National Center for Chronic Disease Prevention and Health Promotion 

Division of Nutrition, Physical Activity, and Obesity

Strategies to Prevent Obesity and Other Chronic Diseases

The CDC Guide to Strategies 

to Support Breastfeeding 

Mothers and Babies
For Free Copies 

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http://www.cdc.gov/breastfeeding

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cdcinfo@cdc.gov

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The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies

Centers for Disease Control and Prevention

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Suggested Citation

Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: 

The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta: U.S. Department of 

Health and Human Services; 2013.

Web site addresses of nonfederal organizations are provided solely as a service to readers. Provision 

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government, and none should be inferred. CDC is not responsible for the content of other 

organizations’ Web pages.
Strategies to Prevent Obesity and Other Chronic Diseases

The CDC Guide to Strategies 

to Support Breastfeeding 

Mothers and Babies

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Division of Nutrition, Physical Activity, and Obesity
ii
iii

Using This Guide............................................................................................................................ 1

Introduction ................................................................................................................................... 3

Strategy 1. Maternity care practices ................................................................................................. 5

Strategy 2. Professional education.................................................................................................. 11

Strategy 3. Access to professional support...................................................................................... 15

Strategy 4. Peer support programs ................................................................................................. 19

Strategy 5. Support for breastfeeding in the workplace.................................................................. 23

Strategy 6. Support for breastfeeding in early care and education................................................... 29

Strategy 7. Access to breastfeeding education and information ...................................................... 33

Strategy 8. Social marketing .......................................................................................................... 37

Strategy 9. Addressing the marketing of infant formula ................................................................. 43

References ..................................................................................................................................... 47

Contents
iv
1

This document provides guidance for public health professionals and others on how to select 

strategies to support breastfeeding mothers and increase breastfeeding rates. It offers the most relevant 

information on each type of strategy. The discussion of each strategy follows the outline defined here.

Strategy

Describes an environmental change or activity intended to prevent disease or promote health in a 

group of people, also referred to as an intervention or approach. Criteria for inclusion of a strategy in 

this document are a rationale supporting the strategy and examples of implemented programs.

Definition

Briefly describes the strategy.

Rationale

Explains why the particular strategy is important to efforts to support breastfeeding mothers and 

increase breastfeeding rates.

Evidence of Effectiveness

Draws on peer-reviewed literature and current practice to summarize the evidence of the strategy’s 

effectiveness. 

Key Considerations

Includes information that may be important to keep in mind during the planning, implementation, or 

evaluation phases of a strategy. 

Action Steps

Identifies specific activities for each strategy that public health professionals can take to implement 

strategies in specific settings, including communities, schools, child care facilities, work sites, and 

medical care facilities.

Program Examples

Includes examples of programs that use the strategy as a way to support and increase breastfeeding. 

Program examples were selected from interventions described in other publications, such as peerreviewed journals or program reports, or identified by key informants and through Internet searches. 

Readers should review these examples for local applicability and evidence of effectiveness.

Resources

Guides the reader to additional materials and information that might be useful in planning, 

implementing, or evaluating the strategy. Many of the examples and success stories in this document 

reflect programs conducted by organizations outside of the Centers for Disease Control and Prevention 

(CDC) and the federal government without CDC or federal funding. These examples are provided 

for illustrative purposes and do not constitute a CDC or federal government activity or endorsement. 

Readers should review these examples for local applicability and evidence of effectiveness.

Using This Guide
2
3

professionals, and other organizations and 

individuals can take to support mothers and 

make breastfeeding easier.

This publication, Strategies to Prevent Obesity 

and Other Chronic Diseases: The CDC Guide to 

Strategies to Support Breastfeeding Mothers and 

Babies, provides information on interventions 

and programs that address many of the steps 

called for by the U.S. Surgeon General. These 

interventions and programs also are designed to 

meet many of the health objectives set forth in 

Healthy People 2020. This 10-year national health 

agenda provides a framework for health promotion 

and disease prevention for the United States. It 

includes new objectives to increase breastfeeding 

rates and improve outcome measures specific to 

work sites and maternity care.

These objectives are in addition to CDC’s ongoing 

goal of decreasing disparities in breastfeeding rates 

and increasing collaboration between partners at 

federal, state, and community levels to overcome 

breastfeeding challenges.

Research has shown that breastfeeding is 

recognized as the best source of nutrition for 

most infants. In 2007, the Agency for Healthcare 

Research and Quality (AHRQ) published 

a summary of systematic reviews and metaanalyses on breastfeeding and maternal and 

infant health outcomes in developed countries.1

The AHRQ report reaffirmed the health benefits 

of breastfeeding and the health risks associated 

with formula feeding and early weaning from 

breastfeeding. Infants who are not breastfed 

experience more episodes of diarrhea, ear 

infections, and lower respiratory tract infections 

and are at higher risk of sudden infant death 

syndrome, diabetes, and obesity. Breastfeeding 

also helps protect mothers from breast and 

ovarian cancer.1

To help support breastfeeding mothers and 

increase breastfeeding rates in the United States, 

the U.S. Surgeon General released The Surgeon 

General’s Call to Action to Support Breastfeeding

in 2011. The Call to Action sets out clear action 

steps that communities, health care systems, 

health care providers, employers, public health 

Introduction 

Healthy People 2020 Objectives

Maternal, Infant, and Child Health (MICH) Objectives Baseline Target

MICH 21: Increase the proportion of infants who are breastfed

Ever 74.0% 81.9%

At 6 months 43.5% 60.6%

At 1 year 22.7% 34.1%

Exclusively through 3 months 33.6% 46.2%

Exclusively through 6 months 14.1% 25.5%

MICH 22: Increase the proportion of employers that have work-site lactation 

support programs 

25.0% 38.0%

MICH 23: Reduce the proportion of breastfed newborns who receive formula 

supplementation within the first 2 days of life 

24.2% 14.2%

MICH 24: Increase the proportion of live births that occur in facilities that 

provide recommended care for lactating mothers and their babies 

2.9% 8.1%
4

Many types of interventions have been 

implemented in the United States and in other 

parts of the world to try to increase breastfeeding 

initiation and duration, as well as exclusive 

breastfeeding. The strategies described in this 

guide focus on policy and environmental 

changes that are designed to increase support for 

women who choose to breastfeed and to increase 

the number of women who choose to breastfeed. 

Strategies were selected on the best available 

evidence, as well as the knowledge and expertise 

of the authors and CDC partners, including 

breastfeeding experts and members of state 

breastfeeding coalitions. 

Because formal evaluation of breastfeeding 

interventions is not widespread, this guide 

includes some practices and interventions that 

have not been formally evaluated but which have 

an established history of use or a strong rationale 

for use. These strategies are included because 

this guide is intended to provide information 

on all major types of interventions known to 

have been implemented to promote and support 

breastfeeding.

Some interventions have been shown to be 

effective when they were evaluated as components 

of multifaceted interventions. CDC does not 

discourage the use of individual interventions 

with limited evidence of effectiveness, but 

recommends that if they are used, they should 

be formally evaluated before they are widely 

disseminated.

The planning process for any new breastfeeding 

intervention should include a process for 

formal evaluation. Evaluation results should 

be disseminated broadly, especially in peerreviewed journals, to increase the evidence base 

for breastfeeding interventions and help other 

decision makers choose effective strategies to 

support and increase breastfeeding. 

