs in the workplace that allow lactating 


Action 16. Ensure that all child care providers accommodate the needs of 


mothers to have direct access to their babies......................................................52
 

breastfeeding mothers and infants .....................................................................53
 

Research and Surveillance.......................................................................................................54
 

Action 17. Increase funding of high-quality research on breastfeeding ................................54
 

Action 18. Strengthen existing capacity and develop future capacity for 


conducting research on breastfeeding ................................................................55
 

Action 19. Develop a national monitoring system to improve the tracking 


of breastfeeding rates as well as the policies and environmental 


Action 20. Improve national leadership on the promotion and support 


factors that affect breastfeeding..........................................................................56
 

Public Health Infrastructure ..................................................................................................57
 

of breastfeeding .................................................................................................57
 

References .....................................................................................................................................59
 

Acknowledgments.........................................................................................................................69
 

Appendix 1. Actions to Improve Breastfeeding ...........................................................................71
 

Appendix 2. Excess Health Risks Associated with Not Breastfeeding.........................................79
 

Appendix 3. Development of the Call to Action..........................................................................81
 

Appendix 4. Abbreviations and Acronyms...................................................................................87
 

ii 
Message from the Secretary, 

U.S. Department of Health and Human Services 

As one of the most universal and natural facets of motherhood, the ability to breastfeed is a great 

gift. Breastfeeding helps mothers and babies bond, and it is vitally important to mothers’ and 

infants’ health. 

For much of the last century, America’s mothers were given poor advice and were discouraged 

from breastfeeding, to the point that breastfeeding became an unusual choice in this country. 

However, in recent decades, as mothers, their families, and health professionals have realized 

the importance of breastfeeding, the desire of mothers to breastfeed has soared. More and more 

mothers are breastfeeding every year. In fact, three-quarters of all newborns in America now begin 

their lives breastfeeding, and breastfeeding has regained its rightful place in our nation as the 

norm—the way most mothers feed their newborns. 

Each mother’s decision about how she feeds her baby is a personal one. Because of the 

ramifications of her decision on her baby’s health as well as her own, every mother in our nation 

deserves information, guidance, and support with this decision from her family and friends, the 

community where she lives, the health professionals on whom she relies, and her employer. 

That is why this Surgeon General’s Call to Action is so important. 

This Call to Action describes specific steps people can take to participate in a society-wide 

approach to support mothers and babies who are breastfeeding. This approach will increase the 

public health impact of everyone’s efforts, reduce inequities in the quality of health care that 

mothers and babies receive, and improve the support that families receive in employment and 

community settings. 

I recall my own cherished memories of breastfeeding, and I am grateful for the help and support I 

received, especially when I went back to work as a young mother. I am also aware that many other 

mothers are not able to benefit from the support I had. As Secretary of the Department of Health 

and Human Services, I urge all Americans to be supportive of breastfeeding mothers and families 

in their communities and to extend their support so that these mothers get the health care, the 

help, and the encouragement they deserve. 

Kathleen Sebelius 

Secretary 

U.S. Department of Health and Human Services 

iii 
iv 
 

 

 

Foreword from the Surgeon General, 

U.S. Department of Health and Human Services 

For nearly all infants, breastfeeding is the best source of infant nutrition and immunologic 

protection, and it provides remarkable health benefits to mothers as well. Babies who are breastfed 

are less likely to become overweight and obese. Many mothers in the United States want to 

breastfeed, and most try. And yet within only three months after giving birth, more than twothirds of breastfeeding mothers have already begun using formula. By six months postpartum, 

more than half of mothers have given up on breastfeeding, and mothers who breastfeed one-yearolds or toddlers are a rarity in our society. 

October 2010 marked the 10th anniversary of the release of the HHS Blueprint for Action on 

Breastfeeding, in which former Surgeon General David Satcher, M.D., Ph.D., reiterated the 

commitment of previous Surgeons General to support breastfeeding as a public health goal. This 

was the first comprehensive framework for national action on breastfeeding. It was created through 

collaboration among representatives from medical, business, women’s health, and advocacy groups as 

well as academic communities. The Blueprint provided specific action steps for the health care system, 

researchers, employers, and communities to better protect, promote, and support breastfeeding. 

I have issued this Call to Action because the time has come to set forth the important roles and 

responsibilities of clinicians, employers, communities, researchers, and government leaders 

and to urge us all to take on a commitment to enable mothers to meet their personal goals for 

breastfeeding. Mothers are acutely aware of and devoted to their responsibilities when it comes 

to feeding their children, but the responsibilities of others must be identified so that all mothers 

can obtain the information, help, and support they deserve when they breastfeed their infants. 

Identifying the support systems that are needed to help mothers meet their personal breastfeeding 

goals will allow them to stop feeling guilty and alone when problems with breastfeeding arise. 

All too often, mothers who wish to breastfeed encounter daunting challenges in moving through 

the health care system. Furthermore, there is often an incompatibility between employment and 

breastfeeding, but with help this is not impossible to overcome. Even so, because the barriers can 

seem insurmountable at times, many mothers stop breastfeeding. In addition, families are often 

unable to find the support they need in their communities to make breastfeeding work for them. 

From a societal perspective, many research questions related to breastfeeding remain unanswered, 

and for too long, breastfeeding has received insufficient national attention as a public health issue. 

This Call to Action describes in detail how different people and organizations can contribute to the 

health of mothers and their children. Rarely are we given the chance to make such a profound and 

lasting difference in the lives of so many. I am confident that this Call to Action will spark countless 

imaginative, effective, and mutually supportive endeavors that improve support for breastfeeding 

mothers and children in our nation. 

Regina M. Benjamin, M.D., M.B.A. 

Vice Admiral, U.S. Public Health Service 

Surgeon General 

v 
vi 
The Importance of Breastfeeding
 

Health Effects 

The health effects of breastfeeding are well recognized and apply to mothers and children in 

developed nations such as the United States as well as to those in developing countries. Breast 

milk is uniquely suited to the human infant’s nutritional needs and is a live substance with 

unparalleled immunological and anti-inflammatory properties that protect against a host of 

illnesses and diseases for both mothers and children.1 

In 2007, the Agency for Healthcare Research and Quality (AHRQ) published a summary of 

systematic reviews and meta-analyses on breastfeeding and maternal and infant health outcomes 

in developed countries.2

 The AHRQ report reaffirmed the health risks associated with formula* 

feeding and early weaning from breastfeeding. With regard to short-term risks, formula feeding is 

associated with increases in common childhood infections, such as diarrhea3

 and ear infections.2 

The risk of acute ear infection, also called acute otitis media, is 100 percent higher among 

exclusively formula-fed infants than in those who are exclusively breastfed during the first six 

months (see Table 1).2 

The risk associated with some relatively rare but serious infections and diseases, such as severe 

lower respiratory infections2,4 and leukemia2,5 are also higher for formula-fed infants. The risk of 

hospitalization for lower respiratory tract disease in the first year of life is more than 250 percent 

higher among babies who are formula fed than in those who are exclusively breastfed at least four 

months.4

 Furthermore, the risk of sudden infant death syndrome is 56 percent higher among 

infants who are never breastfed.2

 For vulnerable premature infants, formula feeding is associated 

with higher rates of necrotizing enterocolitis (NEC).2

 The AHRQ report also concludes that 

formula feeding is associated with higher risks for major chronic diseases and conditions, such as 

type 2 diabetes,6

 asthma,2 and childhood obesity,7 all three of which have increased among U.S. 

children over time. 

As shown in Table 1, compared with mothers who breastfeed, those who do not breastfeed also 

experience increased risks for certain poor health outcomes. For example, several studies have 

found the risk of breast cancer to be higher for women who have never breastfed.2,8,9 Similarly, 

the risk of ovarian cancer was found to be 27 percent higher for women who had never breastfed 

than for those who had breastfed for some period of time.2

 In general, exclusive breastfeeding and 

longer durations of breastfeeding are associated with better maternal health outcomes. 

* The term “formula” is used here to include the broad class of human milk substitutes that infants receive, including commercial 

infant formula. 

1 
The AHRQ report cautioned that, although a history of breastfeeding is associated with a reduced 

risk of many diseases in infants and mothers, almost all the data in the AHRQ review were 

gathered from observational studies. Therefore, the associations described in the report do not 

necessarily represent causality. Another limitation of the systematic review was the wide variation 

in quality among the body of evidence across health outcomes. 

As stated by the U.S. Preventive Services Task Force (USPSTF) evidence review,10 human milk 

is the natural source of nutrition for all infants. The value of breastfeeding and human milk for 

infant nutrition and growth has been long recognized, and the health outcomes of nutrition and 

growth were not covered by the AHRQ review. 

Table 1. Excess Health Risks Associated with Not Breastfeeding 

Outcome Excess Risk* (%) 

Among full-term infants 

Acute ear infection (otitis media)2 100 

Eczema (atopic dermatitis)11 47 

Diarrhea and vomiting (gastrointestinal infection)3 178 

Hospitalization for lower respiratory tract diseases 

in the first year4 257 

Asthma, with family history2 67 

Asthma, no family history2 35 

Childhood obesity7 32 

Type 2 diabetes mellitus6 64 

Acute lymphocytic leukemia2 23 

Acute myelogenous leukemia5 18 

Sudden infant death syndrome2 56 

Among preterm infants 

Necrotizing enterocolitis2 138 

Among mothers 

Breast cancer8 4 

Ovarian cancer2 27 

* The excess risk is approximated by using the odds ratios reported in the referenced studies. Further details are provided in Appendix 2. 

2 
 

Psychosocial Effects 

Although the typical woman may cite the health advantages for herself and her child as major 

reasons that she breastfeeds, another important factor is the desire to experience a sense of 

bonding or closeness with her newborn.12–14 Indeed, some women indicate that the psychological 

benefit of breastfeeding, including bonding more closely with their babies, is the most important 

influence on their decision to breastfeed.12 Even women who exclusively formula feed have 

reported feeling that breastfeeding is more likely than formula feeding to create a close bond 

between mother and child.13 

In addition, although the literature is not conclusive on this matter, breastfeeding may help to 

lower the risk of postpartum depression, a serious condition that almost 13 percent of mothers 

experience. This disorder poses risks not only to the mother’s health but also to the health of her 

child, particularly when she is unable to fully care for her infant.

15 Research findings in this area 

are mixed, but some studies have found that women who have breastfed and women with longer 

durations of breastfeeding have a lower risk of postpartum depression.

16–18 Whether postpartum 

depression affects breastfeeding or vice versa, however, is not well understood.

19 

Economic Effects 

In addition to the health advantages of breastfeeding for mothers and their children, there are 

economic benefits associated with breastfeeding that can be realized by families, employers, 

private and government insurers, and the nation as a whole. For example, a study conducted more 

than a decade ago estimated that families who followed optimal breastfeeding practices could save 

more than $1,200–$1,500 in expenditures for infant formula in the first year alone.20 In addition, 

better infant health means fewer health insurance claims, less employee time off to care for sick 

children, and higher productivity, all of which concern employers.21 

Increasing rates of breastfeeding can help reduce the prevalence of various illnesses and health 

conditions, which in turn results in lower health care costs. A study conducted in 2001 on the 

economic impact of breastfeeding for three illnesses—otitis media, gastroenteritis, and NEC—found 

that increasing the proportion of children who were breastfed in 2000 to the targets established 

in Healthy People 2010 22 would have saved an estimated $3.6 billion annually. These savings were 

based on direct costs (e.g., costs for formula as well as physician, hospital, clinic, laboratory, and 

procedural fees) and indirect costs (e.g., wages parents lose while caring for an ill child), as well as the 

estimated cost of premature death.

23 A more recent study that used costs adjusted to 2007 dollars 

and evaluated costs associated with additional illnesses and diseases (sudden infant death syndrome, 

hospitalization for lower respiratory tract infection in infancy, atopic dermatitis, childhood leukemia, 

childhood obesity, childhood asthma, and type 1 diabetes mellitus) found that if 90 percent of U.S. 

families followed guidelines to breastfeed exclusively for six months, the United States would save 

$13 billion annually from reduced direct medical and indirect costs and the cost of premature death. 

If 80 percent of U.S. families complied, $10.5 billion per year would be saved.

24 

3 
 

 

 

 

Environmental Effects 

Breastfeeding also confers global environmental benefits; human milk is a natural, renewable 

food that acts as a complete source of babies’ nutrition for about the first six months of life.25 

Furthermore, there are no packages involved, as opposed to infant formulas and other substitutes 

for human milk that require packaging that ultimately may be deposited in landfills. For every 

one million formula-fed babies, 150 million containers of formula are consumed;26 while some of 

those containers could be recycled, many end up in landfills. In addition, infant formulas must be 

transported from their place of manufacture to retail locations, such as grocery stores, so that they 

can be purchased by families. Although breastfeeding requires mothers to consume a small amount 

of additional calories, it generally requires no containers, no paper, no fuel to prepare, and no 

transportation to deliver, and it reduces the carbon footprint by saving precious global resources 

and energy. 

Endorsement of Breastfeeding as the Best Nutrition for Infants 

Because breastfeeding confers many important health and other benefits, including psychosocial, 

economic, and environmental benefits, it is not surprising that breastfeeding has been 

recommended by several prominent organizations of health professionals, among them the 

American Academy of Pediatrics 

(AAP),25 American Academy of Family 

Physicians,27 American College of 

Obstetricians and Gynecologists,28 

American College of NurseMidwives,29 American Dietetic 

Association,30 and American Public 

Health Association,31 all of which 

recommend that most infants in the 

United States be breastfed for at least 

12 months. These organizations also 

recommend that for about the first 

six months, infants be exclusively 

breastfed, meaning they should not be 

given any foods or liquids other than 

breast milk, not even water. 

Regarding nutrient composition, 

the American Dietetic Association 

stated, “Human milk is uniquely 

tailored to meet the nutrition needs of 

human infants. It has the appropriate 

balance of nutrients provided in easily 

digestible and bioavailable forms.”30 

4 
The AAP stated, “Human milk is species-specific, and all substitute feeding preparations 

differ markedly from it, making human milk uniquely superior for infant feeding. Exclusive 

breastfeeding is the reference or normative model against which all alternative feeding methods 

must be measured with regard to growth, health, development, and all other short- and long-term 

outcomes.”25 

While breastfeeding is recommended for most infants, it is also recognized that a small number 

of women cannot or should not breastfeed. For example, AAP states that breastfeeding is 

contraindicated for mothers with HIV, human T-cell lymphotropic virus type 1 or type 2, active 

untreated tuberculosis, or herpes simplex lesions on the breast. Infants with galactosemia should 

not be breastfed. Additionally, the maternal use of certain drugs or treatments, including illicit 

drugs, antimetabolites, chemotherapeutic agents, and radioactive isotope therapies, is cause for not 

breastfeeding.25 

Federal Policy on Breastfeeding 

Over the last 25 years, the Surgeons General of the United States have worked to protect, 

promote, and support breastfeeding. In 1984, Surgeon General C. Everett Koop convened the 

first Surgeon General’s Workshop on Breastfeeding, which drew together professional and lay 

experts to outline key actions needed to improve breastfeeding rates.32 Participants developed 

recommendations in six distinct areas: 1) the world of work, 2) public education, 3) professional 

education, 4) health care system, 5) support services, and 6) research. Follow-up reports in 1985 

and 1991 documented progress in implementing the original recommendations.33,34 

In 1990, the United States signed onto the Innocenti Declaration on the Protection, Promotion and 

Support of Breastfeeding, which was adopted by the World Health Organization (WHO) and the 

United Nations Children’s Fund (UNICEF). This declaration called upon all governments to 

nationally coordinate breastfeeding activities, ensure optimal practices in support of breastfeeding 

through maternity services, take action on the International Code of Marketing of Breast-milk 

Substitutes (the Code),35 and enact legislation to protect breastfeeding among working women.36 

In 1999, Surgeon General David Satcher requested that a departmental policy on breastfeeding 

be developed, with particular emphasis on reducing racial and ethnic disparities in breastfeeding. 

The following year, the Secretary of the U.S. Department of Health and Human Services (HHS), 

under the leadership of the department’s Office on Women’s Health (OWH), released the HHS 

Blueprint for Action on Breastfeeding.

37 This document, which has received widespread attention 

in the years since its release, declared breastfeeding to be a key public health issue in the United 

States. 

5 
 

 

Rates of Breastfeeding
 

Over the last few decades, rates of breastfeeding have improved, but in recent years, rates generally 

have climbed more slowly. Figure 1 presents data from 1970 through 2007 from two sources. 

Data before 1999 are from the Ross Mothers Survey.38–40 Data for 1999 through 2007 are from 

the Centers for Disease Control and Prevention’s (CDC) annual National Immunization Survey 

(NIS), which includes a series of questions regarding breastfeeding practices.41 

National objectives for Healthy People 2010, in addition to calling for 75 percent of mothers 

to initiate breastfeeding, called for 50 percent to continue breastfeeding for six months and 25 

percent to continue breastfeeding for one year.22 Healthy People 2010 also included objectives for 

exclusive breastfeeding: targets were for 40 percent of women to breastfeed exclusively for three 

months and for 17 percent to do so for six months.22 

The most recent NIS data shown in Figure 1 indicate that, while the rate of breastfeeding 

initiation has met the 2010 target, rates of duration and exclusivity still fall short of Healthy People 

2010 objectives.41 Among children born in 2007, 75 percent of mothers initiated breastfeeding, 

43 percent were breastfeeding at six months, and 22 percent were breastfeeding at 12 months 

(see Figure 1). Although human milk is the only nutrition most babies need for about the first 

six months, many women discontinue breastfeeding or add other foods or liquids to their baby’s 

diet well before the child reaches six months of age. Among breastfed infants born in 2007, an 

estimated 33 percent were exclusively breastfed through age three months, and only 13 percent 

were exclusively breastfed for six months. 

Although much is known about rates of breastfeeding in the population, mothers’ breastfeeding 

practices have not been well understood until recently. The Infant Feeding Practices Study II,42 

conducted during 2005–2007 by the U.S. Food and Drug Administration (FDA) in collaboration 

with CDC, was designed to fill in some of the gaps. For this longitudinal study of women followed 

from late pregnancy through their infants’ first year of life, participants were selected from across 

the United States. On average, 

members of the study group had 

higher levels of education, were older, 

were more likely to be white, were 

more likely to have a middle-level 

income, and were more likely to be 

employed than the overall U.S. female 

population.42 

Some of the findings from this study 

were discouraging; for instance, 

almost half of breastfed newborns 

were supplemented with infant 

formula while they were still in the 

6 
hospital after birth.43 Most healthy, full-term, breastfed newborns have no medical need to receive 

supplemental infant formula,44 and supplementing with infant formula can be detrimental to 

breastfeeding.25 In addition, more than 40 percent of infants in the Infant Feeding Practices 

Study II sample were consuming solid foods within the first four months after birth43 despite 

recommendations by the AAP that no infant, whether breastfed or formula fed, should be given 

any solid foods until at least the age of four months.25 

Figure 1. National Trends in Breastfeeding Rates Percent 

Healthy 100 

80 

60 

40 

20 

0 

1970 1975 1980 1985 1990 1995 2000 2005 2010

Ever 

At 6 months 

At 1 year 

Exclusive 

6 months 

Exclusive 

3 months 

People 

2010 

Targets 

Year 

Note: Data from before 1999 are from a different source, as indicated by the line break.
 