This guide is best used as an introduction 

to the many interventions that have been 

developed to protect, promote, and support 

breastfeeding. Readers can review the program 

examples, resources, and references or contact 

the organizations involved for more information 

about specific interventions.
5

Rationale 

The maternity care experience can influence both 

breastfeeding initiation and later infant feeding 

behavior. In the United States, nearly all infants 

are born in a hospital, and even though their stay 

is typically short,12 events during this time have a 

lasting effect. Breastfeeding is an extremely timesensitive activity. Experiences with breastfeeding 

in the first hours and days of life are significantly 

associated with an infant’s later feeding.3

Because of its relationship with the birth 

experience, breastfeeding should be supported 

throughout the entire maternity hospital stay, 

not postponed until the infant goes home.

Many of the experiences of mothers and 

newborns in the hospital and the practices in 

place there affect breastfeeding success. In most 

cases, these experiences reflect routine practices 

at the facility level. Routine medications and 

procedures received by mothers during labor can 

affect the infant’s behavior at the time of birth, 

which in turn affects the infant’s ability to suckle 

at the breast.7–10

Strategy 1. Maternity Care Practices

Definition 

Maternity care practices related to breastfeeding take place during the intrapartum hospital* stay 

and include practices related to immediate prenatal care, care during labor and birthing, and 

postpartum care. 

Maternity care practices that support breastfeeding include developing a written breastfeeding 

policy for the facility, providing all staff with education and training on breastfeeding, 

maintaining skin-to-skin contact between mother and baby after birth, encouraging early 

breastfeeding initiation, supporting cue-based feeding, supplementing with formula or water 

only when medically necessary, and ensuring postdischarge follow-up.2–6 Maternity care practices 

that can have a negative effect on breastfeeding include using medications during labor and 

giving formula, water, or sugar water to breastfeeding infants when not medically necessary.2,3,7–11

* We use the term hospital to include hospitals, birthing clinics, and freestanding birth centers.

Infants whose first breastfeed is delayed because 

of being weighed, measured, and cleaned do not 

breastfeed as long as infants who are immediately 

put skin-to-skin with the mother or put to the 

breast within the first hour after birth.5,13

Time Periods for Pregnancy 

and Childbirth

The prenatal period is the time during 

pregnancy but before childbirth.

The peripartum or perinatal period is the 

time surrounding childbirth. It is generally 

considered to include pregnancy and several 

weeks after childbirth.

The intrapartum period is the time just 

before, during, and after childbirth. It is 

generally considered to be the time from 

the onset of true labor until the birth of the 

infant and delivery of the placenta.

The postpartum period is the time shortly 

after childbirth. It is generally considered to 

include the first 6 weeks after childbirth.
6

In addition, mothers who “room in” with their 

infants, rather than having the infant taken to a 

nursery at night, will have more chances to learn 

feeding cues and practice breastfeeding because 

of the infant’s proximity.

Evidence of Effectiveness 

A Cochrane review of studies designed to evaluate 

the effectiveness of interventions to promote the 

initiation of breastfeeding found that institutional 

changes in maternity care practices effectively 

increased breastfeeding initiation and duration 

rates.14 In 1991, the World Health Organization 

(WHO) and the United Nations Children’s Fund 

(UNICEF) established the Baby-Friendly Hospital 

Initiative (BFHI), which supports and recognizes 

hospitals and birthing centers that offer an optimal 

level of care for infant feeding by following the 

BFHI’s Ten Steps to Successful Breastfeeding. These 

steps are practices that hospitals can implement 

that have been shown to improve breastfeeding 

outcomes.4,15,16 The American Academy of 

Pediatrics (AAP) endorsed the BFHI in 2009.17

Multiple studies have demonstrated improved 

breastfeeding outcomes when hospitals adopt 

these steps. Educating hospital staff through an 

18-hour UNICEF training program has been 

shown to enhance compliance with optimal 

maternity care practices and increase breastfeeding 

rates.18 Immediate skin-to-skin contact between 

mother and infant has been associated with 

longer duration of breastfeeding.5,13 In contrast, 

supplemental feeding of breastfed newborns 

negatively affects overall infant health and 

breastfeeding outcomes.1–3,11

Birth facilities that have achieved the BabyFriendly designation typically experience an 

increase in breastfeeding rates.16 A relationship 

has been found between the number of BFHI 

steps in place at a hospital and a mother’s 

breastfeeding success.3,6 One study found that 

mothers who stayed in hospitals that did not 

follow any of the steps were eight times as likely 

to stop breastfeeding before their infants were 

6 weeks old as mothers who stayed at hospitals 

that followed six of the steps.3

 In a randomized 

trial of maternity hospitals and clinics in Belarus, 

regardless of the type of facility, those that received 

the Baby-Friendly designation reported improved 

breastfeeding rates and health outcomes for 

infants and mothers, as well as greater patient 

and staff satisfaction.4

Baby-Friendly Hospital Initiative: Ten 

Steps to Successful Breastfeeding15

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 1 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 breast milk, 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 

upon discharge from the hospital or clinic.
7

Other birthing practices not included in 

the Ten Steps to Successful Breastfeeding 

may also have an effect on breastfeeding. 

For example, lower breastfeeding rates 

have been found among infants whose 

mothers were given labor analgesics8,9

or epidural anesthesia7,10 or who had a 

surgical (cesarean) birth.19–21 Women 

who experience these procedures may 

need extra breastfeeding support.22 

In addition to implementing the Ten 

Steps to Successful Breastfeeding to 

become designated as Baby-Friendly, 

hospitals must also abide by WHO’s 

International Code of Marketing of Breastmilk Substitutes, which prohibits distribution of 

gift bags with formula or other materials that 

promote formula. 

A 2000 Cochrane review found that distributing 

samples of infant formula to new mothers 

negatively affected exclusive breastfeeding.23 

A study in Oregon found that women who 

breastfed exclusively and who did not receive 

commercial discharge bags were more likely to 

exclusively breastfeed for up to 10 weeks than 

women who received the bags.24

Key Considerations 

The Ten Steps to Successful Breastfeeding have 

been implemented in maternity care facilities 

worldwide as part of the BFHI. As of May 

2013, a total of 166 hospitals and maternity care 

facilities in the United States carry the BFHI 

designation. However, this number covers only 

about 7% of all U.S. births. Hospital officials 

should consider the following issues when they 

apply to be designated as Baby-Friendly:

• Designation as a BFHI facility requires that 

the facility demonstrate adherence to all 

Ten Steps to Successful Breastfeeding and 

WHO’s International Code of Marketing of 

Breast-milk Substitutes to outside evaluators. 

• Each step has detailed requirements. 

• Evaluation requires an on-site visit that 

includes interviews with multiple staff 

members and patients, as well as reviews 

of patient charts. 

• Many different types of facilities have 

achieved BFHI status in the United States, 

from small facilities that serve primarily 

low-risk, privately insured patients to 

large facilities that serve mainly high-risk, 

publicly insured or uninsured patients. All 

types of hospitals, including comprehensive 

hospitals, military facilities, and freestanding 

birth centers, have achieved BFHI status. 

Some maternity care practices may be easier to 

improve than others. Hospitals may choose to 

make incremental changes while working to 

improve overall maternity care. For example,

• Incremental changes in maternity care may 

be easier to achieve, particularly if hospital 

leaders are unaware of the role that routine 

maternity care practices can play in 

supporting breastfeeding.

• Changes can include adding new practices 

that support breastfeeding, eliminating 

practices known to negatively affect 
8

National Survey of Maternity Practices in 

Infant Nutrition and Care (mPINC)

In 2007, CDC completed a national survey 

of maternity care feeding practices and 

policies at all facilities in the United States 

and U.S. territories that provide intrapartum 

care. Subsequent mPINC surveys have been 

conducted every 2 years since then. For each 

survey, facilities receive individualized reports, 

and states receive aggregated reports. Facility and 

state leaders use these reports to assess current 

maternity care efforts and look for ways to make 

improvements. 

The Carolina Breastfeeding Institute used 

mPINC data as part of a comprehensive, 

baseline assessment tool for hospitals involved in 

a breastfeeding-friendly health care project. The 

program is designed to support efforts by North 

Carolina hospitals to implement the Ten Steps 

to Successful Breastfeeding and make sure these 

efforts are effective and sustainable. 

breastfeeding, or using some combination 

of these strategies.

• Incremental steps are not limited to those 

identified in the Ten Steps to Successful 

Breastfeeding, but they should be 

evidence-based.25

Program Examples

Baby-Friendly USA 

Baby-Friendly USA is the organization responsible 

for designating maternity care facilities as BabyFriendly in the United States. It works with 

external evaluators to coordinate all BFHI 

activities. The BFHI is a global program sponsored by WHO and UNICEF to encourage and 

recognize hospitals and birthing centers that 

offer an optimal level of care for infant feeding. 

The BFHI helps hospitals give mothers the 

information, confidence, and skills they need to 

successfully initiate and continue breastfeeding 

their babies or to feed formula safely, and it gives 

special recognition to hospitals that have done so.

Action Steps 

1. Review state regulations for maternity 

care facilities to determine if they 

reflect evidence-based practices or other 

practices in this report.

2. Sponsor a statewide summit of key 

decision makers at maternity care 

facilities to improve maternity care 

practices across your state.

3. Provide opportunities for hospital staff 

members to participate in training 

courses in breastfeeding.

4. Focus on hospitals that serve large 

numbers of low-income families and 

those that serve a large portion of your 

state’s population.

5. Create links between maternity care 

facilities and community breastfeeding 

support networks across your state.

6. Integrate maternity care into related 

quality improvement efforts.

7. Encourage hospitals to use The Joint 

Commission’s* Perinatal Care core 

measure set to collect data on exclusive 

breastfeeding.

* The Joint Commission is an independent organization that accredits and certifies health care organizations and programs 

in the United States.
9

St. Dominic’s Hospital in Jackson, Mississippi, 

used its 2007 mPINC data to look for ways to 

improve its maternity care practices. As a result, 

the hospital has changed several of its policies 

and practices, including buying donated human 

milk and not giving formula to mothers at 

discharge. The hospital is also changing bedside 

transition practices to keep infants with their 

mothers instead of taking them to the nursery 

for baths, shots, and newborn exams. 

Colorado Can Do 5! Initiative

This initiative provides informational sessions 

to state hospitals and medical centers on five 

Baby-Friendly steps that are associated with 

breastfeeding duration.25 It is a collaborative 

effort of the Colorado Physical Activity and 

Nutrition Program, the Special Supplemental 

Nutrition Program for Women, Infants, and 

Children (WIC), the Colorado Women’s Health 

Unit, and the Colorado Breastfeeding Coalition. 

As a result of the initiative, 51 of the state’s 55 

hospitals have received training. The Colorado 

Department of Public Health and Environment 

also manages a Listserv with resources and 

updates for a network of hospital staff members 

who provide lactation services.

New York State Department of Health

Officials in New York learned from the results 

of CDC’s National Immunization Survey that 

the state had the highest proportion of breastfed 

infants who were receiving supplemental feeding 

with formula by age 2 days. To address this 

issue, infant feeding data from the New York 

Statewide Perinatal Data System were used 

to rank state hospitals on three breastfeeding 

indicators: initiation, exclusivity, and formula 

supplementation of breastfed infants during 

the birth hospitalization. Each hospital received 

information about its ranking compared with 

other hospitals. 

The data were also added to the Maternity 

Information leaflet given to each patient at time 

of admission and posted on the New York State 

Department of Health (NYSDOH) Web site.

In addition, the NYSDOH provided every 

maternity hospital in the state access to the 

Ten Steps to Successful Breastfeeding: 18-Hour 

Interdisciplinary Breastfeeding Management Course 

in the United States. They also partnered with 

the National Initiative for Children’s Healthcare 

Quality to include 12 state hospitals in a quality 

improvement learning collaborative.

Washington State Department of Health

The Washington State Department of Health’s 

Nutrition and Physical Activity Program funded 

the Breastfeeding Coalition of Washington 

to pilot a project to encourage hospitals to 
10

implement evidence-based maternity care 

practices to improve breastfeeding rates. Yakima 

Valley Memorial Hospital, which is located in 

a rural county and serves a population with 

high rates of health disparities, was chosen for 

this project. The coalition provided a 1.5-hour 

training for doctors, hospital administrators, 

maternity staff, and other staff members.

After the training, the hospital set up the 

multidisciplinary Promoting Breastfeeding 

Success Performance Improvement Committee. 

This committee updated the hospital’s 

breastfeeding policies and procedures, stopped 

the distribution of commercial discharge bags 

with formula, and identified three of the Ten 

Steps to Successful Breastfeeding to focus on. 

Resources

Model Breastfeeding Policy 

Academy of Breastfeeding Medicine 

Provides an example of a breastfeeding policy 

for hospitals.

http://www.bfmed.org/Media/Files/Protocols/

English%20Protocol%207%20Model%20

Hospital%20Policy.pdf

Baby-Friendly USA

Information about the Baby-Friendly designation 

process and requirements and a list of all BabyFriendly facilities in the United States.

http://www.babyfriendlyusa.org

Breastfeeding-Friendly Healthcare Project

Carolina Global Breastfeeding Institute

Example of efforts to improve maternity 

care practices.

http://cgbi.sph.unc.edu/healthcare

National Survey of Maternity Practices in 

Infant Nutrition and Care (mPINC)

Centers for Disease Control and Prevention

Contains information about and reports from 

this national survey of maternity care practices 

and policies.

http://www.cdc.gov/breastfeeding/data/mpinc/

index.htm

Colorado Can Do 5! Initiative

Promotes five steps that have been shown to 

affect breastfeeding duration.

http://www.colorado.gov/cs/Satellite/CDPHEPSD/CBON/1251639562433

Breastfeeding Promotion Program 

New York State Department of Health

Provides breastfeeding resources and information.

http://www.health.ny.gov/community/

pregnancy/breastfeeding

Washington State’s Hospital Initiative 

Project: Breastfeeding Partnership in Yakima 

Washington Department of Health, Nutrition and 

Physical Activity Program

Learn more about efforts in Washington to 

improve hospital practices.

http://depts.washington.edu/waaction/action/

n3/a8.html
11

Rationale 

Health care professionals working in maternity 

care (obstetrics, midwifery, pediatrics, family 

practice) need in-depth knowledge and skills 

directly related to breastfeeding and lactation 

management because 86% of Americans still 

turn to a health professional, such as a doctor, 

as their primary source of health information.26

Other health care providers who interact with 

women of reproductive age or infants need to 

recognize that breastfeeding is a normal and 

biologically important physiologic process that is 

critical to infant and maternal health, and they 

need a basic understanding of breastfeeding. 