Sources: 1970–1998, Ross Mothers Survey;38,39,40 1999–2007, Centers for Disease Control and Prevention, National Immunization Survey. 41
 

Disparities in Breastfeeding Practices 

Despite overall improvements in breastfeeding rates, unacceptable disparities in breastfeeding have 

persisted by race/ethnicity, socioeconomic characteristics, and geography (see Table 2). For example, 

breastfeeding rates for black infants are about 50 percent lower than those for white infants at birth, 

age six months, and age 12 months, even when controlling for the family’s income or educational 

level. On the other hand, the gap between white and black mothers in initiation of breastfeeding has 

diminished over time, from 35 percentage points in 1990 to 18 percentage points in 2007. Yet, the 

gap in rates of breastfeeding continuation at six months has remained around 15 percentage points 

throughout this period.45,46 

7 
Table 2. Provisional Breastfeeding Rates Among Children Born in 2007*
 

Sociodemographic Factor 

Ever Breastfed 

(%) 

Breastfeeding at 

6 Months (%) 

Breastfeeding at 

12 Months (%) 

United States 75.0 43.0 22.4 

Race/ethnicity 

American Indian or Alaska Native 73.8 42.4 20.7 

Asian or Pacific Islander 83.0 56.4 32.8 

Hispanic or Latino 80.6 46.0 24.7 

Non-Hispanic Black or African American 58.1 27.5 12.5 

Non-Hispanic White 76.2 44.7 23.3 

Receiving WIC† 

Yes 67.5 33.7 17.5 

No, but eligible 77.5 48.2 30.7 

Ineligible 84.6 54.2 27.6 

Maternal education 

Not a high school graduate 67.0 37.0 21.9 

High school graduate 66.1 31.4 15.1 

Some college 76.5 41.0 20.5 

College graduate 88.3 59.9 31.1 

* Survey limited to children aged 19–35 months at the time of data collection. The lag between birth and collection of data allows for tracking of 

breastfeeding initiation as well as calculating the duration of breastfeeding. 

† WIC = Special Supplemental Nutrition Program for Women, Infants, and Ch ldren; U.S. Department of Agriculture. 

Source: Centers for Disease Control and Prevention, National Immunization Survey.41 

The reasons for the persistently lower rates of breastfeeding among African American women 

are not well understood, but employment may play a role.47 African American women tend to 

return to work earlier after childbirth than white women, and they are more likely to work in 

environments that do not support breastfeeding.48 Although research has shown that returning to 

work is associated with early discontinuation of breastfeeding,40 a supportive work environment 

may make a difference in whether mothers are able to continue breastfeeding.49,50 

With regard to socioeconomic characteristics, many studies have found income to be positively 

associated with breastfeeding.40,51 For example, a study that included children participating in 

the U.S. Department of Agriculture’s (USDA) Special Supplemental Nutrition Program for 

Women, Infants, and Children (WIC), which uses income to determine eligibility, found they 

were less likely to be breastfed than children in middle- and upper-income families.40 Educational 

status is also associated with breastfeeding; women with less than a high school education are far 

less likely to breastfeed than women who have earned a college degree. Geographic disparities 

are also evident; women living in the southeastern United States are less likely to initiate and 

continue breastfeeding than women in other areas of the country (see Figure 2), and women 

living in rural areas are less likely to breastfeed than women in urban areas.51,52 Understanding 

8 
WA

OR

CA

NV

AK

AZ NM

TX

OK

KS

NE

SD

MT ND

ID

WY

CO

UT

HI

LA

AR

MO

IA

MN

WI

MI

MI

IL IN

OH

KY

TN

MS AL GA

SC

NC

VA

PA

NY

ME

WV

FL

MA

NH

VT

CT

DC

DE

MD

NJ

RI

<55% 55% 64% 65% 74% >75%

the reasons for these disparities is crucial for identifying, developing, and implementing strategies 

to overcome the barriers to breastfeeding that women and families experience throughout our 

country. Research suggests that 1) race and ethnicity are associated with breastfeeding regardless 

of income, and 2) income is associated with breastfeeding regardless of race or ethnicity.51 Other 

possible contributors to the disparities in breastfeeding include the media, which has often cited 

more difficulties with breastfeeding than positive stories,53–55 hospital policies and practices,52 

the recommendations of WIC counselors,56 marketing of infant formula,57 policies on work and 

parental leave,58,59 legislation,52,60 social and cultural norms,57 and advice from family and friends.47 

Figure 2. Percentage of Children Ever Breastfed Among Children Born 

in 2007,* by State 

* Survey limited to children aged 19–35 months at the time of data collection. The lag between birth and collection of data allowed for tracking of 

breastfeeding initiation as well as calculating the duration of breastfeeding. 

Source: Centers for Disease Control and Prevention, National Immunization Survey.41 

9 
Barriers to Breastfeeding 

in the United States 

Even though a variety of evidence indicates that breastfeeding reduces many different health risks 

for mothers and children, numerous barriers to breastfeeding remain—and action is needed to 

overcome these barriers. 

Lack of Knowledge 

Most women in the United States are aware that breastfeeding is the best source of nutrition for 

most infants, but they seem to lack knowledge about its specific benefits and are unable to cite 

the risks associated with not breastfeeding.61–63 For example, a recent study of a national sample of 

women enrolled in WIC reported that only 36 percent of participants thought that breastfeeding 

would protect the baby against diarrhea.61 Another national survey found that only a quarter of 

the U.S. public agreed that feeding a baby with infant formula instead of breast milk increases the 

chances the baby will get sick.62 In addition, qualitative research with mothers has revealed that 

information about breastfeeding and infant formula is rarely provided by women’s obstetricians 

during their prenatal visits.64 Moreover, many people, including health professionals, believe that 

because commercially prepared formula has been enhanced in recent years, infant formula is 

equivalent to breast milk in terms of its health benefits;62,63 however, this belief is incorrect. 

Mothers are also uncertain about what to expect with breastfeeding and how to actually carry it 

out.

64,65 Even though breastfeeding is often described as “natural,” it is also an art that has to be 

learned by both the mother and the newborn. Skills in how to hold and position a baby at the 

breast, how to achieve an effective latch, and other breastfeeding techniques may need to be taught. 

Not surprisingly, some women expect breastfeeding to be easy, but then find themselves faced with 

challenges. The incongruity 

between expectations about 

breastfeeding and the reality of 

the mother’s early experiences 

with breastfeeding her 

infant has been identified 

as a key reason that many 

mothers stop breastfeeding 

within the first two weeks 

postpartum.

66 On the other 

hand, a misperception that 

many women experience 

difficulties with breastfeeding 

may cause excessive concern 

among mothers about its 

feasibility.

67–70 

10 
 

 

The perceived inconvenience of breastfeeding is also an issue; in a national public opinion survey, 

45 percent of U.S. adults indicated that they believed a breastfeeding mother has to give up 

too many habits of her lifestyle.71 In addition, the commitment required by breastfeeding and 

difficulties in establishing breastfeeding are sometimes seen as threats to mothers’ freedom and 

independence.72–76 

Unfortunately, education about breastfeeding is not always readily available to mothers nor easily 

understood by them. Many women rely on books, leaflets, and other written materials as their 

only source of information on breastfeeding,64,65,77 but using these sources to gain knowledge 

about breastfeeding can be ineffective, especially for low-income women, who may have 

more success relying on role models.

78 The goals for educating mothers include increasing their 

knowledge and skills relative to breastfeeding and positively influencing their attitudes about it. 

Social Norms 

In the United States, bottle feeding is viewed by many as the “normal” way to feed infants. 

Moreover, studies of mothers who are immigrants that examine the effects of acculturation 

have found that rates of breastfeeding decrease with each generation in the United States and 

that mothers perceive bottle feeding as more acceptable here than in their home countries.79–86 

Widespread exposure to substitutes for human milk, typically fed to infants via bottles, is 

largely responsible for the development of this social norm. After reviewing data from market 

research and studies conducted during 1980–2005, the U.S. Government Accountability Office 

(GAO) reported that advertising of formula is widespread and increasing in the United States.87 

Furthermore, the strong inverse association between the marketing of human milk substitutes 

and breastfeeding rates was the basis of the WHO International Code of Marketing of Breastmilk Substitutes (the Code).35 The Code has been reaffirmed in several subsequent World Health 

Assembly resolutions. However, its provisions are not legally binding in the United States. 

Certain cultural beliefs and practices also contribute to what women consider to be normal feeding 

practices,76,88 although some of these practices are not recommended today. The mistaken belief that, 

for babies, “big is healthy,” can lead to both formula feeding and inappropriate early introduction 

of solid foods.

89,90 The false idea that larger babies are healthier is common among many racial and 

ethnic groups, and mothers who are part of social networks that hold this belief may be encouraged 

to supplement breastfeeding with formula if the infant is perceived as thin.

91 

Low-income Hispanic women in Denver, Colorado, were found to favor a practice called “best of 

both” (i.e., providing both breast milk and infant formula). Despite guidance that breast milk is the 

only source of nutrition a child needs for about the first six months of life, some women mistakenly 

see the “best of both” as a way to ensure that their babies get both the healthy aspects of human milk 

and what they believe to be the “vitamins” present in infant formula.

67 Another practice associated 

with cultural beliefs is the use of cereal in a bottle because of the misperception that it will prolong 

infants’ sleep.

90 

11 
Poor Family and Social Support 

Women with friends who have breastfed successfully are more likely to choose to breastfeed. On 

the other hand, negative attitudes of family and friends can pose a barrier to breastfeeding. Some 

mothers say that they do not ask for help with breastfeeding from their family or friends because 

of the contradictory information they receive from these sources.74 

In many families, fathers play a strong role in the decision of whether to breastfeed.92,93 Fathers may 

be opposed to breastfeeding because of concerns about what their role would be in feeding, whether 

they would be able to bond with their infant if they were personally unable to feed the baby, and 

how the mother would be able to accomplish household responsibilities if she breastfed.64,72,94,95 

Studies of African American families in which education on breastfeeding was directed at the father 

found a 20 percent increase in breastfeeding rates, indicating that paternal influences on maternal 

feeding practices are critically important in early decision making about breastfeeding.92,96 

Although they can constitute a barrier to breastfeeding, fathers can also be a positive influence. 

A randomized controlled trial of a two-hour prenatal intervention with fathers on how to be 

supportive of breastfeeding found a far higher rate of breastfeeding initiation among participants’ 

partners (74 percent) than among partners of controls (14 percent).93 In another trial, 25 percent 

of women whose partners participated in a program on how to prevent and address common 

problems with lactation (such as pain or fear of insufficient milk) were still breastfeeding at six 

months, compared with 15 percent of women whose partners were informed only about the 

benefits of breastfeeding.97 Among women who experienced challenges with breastfeeding, the 

program effect was even stronger, with 24 percent of participants’ partners breastfeeding at six 

months versus less than 5 percent of partners in the comparison group.97 

12 
Embarrassment 

A study that analyzed data from a national public opinion survey conducted in 2001 found that 

only 43 percent of U.S. adults believed that women should have the right to breastfeed in public 

places.98 Restaurant and shopping center managers have reported that they would either discourage 

breastfeeding anywhere in their facilities or would suggest that breastfeeding mothers move to an 

area that was more secluded.73,99,100 When they have breastfed in public places, many mothers have 

been asked to stop breastfeeding or to leave.99 Such situations make women feel embarrassed and 

fearful of being stigmatized by people around them when they breastfeed.68,95,101,102 Embarrassment 

remains a formidable barrier to breastfeeding in the United States and is closely related to 

disapproval of breastfeeding in public.76,102–104 Embarrassment about breastfeeding is not limited 

to public settings, however. Women may find themselves excluded from social interactions when 

they are breastfeeding because others are reluctant to be in the same room while they breastfeed.65 

For many women, the feeling of embarrassment restricts their activities and is cited as a reason for 

choosing to feed supplementary formula or to give up breastfeeding altogether.104,105 

In American culture, breasts have often been regarded primarily as sexual objects, while their 

nurturing function has been downplayed. Although focusing on the sexuality of female breasts 

is common in the mass media, visual images of breastfeeding are rare, and a mother may never 

have seen a woman breastfeeding.106–109 As shown in both quantitative and qualitative studies, the 

perception of breasts as sexual objects may lead women to feel uncomfortable about breastfeeding 

in public.68,101 As a result, women may feel the need to conceal breastfeeding, but they have 

difficulty finding comfortable and accessible breastfeeding facilities in public places.110,111 

Lactation Problems 

Frequently cited problems with breastfeeding include sore nipples, engorged breasts, mastitis, 

leaking milk, pain, and failure to latch on by the infant.64,112 Women who encounter these 

problems early on are less likely to continue to breastfeed unless they get professional 

assistance.64,90 Research has found that mothers base their breastfeeding plans on previous 

experiences, and resolution of these problems may affect their future decisions about feeding.64,90 

Concern about insufficient milk supply is another frequently cited reason for early weaning of the 

infant.

90,113–116 One national study on feeding practices found that about 50 percent of mothers cited 

insufficient milk supply as their reason for stopping breastfeeding.

112 Having a poor milk supply can 

result from infrequent feeding or poor breastfeeding techniques,115,117–119 but lack of confidence in 

breastfeeding or not understanding the normal physiology of lactation can lead to the perception of 

an insufficient milk supply when in fact the quantity is enough to nurture the baby.

120,121 

Women report receiving conflicting advice from clinicians about how to solve problems with 

breastfeeding.

94,122,123 Successful initiation depends on experiences in the hospital as well as access 

to instruction on lactation from breastfeeding experts, particularly in the early postpartum period. 

Most problems, if identified and treated early, need not pose a threat to the continuation of 

successful breastfeeding.

124–128 

13 
Employment and Child Care 

Employed mothers typically find that returning to work is a significant barrier to breastfeeding. 

Women often face inflexibility in their work hours and locations and a lack of privacy for 

breastfeeding or expressing milk, have no place to store expressed breast milk, are unable to 

find child care facilities at or near the workplace, face fears over job insecurity, and have limited 

maternity leave benefits.13,101,116,129–131 In 2009, the Society for Human Resource Management 

reported that only 25 percent of companies surveyed had lactation programs or made special 

accommodations for breastfeeding.132 Small businesses (fewer than 100 employees) are the least 

likely to have lactation programs, and whether the workplace is large or small, infants are generally 

not allowed to be there.132 Many mothers encounter pressure from coworkers and supervisors 

not to take breaks to express breast milk, and existing breaks often do not allow sufficient time 

for expression.133 When mothers who do not have a private office at work do not have a place to 

breastfeed or express breast milk, they may resort to using the restroom for these purposes, an 

approach that is unhygienic and associated with premature weaning.134–137 

Lack of maternity leave can also be a significant barrier to breastfeeding. Studies show that women 

intending to return to work within a year after childbirth are less likely to initiate breastfeeding, 

and mothers who work full-time tend to breastfeed for shorter durations than do part-time or 

unemployed mothers.129,138 Women with longer maternity leaves are more likely to combine 

breastfeeding and employment.139 In a survey of 712 mothers, each week of maternity leave 

increased the duration of breastfeeding by almost one-half week.140 Jobs that have less flexibility 

and require long separations of mother and baby further complicate breastfeeding.131 Hourly wage 

14 
workers face different challenges than salaried workers, as the former typically have less control 

over their schedules, and their pay may be reduced if they take breaks to express breast milk.141 

Barriers Related to Health Services 

Studies have identified major deficits relevant to breastfeeding in hospital policies and clinical 

practices, including a low priority given to support for breastfeeding and education about it, 

inappropriate routines and provision of care, fragmented care, and inadequate hospital facilities for 

women who are breastfeeding.142,143 A recent report that summarizes maternity practices related to 

breastfeeding in 2,687 hospitals and birth centers in the United States indicated that these practices 

are often not evidence based and frequently interfere with breastfeeding.52 For example, 24 percent 

of birth facilities in the survey reported giving supplemental feeding to more than half of healthy, 

full-term, breastfed newborns during the postpartum stay,52 a practice shown to be unnecessary and 

detrimental to breastfeeding.144,145 In addition, 70 percent of facilities that participated in the survey 

reported giving breastfeeding mothers gift packs containing samples of infant formula,52 which can 

have a negative influence on both the initiation and duration of breastfeeding.146–149 

Separating mothers from their babies during their hospital stay has a negative impact on the 

initiation and duration of breastfeeding,150,151 yet DiGirolamo and colleagues152 reported that only 

57 percent of U.S. hospitals and birth centers allowed newborns to stay in the same room as their 

mothers. In addition, an inverse relationship exists between breastfeeding rates and invasive medical 

interventions during labor and delivery, such as cesarean section.153 Cesarean delivery is associated 

with delayed skin-to-skin contact between mother and baby, increased supplemental feeding, 

and separation of mother and baby, all of which lead to suboptimal breastfeeding practices.153–157 

Nevertheless, cesarean births are not rare; preliminary data for 2007 indicate that almost one-third of 

women (32 percent) in the United States gave birth by cesarean section in that year, which is higher 

than the prevalence of 21 percent reported just 10 years prior in 1997.158,159 

Obstetrician-gynecologists, pediatricians, and other providers of maternal and child care have 

a unique opportunity to promote and support breastfeeding. Although pregnant women and 

mothers consider the advice of clinicians to be very important with regard to their decisions about 

breastfeeding, clinicians often underestimate their own influence on breastfeeding.160,161 Clinicians 

report feeling that they have insufficient knowledge about breastfeeding and that they have 

low levels of confidence and clinical competence in this area.143 A recent survey of pediatricians 

showed that many believe the benefits of breastfeeding do not outweigh the challenges that may 

be associated with it, and they reported various reasons to recommend against breastfeeding.162 

Physicians who are ambivalent about breastfeeding or who feel inadequately trained to assist 

patients with breastfeeding may be unable to properly counsel their patients on specifics about 

breastfeeding techniques, current health recommendations on breastfeeding, and strategies to 

combine breastfeeding and work.90,101,143,161,163–165 Furthermore, a study of clinicians’ knowledge and 

attitudes about breastfeeding found that some clinicians used their own breastfeeding experiences 

to replace evidence-based knowledge and recommendations they shared with their patients.160 

15 
Breastfeeding from the 

Public Health Perspective 

Mothers and Their Families 

Mothers who are knowledgeable about the numerous health benefits of breastfeeding are more 

likely to breastfeed.61,166 Research has shown that mothers tend to believe that breastfeeding is 

best for their babies, but they appear to know less about the specific reductions in health risks 

that occur through breastfeeding and the consumption of breast milk.61 Without knowing this 

information, mothers cannot properly weigh the advantages and disadvantages of breastfeeding 

versus formula feeding, and thus they cannot make a truly informed decision about how they 

want to feed their babies. 

Although having information about the health advantages of breastfeeding is important, 

knowing how to breastfeed is crucial. Mothers who do not know how to initiate and continue 

breastfeeding after a child is born may fear that it will always be painful or that they will be unable 

to produce enough milk to fully feed the baby. As a result, they may decide to formula feed the 

child. Expectant mothers who believe that breastfeeding is difficult or painful identify the fear of 

discomfort as a major negative influence on their desire to initiate breastfeeding,68,74 and mothers 

often expect that breastfeeding will be difficult during the first couple of months.67,167 

Prenatal classes can be used 

to help inform women about 

the health advantages of 

breastfeeding, both for babies 

and mothers, and instructors 

can explain to women the 

process and techniques they 

can use to breastfeed.168 

Furthermore, these classes 

can help prepare expectant 

mothers for what they 

should actually experience by 

providing them with accurate 

information on breastfeeding. 

However, pregnant women 

may not be aware of where 

classes on breastfeeding are 

offered, or even that they 

exist. Thus, clinicians have an 

important responsibility to 

16 
help their patients find a breastfeeding class in which they can participate before their babies are 

born. If clinicians do not readily provide information about such classes, mothers can ask their 

clinicians for assistance and advice about how they can find a class. In addition, women can turn 

to other mothers for information and help with breastfeeding. These women could include other 

breastfeeding mothers in their communities, whether they are family, friends, or mothers they 

have met through mother-to-mother support groups, as well as women who are knowledgeable 

and have previous experience with breastfeeding. 

Women should be encouraged to discuss with others their desire and plans to breastfeed, whether 

such persons are clinicians, family and friends, employers, or child care providers. When a woman 

has decided she wants to breastfeed, discussing her plans with her clinician during prenatal care 

and again when she is in the hospital or birth center for childbirth will enable her clinician to give 

her the type of information and assistance she needs to be successful.124 Her partner and the baby’s 

grandmothers also play critical support roles when it comes to breastfeeding, both with regard to 

assisting in decision making about how the baby is fed and in providing support for breastfeeding 

after the baby is born.92,169 

Many women mistakenly think they cannot breastfeed if they plan to return to work after 

childbirth, and thus they may not talk with their employers about their desire to breastfeed or 

how breastfeeding might be supported in the workplace.101 If employers are unaware of what is 

required, mothers can explain that federal law now requires employers to provide breastfeeding 

employees with reasonable break time and a private, non-bathroom place to express breast milk 

during the workday, up until the child’s first birthday. 

In 2009, half of all mothers with children under the age of one year were employed,170 and thus 

supportive child care is essential for breastfeeding mothers. Before the child is born, parents can 

visit child care facilities to determine whether the staff and facility can provide the type of child 

care that helps a mother to provide breast milk to her baby even if she is separated from the baby 

because of work. By telling these important people she wants to breastfeed and by discussing ways 

they can be supportive, an expectant mother is taking a proactive role in ensuring that she and her 

baby have an environment that gives breastfeeding the best possible start. 

Despite the best planning, however, problems or challenges may arise, and when they do, mothers 

deserve help in solving them. Many sources of assistance are available, such as certified lactation 

consultants and other clinicians, WIC staff, and peer counselors.171–174 Ideally, a mother will 

have access to trained experts who can help her with breastfeeding, and by asking her health care 

or WIC provider about obtaining help if she needs it, a mother is taking appropriate action to 

build a support system. Even after childbirth, a mother can ask for referrals to community-based 

or other types of support, including telephone support. The important thing for mothers to 

remember is that they should be able to receive help, but they may have to ask for it. 

As noted previously, fathers can have a tremendous influence on breastfeeding. Some fatherfocused efforts are under way in the United States, including the USDA’s Fathers Supporting 

Breastfeeding program, which uses a video, posters, and brochures designed to target African 

17 
American and other fathers to positively influence a woman’s decision to breastfeed.175 In 

addition, an innovative pilot study in a Texas WIC program used a father-to-father peer 

counseling approach to improve breastfeeding rates among participants’ wives and partners. The 

program not only demonstrated improved breastfeeding rates but also showed improvements 

in fathers’ knowledge about breastfeeding and their beliefs that they could provide support to 

their breastfeeding partners.176 Elsewhere, an intervention intended for both fathers and the 

baby’s grandmothers that discussed the benefits and mechanics of breastfeeding, as well as the 

need for emotional and practical support, was described as enjoyable, acceptable, and useful by 

participants.177 

Grandmothers also have tremendous influence on a woman’s decisions and practices relative to 

feeding her infant.177,178 If a baby’s grandmother previously breastfed, she can share her experience 

and knowledge and can support a mother through any challenges with breastfeeding.169 

Conversely, if a baby’s grandmother did not breastfeed, she may try to discourage it or suggest 

formula feeding whenever a problem arises.179 Mothers who breastfeed want their own mothers 

to be supportive of them and of their decision to breastfeed, regardless of how they fed their own 

children, and they want them to be knowledgeable about current information on breastfeeding.169 

In conclusion, knowing about the health 

risks of not breastfeeding is important for 

mothers, but knowing how to breastfeed 

is critical as well. Prenatal classes on 

breastfeeding are valuable, and mothers 

should discuss with a variety of other people 

their interest in breastfeeding. Talking to 

their clinicians about their intention to 

breastfeed is important, as is asking about 

the provisions for breastfeeding or expressing 

milk where they work. Both the father of 

the child and the woman’s mother may play 

important roles in the decision to breastfeed. 

Mothers deserve help with this important 

decision. 

Communities 

A woman’s ability to initiate and sustain 

breastfeeding is influenced by a host of factors, 

including the community in which she lives.54 

A woman’s community has many components, 

such as public health and other communitybased programs, coalitions and organizations, 

schools and child care centers, businesses 

18 
and industry, and the media. The extent to which each of these entities supports or discourages 

breastfeeding can be crucial to a mother’s success in breastfeeding. 

Although the USDA’s WIC program has always encouraged breastfeeding, federal regulations 

enacted as part of the 2009 appropriations for the program contain robust provisions that expand 

the scope of WIC’s activities to encourage and support its participants in breastfeeding.180 Federal 

regulations specify the actions that state agencies must take to ensure 1) a sustainable 

infrastructure for breastfeeding activities; 2) the prioritization of breastfeeding mothers and children 

in the WIC certification process; 3) activities to support education in nutrition for breastfeeding 

mothers, including peer support; and 4) allowances for using program funds to carry out activities 

that improve support for breastfeeding among WIC participants. WIC has begun a nationwide 

training program for all local agencies called Using Loving Support to Grow and Glow in WIC: 

Breastfeeding Training for Local WIC Staff to ensure that all WIC staff can promote and support 

breastfeeding.181 

Exclusive breastfeeding is rewarded in the WIC program in multiple ways, including offering a 

food package with a higher monetary value for breastfeeding participants than for participants 

who do not breastfeed or who do so only partially. In 2009, a variety of items, including larger 

amounts of fruits and vegetables, was added to the food package for women who breastfeed 

19 
 

to provide enhanced support for them. Additionally, the new food package provided higher 

quantities of complementary foods to be given to breastfed babies who are at least six months old. 

Before their babies are born, WIC clients receive education and counseling about breastfeeding 

and are followed up soon after the birth. Many breastfeeding mothers in WIC receive breast 

pumps and other items to support the continuation of breastfeeding. The USDA uses a social 

marketing approach to encourage and support breastfeeding that began with the campaign Loving 

Support Makes Breastfeeding Work,182 as well as a research-based, culturally sensitive set of social 

marketing resources known as Breastfeeding: A Magical Bond of Love, which is specifically for 

Hispanic participants.183 

Clinicians are another important source of education and support for breastfeeding. When a mother 

is discharged from a maternity facility after childbirth, she may need continued breastfeeding 

support, not only from her family but also from professionals affiliated with the maternity facility. 

Professional post-discharge breastfeeding support of mothers can take many forms, including 

planned follow-up visits at the maternity facility, telephone follow-ups initiated by the maternity 

facility, referrals to community-based support groups and organizations, and home visits. The 

Affordable Care Act passed in 2010 includes a provision to expand home visitation programs for 

pregnant women and children from birth through kindergarten entry.184 This funding has the 

potential to greatly improve follow-up breastfeeding care for low-income families if breastfeeding is 

adequately incorporated into the programs. 

Posting information on Web sites, providing online support, and having breastfeeding “warmlines” 

and hotlines that mothers can call whenever they need help or to ask specific breastfeeding-related 

questions are additional ways that mothers typically find help postpartum.10,185,186 To be most 

effective, however, postpartum support needs to be a comprehensive strategy designed to help 

women overcome challenges in sustaining exclusive, continued breastfeeding.10,148,187,188 

The provision of peer support is another method that has been shown to improve breastfeeding 

practices.173,174,189–191 Peer support can be given in structured, organized programs, or it can be 

offered informally by one mother to another. Peer counselors are mothers who have personal 

experience with breastfeeding and are trained to provide counseling about and assistance with 

breastfeeding to other mothers with whom they share various characteristics, such as language, 

race/ethnicity, and socioeconomic status. They reinforce breastfeeding recommendations in a 

socially and culturally appropriate context. Peer counselors may be effective in part because they 

are seen as role models192 and also because they often provide assistance through phone calls or 

home visits.173 

Peer-counseling programs that provide breastfeeding support for low-income women who are 

enrolled in or eligible for WIC have been found to be effective at both agency and individual 

levels in improving breastfeeding rates.193 For example, using peer counselors for prenatal WIC 

participants increased the agency’s enrollment of breastfeeding postpartum women.172 Individually, 

a breastfeeding support program that included peer counseling increased breastfeeding initiation 

among WIC participants in Michigan by about 27 percentage points and the duration of 

20 
breastfeeding by more than three weeks.171 Hispanic immigrant mothers in Houston who were 

eligible for WIC and who received breastfeeding support from peer counselors were nearly twice as 

likely as nonparticipants to be exclusively breastfeeding at four weeks postpartum, and they were 

significantly less likely to supplement breast milk feedings with water or tea.194 Several investigations 

of peer counseling have identified the prenatal period as particularly important for establishing 

relationships between peer counselors and WIC participants. Results of these studies indicate that 

counseling during this period allows peer counselors to proactively address participants’ questions 

and concerns about breastfeeding and enables both the counselor and the mother to prepare for 

support that will be provided in the early postpartum days.172 

Peer support also can be given through volunteer community-based groups and organizations, such 

as La Leche League (www.llli.org) and other nursing mothers’ support groups. In addition, newer 

community organizations are emerging, such as the African-American Breastfeeding Alliance, 

the Black Mothers’ Breastfeeding Association (www.blackmothersbreastfeeding.org), and Mocha 

Moms (www.mochamoms.org). Beyond advocating for community support for breastfeeding, these 

organizations and groups provide peer support focused on women of color and provide culturally 

tailored breastfeeding support that may not be available or sought after from other support groups. 

These new groups and organizations, however, may have limited membership rolls and thus very 

small budgets. Financial assistance from foundations and government may be needed early on to 

firmly establish and support these organizations, which strive to meet the needs of communities that 

are typically underserved in terms of health and social services. 

In a review of 34 trials that included more than 29,000 mother-infant pairs across 14 countries, 

professional and lay support together were found to increase the duration of any breastfeeding, as well 

as the duration of exclusive breastfeeding.189 For women who received both forms of support, the risk 

of breastfeeding cessation was significantly lower at six weeks and at two months than it was among 

those who received the usual care. Exclusive breastfeeding was significantly extended when counselors 

were trained using a program sponsored by WHO and UNICEF.189 

Marketing of infant formula within communities is another negative influence on breastfeeding. The 

WHO International Code of Marketing of Breast-milk Substitutes declares that substitutes for breast 

milk should not be marketed in ways that can interfere with breastfeeding.35 Yet formula is marketed 

directly to the consumer through television commercials and print advertisements and indirectly 

through logo-bearing calendars, pens, and other materials in hospitals or doctors’ offices. Formula 

also is marketed through the distribution of gift packs at discharge that contain samples of formula 

or coupons, often in bags with a manufacturer’s name or logo. 

Research indicates that the marketing of substitutes for breast milk has a negative effect on 

breastfeeding practices. For example, advertising infant formula in doctors’ offices that women 

visit before their babies are born lowers the rate of breastfeeding among these women.195 In 

the immediate postpartum period, such as in the hospital after childbirth, the marketing of 

infant formula can deter exclusive breastfeeding196 and may have an even stronger effect among 

women who do not have well-defined goals for breastfeeding.197 In addition, women who receive 

21 
commercial discharge packs that include formula are less likely to be breastfeeding exclusively at 

10 weeks postpartum than are women who do not receive them.149 A Cochrane review concluded 

that women who received discharge packs were less likely to be exclusively breastfeeding at any 

time postpartum than women who did not receive a discharge pack.198 

Some of the marketing strategies used by infant formula companies may require review to 

ensure they are truthful and that they are not detrimental to breastfeeding. For example, in 

December 2009, a federal court upheld a $13.5 million jury verdict against manufacturer 

Mead Johnson & Co. for false and misleading advertising; the court permanently barred Mead 

Johnson from claiming that its Enfamil LIPIL infant formula would give babies better visual 

and brain development than ingredients in store-brand formula.199 In 2006, the GAO found 

that manufacturers of infant formula had violated the USDA Food and Nutrition Service rules 

by using the WIC logo and acronym in advertising formula.87 Voluntary adherence by formula 

manufacturers to recommended guidelines on formula marketing may not be effective or 

consistent throughout the industry, and thus formal guidelines and monitoring may be necessary 

to ensure that policies and procedures are followed. 

In recent years, advertising and social marketing have been used more frequently to promote 

and support breastfeeding. The USDA national breastfeeding promotion campaign mentioned 

earlier, Loving Support Makes Breastfeeding 

Work, was launched in 1997 to promote 

breastfeeding to WIC participants and 

their families by using social marketing 

techniques, including mass media and 

educational materials, and through staff 

training. The goals of the campaign are to 

encourage WIC participants to initiate and 

continue breastfeeding, to increase referrals to 

WIC for support for breastfeeding through 

community outreach, to increase the public’s 

acceptance and support of breastfeeding, 

and to provide technical assistance to state 

and local WIC staff who are promoting and 

supporting breastfeeding. 

This campaign emphasizes the concept 

that the support of family and friends, the 

health care system, and the community are 

all essential for a breastfeeding mother to be 

successful.182 An evaluation in 1997 of the 

campaign’s effects in Iowa demonstrated an 

increase in initiation of breastfeeding from 

57.8 percent at baseline to 65.1 percent one 

22 
year after implementation of the campaign. The percentage of mothers continuing to breastfeed at 

six months postpartum also increased, from 20.4 percent at baseline to 32.2 percent one year after 

the campaign was implemented.200 Campaign materials continue to be available. 

In 2004, the HHS/OWH and the Advertising Council launched a national campaign encouraging 

first-time mothers to breastfeed exclusively for six months. The tagline of the two-year campaign 

was “Babies were born to be breastfed.”201 The campaign focused on research showing that babies 

who are breastfed exclusively for six months are less likely to develop certain illnesses or to become 

obese than babies who are not breastfed, and it consistently emphasized the importance of exclusive 

breastfeeding for six months. Awareness of the breastfeeding campaign increased from 28 percent 

to 38 percent a year after it was started.201 Additionally, the percentage of those sampled who agreed 

that babies should be exclusively breastfed for six months increased from 53 percent before the 

campaign to 62 percent one year after the campaign was implemented.201 

As the 2004–2006 national breastfeeding awareness campaign demonstrated, people seek and find 

health information from a variety of sources. Evidence points to increasing reliance on the Internet 

for health information, particularly among those aged 18–49 years. In a report of findings from 

the 2008 Pew Internet and American Life Project Survey of more than 2,000 adults, when asked 

what sources they turned to for health or medical information, 86 percent reported asking a health 

professional, such as a physician, 68 percent asked a friend or family member, and 57 percent said 

they used the Internet.202 Social networking sites, such as Facebook and MySpace, appear to be less 

likely sources for gathering or sharing actual health information; instead, they serve as tools to help 

users refine the health questions they ask their clinicians.202 To date, most educational outreach on 

breastfeeding has been conducted interpersonally, on a face-to-face basis, sometimes with a videotape 

included as part of the instruction. As more people become regular users of various types of 

electronic communication such as social networking sites and mobile messaging, new strategies will 

be needed for conducting outreach and for communicating health information to families. 

In summary, a woman’s ability to initiate and continue breastfeeding is influenced by a host 

of community-based factors. Family members, such as fathers and babies’ grandmothers, are 

important parts of a mother’s life. It may be important for community-based groups to include 

them in education and support programs for breastfeeding. Postpartum support from maternity 

facilities is an important part of helping mothers to continue breastfeeding after discharge. 

Community-based support groups, organizations, and programs, as well as the efforts of peer 

counselors, expand on the support that women obtain in the hospital and provide a continuity of 

care that can help extend the duration of breastfeeding. 

In addition, public health efforts such as the 2004–2006 national breastfeeding awareness 

campaign may influence women to initiate and continue breastfeeding by helping to improve 

their knowledge and understanding of the reduced health risks and other positive outcomes 

associated with breastfeeding. The sources from which these messages are communicated, 

however, may need to evolve as more people use Web-based technologies to search for health and 

other types of information. In summary, a multifaceted approach to promoting and supporting 

breastfeeding is needed at the community level. 

23 
Health Care 

The U.S. Preventive Services Task Force (USPSTF) specifically recommends that promotion 

and support for breastfeeding be provided throughout the encounters women have with health 

professionals during prenatal and postpartum care, as well as during their infants’ medical care.168 

In addition, education and counseling on breastfeeding are unanimously recognized by the AAP 

and the American College of Obstetricians and Gynecologists in their Guidelines for Perinatal Care 

203 as a necessary part of prenatal and pediatric care. Similarly, the American Academy of Family 

Physicians27 and the American College of Nurse-Midwives29 call for the consistent provision of 

breastfeeding education and counseling services. Yet many clinicians are not adequately prepared 

to support mothers who wish to breastfeed. 