Health care providers can influence a woman’s 

decision to breastfeed and her ability and desire 

to continue breastfeeding.27 However, some 

clinicians lack the skills to help women when 

they have problems with breastfeeding. Some 

also believe that breastfeeding provides only 

modest benefits and that formula-fed babies are 

just as healthy as breastfed babies.28 Education 

to improve health care providers’ knowledge, 

skills, and attitudes in this area is a key step to 

increasing professional support for breastfeeding. 

Evidence of Effectiveness 

The results of a recent study on the effects of 

practitioner education on breastfeeding initiation 

and exclusivity at four Massachusetts hospitals 

with low breastfeeding rates found a statistically 

significant increase in initiation (from 59% to 

65%). The training was taught by public health 

professionals, perinatal clinicians, and peer 

counselors in three 4-hour sessions. It covered 

a broad range of breastfeeding topics, from 

managing hyperbilirubinemia (which causes 

jaundice) to providing culturally competent care.29

To address the lack of breastfeeding knowledge 

among doctors, the AAP worked with several 

partners to develop its Breastfeeding Residency 

Curriculum for medical residents in pediatrics, 

family medicine, and obstetrics and gynecology. 

An evaluation of the curriculum found that 

residents at six intervention sites improved 

significantly in knowledge, practice patterns, 

and confidence compared with residents at seven 

control sites.30

The study’s results also showed a significant 

increase in exclusive breastfeeding rates for 

6-month-old infants at intervention sites (from 

2.3% to 9.0%). At control sites, 6-month-old 

infants were half as likely to be exclusively 

breastfeeding after the intervention.30

Strategy 2. Professional Education

Definition 

Professional education includes any program that improves the knowledge, skills, attitudes, or 

behaviors of health care providers in relation to the importance of breastfeeding, the physiology 

and management of lactation, or the need for breastfeeding counseling for mothers. Health 

care providers are defined here as doctors, nurses, midwives, nurse practitioners, nutritionists, 

lactation consultants, and other health care professionals working in maternity care.
12

Key Considerations 

• Breastfeeding education programs can 

be provided in person or online and can 

range from 1-hour lectures to intensive 

courses that last several weeks. Building 

skills to help health care providers deal 

with even routine lactation problems 

takes a combination of extensive formal 

instruction and practical experience. Short 

lectures should only be used to raise general awareness and increase acceptance of 

breastfeeding and lactation management.

• Health care providers need to be aware of 

how the procedures they perform or the 

medications they prescribe can directly or 

indirectly affect women who breastfeed 

now or who may do so in the future. 

• Nurses often provide the most regular care 

for breastfeeding mothers and infants. 

Professional education provided through 

school curricula, in-service training, and 

continuing education can help ensure 

that nurses learn about breastfeeding 

approaches and techniques. 

Action Steps 

1. Make available and coordinate grand 

rounds or in-service presentations on 

breastfeeding by health care professionals with training in this area.

2. Distribute clinical protocols developed 

by experts, such as the Academy 

of Breastfeeding Medicine, to 

local doctors.

3. Expand the reach of professional 

development by providing training. 

4. Identify and promote access to 

evidence-based online and CDbased training courses for the health 

care workforce.
13

racially and ethnically diverse populations. The 

curriculum has seven major sections: advocacy, 

community outreach and coordination of care, 

anatomy and physiology, basic skills, peripartum 

support, ambulatory management, and cultural 

competency. Technical assistance is provided by 

the AAP and other experts. 

Educating Physicians In their Communities 

(EPIC)

The first EPIC training was launched in 2000 

in Georgia to give free educational programs 

on immunization to doctors in private practice. 

In 2007, the Georgia Chapter of the AAP 

launched the EPIC Breastfeeding Program. 

The curriculum for this program is intended to 

educate health care providers about the most 

current breastfeeding information available so 

they can provide optimal care and guidance to 

breastfeeding mothers. 

A Case Study in Breastfeeding and 

Human Lactation 

This University of Pennsylvania School of 

Nursing course is for junior and senior nursing 

students. The course gives students who plan to 

work with women and infants a way to focus 

their knowledge in the area of breastfeeding. 

The course combines classroom and clinical 

experiences that focus on current research and 

issues related to breastfeeding. 

Certified Lactation Counselor (CLC) 

Training Program

The CLC Training Program is a 40-hour course 

taught at several locations across the United States. 

It is designed to provide up-to-date, research-based 

information on lactation, the art of counseling, 

and comprehensive breastfeeding management. 

The CLC Training Program also offers continuing 

education credits for registered nurses, registered 

dieticians, International Board Certified Lactation 

Consultants (IBCLCs), and nurse-midwives.

World Health Organization Course 

for BFHI Hospitals

To be designated as Baby-Friendly under the 

Baby-Friendly Hospital Initiative (BFHI), 

a facility must train its staff on the topics 

covered in the WHO course entitled Section 

3: Breastfeeding Promotion and Support in a 

Baby-friendly Hospital. The following topics 

are covered in this course:

• Session 1: BFHI: a part of the 

Global Strategy

• Session 2: Communication skills

• Session 3: Promoting breastfeeding 

during pregnancy 

• Session 4: Protecting breastfeeding 

• Session 5: Birth practices and 

breastfeeding 

• Session 6: How milk gets from breast 

to baby 

• Session 7: Helping with a breastfeed 

• Session 8: Practices that assist 

breastfeeding 

• Session 9: Milk supply 

• Session 10: Infants with special needs 

• Session 11: If baby cannot feed at the 

breast 

• Session 12: Breast and nipple conditions 

• Session 13: Maternal health concerns 

Program Examples 

Breastfeeding Promotion in Physicians’ 

Office Practices (BPPOP III) 

The AAP’s BPPOP III program works to increase 

doctors’ confidence and skills in breastfeeding 

care. As part of this program, a curriculum 

was developed to teach residents in pediatrics, 

family medicine, and obstetrics and gynecology 

how to promote and manage breastfeeding in 
14

Resources

Breastfeeding Promotion in Physicians’ 

Office Practices (BPPOP III) 

American Academy of Pediatrics

Provides information about the BPPOP III 

professional training program and the locations 

in the pilot study. 

http://www2.aap.org/breastfeeding/curriculum/

curriculum_developers.html

Academy of Breastfeeding Medicine (ABM)

The ABM clinical protocols inform providers 

about the care of breastfeeding mothers and 

infants.

http://www.bfmed.org/Resources/Protocols.aspx

Certified Lactation Counselor (CLC) 

Training Program

Provides information about the CLC 

Training Program.

http://www.healthychildren.cc/CLC.HTM

Educating Physicians In their 

Communities (EPIC)

Find out more about EPIC trainings for 

doctors in Georgia. 

http://www.gaepic.org

International Lactation Consultant 

Association (ILCA)

A listing of courses offered by the ILCA.

http://www.ilca.org

Wellstart International

Information and resources to improve the 

knowledge, skills, and abilities of health care 

providers related to optimal infant and maternal 

health and nutrition.

http://www.wellstart.org

Core Competencies in Breastfeeding Care 

and Services for All Health Professionals

United States Breastfeeding Committee

This document provides health care professionals 

with guidelines and a framework for integrating 

evidence-based breastfeeding knowledge, skills, 

and attitudes into standard health care delivery.

http://www.usbreastfeeding.org/HealthCare/

TrainingforHealthCareProfessionals/

CoreCompetencies/tabid/225/Default.aspx
15

Rationale 

Women’s early experiences with breastfeeding can 

affect whether and how long they continue to 

breastfeed. Lack of support from professionals is a 

barrier to breastfeeding, especially among African 

American women.31,32 Mothers often identify 

support received from health care providers 

as the most important intervention the health 

care system could have offered to help them 

breastfeed. However, few health care professionals 

are adequately trained and experienced in 

providing breastfeeding support.33 Short hospital 

stays after birth mean that the responsibility for 

breastfeeding support often rests with health care 

professionals who provide ongoing care, such as 

primary care doctors and lactation consultants.32,34

The role of these health care professionals is to 

give consistent and evidence-based advice and 

support to help mothers breastfeed effectively and 

continue breastfeeding. 

Evidence of Effectiveness

A 2005 Cochrane review of support for 

breastfeeding mothers found that professional 

support had a significant beneficial effect on 

exclusive breastfeeding in the first few months 

after an infant was born.35 The review also found 

that professional support had a beneficial effect 

on breastfeeding duration, but this effect was 

only significant at 4 months.

A review of breastfeeding interventions in primary 

care by the U.S. Preventive Services Task Force did 

not find that individual professional support alone 

significantly affected breastfeeding outcomes.36

However, reviewers did find that professional 

support given as part of a multicomponent 

intervention during the prenatal and postnatal 

periods increased short-term exclusive breastfeeding and duration of any breastfeeding. 

A randomized controlled trial in Texas was used 

to determine whether assigning first-generation 

Hispanic mothers who were feeding their infants 

both breast milk and formula at age 1 week 

to a hospital-based breastfeeding clinic would 

increase exclusive breastfeeding at 1 month. 

Mothers in the intervention group were offered 

breastfeeding support from paraprofessionals 

supervised by a registered nurse or IBCLC. 

Mothers in this group had significantly higher 

rates of exclusive breastfeeding than mothers 

in the control group who did not receive the 

intervention (16.8% versus 10.4%).37

An evaluation of the results of a randomized 

intervention among primarily low-income 

Hispanic and African American women in New 

York City found that women who received two 

prenatal and one postnatal visit or telephone call 

Strategy 3. Access to Professional Support

Definition

Access to support from health care professionals such as doctors, nurses, or lactation consultants 

is important for the health of the mother during pregnancy, after giving birth, and after release 

from the hospital. If a mother chooses to breastfeed, this support may include counseling or 

behavioral interventions to improve breastfeeding outcomes. It may also include helping the 

mother and baby with latch and positioning, helping with a lactation crisis, counseling mothers 

returning to work or school, or addressing concerns of mothers and their families. 

Professional support can be given in many different ways and settings—in person, online, over 

the telephone, in a group, or individually. Some women receive individual in-home visits from 

health care professionals, while others visit breastfeeding clinics at hospitals, health departments, 

or women’s health clinics. 
16

from a lactation consultant were more likely to 

be breastfeeding at week 20 than women who 

received standard care (53.0% versus 39.3%).38

Exclusive breastfeeding rates did not differ 

between the two groups. 

Key Considerations

• The Patient Protection and Affordable 

Care Act of 2010 (as amended by the 

Healthcare and Education Reconciliation 

Act of 2010 and referred to collectively as 

the Affordable Care Act) expands insurance 

coverage, consumer protections, and 

primary care access in the United States. 

It also emphasizes prevention in addition 

to care and treatment. Comprehensive 

breastfeeding support and counseling 

from trained providers, as well as access 

to breastfeeding supplies, for pregnant 

and nursing women is recommended 

in comprehensive guidelines from 

the Health Resources and Services 

Administration (HRSA).

• Professional support can be provided 

during both the prenatal and postpartum 

periods, but it is particularly critical in 

the first few weeks after delivery, when 

lactation is being established. 

• Support may be given by trained doctors, 

nurses, lactation consultants, or other 

trained health care professionals. Many 

third-party payers in the United States 

do not reimburse for services given by 

lactation professionals unless they are 

otherwise eligible for reimbursement 

as nurses, doctors, or other health care 

professionals. 

• Lack of reimbursement may be a barrier 

to seeking professional support for many 

women because they would have to pay 

out-of-pocket for this support. 

• The Affordable Care Act requires new health 

plans to cover prenatal and postpartum 

breastfeeding counseling and supplies. For 

example, they must cover rental fees for 

breast pumps at no out-of-pocket cost (e.g., 

for co-pays, co-insurance, or deductibles). 

For Medicaid, the Affordable Care Act 

also provides states the opportunity to earn 

a one percentage point increase in their 

federal matching rate (starting on January 

1, 2013) if they cover certain recommended 

immunizations and preventive services for 

beneficiaries without cost-sharing.

• Professional support can be given through 

telephone hotlines or live online chats. Hotlines include those staffed 24 hours a day, 7 

days a week; those staffed only during working hours; those that offer call-back support 

to mothers who leave a message describing 

their needs; and those with pager services 

similar to the on-call services used by health 

care professionals. Some online communities 

offer live chats with IBCLCs, pediatricians, 

or other health care professionals.

• IBCLCs are health care professionals who 

specialize in the clinical management 

of breastfeeding. They are certified by 

the International Board of Lactation 
17

Consultant Examiners, which operates 

under the direction of the U.S. National 

Commission for Certifying Agencies. 

IBCLCs and other lactation professionals 

work in a variety of health care settings, 

such as hospitals, private pediatric or 

other medical offices, public health 

clinics, and their own private practices.

Program Examples 

Best Start Three Step Counseling Strategy 

This counseling method addresses barriers to 

breastfeeding through open-ended questions, 

affirmation, and education. It can be used by a 

wide range of health care professionals, and it 

is time efficient. This strategy has been used in 

WIC clinics to support breastfeeding women.

SoonerCare 

The Oklahoma Health Care Authority administers this state Medicaid program, which covers 

lactation consultant services for SoonerCare 

members up to 60 days postpartum. To be 

reimbursed, lactation consultants must be 

licensed by the state as a nurse or dietician 

and be an IBCLC. Consultations are provided 

face-to-face in an individual setting, such as in 

an office, patient’s home, or other confidential 

outpatient location. The program allows six 

sessions per pregnancy. 

MilkWorks 

This nonprofit, community breastfeeding center 

in Lincoln, Nebraska, was founded in 2001 by 

a small group of mothers working in the health 

care field who identified a lack of outpatient 

breastfeeding services for mothers in the area. 

Currently, MilkWorks has about 20 part-time 

employees, including a breastfeeding medicine 

specialist, IBCLCs, breastfeeding educators, 

and registered dieticians. Staff provide clinical 

services to about 1,000 mothers a year at the 

main location, in homes, and at two inner-city 

outreach clinics that serve Spanish-speaking and 

single or young mothers. Nursing, dietetic, child 

development, and family practice residents work 

in the clinics to increase breastfeeding knowledge 

among health care providers. 