The USPSTF168 concluded that promotion and support of breastfeeding are likely to be most 

effective when integrated into systems of care that include training of clinicians and other health 

team members, policy development, and support from senior leadership. Moreover, the task 

force noted that many successful multicomponent programs that support pregnant women and 

mothers of young children include the provision of lay support or referral to community-based 

organizations. The task force also noted that breastfeeding interventions, like all other health 

care interventions designed to encourage healthy behaviors, should strive to empower individuals 

to make informed choices supported by the best available evidence. As with interventions to 

achieve a healthy weight or to quit smoking, the task force calls for breastfeeding interventions to 

be designed and implemented in ways that do not make women feel guilty when they make an 

informed choice not to breastfeed. 

In the United States, the majority of pregnant 

women plan to breastfeed,166 and yet there is a 

clear gap between the proportion of women who 

prenatally intend to breastfeed and those who 

actually do so by the time they are discharged 

after a brief hospital stay.166,204 The experiences 

that mothers and infants have as patients during 

the maternity stay shape the infant’s feeding 

behaviors;161 however, the quality of prenatal, 

postpartum, and pediatric medical care in 

the United States has been inconsistent.152,205 

Mothers’ experiences as they receive this care have 

an influence on their intention to breastfeed,206 

the biologic establishment of lactation,144 and 

breastfeeding duration.207 

Nearly all births in the United States occur in 

hospital settings,159 but hospital practices and 

policies in maternity settings can undermine 

24 
maternal and infant health by creating barriers to supporting a mother’s decision to breastfeed. 

National data from the ongoing CDC survey of Maternity Practices in Infant Nutrition and 

Care (mPINC), which assesses breastfeeding-related maternity practices in hospitals and birth 

centers across the United States, indicate that barriers to breastfeeding are widespread during 

labor, delivery, and postpartum care, as well as in hospital discharge planning.208 Results of the 

2007 mPINC survey showed that, on average, U.S. hospitals scored only 63 out of a possible 100 

points on an overall measure of breastfeeding-related maternity care.208 Furthermore, geographic 

disparities in care52 correspond closely with the geographic patterns of state-level breastfeeding,41 

highlighting the southern United States as particularly in need of improvement in the quality of 

routine maternity care. 

Examples of barriers to breastfeeding include placement of the stable, healthy, full-term newborn 

on an infant warmer immediately upon delivery rather than skin-to-skin with the mother,64 

provision of infant formula or water to breastfed newborns without medical indication,44 removal 

of the newborn from the mother’s room at night,209 inadequate assurance of post-discharge 

follow-up for lactation support,10 and provision of promotional samples of infant formula from 

manufacturers.149 Many studies have shown that practices such as these are associated with a 

shorter duration of breastfeeding.152,210 

A set of maternity care practices has been identified that, when implemented together,148,211,212 results 

in better breastfeeding outcomes.152,213–216 The Baby-Friendly Hospital Initiative217 established by 

WHO and UNICEF in 1991 includes these maternity practices, which are known as the Ten Steps 

to Successful Breastfeeding. The Joint Commission, an organization that accredits and certifies 

health care organizations and programs in the United States, has identified the concept of bundles 

of care such as those in the Ten Steps to Successful Breastfeeding as a promising strategy to improve 

the care provided to patients.218 In addition, researchers in California have found that disparities 

in in-hospital rates of exclusive breastfeeding are not found in hospitals that have implemented the 

policies and practices of the Baby-Friendly Hospital Initiative, while the opposite is true in hospitals 

that are in the same geographic region but are not designated as Baby-Friendly.204 

Upon discharge from the hospital, mothers may have no means of identifying or obtaining the 

skilled support needed to address their concerns about lactation and breastfeeding; further, there 

may be barriers to reimbursement for needed lactation care and services.219 In addition, limited 

communication between clinicians across health care settings220 and between clinicians and 

mothers also may make mothers less likely to comply with recommended postpartum health care 

visits than they were during the prenatal period.205 

Increased recognition of the responsibility that clinicians have to encourage and support 

breastfeeding25 has led to the development of initiatives to improve continuity of care and 

support for breastfeeding. The AAP’s Safe and Healthy Beginnings program provides a 

framework for continuity of care from the prenatal period through childbirth to the postpartum 

period and beyond, and it includes standards of care to prevent breastfeeding problems and 

hyperbilirubinemia.205,222 In various communities, the health care system has successfully 

25 
coordinated with community networks to provide breastfeeding support to ensure that mothers 

have access to breastfeeding assistance after they return home. An important part of this assistance 

is having access to trained individuals who have established relationships with members of the 

health care community,223 are flexible enough to meet mothers’ needs outside of traditional work 

hours and locations,224 and provide consistent information.225 

The Ten Steps to Successful 


Breastfeeding
 

1.	 Have a written breastfeeding policy that is 


routinely communicated to all health care staff.
 

2.	 Train all health care staff in skills necessary to 


implement this policy.
 

3.	 Inform all pregnant women about the benefits 


and management of breastfeeding.
 

4.	 Help mothers initiate breastfeeding within one 


hour of birth.
 

5.	 Show mothers how to breastfeed and how to 


maintain lactation, even if they are separated 


from their infants.
 

6.	 Give newborn infants no food or drink other 


than breastmilk, unless medically indicated.
 

7.	 Practice “rooming in”—allow mothers and 


infants to remain together 24 hours a day.
 

8.	 Encourage breastfeeding on demand. 

9.	 Give no pacifiers or artificial nipples to 


breastfeeding infants.
 

10.	 Foster the establishment of breastfeeding support 

groups and refer mothers to them on discharge 

from the hospital or clinic. 

—Baby-Friendly USA221 

For any kind of health service, adequate 

education and training are essential. Even so, 

a study of obstetricians’ attitudes, practices, 

and recommendations206 found that although 

86 percent of clinicians reported having 

prenatal discussions about infant feeding, 

and 80 percent of them recommended 

breastfeeding, nearly 75 percent admitted 

they had either inadequate or no training 

in how to appropriately educate mothers 

about breastfeeding. The information 

on breastfeeding included in medical 

texts is often incomplete, inconsistent, 

and inaccurate.226 In addition, although 

formative research has revealed that hospital 

management recognizes the public health 

importance of breastfeeding and agrees that 

it is the optimal nutrition for most infants, 

management is largely unaware of the specific 

characteristics of supportive breastfeeding 

care. Despite recognizing the demand for 

evidence-based health care, many hospital 

executives are unable to accurately identify 

which current routine maternity practices are 

evidence based.226 

Notwithstanding the widespread recognition of the need for health care professionals to provide 

education and counseling on breastfeeding to their patients, both education and counseling 

are often inadequate or inappropriate. Interestingly, Taveras and colleagues161 found that 

clinicians’ perceptions of the counseling they provided on breastfeeding did not match their 

patients’ perceptions of the counseling received. By linking clinicians’ and patients’ reports on 

the counseling, they found that among mothers whose prenatal clinicians stated they always or 

usually discussed breastfeeding with their patients, only 16 percent of mothers indicated that 

breastfeeding had been discussed during their prenatal visits. Further, among mothers whose 

pediatric clinicians reported routine counseling on breastfeeding, only 25 percent of mothers 

indicated receipt of such counseling. 

26 
International Board Certified Lactation Consultants (IBCLCs) are health care professionals 

who specialize in the clinical management of breastfeeding. The only health care professionals 

certified in lactation management, they carry certification by the International Board of 

Lactation Consultant Examiners (IBLCE). Like all other U.S. certification boards for health 

care professionals, the IBLCE operates under the direction of the U.S. National Commission 

for Certifying Agencies and maintains rigorous professional standards. IBCLC candidates 

must demonstrate sufficient academic preparation as well as experience in supervised, direct 

consultation on breastfeeding to be eligible to take the certification exam.227 

Upon certification, IBCLCs work in inpatient, ambulatory, and community care settings. IBCLC 

certification helps ensure a consistent level of empirical knowledge, clinical experience, and 

professional expertise in the clinical management of complex lactation issues. Evidence indicates 

that, on discharge, rates of exclusive breastfeeding and of any breastfeeding are higher among 

women who have delivered their babies in hospitals with IBCLCs on staff than in those without 

these professionals.228,229 Further, employment of IBCLCs in neonatal intensive care units increases 

the percentage of a particularly vulnerable infant population—those born at other facilities and 

transferred to neonatal intensive care units—who leave the hospital receiving human milk.230 

Ample evidence of the need for support from IBCLCs has not yet translated, however, to 

comprehensive availability of their care. A major barrier to availability is the lack of third-party 

reimbursement. Not surprisingly, availability varies widely across the United States, with nearly 

10 IBCLCs per 1,000 live births in Vermont and only 0.83 per 1,000 live births in Nevada.231 

Data from Mannel and Mannel232 indicate a need for approximately 8.6 IBCLCs per 1,000 

live births, an estimate that accounts for prenatal education on breastfeeding, inpatient support 

during the maternity stay, outpatient follow-up after discharge, telephone follow-up, and program 

development and administration. In most states, there currently are not enough IBCLCs to meet 

the needs of breastfeeding mother-infant pairs.231–233 

In 2006, an estimated 12.8 percent of all U.S. births were preterm (less than 37 completed weeks 

of gestation), and 8.3 percent of infants had a low birth weight (less than 2,500 grams).234 In 

many cases, mothers of these babies initially have difficulty producing enough milk to meet their 

infants’ immunologic and nutritional needs.235,236 However, use of infant formula introduces 

multiple health risks,2

 such as NEC, in addition to the inherent health risks of prematurity and 

low birth weight.234 Formula feeding appears to be a risk factor for NEC, and the use of donor 

milk (milk donated by lactating women for infants other than their own) may have the potential 

to prevent some cases of NEC.237–241 Approximately 12 percent of preterm infants weighing less 

than 1,500 grams will suffer from NEC infection.242 Early mortality in surgical cases is nearly 50 

percent, making it the most common cause of death among neonates requiring gastrointestinal 

surgery.243 Hospitalization for all surgical NEC averages 62 days, at a cost of nearly $300,000 per 

patient.244 Researchers estimate that across the United States, NEC treatment costs account for 19 

percent of all initial newborn health care costs.245 Human milk is vital to the survival of vulnerable 

neonates and plays an important role in addressing the substantial burden imposed by NEC on 

affected families and in reducing health care costs associated with NEC.246 

27 
Donor milk banks collect, pasteurize, store, and distribute 

the human milk that has been donated. Currently, 12 

donor milk banks operate across the United States and 

Canada; 11 are nonprofit247 and 1 is commercial (Prolacta 

Bioscience, Inc., Monrovia, CA). Milk banking poses 

numerous challenges because of the necessity of ensuring 

that donor milk is both safe and nutritionally sound. 

Breast milk is a means of viral transmission, and thus it 

is essential that donors are screened for significant viral 

diseases, such as HIV, human T-cell leukemia virus, and 

hepatitis C. Pathogens can also be introduced during 

collection, transportation, or processing. Although heat 

treatment can destroy most infectious pathogens in 

milk, excessive heat will destroy some of the nutritional 

components of the milk as well.248 

The Human Milk Banking Association of North 

America (HMBANA) has developed guidelines for its 

member milk banks to address some of these challenges 

and has set standards for health history screening; for 

serum screening; and for milk collection, processing, 

pasteurization, storage, and dispensing.249 Although HMBANA requires that its members adhere 

to these guidelines as a condition of membership, they are not enforced by the FDA. Informal 

mechanisms for sharing of donor human milk through newspaper or Internet sites have also 

arisen, but these pose significant risks because of the inability to screen the donor and ensure that 

the milk has not been infected, diluted, or contaminated. 

In 2008, the 11 nonprofit milk banks distributed 1.4 million ounces of milk to hospitals. 

However, to meet the needs of just the infants born weighing less than 1,500 grams, an estimated 

9 million ounces would be required.250 Barriers to having more donor milk available include 

lack of knowledge among clinicians, confusion on the part of payers, and ambivalence in public 

health policy about the role of banking donor milk.251 In the United States, there is no federal 

infrastructure to regulate the screening, collection, storage, and distribution of donor milk. The 

lack of a proactive federal policy on donor milk has contributed to a lack of clarity in policies that 

affect its banking and in the regulatory responsibilities for state versus federal agencies.252 

In summary, most women plan to breastfeed, but the policies and practices of the institution 

where they give birth may undermine their intentions. The Ten Steps to Successful Breastfeeding 

is a standard for hospital performance. Once discharged, mothers may find that the health care 

system is not supportive. The support of health care professionals is particularly important at this 

time; unfortunately, many health professionals have had inadequate education and training in 

breastfeeding. IBCLCs are an excellent source of assistance for breastfeeding mothers. 

28 
Employment 

The percentage of women in the U.S. workforce has increased dramatically over the last century, 

particularly in the last 50 years. In 2004, more than 70 percent of women of childbearing age 

(20–44 years) were in the civilian labor force.253 An estimated 67 percent of mothers who had 

their first child in 2001–2003 worked during their pregnancy, mostly on a full-time basis.254 In 

2009, 50.1 percent of all mothers with children younger than 12 months were employed, and 69 

percent of those employed worked full-time (35 or more hours per week).170 

In 2001, child care arrangements for infants were such that 26 percent of nine-month-old infants 

were regularly cared for by relatives, 15 percent were cared for by a nonrelative in either their own 

or another family’s home, and 9 percent were in center-based care.255 By percentage, more black 

than white infants were in center-based care.255 The Child Care and Development Fund helps 

low-income families obtain child care so they can work or attend training or education. Among 

infants served by this program, 49 percent were in center-based care.256 

Among employed mothers, studies have found lower initiation rates257–259 and shorter duration 

of breastfeeding.58,138,257,258,260–265 Rates of breastfeeding initiation and duration are higher in 

women who have longer maternity leave,58,140,257,258,260–265 work part-time rather than fulltime,138,259,260.263,264,266 and have breastfeeding support programs in the workplace.50,267,268 

Because most lactating mothers who are employed express milk at work for a child care provider 

to bottle feed to the infant later,42 these providers are essential in helping employed mothers 

continue to breastfeed after returning to work. However, a mother feeding her infant directly 

from the breast during the workday is the most effective strategy of combining employment and 

breastfeeding because it promotes the duration and intensity of breastfeeding49 and strengthens 

the relationship between mother and infant in the critical first months of life. The skin-to-skin 

closeness that occurs during breastfeeding promotes bonding and attachment between mother and 

infant, increases the efficiency of breastfeeding, and enhances the neurological and psychosocial 

development of the infant.269,270 

Currently, among 173 countries, the United States is one of only four without a national policy 

requiring paid maternity leave (the others are Swaziland, Liberia, and Papua New Guinea).271 

The Family and Medical Leave Act of 1993 generally provides for up to 12 weeks of unpaid, 

job-protected maternity leave, but unpaid leave is not feasible for many low-income families. The 

International Labor Organization (ILO) recommends a minimum of 18 weeks of paid maternity 

leave.272 In the European Union (EU), 13 member countries meet this minimum, and the EU 

has proposed that all members adopt the minimum of 18 weeks with full pay, although it makes 

a provision for a ceiling on pay.273 The European Commission, which presents proposals for 

European law, recommends that full earnings be paid but allows for an upper limit on the amount 

paid, while the ILO recommends that the full wage be paid.272 Canada provides 50 weeks of 

partially paid maternity and parental leave.274 

29 
In 2009, approximately 14 percent of U.S. 

employers offered paid maternity leave 

beyond short-term disability benefits.132 

Although relatively few workers have this 

benefit, economic disparities exist even 

within this group. Higher income workers 

are more likely than low-income workers 

to have a paid maternity leave benefit; 

the U.S. Department of Labor estimates 

that of those with an average wage of 

more than $15 per hour, 11 percent have 

paid leave, compared with just 5 percent 

of those making less than $15 per hour. 

Additionally, some employment sectors 

are more likely to have paid maternity 

leave than others. Studies estimate that 14 

percent of management, professional, and 

similar workers have a paid family leave benefit, while only 5 percent of service, 9 percent of sales 

and office, and 4 percent of industrial workers have it.275 

As of March 2010, five states had laws that ensure some level of paid maternity leave (California, 

Hawaii, New Jersey, New York, and Rhode Island).276 More workers in these states are covered 

by laws ensuring paid maternity leave than are covered by the Family and Medical Leave Act; 

these laws could serve as a model for national programs that include lower-income workers. 

Two of these states cover all female workers, two cover all workers who participate in the state 

unemployment and disability insurance program, and one covers all women in the private sector. 

Two other states, Minnesota and New Mexico, have at-home infant care programs that fund 

low-income parents to stay home with their infants.277 In the United States, those states that have 

some form of maternity leave usually cover only part of the wage and have an upper limit on the 

benefit.58,278 Criteria for eligibility that are based on the number of employees, hours of work per 

week, or duration of employment effectively exclude large percentages of low-wage workers and 

women who are leaving welfare to work. Low-income families have fewer resources than middleclass families, and providing fully paid maternity leave might increase all employees’ ability to take 

such leave, irrespective of income. 

Various models and guidelines exist for implementing support for lactation and direct 

breastfeeding in the workplace. One example is the comprehensive resource kit, The Business Case 

for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits, which 

was developed by the Health Resources and Services Administration (HRSA).279 The kit includes 

booklets for business and human resource managers, an employee’s guide to breastfeeding and 

working, reproducible resources, and a CD-ROM.279 Program components outlined in the kit 

include flexible breaks and work schedules, a sanitary and private place to express milk, education 

for pregnant and lactating women, and support from supervisors and coworkers. 