Action Steps

1. Collaborate with state Medicaid and 

insurance commissioners to explore 

ways to increase access to lactation 

services. 

2. Consider options for developing walk-in 

breastfeeding clinics that are available to 

all new mothers in the community and 

that are staffed by trained breastfeeding 

professionals who are reimbursed for all 

services provided.

3. Create comprehensive, statewide 

networks to provide home-based or 

clinic-based follow-up care to newborns 

in the state. 

4. Develop and disseminate a resource 

directory of local lactation support 

services available to new mothers.

5. Given that the WIC Program serves 

53% of all new mothers and infants, 

ensure that WIC participants have 

professional services for breastfeeding 

support in place before they are 

discharged from the hospital.
18

La Leche League International (LLLI)

The LLLI operates a toll-free telephone helpline 

(1-877-452-5324) from 9 am to 9 pm CST. 

Callers are required to leave a message, which 

is answered by a trained volunteer. The LLLI 

also has an online help form that women can 

use to get answers to breastfeeding questions 

(http://www.llli.org/help_form).

Harris County Breastfeeding Coalition 

The Harris County Breastfeeding Coalition in 

Texas set up a hospital-based breastfeeding clinic 

that is staffed by paraprofessionals supervised 

by a lactation specialist at Baylor College of 

Medicine’s Ben Taub General Hospital. This 

clinic provides breastfeeding support to highrisk mothers who are referred by hospital staff 

or mothers who request this service within 

2 weeks of discharge.

Mothers receive counseling and direct assistance 

from breastfeeding counselors who have 

completed the Texas Department of Health’s 

lactation management training program. 

Complex cases are referred to the clinic manager 

(a registered nurse or IBCLC). Follow-up visits 

or telephone contact is arranged when problems 

are not resolved during the initial visit. Mothers 

are also referred to other sources of breastfeeding 

support in the community. Support from 

breastfeeding counselors is provided without 

charge beyond the costs for infant check-ups.

Resources 

Breastfeeding and Follow-Up Clinic of 

Stormont-Vail HealthCare

Provides professional support through a 

postdischarge visit by clinic staff in Kansas.

http://www.stormontvail.org/birthplace/

Find a Lactation Consultant

International Lactation Consultant Association

Provides a directory to help mothers find IBCLCs 

working in private practice and hospitals.

http://www.ilca.org

MilkWorks

An example of a community breastfeeding center. 

http://www.milkworks.org

SoonerCare

Oklahoma Health Care Authority

This state Medicaid program covers lactation 

consultant services for members up to 60 days 

postpartum.

http://okhca.org/individuals.aspx?id=3091

&menu=44

Medicaid Coverage of Lactation Services

Center for Medicaid and CHIP Services

This issue brief explores how the Centers for 

Medicare & Medicaid Services can encourage and 

help states increase access to lactation services.

http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Qualityof-Care/Downloads/Lactation_Services_

IssueBrief_01102012.pdf
19

Rationale

Women’s decision-making processes are highly 

influenced by their social networks. These 

networks can be either barriers or points of 

encouragement for breastfeeding.39,40 For new 

mothers, the preferred resource for information 

about child rearing is other mothers.41 Advice 

from friends and family is commonly cited as 

a reason for decisions about infant feeding, as 

is knowing someone that has breastfed.40,42,43

Perceived social support has also been found to 

predict breastfeeding success.44

Women who serve as peer counselors can help 

other women overcome barriers to breastfeeding 

and prevent and manage breastfeeding problems 

during both the prenatal and postpartum 

periods.40 For example, peer counselors help 

pregnant women make informed infant feeding 

decisions and prepare for the breastfeeding 

experience. After childbirth, peer counselors 

provide breastfeeding information, emotional 

support, nonmedical assistance, and referrals 

as needed. Peer support may represent a costeffective, individually tailored approach and 

culturally competent way to promote and 

support breastfeeding for women from different 

socioeconomic backgrounds, especially in places 

where professional breastfeeding support is not 

widely available.36,45,46 Given the importance 

of peer counseling, many WIC clinics provide 

this service.

Evidence of Effectiveness 

Systematic reviews of peer support programs 

have found them to be effective in increasing 

the initiation, duration, and exclusivity of 

breastfeeding.14,35,36 Significant increases in 

initiation, duration, and exclusivity were 

observed among women who received support 

from a peer counselor or other lay person.35,36

Multifaceted interventions with peer support 

as one of the main components have also been 

found to be effective in increasing breastfeeding 

initiation and duration.35

A study conducted in Michigan at WIC clinics 

among low-income women who asked for peer 

support compared those who received support 

with those who did not. Women in the second 

group did not receive peer support because of a 

higher demand for services than the clinics could 

meet. The results of this study demonstrated 

that women who received the requested services 

breastfed 2 weeks longer and were 22% more 

likely to initiate breastfeeding than those who did 

not receive services.46

Studies that compared breastfeeding rates among 

women who visited WIC clinics that offered 

peer counseling in Maryland and Missouri with 

clinics that did not offer counseling found a 

significantly higher rate of breastfeeding initiation 

in clinics with counseling.47,48 Peer support is 

Strategy 4. Peer Support Programs

Definition

The goal of peer support is to encourage and support pregnant and breastfeeding women. 

It is often provided by mothers who are from the same community and who are currently 

breastfeeding or have done so in the past. It can be provided in several ways. The two most 

common and effective methods are peer support groups and individual peer support from 

a peer counselor. Women who provide peer support receive specific training. They may lead 

support groups or talks with groups in the community or provide one-on-one support through 

telephone calls or visits in a home, clinic, or hospital. Contact may be made by telephone, in 

the home, or in a clinical setting. Peer support includes emotional support, encouragement, 

education about breastfeeding, and help with solving problems.
20

effective in many population groups, including 

disadvantaged, middle-income, and low-income 

populations. Peer support is considered vital 

to breaking down barriers to breastfeeding in a 

woman’s social network, especially among groups 

with low breastfeeding rates.47,49,50 A randomized 

controlled trial of a peer support program among 

low-income Latina women found that women 

who received individual peer counseling were 

more likely to be breastfeeding at 1 and 3 months 

postpartum than those who received only routine 

breastfeeding support.45 In addition, more women 

in the intervention group initiated breastfeeding. 

Key Considerations 

• For individual peer support, consider the 

following:

◆ Timing is important. The first days and 

weeks of breastfeeding are critical for 

establishing breastfeeding. 

◆ Peer mothers should have the same or 

a similar sociocultural background as 

mothers needing support. 

◆ Peer support programs have used both 

paid and volunteer counselors. However, 

a report prepared for the U.S. Department of Agriculture’s (USDA’s) Food 

and Nutrition Service found that paying 

counselors helped retain counselors and 

sustain programs.49

• For peer support groups, consider the 

following:

◆ Timing is important. Support groups 

are especially helpful in the first few days 

after childbirth, although many mothers 

benefit from longer term participation. 

◆ Groups are usually ongoing and 

meet regularly at an easily accessible 

location. Some groups may charge 

a fee or request donations, but most 

group leaders are volunteers. Some 

organizations provide breastfeeding 

management and support from IBCLCs 

or other health care professionals who 

specialize in lactation.