30 
In 2010, the Affordable Care Act included a provision requiring employers to provide workplace 

accommodations that enable employees who are breastfeeding to express their milk. Specifically, 

Section 4207 of the Affordable Care Act amends the Fair Labor Standards Act of 1938 by 

requiring employers to provide reasonable, though unpaid, break time for a mother to express 

milk and a place, other than a restroom, that is private and clean where she can express her 

milk.184 

Given that 26 percent of mothers employed full-time in 2003 were breastfeeding when their 

infant was aged six months,264 it is clear that a substantial percentage of U.S. mothers manage 

to combine breastfeeding and paid work. However, U.S. mothers overall have less support for 

continuing to breastfeed after returning to work than is recommended by the ILO. The ILO 

recommends that provision be made for a place to breastfeed under hygienic conditions at or 

near the workplace and that the frequency and length of nursing breaks be adapted to particular 

needs.272 Legislation in EU countries generally meets the ILO standards.280 In 2009, 15 U.S. 

states required that employers support breastfeeding employees when they return to work.231 An 

employee benefits survey conducted in 2009 in the United States indicated that 25 percent of 

employers have on-site lactation rooms, with smaller businesses least likely to have these rooms.132 

In 2008, 31 percent of employed mothers with infants worked part-time (34 or fewer hours per 

week),254 suggesting that many mothers are using part-time employment to help them balance 

work and family needs. The 2005–2007 Infant Feeding Practices Study II found that among 

mothers who worked and breastfed, 32 percent kept the infant at work and breastfed during the 

workday, 8 percent went to the infant to breastfeed, and 3 percent had the baby brought to them 

at the work site in order to breastfeed.49 

Breastfeeding mothers with out-of-home arrangements for child care need the cooperation and 

support of the child care provider in order to continue breastfeeding. These mothers represent a 

very large number of women, as approximately half of infants of working mothers are in out-ofhome child care.255 The current national guidelines on out-of-home child care from the National 

Resource Center for Health and Safety in Child Care and Early Education,281 which are supported 

by HRSA, are under revision and will be released in a third edition in 2011. Meanwhile, selected 

standards from the new third edition have been published online and provide information about 

how child care providers should support breastfeeding mothers and families.282 The new guidelines 

recommend that those who provide child care should encourage, make arrangements for, and 

support breastfeeding families, such as by providing a space for a mother to breastfeed or express 

milk for her child. Additionally, the new guidelines include information about preparing, storing, 

and handling expressed human milk, as well as the importance of feeding all children on cue 

rather than on a schedule.282 

However, the 2002 guidelines still have not been implemented in all states,283 and in some 

states, child care homes that serve small numbers of children are not covered by the guidelines. 

Furthermore, some states, such as Colorado and Wisconsin, have developed their own guidelines 

and training materials for child care providers with respect to breastfed infants.284–286 A recent 

31 
study in Colorado found that providers of child care scored low on a test of proper procedures for 

storing and feeding breast milk but that they were interested in receiving information or training 

about infant feeding.287 

In conclusion, employment is now the norm for U.S. women of childbearing age. Employed 

women currently are less likely to initiate breastfeeding, and they tend to breastfeed for a shorter 

length of time than women who are not employed. Most employed mothers who are lactating 

must express milk at work for their children and should be provided with accommodations to 

do so. However, directly breastfeeding a child during the workday offers additional opportunities 

for mother-child bonding and helps to sustain the exclusivity and duration of breastfeeding.42 

Mothers should have a hygienic area in or near their workplace to breastfeed, and their breaks for 

nursing should be adapted to their particular needs. Further, child care providers need to support 

mothers who wish to breastfeed. 

Research and Surveillance 

Although there is a body of research on breastfeeding and some national monitoring is in place 

to track trends, significant knowledge gaps are evident.2,288–291 These gaps must be filled to ensure 

that accurate, evidence-based information is available to parents, health clinicians, public health 

programs, and policy makers. New studies can provide insight into questions, such as how 

to 1) reduce disparities in breastfeeding rates that are associated with race/ethnicity, income, 

and preterm birth; 2) identify the comprehensive cost savings for parents, insurers, and the 

government that result from breastfeeding; and 3) develop best practices for management and 

support of lactation and breastfeeding. Expanded surveillance of breastfeeding would provide a 

more timely and representative understanding of patterns of breastfeeding in this country and of 

areas that could be prioritized to improve support for breastfeeding. 

Paradoxically, rates of breastfeeding are not optimal among those most likely to benefit from 

it. For example, breastfeeding rates are particularly low among low-income women,41 and yet 

the health benefits that accrue from breastfeeding are especially important for women with low 

incomes and their families, as they already suffer a higher burden of illness and are the least 

able to pay for health services or afford time away from work because of illness. Because of their 

increased susceptibility to life-threatening illnesses, human milk also is particularly beneficial to 

preterm infants. In 2006, 12.8 percent of live births were preterm.234 Mothers who give birth 

preterm often face challenges with breastfeeding, and rates of breastfeeding are lower among 

preterm infants compared with full-term infants.292 New research is needed to identify barriers 

to and supports for breastfeeding among populations with low rates of breastfeeding. Evidencebased findings could lead to the implementation of improved strategies that could result in higher 

breastfeeding rates and have a major impact on public health. 

In addition to improving knowledge about ways to increase breastfeeding rates, research on the 

economic benefits accrued from high rates of continued breastfeeding and, conversely, the costs of 

low rates of breastfeeding is needed to understand the financial impact of breastfeeding. Although 

32 
previous research found significant cost savings associated with breastfeeding,20,23,24 current and 

comprehensive economic studies that more precisely estimate the complete cost-benefit ratio of 

breastfeeding and related activities are critical to inform policy making. 

Despite overwhelming evidence of the reduced health risks associated with breastfeeding and 

consuming breast milk, there are still gaps in our knowledge regarding management and support 

for lactation and breastfeeding under both typical and special circumstances. Identification 

of evidence-based best practices would provide essential insights for programs that promote 

breastfeeding and enhance the acceptance of these programs by clinicians and the public at large. 

Challenges exist in conducting studies on breastfeeding. For instance, researchers often have to 

rely on retrospective information provided by a mother when asking her to recall details about her 

previous breastfeeding experiences and practices. In addition, the absence of uniform definitions 

for such terms as “breastfeeding” and “exclusive breastfeeding” has rendered generalization across 

studies difficult.2

 Both increasing the validity of measures and standardizing the terminology are 

necessary to improve the accuracy and interpretation of research findings. Another concern is that 

there may not be enough researchers in the field; enhancing the opportunities for collaboration 

among researchers and providing new training opportunities for emerging scientists would help 

ensure the availability of scientific talent to usher in a new era of breastfeeding research. 

Increasing the number of scientists properly trained to study breastfeeding could allow both 

current and new researchers to design and carry out scientifically sound and rigorous studies 

on breastfeeding topics.2

 Because of ethical considerations, research on the health outcomes of 

different modes of infant feeding is limited to observational studies, the results of which can only 

provide inferences on the association between feeding type and outcomes (unlike experimental 

or randomized controlled trials, which permit assessment of cause and effect). Thus, researchers 

need to develop innovative study designs that will improve our understanding of the relationships 

between breastfeeding and various outcomes. For example, women could be randomly assigned 

to receive an intervention that increases the proportion who exclusively breastfeed their children 

for six months and continue 

breastfeeding at least one year. 

Health outcomes in those 

children could be tracked and 

compared with health outcomes 

of children who received less 

breast milk. 

At present, several national 

systems provide data on national 

breastfeeding rates, but few 

systems exist to collect data 

at state and local levels. The 

NIS293 provides annual state33 
level breastfeeding rates, but its sample is too small to permit interpretation of year-to-year changes 

for most states. The Pregnancy Risk Assessment Monitoring System allows for the calculation of 

breastfeeding initiation rates and duration up to 2–4 months, but currently only 31 states participate 

in this system.294 Local breastfeeding statistics are generally unavailable except for data from the 

Pediatric Nutrition Surveillance System, but these data are primarily from WIC participants, and 

not all states participate.295 Some information is available through birth certificate data, but only 28 

states currently capture initiation of breastfeeding on the birth certificate.296 

In addition to monitoring breastfeeding rates, it is important to track changes in the policies 

that affect breastfeeding and how it is supported. The CDC Breastfeeding Report Card231 

reports annually on a handful of 

breastfeeding-related indicators 

but is limited in scope. To date, 

little is known about the extent 

to which businesses are making 

accommodations for breastfeeding 

mothers, whether the United States 

has an adequate supply of skilled 

certified lactation consultants for 

women having difficulties with 

breastfeeding, or how broadly peer 

counseling programs are being 

operated in this country. 

Another way that trends in 

breastfeeding and related indicators 

are monitored is through the 

Healthy People initiative.297 

Healthy People, which provides 

a framework for health promotion and disease prevention for the nation, is designed to identify 

the most significant threats to public health and establish national goals to help reduce these 

threats. The breastfeeding objectives in Healthy People 2010 were retained in Healthy People 2020, 

but with higher targets. New objectives related to maternity practices, reduction in the early 

supplementation of breastfed newborns with formula, and worksite lactation support have been 

added (see Table 3). 

In summary, additional research and surveillance are needed on many aspects of breastfeeding in 

the United States. For example, more research is needed on the barriers to breastfeeding among 

populations with low rates of breastfeeding. Economic research is also needed on how breastfeeding 

affects mothers and employers, as is research on best practices for management and support of 

lactation and breastfeeding. Building capacity for research on breastfeeding should be a priority. 

Although national surveillance on breastfeeding has improved considerably in the last decade, 

surveillance at state and local levels is limited. 

34 
Table 3. Healthy People 2020 Objectives for Breastfeeding
 

Objective Baseline (%) Target (%) 

Increase the proportion of infants who are breastfed (MICH 21) 

Ever 74.0* 81.9 

At 6 months 43.5* 60.6 

At 1 year 

Exclusively through 3 months 

Exclusively through 6 months 

Increase the proportion of employers that have worksite lactation support 

programs (MICH 22) 

Reduce the proportion of breastfed newborns who receive formula 

supplementation within the first 2 days of life (MICH 23) 

Increase the proportion of live births that occur in facilities that provide 

recommended care for lactating mothers and their babies (MICH 24) 

22.7* 

33.6* 

14.1* 

25† 

24.2* 

2.9‡ 

34.1 

46.2 

25.5 

38 

14.2 

8.1 

MICH = Maternal, Infant, and Child Health. 

* Source: Centers for Disease Control and Prevention, National Immunization Survey, 2006 data.41 

† Source: Society for Human Resource Management Survey, 2009.132 

‡ Source: Centers for Disease Control and Prevention, Breastfeeding Report Card—United States, 2009.231 

Public Health Infrastructure 

An effective national public health program requires the basic coordination and monitoring 

of services. Activities to promote and support breastfeeding originate from a wide variety of 

entities, including federal, state, and local governments; nonprofit organizations; and professional 

associations. Within the federal government, numerous agencies have developed programs on 

breastfeeding, and others have programs that affect breastfeeding indirectly. The USDA operates 

the WIC program, which serves more than half the infants born in the United States. In HHS, 

several breastfeeding initiatives exist within the Maternal and Child Health Bureau, the National 

Institutes of Health, CDC, FDA, AHRQ, OWH, and the Indian Health Service. In addition, 

the U.S. Department of Defense sets standards for accommodating breastfeeding among military 

personnel. 

Although the work of each of these agencies is valuable, no formal structure for coordination of 

federal breastfeeding initiatives exists to reduce overlap or to identify gaps in current programs. 

Creation of a federal interagency work group on breastfeeding could help overcome these 

challenges and improve coordination and collaboration across agencies to improve support for 

breastfeeding. 

The United States Breastfeeding Committee (USBC) (www.usbreastfeeding.org) provides a forum 

for nongovernmental organizations and liaisons from the federal government to collaborate on 

joint initiatives in support of breastfeeding. The committee was formed in 1995 with the support 

35 
of then Assistant Surgeon General Audrey Nora, M.D., M.P.H. The mission of the USBC is 

to protect, promote, and support breastfeeding in the United States and, thus far, it has taken 

several steps toward accomplishing this mission. To start, the USBC unveiled Breastfeeding in the 

United States: A National Agenda,

298 which served as the first step in a strategic plan for improving 

breastfeeding in the United States. Much like this Call to Action, the USBC’s national agenda 

recognizes the importance of breastfeeding and sets forth a societal approach to help improve 

breastfeeding practices. 

In addition to writing position statements on breastfeeding, the USBC has been instrumental in 

bringing important partners together to move forward the breastfeeding agenda. For instance, it 

held the First National Conference of State Breastfeeding Coalitions in 2006; these important 

meetings have continued every two years to enable states to network and share successful strategies 

to improve support for breastfeeding. 

All 50 states have now formed breastfeeding coalitions, and there are many local, tribal, and 

territorial coalitions as well. These coalitions catalyze local and state efforts to promote and 

support breastfeeding. Although the USBC supports state coalitions with technical assistance, 

Web-based communications support, and a biannual conference, most of these coalitions are 

small and unfunded. Additionally, most state health departments have no staff responsible for 

breastfeeding activities, except within the WIC program. This lack of a state infrastructure makes 

it difficult to carry out any new breastfeeding programs at the state level. 

In summary, many organizations and agencies, both inside and outside the government, are 

currently working to increase rates of breastfeeding and to support mothers and their infants in a 

variety of ways. The USBC is a focal point for efforts in this area, and all 50 states have their own 

breastfeeding coalitions. 

36 
A Call to Action
 

Given the importance of breastfeeding for the health and well-being of mothers and children, it 

is critical that we take action across the country to support breastfeeding. Women who choose to 

breastfeed face numerous barriers. Only through the support of family members, communities, 

clinicians, health care systems, and employers will we be able to make breastfeeding become 

the easy choice, the default choice. This section describes the recommended actions and their 

associated implementation strategies in detail. A summary of this information is provided in table 

form in Appendix 1. 

37 
Mothers and Their Families 

Action 1. Give mothers the support they need to breastfeed 


their babies.
 

In the United States, women often lack information on breastfeeding, and women who decide 

to breastfeed their children are frequently not given support. The result is that many mothers 

see breastfeeding as a goal they cannot achieve for themselves and their babies. Furthermore, 

many mothers are not aware of the excess risks to babies’ and mothers’ health associated with 

not breastfeeding. To achieve their goals for breastfeeding, mothers should seek the information, 

support, and care they deserve. 

Implementation Strategies 

Help pregnant women to learn about the importance of breastfeeding for their babies and 

themselves. Doctors and midwives are expected to give women accurate and complete information 

on infant feeding as part of routine prenatal care, but if it is not provided, mothers have the right 

to ask for it. Mothers can obtain this information from their clinicians to ensure they have the 

knowledge they need to make the decision about infant feeding that is best for them. 

Teach mothers to breastfeed. Like many other activities, breastfeeding requires preparation 

and effort at first. Pregnant women who learn about how to breastfeed are more likely to 

be successful than those who do not. Women can obtain helpful information about how to 

breastfeed from classes, books, online resources, and the U.S. Department of Agriculture’s 

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as 

from other mothers who have breastfeeding experience. 

Encourage mothers to talk to their maternity care providers about plans to breastfeed. 

Every mother and baby deserves maternity care that supports breastfeeding, and to obtain that 

care, a mother must let her doctor or other health care clinician know she wants to breastfeed. 

Mothers can discuss with their clinicians the types of care they expect during and after their 

maternity stay to ensure that care is compatible with breastfeeding. 

Support mothers to have time and flexibility to breastfeed. To ensure the best and most 

supportive environment for breastfeeding, mothers can engage in conversations with family, 

friends, employers, child care providers, and others to ask for and create a plan that will 

accommodate their ability to continue breastfeeding at home and after returning to work or 

school. Having help around the house for the first few weeks at home after childbirth will 

allow a mother and her baby to concentrate on learning how to breastfeed. 

Encourage mothers to ask for help with breastfeeding when needed. Some early challenges 

with breastfeeding are normal, while others may be signs of breastfeeding problems. If a 

mother experiences severe pain or other problems with breastfeeding, asking for help will 

assist her in achieving her breastfeeding goal. Mothers can ask for help from their doctors or 

38 
midwives, lactation consultants, and other mothers with breastfeeding experience. With help 

from these people, mothers can resolve most breastfeeding problems and go on to enjoy their 

breastfeeding experiences. 

Action 2. Develop programs to educate fathers and 

grandmothers about breastfeeding. 

A woman’s decision to breastfeed is strongly influenced by the beliefs and attitudes of her family and 

friends. Unfortunately, family and friends may discourage a mother from breastfeeding if it is not 

accepted within their culture. Often, when a mother is thinking about how to feed her baby, she 

values the advice of her partner the most, followed by the advice of her mother, family, and friends. 

In fact, she often values their advice more than the advice of health care professionals. 

Partners are particularly important because their approval means so much to a mother, and 

her partner is often a mother’s primary source of support. Although fathers want the best for 

their family, they may become jealous or resentful or get the feeling that they will not be able to 

bond with their child if their partner chooses to breastfeed. The baby’s grandmothers are also very 

influential because mothers who have recently given birth rely on them for support and advice. To 

make breastfeeding successful, mothers need the support and encouragement of all of these people. 

Implementation Strategies 

Launch or establish campaigns for breastfeeding education that target a mother’s primary 

support network, including fathers and grandmothers. Local campaigns can use print, 

billboard, radio, and television public service announcements that feature members of a 

specific population for more effective reach. 

Offer classes on breastfeeding that are convenient for family members to attend. 

Educational materials and classes that are directed toward fathers and grandmothers need 

to be developed to attract and involve this extended support network. To encourage the 

participation of family 

and friends, consideration 

should be given to 

involving churches, civic 

organizations, health 

clubs, community centers, 

and schools because these 

venues may be more 

accessible than health 

care institutions. Offering 

classes during a variety of 

hours and days also may 

improve participation. 

39 
Communities 

Action 3. Strengthen programs that provide mother-tomother support and peer counseling. 

A mother-to-mother volunteer organization called La Leche League introduced the idea of giving 

support to breastfeeding women from their peers in the community—in most cases, women who are 

not health care professionals. Counseling by a woman’s peers has helped to increase the number of 

women who choose to breastfeed and the length of time they continue with breastfeeding. Success 

with such counseling has been achieved among economically disadvantaged women and those with 

diverse cultural backgrounds. Support by a woman’s peers can be provided through telephone calls; 

visits in the hospital, home, or clinic; group classes; or informal support groups. 

Implementation Strategies 

Create and maintain a sustainable infrastructure for mother-to-mother support groups 

and for peer counseling programs in hospitals and community health care settings. 

Hospitals and birth centers have a unique opportunity to ensure that mothers are connected 

to support systems in the community after they are discharged. With virtually all babies in the 

United States born in such facilities, this strategy has the potential of broad reach. Hospitals 

and birth centers can provide these services themselves or collaborate with community health 

groups to increase mothers’ access to peer support groups or peer counselors. 

Establish peer counseling as a core service available to all women in WIC. With rates of 

breastfeeding being consistently lowest among low-income women, the provision of additional 

support for breastfeeding mothers is especially important in the WIC program. WIC’s existing 

peer counseling program has proven to be effective, but currently it is not offered in all local 

WIC agencies. 

40 
Action 4. Use community-based organizations to promote 

and support breastfeeding. 

Organizations that are based in communities and do their work there are aware of the specific 

barriers that women in their communities face and can identify workable solutions for these 

women. In most cases, these organizations understand the culture and customs of the residents 

in the community, as well as their needs and opportunities. Questions and concerns about 

breastfeeding may be handled by organizations whose primary mission is to promote and support 

breastfeeding or by other organizations involved in family health. 