• Training is a necessary component of peer 

support and should include basic breastfeeding management, nutrition, infant growth 

and development, counseling techniques, 

and criteria for making referrals. In both individual and group settings, peer counselors 

are trained by, gain practical experience from, 

and are monitored or overseen by a health 

care professional. These professionals include 

IBCLCs, nurses, nutritionists, or doctors 

with training in skilled lactation care.

• Other factors critical to the success of 

peer support programs are leadership and 

support from management, adequate 

supervision of counselors, standardized and 

ongoing training for counselors, access to 

IBCLCs, and community partnerships for 

making and receiving referrals for mothers. 

Integrating peer support within the overall 

health system seems to contribute to the 

ongoing maintenance of a program.49

• Peer support can be provided and received 

in many different ways, and contact does 
21

not have to be in person only. Internet 

and telecommunication technology can 

be used to increase contact and enhance a 

peer support program. 

• Fathers can have a tremendous influence 

on breastfeeding, and they can offer 

support that helps mothers breastfeed.42,51

An innovative pilot study in a Texas 

WIC Program used a father-to-father 

peer counseling approach. The program 

increased breastfeeding rates and improved 

fathers’ knowledge about breastfeeding 

and their belief that they could provide 

support to their breastfeeding partners.52

• Grandmothers also influence a woman’s 

decisions and practices related to feeding 

her infant.53–56 If a baby’s grandmother 

previously breastfed, she can share her 

experience and knowledge, and she can 

support a mother through any challenges. 

If a baby’s grandmother did not breastfeed, 

she may try to discourage it or suggest 

formula feeding when a problem 

arises.56 Breastfeeding support programs 

that include grandmothers and older 

women could help increase support for 

breastfeeding women (see the Naomi and 

Ruth Project in the Program Examples).

Action Steps 

1. Given the reach of the WIC Program, 

help WIC providers increase the availability of peer counseling services for all 

WIC participants.

2. Establish peer counseling programs 

for women not eligible for the WIC 

Program.

3. Improve the quality of existing peer 

counseling services by increasing 

contact hours, improving training, and 

making prenatal visits earlier.

4. Make sure that peer counselors have 

support and adequate supervision from 

an IBCLC.

5. Create and maintain a sustainable 

infrastructure for mother-to-mother 

support groups and peer counseling 

programs in hospitals and community 

health care settings.

Program Examples

Using Loving Support to Implement Best 

Practices in Peer Counseling 

In 2004, the USDA’s Food and Nutrition Service 

launched a project called Using Loving Support

to Implement Best Practices in Peer Counseling 

to help managers and staff in WIC Programs 

implement and expand breastfeeding peer 

counseling programs. The goal of the project was 

to help WIC Programs use the Loving Support

model as a framework to design, build, and 

sustain peer counseling programs. Two training 

curricula were developed for the project—one 

for managers of peer counseling programs and 

one for trainers of peer counselors.

In 2011, the training curricula were updated, and 

the project name was changed to Loving Support

Through Peer Counseling: A Journey Together. 

Peer counselors receive extensive training on how 

to support pregnant and breastfeeding mothers 

in WIC Programs at home through telephone 

contacts. In many programs, peer counselors also 

provide clinic-based counseling, make home visits 

during the early postpartum period, lead prenatal 

breastfeeding classes and postpartum support 

groups, and provide one-on-one support in the 

hospital setting.
22

Breastfeeding: Heritage and Pride 

This peer counseling program is a collaborative 

effort between Hartford Hospital, the 

Hispanic Health Council, and the University 

of Connecticut’s Family Nutrition Program. 

Perinatal peer support is provided to low-income 

Latina women living in Hartford, Connecticut. 

The program calls for at least one home visit 

during the prenatal period and daily visits during 

the hospital stay. Peer counselors are required to 

make three contacts after hospital discharge, with 

the initial contact made within 24 hours. Peer 

counselors are paid and receive benefits if they 

work at least 20 hours a week.

Naomi and Ruth Project 

This project is a faith-based initiative of the 

Indiana Black Breastfeeding Coalition. It was 

started in an African American church after 

several young women began breastfeeding their 

infants during services. A survey of church 

members found that many of the older women 

had breastfed and were willing to offer advice 

and support to breastfeeding mothers. This 

discovery sparked a new mentoring relationship 

between older women and younger women 

in the community. Older women who act as 

mentors are often grandmothers, aunts, or wellrespected women in the community.

La Leche League International 

The LLLI offers group peer support 

services nationwide through an ongoing 

series of four meetings, often held 

monthly. Telephone counseling and 

support are available to mothers 24 

hours a day. In addition to leading 

LLLI meetings, some leaders make 

home visits. Leaders are mothers who 

are members of the LLLI and who 

have breastfed at least one child for 

at least 9 months. Although they are 

volunteers, they have undergone an 

LLLI accreditation process that includes training 

and education about breastfeeding management, 

parenting, child development, communication 

skills, and supporting and counseling mothers.

Resources 

La Leche League International 

Information and materials related to the LLLI 

Peer Counselor Program. 

http://www.llli.org/llleaderweb/lv/

lvaugsep99p92.html

This Web site helps women find an LLLI support 

group in a specific area. 

http://lalecheleague.org/leaderinfo.html

Loving Support Makes Breastfeeding Work 

U.S. Department of Agriculture, Food and 

Nutrition Service

Information and materials about this USDA peer 

counseling program for WIC Programs. 

http://www.nal.usda.gov/wicworks/Learning_

Center/loving_support.html

Breastfeeding: Heritage and Pride

A community-based program in Connecticut 

working to improve breastfeeding initiation and 

duration among low-income women. 

http://www.hispanichealth.com/hhc/breastfeeding
23

Strategy 5. Support for Breastfeeding in the Workplace

Rationale 

Mothers are one of the fastest growing segments 

of the U.S. labor force. In 2012, 57% of all 

mothers with infants were employed.59 Working 

full-time outside the home is related to a shorter 

duration of breastfeeding.60,61 Intentions to 

work full-time are associated with lower rates of 

breastfeeding initiation and shorter duration.62

Low-income women, among whom African 

American and Hispanic women are overrepresented, are more likely than their higher income 

counterparts to return to work earlier and to 

have jobs that make it challenging for them to 

continue breastfeeding.60,63

Conversely, rates of breastfeeding initiation and 

duration are higher among women who have 

longer maternity leave,64 work part-time rather 

than full-time,65 or have breastfeeding support 

programs in the workplace.63,66

Evidence of Effectiveness 

A cross-sectional survey was conducted among a 

sample of women working for a large public-sector 

employer that had used at least one component 

of a work site lactation program in the past 3 

years.67 The program offered (1) prenatal classes on 

breastfeeding and how to maintain breastfeeding 

after returning to work, (2) telephone support 

from a nurse during a woman’s maternity leave, 

(3) a return-to-work consultation with a nurse, 

and (4) access to lactation rooms. 

Individual program components associated with 

exclusive breastfeeding at 6 months were telephone 

support and return-to-work consultation. In 

addition, the percentage of women who were 

exclusively breastfeeding at 6 months increased 

with each additional service received. 

Definition

Support for breastfeeding in the workplace can include several types of employee benefits and 

services.57,58 Examples include the following:

• Developing corporate policies to support breastfeeding women.

• Providing designated private space for women to breastfeed or express milk.

• Allowing flexible scheduling to support milk expression during work.

• Giving mothers options for returning to work, such as teleworking, part-time work, or 

extended maternity leave.