Implementation Strategies 

Support and fund small nonprofit organizations that promote breastfeeding in 

communities of color. Addressing the socioeconomic, racial, and ethnic inequities in 

breastfeeding requires focusing on those communities with low rates of breastfeeding. 

Resources for local organizations that support breastfeeding are extremely limited, making 

the provision of mother-to-mother support, community advocacy, and outreach efforts 

difficult. Educational messages, training, tools, and other resources need to reflect local 

culture, ethnicity, language, and literacy levels. 

Integrate education and support for breastfeeding into public health programs that serve 

new families. A variety of people and programs are now operating in communities to meet 

the needs of new families, including home visitors, community-based doulas (women who 

help mothers during and after childbirth), advocates for prevention of domestic violence, 

public health nurses, and early childhood and Healthy Start programs. Assistance with 

breastfeeding is a natural extension of the other functions these programs provide and 

contributes to the common goals of improving the health and well-being of families. 

Ensure around-the-clock access to resources that provide assistance with breastfeeding. 

Difficulties with breastfeeding can occur at any time of the day or night and on weekends. If 

mothers are unable to get help when they need it, they can become discouraged and give up 

on breastfeeding. The use of telephone triage, “warmlines,” hotlines, online networks, and 

pretested referral patterns in each community can provide the human contacts needed to help 

mothers work through their breastfeeding problems. 

41 
Action 5. Create a national campaign to promote 

breastfeeding. 

Social marketing is a promising way of ensuring that new generations understand the value of 

breastfeeding and can make well-informed decisions about infant feeding. Social marketing, 

unlike traditional marketing, engages members of the community with each other (often through 

forums or blogs on the Internet). The national educational campaign and the strategies used must 

be culturally sensitive and appropriate. Developing such a campaign calls for long-term strategies 

and requires careful planning and a thorough understanding of social marketing. 

Implementation Strategies 

Develop and implement a national public health campaign on breastfeeding that 

relies heavily on social marketing. A task force with wide representation should frame the 

problem, define the audience, determine effective messages, and choose the behaviors to be 

changed and promoted. To have broad reach, the campaign needs to be well funded and 

sustained over a prolonged period. 

Use a variety of media venues to reach young women and their families. While television and 

print media remain viable avenues for disseminating public health messages, the increasing use of 

electronic communication channels opens many new possibilities for promoting breastfeeding. 

Use of these new social media will require that promoters adapt quickly to changing technology 

and develop new kinds of messages appropriate to these venues. 

42 
Action 6. Ensure that the marketing of infant formula is 

conducted in a way that minimizes its negative impacts on 

exclusive breastfeeding. 

The International Code of Marketing of Breast-milk Substitutes (the Code) establishes rules for 

the protection of mothers from the influences of false and misleading advertising, including 

unethical marketing practices of substitutes for breast milk. The Code, developed in concert 

with manufacturers of infant formula, spells out both appropriate and inappropriate marketing 

practices. Although its provisions are not legally binding in the United States, various means of 

encouraging voluntary adherence should be developed. 

Implementation Strategies 

Hold marketers of infant formula accountable for complying with the International 

Code of Marketing of Breast-milk Substitutes. In particular, the Code precludes advertising 

directly to consumers and does not allow for distribution of free samples to the public. 

Until 1990, manufacturers of formula refrained from directly advertising to consumers. 

Manufacturers could voluntarily return to this practice, and hold themselves accountable 

through their joint participation in the International Formula Council. Public health entities 

could help by making information on violations of the Code publicly available. 

Take steps to ensure that claims about formula are truthful and not misleading. With the 

proliferation of new kinds of infant formula, a variety of claims are being made about their 

contents and health benefits. The validity of these claims should be reviewed. Furthermore, 

research is needed on how consumers perceive the claims being made, whether they think 

messages are believable, and how these claims affect consumers’ behavior. The findings should 

be used to identify the marketing practices likely to have a negative impact on exclusive 

breastfeeding. 

Ensure that health care clinicians do not serve as advertisers for infant formula. The 

distribution of materials such as free samples, pamphlets, notepads, growth charts, or gifts 

that bear logos from companies marketing infant formula implicitly endorses formula feeding. 

Displays of posters, products, or decorations from these companies in a health care professional’s 

office or in a hospital or clinic leave the impression that clinicians favor formula feeding over 

breastfeeding. Given the health consequences of not breastfeeding, clinicians should not 

implicitly promote infant formula by providing venues for its advertisement. 

43 
Health Care 

Action 7. Ensure that maternity care practices throughout 

the United States are fully supportive of breastfeeding. 

In the United States, nearly all infants (99 percent) are born in hospital settings, and guidelines 

based on available evidence have been established to ensure the delivery of appropriate maternity 

care in these settings. Unfortunately, the evidence-based guidelines for quality maternity care 

are applied inconsistently. In fact, maternity care practices often reflect clinicians’ personal 

experiences with breastfeeding and may be based on misinformation that interferes with successful 

breastfeeding. Maternity care of high quality will be delivered to all patients only if standards are 

consistently applied to every mother and infant. 

Implementation Strategies 

Accelerate implementation of the Baby-Friendly Hospital Initiative. In order to help 

hospitals work together, learn from each other, and share successful strategies to achieve 

Baby-Friendly designation, public health agencies need to expand their capacity to provide 

assessment of and technical assistance with Baby-Friendly practices. These strategies include 

examining the different ways of designating an institution as Baby-Friendly that are used 

internationally. Creating incentives for participation in the initiative may be helpful. 

Establish transparent, accountable public reporting of maternity care practices in the 

United States. The Joint Commission can add the responses of maternity facilities on their 

Perinatal Care Core Measure set to the Joint Commission Quality Reports and related data 

reports that the commission provides to facilities to help them improve practices. 

44 
Establish a new advanced certification program for perinatal patient care. Such a 

program would recognize facilities for making exceptional efforts to foster better quality of 

care, improve breastfeeding support, and achieve better health outcomes in maternal and 

newborn care. Criteria for certification would include following the practices for maternal and 

newborn care in the Ten Steps to Successful Breastfeeding established by the World Health 

Organization and the United Nations Children’s Fund. The Joint Commission has existing 

certification programs, such as its Disease-Specific Care Certification Programs, which could 

serve as models for perinatal care. 

Establish systems to control the distribution of infant formula in hospitals and 

ambulatory care facilities. Control systems for medications are generally used to ensure 

appropriate preparation, dosing, and administration; to track lot numbers; to monitor 

expiration dates; and to control inventories. The same procedures could be applied to infant 

formula use in hospitals and ambulatory care settings to support the safety of infants and to 

improve quality of care. Failure to monitor infant formula through these procedures leads to 

overuse of formula and excessive supplementation without medical indications. 

Action 8. Develop systems to guarantee continuity of skilled 

support for lactation between hospitals and health care 

settings in the community. 

Upon discharge from their stay in the hospital, many mothers are unable to find and receive 

skilled breastfeeding support. Mothers often are left on their own to identify resources to help 

with questions and problems they may have with breastfeeding. Furthermore, hospitals, clinicians 

in the community, and community organizations typically lack systems to help connect mothers 

to skilled persons who can offer support for breastfeeding. Ideally, there would be a system to 

ensure that breastfeeding mothers and their infants would receive skilled support with lactation 

from informed and available health care teams. Hospitals, primary care clinicians, and community 

organizations share responsibility for creating such systems. 

Implementation Strategies 

Create comprehensive statewide networks for home- or clinic-based follow-up care to 

be provided to every newborn in the state. Follow-up support for breastfeeding needs to be 

integrated into home visitation and postpartum care programs. Staff training in breastfeeding 

management would be fundamental to this care. 

Establish partnerships for integrated and continuous follow-up care after discharge from 

the hospital. Communities often provide a variety of resources to help breastfeeding mothers, 

including peer support networks, breastfeeding clinics, lactation consultants, and support 

groups. Health care systems can ensure that their patients are informed about such resources 

and can facilitate connections to these resources. They can also help to strengthen or create 

these programs. 

45 
Establish and implement policies and programs to ensure that participants in WIC 

have services in place before discharge from the hospital. Community partners and key 

stakeholders, such as hospitals, lactation consultants, and other clinicians, can work with 

WIC to establish continuity of care for WIC participants who breastfeed their infants. In 

addition, WIC state agencies can collaborate with state hospital associations to identify key 

barriers to the provision of WIC services within the hospital setting. WIC state agencies and 

hospitals can partner to establish policies to ensure that WIC participants receive in-hospital 

education and support for breastfeeding, including identification of a WIC peer counselor and 

scheduling of follow-up support for breastfeeding by WIC staff in the community. 

Action 9. Provide education and training in breastfeeding for 

all health professionals who care for women and children. 

Clinicians are consistently identified by patients as preferred sources of information and guidance 

on breastfeeding. Therefore, clinicians need to demonstrate competency in supporting lactation and 

breastfeeding. Inadequate education and training of clinicians has been identified as a major barrier 

to breastfeeding, and education on breastfeeding is not a core element of most medical school or 

residency programs or of programs in nursing education. Unfortunately, there are few opportunities 

for future physicians and nurses to obtain education and training on breastfeeding, and the 

information on breastfeeding in medical texts is often incomplete, inconsistent, and inaccurate. 

In addition, breastfeeding mothers and their children have health care needs that are unrelated to 

lactation, but clinicians should understand the impact their services may have on breastfeeding. 

46 
Implementation Strategies 

Improve the breastfeeding content in undergraduate and graduate education and 

training for health professionals. Because preprofessional education and training provide 

the foundation that supports later clinical practice, quality breastfeeding content is necessary 

to prepare those who will eventually care for breastfeeding women or their infants. However, 

even health care professionals whose services are not directly related to breastfeeding often 

encounter breastfeeding mothers and their children. Therefore, all health care professionals 

need to ensure that the care they provide is compatible with breastfeeding. 

Establish and incorporate minimum requirements for competency in lactation care into 

health professional credentialing, licensing, and certification processes. Competency 

in lactation care among multiple health professional disciplines and specialties is required 

to ensure optimal breastfeeding management and support. These disciplines and specialties 

include but are not limited to physicians, nurses, physician assistants, midwives, lactation 

consultants, dietitians, social workers, physical therapists, and pharmacists. In addition to 

developing standards, certifying boards and other professional organizations can ensure 

competency in lactation care through training, continuing education, exams, and quality 

improvement programs. 

Increase opportunities for continuing education on the management of lactation to 

ensure the maintenance of minimum competencies and skills. Education on breastfeeding 

can be integrated into related topic areas in continuing education. Flexible, practice-based 

learning approaches may be especially effective. 

Action 10. Include basic support for breastfeeding as 

a standard of care for midwives, obstetricians, family 

physicians, nurse practitioners, and pediatricians. 

Midwives, obstetricians, family physicians, nurse practitioners, and pediatricians provide care 

that supports their patients’ interests and health needs, including breastfeeding. Their full support 

of breastfeeding may be limited by the use of practices that unintentionally and unnecessarily 

interfere with breastfeeding. These practices directly affect mothers’ and babies’ abilities to start 

and continue breastfeeding. 

Implementation Strategies 

Define standards for clinical practice that will ensure continuity of care for pregnant 

women and mother-baby pairs in the first four weeks of life. The standard of care should 

include actions that are important for the promotion and support of breastfeeding, including 

providing prenatal counseling on feeding decisions, setting accountability standards for 

postpartum follow-up care, monitoring neonatal weight gain, and establishing referral 

mechanisms for skilled lactation care. Models should be established to integrate assistance with 

breastfeeding into routine practice settings. 

47 
Conduct analyses and disseminate their findings on the comparative effectiveness of 

different models for integrating skilled lactation support into settings where midwives, 

obstetricians, family physicians, nurse practitioners, and pediatricians practice. Skilled 

lactation support may be provided by trained physicians, by lactation consultants affiliated 

with a physician practice, through stand-alone clinics, or by referrals. Models of care differ in 

the degree to which care is provided for all breastfeeding mothers to prevent difficulties and 

the extent to which care is provided for women already having problems. Identification of best 

practices and optimal care models is needed. 

Action 11. Ensure access to services provided by 


International Board Certified Lactation Consultants.
 

International Board Certified Lactation Consultants (IBCLCs) are the only health care 

professionals certified in lactation care. They have specific clinical expertise and training in the 

clinical management of complex problems with lactation. Better access to the care provided by 

IBCLCs can be achieved by accepting them as core members of the health care team and creating 

opportunities to prepare and train more IBCLCs from racial and ethnic minority groups that are 

currently not well represented in this profession. 

Implementation Strategies 

Include support for lactation as an essential medical service for pregnant women, 

breastfeeding mothers, and children. Third party payers typically define a standard package 

of health benefits for women and children. Including standard coverage for IBCLCs as 

“covered providers” when they perform services within the scope of their certification would 

ensure that mothers and children have access to these services through insurance maternity 

benefits. Federally funded health benefit programs, such as Medicaid, the Children’s Health 

Insurance Programs, Tricare, and the Federal Employee Health Benefit program, could serve as 

models for such a standard benefit package. 

Provide reimbursement for IBCLCs independent of their having other professional 

certification or licensure. The taxonomy for health care clinicians defines qualifications 

of clinicians to be reimbursed. One option for reimbursement would be to place certified 

lactation consultants within the category of “nursing service related providers,” and specifying 

the nature of care they provide would allow for reimbursement of IBCLCs without requiring 

that they are also registered nurses. Alternatively, developing state licensure of lactation 

consultants could help to achieve the same purpose. 

Work to increase the number of racial and ethnic minority IBCLCs to better mirror 

the U.S. population. Racial and ethnic minority communities tend to be underserved by 

lactation consultants. More students from these communities could be trained in human 

lactation to increase careers in lactation consultation. Area Health Education Centers could be 

encouraged to establish community-based training sites in lactation services. 

48 
Action 12. Identify and address obstacles to greater 

availability of safe banked donor milk for fragile infants. 

Growing evidence supports the role of donated human milk in assisting infants with special needs, 

such as infants in newborn intensive care units who are unable to receive their own mothers’ milk, 

to achieve the best possible health outcome. In these situations, use of banked donor milk may 

protect the infant from the risks that might result from not breastfeeding. Unfortunately, demand 

for donor milk outpaces supply because of logistical challenges related to transportation of 

donated milk, the lack of clarity in oversight, and the high cost of providing banked human milk. 

A national strategy is needed to efficiently and effectively address the issues involved in providing 

banked donor milk to vulnerable infant populations. 

Implementation Strategies 

Conduct a systematic review of the current evidence on the safety and efficacy of donor 

human milk. A systematic review will provide a common understanding of the health 

outcomes resulting from the use of this milk by analyzing the results of all of the available 

published research. Additionally, a systematic review will help identify any areas where the 

evidence is not conclusive and where more research is needed. 

Establish evidence-based clinical guidelines for the use of banked donor milk. Necessary 

components of the guidelines include discussion of the use of donor human milk for a variety of 

infants, such as those who have a low or very low birth weight, are premature, or have particular 

medical needs; issues related to collection 

of and payment for donor milk; and the 

complex biomedical ethics of prioritizing 

the distribution of banked donor milk. 

Convene a study on federal regulation 

and support of donor milk banks. 

Such a study could examine possible 

models for regulating and funding milk 

banks. In addition, it should consider 

policy options to address concerns 

about biomedical ethics related to 

compensation for donating milk and the 

for-profit sale of banked donor milk. It 

also could examine models for payment, 

including WIC or health insurance 

program benefits that cover the use of 

banked donor milk. It is important 

also to consider how human milk 

banks might be a resource in planning 

responses to national emergencies. 

49 
Employment 

Action 13. Work toward establishing paid maternity leave 

for all employed mothers. 

Most women of childbearing age in the United States are in the labor force. Numerous studies 

have demonstrated that providing paid maternity leave for employed mothers increases the 

success of breastfeeding. The International Labor Organization, an arm of the United Nations, 

recommends a paid maternity leave of 18 weeks and also recommends that employers not be 

solely responsible for funding maternity leave, as this could create a disincentive to hire women. 

The International Labor Organization’s recommendations might be reasonable goals for the 

United States. In this country, the Family and Medical Leave Act of 1993 provides for 12 weeks of 

unpaid leave that can be used for maternity leave. However, unpaid leave is usually not an option 

for lower-income mothers, who are disproportionately women of color. Therefore, paid leave is 

necessary to reduce the differential effect of employment on breastfeeding among disadvantaged 

racial, ethnic, and economic groups, which in turn would allow disadvantaged populations to 

benefit from the health effects of breastfeeding. 

Implementation Strategies 

Add maternity leave to the categories of paid leave for federal civil servants. This change is 

an important step toward filling gaps and expanding access to paid maternity leave. A benefit 

of paid maternity leave for federal government workers would be useful to mothers employed 

by the federal government and encourage other work sectors to implement similar programs. 

Several private-sector employers have successfully provided paid leave. The federal government 

should assess existing model programs to develop a program for its employees. 

Develop and implement programs in states to establish a funding mechanism for paid 

maternity leave. Currently, several states have passed or are considering legislation to establish 

paid family or maternity leave. The funding mechanisms used or proposed include the State 

Temporary Disability Insurance program and state-administered insurance systems for family 

leave that are financed by employer or employee payroll deductions. States are encouraged to 

be creative in developing ways to fund paid maternity leave. 

50 
Action 14. Ensure that employers establish and maintain 

comprehensive, high-quality lactation support programs for 

their employees. 

In the United States, a majority of mothers have returned to the workplace by the time their 

infants are six months old. Continuation of breastfeeding after returning to work is facilitated 

if the employer offers a lactation support program. The evidence demonstrates that supportive 

policies and programs at the workplace enable women to continue providing human milk for 

their infants for significant periods after they return to work. High-quality lactation programs 

go beyond just providing time and space for breast milk expression, but also provide employees 

with breastfeeding education, access to lactation consultation, and equipment such as highgrade, electric breast pumps. Currently, only a quarter of U.S. employers provide breastfeeding 

employees with a place to express breast milk at the workplace. 

Implementation Strategies 

Develop resources to help employers comply with federal law that requires employers to 

provide the time and a place for nursing mothers to express breast milk. As part of the 

Affordable Care Act enacted in 2010, the Fair Labor Standards Act was amended to require 

employers to provide reasonable break time and a private place for nursing mothers to express 

milk while at work. Programs are needed to educate employers about the new law, supply 

examples of how it can be implemented in a variety of work settings, and provide assistance to 

businesses that find compliance difficult. 

Design and disseminate materials to educate employers about the benefits of providing 

more comprehensive, high-quality support for breastfeeding employees. The Health 

Resources and Services Administration resource kit, The Business Case for Breastfeeding: Steps for 

Creating a Breastfeeding Friendly Worksite, is one model of how to promote employer support 

for breastfeeding employees. Developing Web sites, videos, conference exhibits, and peer-topeer marketing strategies could all be useful for expanding the use of lactation programs and 

implementing effective programs across a variety of work settings. New materials that focus 

on the unique concerns of non-office work environments and workplaces with few employees 

should be developed. 

Develop and share innovative solutions to the obstacles to breastfeeding that women 

face when returning to work in non-office settings. While there are numerous examples 

of creating lactation rooms in office buildings and large stores, many work environments are 

more challenging for breastfeeding women returning to work. For example, farm workers may 

find it difficult to access a private place shielded from public view. Service workers who are on 

the road may not have a regular workplace where they can express milk. Challenges also exist 

in allowing break time for breast milk expression in businesses where there are few employees 

to cover during breaks. Many employers have already worked with workplace lactation 

consultants to develop innovative solutions, such as special trailers, makeshift temporary 

spaces, or “floater” employees, to enable nursing mothers to take breaks. 

51 
Promote comprehensive, high-quality lactation support programs as part of a basic 

employee benefits package. There are cost savings from better retention of experienced 

workers, higher employee morale, greater loyalty and productivity of employees, reduction in 

absenteeism and sick leave taken by parents of young children, and lower costs for health care 

and health insurance. While the percentage of employers having lactation support programs 

has increased over the past decade, many women still find it difficult to combine breastfeeding 

with work. 

Action 15. Expand the use of programs in the workplace that 

allow lactating mothers to have direct access to their babies. 

Although working mothers can express and store their milk for other persons to feed to their 

infants, this option should be only one approach in a multipronged strategy to achieve the goal of 

increasing support in the workplace. Directly breastfeeding the infant during the workday is the 

most effective strategy of combining employment and breastfeeding because it increases both the 

duration and intensity of breastfeeding. Possible strategies for working mothers include having 

the mother keep the baby with her while she works, allowing the mother to go to the baby to 

breastfeed during the workday, telecommuting, offering flexible work schedules, maintaining parttime work schedules, and using on-site or nearby child care centers. 

52 
Implementation Strategies 

Create incentive or recognition programs for businesses that establish, subsidize, and 

support child care centers at or near the business site. If mothers are able to go to their 

babies during the work day, they would be able to breastfeed and not need to express and 

store their milk. Program incentives provided for expressing and storing milk should also be 

provided for strategies that enable direct breastfeeding. 

Identify and promote innovative programs that allow mothers to directly breastfeed their 

babies after they return to work. These innovative solutions can then be widely disseminated 

to businesses and other employers. The Business Case for Breastfeeding resource kit was adapted 

recently to apply specifically to the conditions in Fortune 500 companies. Organizations 

can use case studies of programs already functioning successfully in such large businesses or 

agencies as models for implementing programs. 

Action 16. Ensure that all child care providers accommodate 

the needs of breastfeeding mothers and infants. 

Because most employed mothers return to work in their babies’ first year of life, providers of 

child care have a critical role to play in supporting employed mothers who breastfeed. Child care 

centers are regulated by the individual states, and although there are national standards on support 

of breastfeeding mothers and caring for breastfed infants, few states have regulations mandating 

that these standards be enforced at the state level. 

Implementation Strategy 

Promote adoption of the breastfeeding standards in Caring for Our Children: National 

Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care. 

Some states have developed their own child care guidelines based on these standards,281 and 

these guidelines can serve as models for other states. States should facilitate training for these 

providers on how to support breastfeeding mothers and how to feed breast milk to infants. 

Facilitation might include developing instructional materials, providing incentives for training, 

or requiring training in breastfeeding-related topics for all providers who care for infants. 

Because the national guidelines recommend such training, models are already available. The 

federal government might encourage adoption of the national guidelines through educational 

programs for state health departments or other state agencies that license or oversee child care. 

53 
Research and Surveillance 

Action 17. Increase funding of high-quality research 

on breastfeeding. 

In particular, new research is needed on 

•	 Methods to increase rates of breastfeeding among populations with current low rates. 

At present, the evidence available for selecting the most cost-effective interventions to 

promote and support breastfeeding is quite limited. Randomized designs and evaluations 

of existing programs designed to advance breastfeeding could add to this evidence. 

•	 The economic impact of breastfeeding in the United States. Increasingly, public health 

investments must be justified by analyses that demonstrate economic value for society as a 

whole, for health care institutions, or for purchasers of care. Although some studies have 

documented the potential for significant cost savings through breastfeeding, more precise 

information is needed on who will benefit from these savings. 

54 
•	 Ways to better manage lactation and breastfeeding. Health professionals must deal 

with a variety of special situations (such as physiological problems, infectious diseases, or 

medical interventions) that may make breastfeeding challenging or that may need to be 

managed differently if a woman is breastfeeding. The evidence base for making clinical 

decisions in these situations is often lacking and thus needs to be expanded. 

Implementation Strategy 

Designate additional research funding for studies on how to increase breastfeeding 

rates, the economics of breastfeeding, and management of lactation. This objective can 

be accomplished by issuing program announcements, requests for research applications, and 

contract proposals. 

Action 18. Strengthen existing capacity and develop future 

capacity for conducting research on breastfeeding. 

Researchers who study breastfeeding need more opportunities to collaborate with other 

investigators, such as behavioral scientists, medical researchers, economists, and lawyers. In 

addition, enhanced training opportunities are needed to ensure that a skilled cadre of future 

scientists is ready to undertake research on breastfeeding. 

Implementation Strategies 

Develop a national consortium on breastfeeding research. Such a consortium would 

help overcome the limitations that researchers now face in designing studies, increase 

the generalizability of research on breastfeeding, help prioritize key research areas, enable 

expanded and advanced research to be performed, and foster the timely translation of research 

into practice. Such a consortium would bring together researchers to 

•	 Standardize definitions of specific terms and measures used to classify the variables used 

in research on breastfeeding. 

•	 Promote the use of these definitions. 

•	 Identify ethical study designs that would expand the knowledge that has been generated 

thus far from observational studies. 

•	 Develop and update national agendas for surveillance and research on topics related to 

breastfeeding and infant nutrition. 

•	 Spearhead funding strategies to help accomplish the agenda developed by the consortium. 

•	 Facilitate communication among researchers. 

•	 Promote the dissemination of research findings and monitor the translation of research 

into best practices. 

55 
Enhance the training of scientists in basic and applied research on lactation, 

breastfeeding, and women’s and children’s health. These enhancements may include the 

development of specific curricula in medical schools, in educational programs for other health 

professionals, and in health science programs to ensure that a skilled cadre of scientists is 

available and appropriately trained to undertake this research. 

Action 19. Develop a national monitoring system to 

improve the tracking of breastfeeding rates as well as the 

policies and environmental factors that affect breastfeeding. 

Although the Centers for Disease Control and Prevention (CDC) tracks breastfeeding rates 

annually through the National Immunization Survey and other systems, representative local data 

are generally unavailable and are not as timely as needed. Furthermore, few systems exist to track 

changes in breastfeeding behavior and attitudes. 

Implementation Strategies 

Enhance the CDC Breastfeeding Report Card by including a broader array of process 

indicators and showing trends over time. Currently, the Breastfeeding Report Card tracks 

breastfeeding rates, as well as indicators of state-level factors that affect breastfeeding rates, 

such as the strength of breastfeeding coalitions, state infrastructure, legislation, maternity 

practices, and professional support. However, a more comprehensive set of indicators would 

make the tool more useful over time. 

Collect data in all states on the initiation of breastfeeding and in-hospital supplementation 

with formula through the U.S. Standard Certificate of Live Birth. Since 2003, the U.S. 

Standard Certificate of Live Birth developed by CDC has included a question on whether the 

infant was ever breastfed. To date, only 28 states have adopted this question. New Jersey has 

expanded the question to ask about in-hospital feeding of infant formula, which allows for the 

calculation of exclusive breastfeeding rates, as well as rates of supplementation. 

Develop systems to collect key information on policy and environmental supports 

for breastfeeding. The CDC Survey on Maternity Practices in Infant Nutrition and 

Care (mPINC) is one model of tracking how institutions are supporting breastfeeding. 

Similar models are needed to track other supports for breastfeeding, such as workplace 

accommodations for breastfeeding, the accessibility of certified lactation consultants, the 

availability and use of peer counselors in breastfeeding, and the level of knowledge among 

clinicians about breastfeeding. Such systems can provide ongoing feedback about strengths 

and weaknesses in the overall environment so that successes can be noted and needed 

improvements can be identified. 

56 
Public Health Infrastructure
 

Action 20. Improve national leadership on the promotion 

and support of breastfeeding. 

Low rates of breastfeeding are a public health problem of national significance. Although many 

organizations and public health agencies have contributed to improvements in breastfeeding over 

time, coordinated leadership of these efforts is still lacking. Increased efforts are needed to develop 

and implement an action plan on breastfeeding. 

Implementation Strategies 

Create a federal interagency work group on breastfeeding. The federal government needs 

to play a central role in coordinating efforts to promote, protect, and support breastfeeding. 

No single federal agency can take full responsibility for breastfeeding because activities occur 

in many different agencies, including those devoted to health, agriculture, labor, defense, and 

education. All of these agencies have roles and responsibilities related to the promotion and 

support of breastfeeding. The U.S. Department of Health and Human Services could lead 

an interagency work group to bring together relevant staff to plan, carry out, and monitor 

initiatives in breastfeeding. 

Increase the capacity of the United States Breastfeeding Committee and affiliated state 

coalitions to support breastfeeding. This committee brings together professional, civic, and 

academic organizations that have a shared vision of better support for breastfeeding, but it 

requires increased funding and staff to carry out its strategic plan. The United States Breastfeeding 

Committee is affiliated with state breastfeeding coalitions in all 50 states that carry out activities at 

state and local levels. The capacity of state breastfeeding coalitions should be enhanced to enable 

them to be an effective force in promoting and supporting breastfeeding. 

57 
58 
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276. National Conference of State Legislatures. State 

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279. Health Resources and Services Administration. The 

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287. Clark A, Anderson J, Adams E, Baker S. Assessing the 

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68 
Acknowledgments
 

The Surgeon General’s Call to Action to Support Breastfeeding was prepared by the Centers for 

Disease Control and Prevention and the Office on Women’s Health under the direction of the 

Office of the Surgeon General. These three agencies are part of the U.S. Department of Health 

and Human Services, which published the Call to Action. 

Regina Benjamin, M.D., M.B.A. 

Vice Admiral, U.S. Public Health Service 

Surgeon General 

Thomas R. Frieden, M.D., M.P.H. 

Director 

Centers for Disease Control and Prevention 

Wanda K. Jones, Dr.P.H. 

Principal Deputy Assistant Secretary for Health 

Office of the Assistant Secretary for Health 

Federal Steering Committee 

Laurence Grummer-Strawn, Ph.D. 

Scientific Editor 

Captain, U.S. Public Health Service 

Nutrition Branch Chief 

Centers for Disease Control and Prevention 

Suzanne Haynes, Ph.D. 

Managing Editor 

Senior Science Advisor 

Office on Women’s Health 

Office of the Assistant Secretary for Health 

Mary Beth Bigley, Dr.P.H., M.S.N., A.N.P. 

Contributing Editor 

Acting Director, Office of Science and 

Communications 

Office of the Surgeon General 

Office of the Assistant Secretary for Health 

Deborah Dee, Ph.D., M.P.H. 

Lieutenant Commander, U.S. Public Health Service 

Epidemiologist 

Centers for Disease Control and Prevention 

Sara Fein, Ph.D. 

Consumer Science Specialist 

Center for Food Safety and Applied Nutrition 

U.S. Food and Drug Administration 

Isadora Hare, M.S.W., L.C.S.W. 

Perinatal Health Specialist 

Maternal and Child Health Bureau 

Health Resources and Services Administration 

Tihesha Jenkins-Salley, M.P.H., R.D. 

Nutritionist 

Food and Nutrition Service 

U.S. Department of Agriculture 

Judith Labiner-Wolfe, Ph.D. 

Evaluation Specialist 

Office on Women’s Health 

Office of the Assistant Secretary for Health 

Ruowei Li, M.D., Ph.D. 

Epidemiologist 

Centers for Disease Control and Prevention 

David Meyers, M.D. 

Director 

Center for Primary Care, Prevention, and 

Clinical Partnerships 

Agency for Healthcare Research and Quality 

Tonse Raju, M.D. 

Medical Officer-Program Scientist 

Eunice Kennedy Shriver National Institute of Child 

Health and Human Development 

National Institutes of Health 

Katherine Shealy, M.P.H., I.B.C.L.C. 

Public Health Advisor 

Centers for Disease Control and Prevention 

Denise Sofka, M.P.H., R.D. 

Public Health Analyst 

Maternal and Child Health Bureau 

Health Resources and Services Administration 

Judith Thierry, D.O., M.P.H. 

Captain, U.S. Public Health Service 

Maternal and Child Health Coordinator 

Indian Health Service 

69 
70 
Appendix 1. Actions to Improve Breastfeeding 

Mothers and Their Families 

Implementation Strategies	 Potential Actors 

Help pregnant women to learn about the importance of 

breastfeeding for their babies and themselves. 

Women 

Family members and friends

Clinicians 

Teach mothers to breastfeed.	 Women 

Family members and friends

Clinicians 

Encourage mothers to talk to their maternity care providers about 	

plans to breastfeed.	 

Women 

Family members and friends

Clinicians 

Support mothers to have time and flexibility to breastfeed.	 Women 

Family members and friends

Clinicians 

Encourage mothers to ask for help with breastfeeding when needed.	 Women 

Family members and friends

Action 1. Give mothers the support they need to breastfeed their babies. 

Clinicians 

Action 2. Develop programs to educate fathers and grandmothers 

about breastfeeding. 

Implementation Strategies	 Potential Actors 

Launch or establish campaigns for breastfeeding education that 

target a mother’s primary support network, including fathers and 

grandmothers. 

Public health entities 

Community organizations

Offer classes on breastfeeding that are convenient for family 

members to attend. 

Community organizations

Hospitals 

71 
Communities
 

Action 3. Strengthen programs that provide mother-to-mother support 

and peer counseling. 

Implementation Strategies	 Potential Actors 

Create and maintain a sustainable infrastructure for motherto-mother support groups and for peer counseling programs in 

hospitals and community health care settings. 

Public health entities 

Community organizations 

Establish peer counseling as a core service available to all women 

in WIC.* 

Federal, state, and local WIC 

programs 

Action 4. Use community-based organizations to promote and 

support breastfeeding. 

Implementation Strategies	 Potential Actors 

Support and fund small nonprofit organizations that promote 	

breastfeeding in communities of color.	 

Federal, state, and local 

governments


Foundations
 

Integrate education and support for breastfeeding into public health 

programs that serve new families. 

Public health entities 

Community organizations 

Ensure around-the-clock access to resources that provide assistance 

with breastfeeding. 

Public health entities 

Community organizations 

Action 5. Create a national campaign to promote breastfeeding. 

Implementation Strategies	 Potential Actors 

Develop and implement a national public health campaign on 

breastfeeding that relies heavily on social marketing. 

Federal, state, and local partners 

Use a variety of media venues to reach young women and 

their families. 

Public health entities 

Community organizations 

Action 6. Ensure that the marketing of infant formula is conducted in a way 

that minimizes its negative impacts on exclusive breastfeeding. 

Implementation Strategies	 Potential Actors 

Hold marketers of infant formula accountable for complying with 

the International Code of Marketing of Breast-milk Substitutes. 

Public health entities 

Infant formula manufacturers 

Take steps to ensure that claims about formula are truthful 

and not misleading. 

HHS/FDA† 

Federal Trade Commission 

Ensure that health care clinicians do not serve as advertisers for 

infant formula. 

Health care professionals 

* WIC = Special Supplemental Nutrition Program for Women, Infants, and Children; U.S. Department of Agriculture. 

† HHS/FDA = U.S. Department of Health and Human Services/U.S. Food and Drug Administration. 

72 
Action 7. Ensure that maternity care practices throughout the United States are fully 

supportive of breastfeeding. 

Implementation Strategies Potential Actors 

Accelerate implementation of the Baby-Friendly 

Hospital Initiative. 

Public health entities 

Establish transparent, accountable public reporting of maternity 

care practices in the United States. 

HHS/CDC*

The Joint Commission 

Establish a new advanced certification program for perinatal 

patient care. 

Public health entities 

The Joint Commission 

Establish systems to control the distribution of infant formula in 

hospitals and ambulatory care facilities. 

Hospitals

Ambulatory care facilities 

Action 8. Develop systems to guarantee continuity of skilled support for lactation 

between hospitals and health care settings in the community. 

Implementation Strategies Potential Actors 

Create comprehensive statewide networks for home- or 

clinic-based follow-up care to be provided to every newborn 

in the state. 

Public health entities 

Community organizations 

Establish partnerships for integrated and continuous follow-up 	

care after discharge from the hospital.	 

Hospitals

Health care systems

Primary care clinicians

Community organizations 

Establish and implement policies and programs to ensure that 	

participants in WIC†

 have services in place before discharge 	

from the hospital. 

Federal, state, and local WIC programs

Hospitals

Primary care clinicians

Community organizations 

Health Care
 

Action 9. Provide education and training in breastfeeding for all health professionals 

who care for women and children. 

Implementation Strategies Potential Actors 

Improve the breastfeeding content in undergraduate and 

graduate education and training for health professionals. 

Health professional organizations

Medical schools 

Establish and incorporate minimum requirements for 

competency in lactation care into health professional 

credentialing, licensing, and certification processes. 

Health professional organizations

Credentialing boards 

Increase opportunities for continuing education on the 

management of lactation to ensure the maintenance of 

minimum competencies and skills. 

Health professional organizations

Medical schools 

(continued) 

73 
Health Care (continued)
 

Action 10. Include basic support for breastfeeding as a standard of care for midwives, 

obstetricians, family physicians, nurse practitioners, and pediatricians. 

Implementation Strategies Potential Actors 

Define standards for clinical practice that will ensure continuity 

of care for pregnant women and mother-baby pairs in the first 

HHS/HRSA‡
 

Health professional organizations
 

four weeks of life.
 

Conduct analyses and disseminate their findings on the comparative effectiveness of different models for integrating skilled 


lactation support into settings where midwives, obstetricians, 


family physicians, nurse practitioners, and pediatricians practice.
 

HHS/AHRQ§
 

Action 11. Ensure access to services provided by International Board Certified 

Lactation Consultants. 

Implementation Strategies Potential Actors 

Include support for lactation as an essential medical service for 

pregnant women, breastfeeding mothers, and children. 

HHS/CMS¶ 

Third-party payers 

Provide reimbursement for International Board Certified 

Lactation Consultants (IBCLCs) independent of their having 

other professional certification or licensure. 

HHS/CMS

Third-party payers 

Work to increase the number of racial and ethnic minority 

IBCLCs to better mirror the U.S. population. 

HHS/HRSA 

Action 12. Identify and address obstacles to greater availability of safe banked donor 

milk for fragile infants. 

Implementation Strategies Potential Actors 

Conduct a systematic review of the current evidence on the 

safety and efficacy of donor human milk. 

HHS/AHRQ 

Establish evidence-based clinical guidelines for the use of banked 

donor milk. 

HHS/MCHB**


Health professional organizations
 

Convene a study on federal regulation and support of donor 

milk banks. 

Institute of Medicine 

* HHS/CDC = U.S. Department of Health and Human Services/Centers for Disease Control and Prevention. † WIC = Special Supplemental Nutrition Program for Women, Infants, and Children; U.S. Department of Agriculture. ‡ HHS/HRSA = U.S. Department of Health and Human Services/Health Resources and Services Administration. § HHS/AHRQ = U.S. Department of Health and Human Services/Agency for Healthcare Research and Quality. ¶ HHS/CMS = U.S. Department of Health and Human Services/Centers for Medicare & Medicaid Services. 

** HHS/MCHB = U.S. Department of Health and Human Services/Maternal and Child Health Bureau. 

74 
Employment
 

Action 13. Work toward establishing paid maternity leave for all employed mothers. 

Implementation Strategies Potential Actors 

Add maternity leave to the categories of paid leave for federal civil servants. Federal government

State governments 

Develop and implement programs in states to establish a funding 

mechanism for paid maternity leave. 

State governments 

Action 14. Ensure that employers establish and maintain comprehensive, high-quality 

lactation support programs for their employees. 

Implementation Strategies Potential Actors 

Develop resources to help employers comply with federal law that requires 

employers to provide the time and a place for nursing mothers to express 

breast milk. 

DOL, HHS* 

Public health entities 

Employer organizations 

Design and disseminate materials to educate employers about the benefits

of providing more comprehensive, high-quality support for breastfeeding

employees. 

Public health entities 

Develop and share innovative solutions to the obstacles to breastfeeding that 	

women face when returning to work in non-office settings.	 

DOL, HHS 

Public health entities 

Employers 

Promote comprehensive, high-quality lactation support programs as part of a 

basic employee benefits package. 

Employers 

Action 15. Expand the use of programs in the workplace that allow lactating mothers 

to have direct access to their babies. 

Implementation Strategies Potential Actors 

Create incentive or recognition programs for businesses that establish, 	

subsidize, and support child care centers at or near the business site.	 

Federal government

State governments

Community organizations 

Identify and promote innovative programs that allow mothers to directly 	

breastfeed their babies after they return to work. 	

Public health entities 

Employers

Chambers of Commerce 

Action 16. Ensure that all child care providers accommodate the needs of 

breastfeeding mothers and infants. 

Implementation Strategy Potential Actors 

Promote adoption of the breastfeeding standards in Caring for Our 

Children: National Health and Safety Performance Standards: Guidelines 

for Out-of-Home Child Care. 

HHS/HRSA† 

State governments 

* DOL, HHS = U.S. Department of Labor; U.S. Department of Health and Human Services. 

† HHS/HRSA = U.S. Department of Health and Human Services/Health Resources and Services Administration. 

75 
Research and Surveillance
 

Action 17. Increase funding of high-quality research on breastfeeding. 

Implementation Strategy	 Potential Actors 

Designate additional research funding for studies on how to 

increase breastfeeding rates, the economics of breastfeeding, 

HHS/NIH*


Foundations
 

and management of lactation.
 

Action 18. Strengthen existing capacity and develop future capacity for conducting 

research on breastfeeding. 

Implementation Strategies	 Potential Actors 

Develop a national consortium on breastfeeding research.	 HHS/NIH


Researchers
 

Enhance the training of scientists in basic and applied research 

on lactation, breastfeeding, and women’s and children’s health. 

HHS/NIH

Universities and medical schools 

Action 19. Develop a national monitoring system to improve the tracking of 

breastfeeding rates as well as the policies and environmental factors that affect 

breastfeeding. 

Implementation Strategies	 Potential Actors 

Enhance the CDC Breastfeeding Report Card by including 

a broader array of process indicators and showing trends 


over time. 


HHS/CDC†
 

Collect data in all states on the initiation of breastfeeding and 

in-hospital supplementation with formula through the U.S. 


Standard Certificate of Live Birth.
 

State governments
 

Develop systems to collect key information on policy and 

environmental supports for breastfeeding. 

HHS/CDC 

* HHS/NIH = U.S. Department of Health and Human Services/National Institutes of Health. 

† HHS/CDC = U.S. Department of Health and Human Services/Centers for Disease Control and Prevention. 

76 
Public Health Infrastructure
 

Action 20. Improve national leadership on the promotion and support 

of breastfeeding. 

Implementation Strategies Potential Actors 

Create a federal interagency work group on breastfeeding. Federal government 

Increase the capacity of the United States Breastfeeding 

Committee and affiliated state coalitions to support breastfeeding. 

Public health entities 

77 
78 
Appendix 2. Excess Health Risks Associated 

with Not Breastfeeding 

Outcome Excess Risk* (%)(95% CI†) Comparison Groups 

Among full-term infants 

Acute ear infections (otitis media)2 100 (56, 233) EFF‡ vs. EBF§ for 3 or 6 mos 

Eczema (atopic dermatitis)11 47 (14, 92) EBF <3 mos vs. EBF ≥3 mos 

Diarrhea and vomiting 

(gastrointestinal infection)3 

178 (144, 213) Never BF¶ vs. ever BF 

Hospitalization for lower respiratory 

tract diseases in the first year4 

257 (85, 614) Never BF vs. EBF ≥4 mos 

Asthma, with family history2 67 (22, 133) BF <3 mos vs. ≥3 mos 

Asthma, no family history2 35 (9, 67) BF <3 mos vs. ≥3 mos 

Childhood obesity7 32 (16, 49) Never BF vs. ever BF 

Type 2 diabetes mellitus6 64 (18, 127) Never BF vs. ever BF 

Acute lymphocytic leukemia2 23 (10, 41) Never BF vs. >6 mos 

Acute myelogenous leukemia5 18 (2, 37) Never BF vs. >6 mos 

Sudden infant death syndrome2 56 (23, 96) Never BF vs. ever BF 

Among preterm infants 

Necrotizing enterocolitis2	 138 (22, 2400) Never BF vs. ever BF 

Among mothers 

Breast cancer8 4 (3, 6)	 Never BF vs. ever BF 

(per year of breastfeeding) 

Ovarian cancer2 27 (10, 47)	 Never BF vs. ever BF 

* The excess risk is approximated by using the odds ratios reported in the referenced studies. 

† CI = confidence interval. 

‡ EFF = exclusive formula feeding. 

§ EBF = exclusive breastfeeding. 

¶ BF = breastfeeding. 

79 
80 
Appendix 3. Development of the Call to Action
 

The Surgeon General’s Call to Action to Support Breastfeeding was prepared by the Centers for 

Disease Control and Prevention and the Office on Women’s Health under the direction of the 

Office of the Surgeon General. These three agencies are part of the U.S. Department of Health 

and Human Services, which published the Call to Action. Representatives from these agencies 

collaborated with a federal steering committee that included representatives from several other 

federal agencies. The members of the steering committee are listed in the Acknowledgments 

(page 69). The steering committee sought input from several sources to identify priority actions 

and directions for concerted national efforts to promote breastfeeding. 

First, comments were solicited from the general public through an open Web site that allowed 

users to submit comments and review all previously submitted comments. The comment period 

was April 1–May 31, 2009. A total of 2,354 distinct comments was received, and then all 

comments were categorized by primary subject area. All comments were read, and a summary 

report that drew out major themes and specific quotes for review by the steering committee 

was produced. 

Summary of Subject Areas Included in Public Comments 

on National Breastfeeding Efforts 

Topic 

Total No. of 

Comments 

Maternal and Infant Care Practices: Prenatal, Hospital, and Post-Delivery Care 516 

Paid Maternity Leave 302 

Access to Lactation Care and Support 288 

Worksite Lactation Support, On-Site Child Care, and Expression of Milk 248 

Support for Breastfeeding in Public Settings 217 

Portrayal of Breastfeeding in Traditional Popular Media and New Electronic Media 176 

Health Professional Education, Publications, and Conferences 146 

Use of Banked Human Milk 114 

Community Support for Breastfeeding in Complementary Programs (e.g., Early Head 

Start, Home Visitation, Parental Training) 101

Peer Support and Education of Family Members and Friends 91 

Research and Surveillance 57 

Other Areas 98 

Total 2,354 

81 
Second, an expert panel met in Washington, DC, on April 28–29, 2009, to conduct more 

in-depth discussions about the content of a Call to Action (see list of participants, p. 81). The 

meeting began with the expert panel listening to a group of mothers describe the challenges they 

had faced when breastfeeding. The expert panel then offered their individual recommendations 

for policy and environmental changes needed to better support breastfeeding. Additionally, small 

groups were formed to put forward summary recommendations in key areas. 

Third, in July and August of 2009, hearings for stakeholders were conducted in Arlington, 

Virginia, and Atlanta, Georgia, to hear from critical organizations whose work directly affects 

breastfeeding. Each organization was given eight minutes to present its perspective on the greatest 

needs in breastfeeding, followed by a short question-and-answer period. All presenters also 

delivered a written copy of their testimony for consideration by the steering committee. 

Finally, the steering committee reviewed recommendations and priorities delineated at various 

meetings, including the strategic planning session of the United States Breastfeeding Committee 

(Washington, DC, January 2009), the Breastfeeding and Feminism Symposium (Greensboro, 

North Carolina, March 2009), the Academy of Breastfeeding Medicine Summit on Breastfeeding 

(Washington, DC, June 2009), and the USDA/CDC panel on Using Policy and Environmental 

Approaches to Reduce Black-White Breastfeeding Disparities (Atlanta, Georgia, December 2009). 

The steering committee met frequently throughout 2009 to consider the most important actions 

needed to support breastfeeding and to write the present document. 

82 
Participants on the Expert Panel 

April 28–29, 2009: Washington, DC 

Panel of mothers 

Aaliyah Alim 

Bonita Butler 

Kahlil Kuykendall 

Rashida Jefferson 

Chelai Johnson 

Coyan Lewis 

Jessica Silva 

Damali Smith 

Professional participants 

Margaret E. Bentley, Ph.D., M.A. 

Professor of Nutrition, Associate Dean for Global Health, Gillings School of Global Public Health 

University of North Carolina at Chapel Hill 

Karen Bonuck, Ph.D. 

Associate Professor, Deparment of Family and Social Medicine, Department of Obstetrics & Gynecology 

and Women’s Health 

Albert Einstein College of Medicine 

Karin Cadwell, Ph.D., F.A.A.N., R.N., I.B.C.L.C. 

Faculty Member, Union Institute and University; Convener, Baby-Friendly-USA 

Healthy Children Project 

Gerald Calnen, M.D. 

Vice-President and President-Elect 

Academy of Breastfeeding Medicine 

Cathy Carothers, I.B.C.L.C., R.L.C. 

Codirector
 

Every Mother, Inc.
 

Mei Chung, M.P.H., Ph.D.(c) 

Research Associate 

Tufts Medical Center Evidence-Based Practice Center 

Cate Colburn-Smith 

Workplace Lactation Expert 

Moms on Board 

Kendall Cox, I.B.C.L.C., R.L.C. 

Codirector
 

Every Mother, Inc.
 

Roger A. Edwards, Sc.D. 

Assistant Professor, Bouvé College of Health Sciences 

Northeastern University 

Lori Feldman-Winter, M.D., M.P.H. 

Associate Professor, Pediatrics 

Cooper University Hospital 

83 
Lawrence M. Gartner, M.D. 

Professor Emeritus, Pediatrics and Obstetrics/Gynecology 

University of Chicago 

Sarah Grosshuesch, M.P.H. 

Public Health Educator 

Municipality of Anchorage, AK 

Jane Heinig, Ph.D. (in absentia) 

Executive Director, Human Lactation Center 

University of California at Davis 

Cynthia R. Howard, M.D., M.P.H. 

Associate Professor of Pediatrics, University of Rochester 

Rochester General Hospital 

Carol Kolar, R.N., C.M.P. 

Director of Education 

La Leche League International 

Michael S. Kramer, M.D. 

James McGill Professor of Pediatrics and of Epidemiology and Biostatistics 

McGill University 

Miriam H. Labbok, M.D., M.P.H., M.M.S., F.A.C.P.M., F.A.B.M., I.B.C.L.C. 

Professor, Gillings School of Global Public Health; Director, Carolina Global Breastfeeding Institute 

University of North Carolina at Chapel Hill 

Ruth A. Lawrence, M.D., F.A.A.P., F.A.A.C.T. 

Professor of Pediatrics, School of Medicine and Dentistry 

University of Rochester 

Katy Lebbing, I.B.C.L.C., R.L.C. 

Lactation Consultant 

Silver Cross Hospital 

Rebecca Mannel, I.B.C.L.C., F.I.L.C.A. 

Clinical Operations Manager, Women’s & Newborn Service, Oklahoma University Medical Center; 

Clinical Instructor 

University of Oklahoma Health Sciences Center 

Joan Meek, M.D., M.S. 

Clinical Associate Professor, Clerkship Director, Department of Clinical Sciences 

Florida State University 

Paula Meier, D.N.Sc., R.N., F.A.A.N. 

Director of Clinical Research and Lactation, Special Care Nursery; Professor, Women, Children, 

and Family Nursing, College of Nursing 

Rush Medical College 

Karen Minatelli 

Director, Work and Family Programs 

National Partnership for Women and Families 

84 
Georgia Morrow, R.N., I.B.C.L.C. 

Coordinator 

Mothers’ Milk Bank of Ohio 

Judy Norsigian 

Co-Founder, Boston Women’s Health Book Collective; Co-Author, Our Bodies, Ourselves 

Boston Women’s Health Collective 

Amanda Perez, M.S.W. 

Senior Training Specialist 

Early Head Start National Resource Center @ ZERO TO THREE 

Amelia Psmythe 

Director 

Breastfeeding Coalition of Oregon 

Kiddada Ramey, M.A.T. 

Founder and President 

Black Mothers’ Breastfeeding Association 

Phyllis Sharps, Ph.D., R.N., F.A.A.N. 

Associate Professor, School of Nursing 

Johns Hopkins University 

Wendy Slavit, M.P.H., C.H.E.S. 

Manager, Center for Prevention and Health Services 

National Business Group on Health 

Julie Smith, Ph.D. 

Research Fellow, Australian Centre for Economic Research on Health 

Australian National University 

Alison Stuebe, M.D., M.Sc. 

Assistant Professor, Obstetrics and Gynecology 

University of North Carolina at Chapel Hill 

Lisa Summers, M.S.N., Dr.P.H., C.N.N. 

Director of Professional Services 

American College of Nurse-Midwives 

Letty D. Thall, M.S.S. 

Director of Public Policy 

Maternity Care Coalition 

Anne Butzen Thornill, M.P.H. 

Senior Health Promotion Manager 

North Carolina Prevention Partners 

Mary Rose Tully, M.P.H., I.B.C.L.C. 

Director of Lactation Services, Women’s and Children’s Hospitals, University of North Carolina Health Care, 

 Gillings School of Global Public Health 

University of North Carolina at Chapel Hill 

Jill Youse 

Executive Director 

International Breast Milk Project 

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Participants at Stakeholder Hearings 

July 30, 2009: Arlington, Virginia 

•	 American Academy of Family Physicians 

•	 American Academy of Pediatrics 

•	 American Breastfeeding Institute 

•	 American College of Nurse-Midwives 

•	 American Nurses Association 

•	 American Public Health Association 

•	 Association of State and Territorial Public Health Nutrition Directors 

•	 Association of Women’s Health, Obstetric and Neonatal Nurses 

•	 Baby-Friendly USA 

•	 Breastfeeding Coalition of the Uniformed Services 

•	 Breastfeeding Task Force of Greater Los Angeles, California Breastfeeding Coalition 

•	 Carolina Global Breastfeeding Institute 

•	 Healthy Children Project 

•	 Human Milk Banking Association of North America 

•	 International Board of Lactation Consultant Examiners 

•	 La Leche League International 

•	 Lamaze International 

•	 National Alliance for Breastfeeding Advocacy 

•	 National Association of Pediatric Nurse Practitioners 

•	 National Business Group on Health 

•	 National WIC Association, Breastfeeding Committee 

•	 Pennsylvania Breastfeeding Coalition 

•	 United States Breastfeeding Committee 

•	 United States Lactation Consultant Association 

•	 Wellstart International 

August 13, 2009: Atlanta, Georgia 

•	 Abbott Nutrition 

•	 Ameda Breastfeeding Products 

•	 Evenflo Company, Inc. 

•	 Greenberg Quinlan Rosner Research 

•	 International Formula Council 

•	 Lansinoh Laboratories, Inc. 

•	 Mead Johnson Nutrition 

•	 Medela, Inc. 

•	 Nestlé Infant Nutrition 

•	 Prolacta Bioscience, Inc. 

•	 Wyeth Nutrition 

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Appendix 4. Abbreviations and Acronyms
 

AAP American Academy of Pediatrics 

AHRQ Agency for Healthcare Research and Quality 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare & Medicaid Services 

DOL U.S. Department of Labor 

EU European Union 

FDA U.S. Food and Drug Administration 

GAO Government Accountability Office 

HHS U.S. Department of Health and Human Services 

HMBANA Human Milk Banking Association of North America 

HRSA Health Resources and Services Administration 

IBCLC International Board Certified Lactation Consultant 

IBLCE International Board of Lactation Consultant Examiners 

ILO International Labor Organization 

MCHB Maternal and Child Health Bureau 

mPINC Maternity Practices in Infant Nutrition and Care 

NEC necrotizing enterocolitis 

NIH National Institutes of Health 

NIS National Immunization Survey 

OWH Office on Women’s Health 

UNICEF United Nations Children’s Fund 

USBC United States Breastfeeding Committee 

USDA U.S. Department of Agriculture 

USPSTF U.S. Preventive Services Task Force 

WHO World Health Organization 

WIC Special Supplemental Nutrition Program for Women, Infants, and Children 

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U.S. Department of Health and Human Services 

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