• Providing on-site or nearby child care.

• Providing high-quality breast pumps.

• Allowing babies at the workplace.

• Offering professional lactation management services and support. 
24

Several studies have indicated that support for 

lactation at work benefits not only families but 

employers as well by improving productivity; 

enhancing the employer’s public image; and 

decreasing absenteeism, health care costs, and 

employee turnover.66,68,69

Key Considerations 

• Educate employers on the benefits of 

having a lactation policy in the workplace 

that is in compliance with state and 

federal laws.

• Consider recognition programs that 

highlight employers with exemplary 

programs and allow employers to apply 

for recognition. 

• Some work sites, such as academic 

institutions and hospitals that also serve 

people who are not employees, can 

consider extending onsite breastfeeding 

support to nonemployees.

Action Steps 

1. Provide employers with resources and 

technical assistance to help them comply with federal and state regulations on 

breastfeeding support in the workplace. 

2. Sponsor a summit of employers, 

business organizations, and other key 

decision makers to develop a strategy to 

implement high-quality breastfeeding 

support programs in the workplace.

3. Support training on how to implement the steps in The Business Case 

for Breastfeeding tool kit (see Program 

Examples for more information).

4. Create links between state agencies that 

are responsible for implementing existing laws on work-site accommodations.

5. Develop a resource to help employers 

find creative ways to provide breastfeeding support in the workplace.

6. Enhance lactation support within 

state agencies.

7. Create recognition programs for 

businesses to set up high-quality 

breastfeeding support programs in 

the workplace.

• Lactation programs can include policies 

that allow mothers to bring their infants to 

work until they reach a certain age.
25

Program Examples

AOL WellBaby Program

The AOL WellBaby Program was launched 

in 2003 as part of AOL’s employee wellness 

program. The program offers preconception, 

pregnancy, and lactation support, including 

providing lactation consultation and rooms 

where mothers can breastfeed or express milk. 

The program serves more than 110 families a 

year and has reported a return on investment 

that is three to five times what is spent. 

The Business Case for Breastfeeding

The Maternal and Child Health Bureau (MCHB) 

in HRSA developed a program for employers 

called The Business Case for Breastfeeding. This 

program addresses barriers and the educational 

needs of employers and includes tool kits and 

guidelines for senior managers, human resources 

managers, and breastfeeding employees. During 

2007–2009, the MCHB worked with the Office 

of Women’s Health in the U.S. Department of 

Health and Human Services (HHS) to provide 

training in 30 states on how to use these materials. 

Those who receive training are then able to train 

others in their state and community.

The program is being used to help large 

businesses and organizations set up lactation 

programs for their employees. Most recently, the 

focus has been on getting information, education, 

and resources to employers in nontraditional, 

nonoffice settings. The U.S. Department of Labor 

provides technical assistance for this effort.

Factors to Consider When Setting Up 

a Workplace Lactation Program 

• Population: The number of women 

who need support, the resources 

available,68 and the settings in which 

female employees work. 

• Space: Lactation accommodations can 

take many forms, from a converted office 

or private space to a formal nursing 

mothers’ room. This space cannot be 

a bathroom.

• Time: Employers can use many different 

strategies to make sure mothers have 

enough time to breastfeed or express 

milk. Examples include flexible work 

schedules and locations, break times for 

pumping, on-site child care services, and 

job sharing.

• Support: Employers can do a lot to create 

an atmosphere that supports employees 

who breastfeed. A supportive atmosphere 

will be easier to achieve as workplace 

support programs are promoted to 

human resources managers, employee 

health coordinators, insurers, and health 

care providers. 

Several guides and tool kits with information 

about different types of practices can be 

used to support breastfeeding women in 

the workplace. These materials are available 

online from the United States Breastfeeding 

Committee, the National Business Group 

on Health, and the Health Resources and 

Services Administration. 

See the Resources section (page 27) for more 

information. 
26

In New York, the New York State Department 

of Health’s Obesity Prevention Program and 

Healthy Heart Program and the New York State 

Breastfeeding Coalition adapted materials from 

The Business Case for Breastfeeding to help 

businesses and public health agencies implement 

or expand lactation programs in the workplace 

and support the state’s Nursing Mothers in the 

Workplace Act. Through a partnership with the 

state’s WIC Program, a Web-based Return to 

Work Toolkit is being developed for low-income 

breastfeeding mothers who are making the 

transition back to work. 

The group also is redesigning its Web site 

(http://www.breastfeedingpartners.org) to 

include information to help employers develop, 

implement, and promote lactation programs in 

the workplace. 

Infant at Work Program 

The Kansas Department of Health and 

Environment’s Infant at Work Program allows 

mothers to bring their infants to work until age 

6 months. Participating mothers must agree to 

all policies of the program, sign a consent and 

waiver form, and identify alternate care givers 

at the workplace who will care for their infant 

when they are temporarily unavailable.

Tippecanoe County WIC Program 

The Tippecanoe County WIC Program in 

Indiana allows staff to bring exclusively breastfed 

infants to work until age 6 months. 

Breastfeeding Legislation

In March 2010, President Obama signed the 

Patient Protection and Affordable Care Act 

into law. Section 4207 provides nonexempt 

breastfeeding employees with “reasonable 

break time” and a private place, other than a 

bathroom, to express breast milk during the 

workday up until a child’s first birthday. The 

law does not preempt state laws that provide 

greater protections to employees. 

In 2008, Navajo Nation lawmakers passed 

a law that requires employers working in or 

doing contract work for the Navajo Nation 

to provide ways for mothers to continue to 

breastfeed. The Navajo Nation Healthy Start 

Act allows a mother unpaid time during 

work hours to breastfeed her infant or to use 

a breast pump. The act is enforced by the 

Navajo Nation Labor Commission. 

Both California (in 2002) and New Jersey 

(in 2008) passed Family Leave Insurance 

to allow employees to take leave for several 

reasons, including to bond with newborn or 

newly adopted children and to care for sick 

family members. This insurance provides 

partial wage replacement for 12 weeks in 

California and 6 weeks in New Jersey. 
27

Resources 

AOL WellBaby Program 

This employee wellness program includes lactation 

support, such as lactation consultation and rooms 

for mothers to breastfeed or express milk.

http://www.businessgrouphealth.org/pub/

f3002033-2354-d714-51d4-f144c4d536e8

Colorado Breastfeeding Coalition 

YouTube Videos

These videos share the experiences of employees 

and employers related to lactation support in 

the workplace. 

http://cobfc.org

The Business Case for Breastfeeding

Health Resources and Services Administration 

Program with several resources, including 

tool kits and guidelines, to help employers 

understand the benefits of making 

accommodations for breastfeeding mothers. 

http://www.womenshealth.gov/breastfeeding/

government-in-action/business-case-forbreastfeeding

Infant at Work Program 

Kansas Department of Health and Environment 

Information about this state program that allows 

mothers to bring their infants to work until age 

6 months. 

http://da.ks.gov/ps/subject/arc/resources/

doainfant.pdf

Worksite Wellness Program Toolkit 

Massachusetts Department of Public Health 

This tool kit includes information and resources 

to help employers support employees to engage in 

healthy behaviors. It includes a section on policies, 

programs, and resources on lactation support.

http://www.mass.gov/eohhs/docs/dph/mass-inmotion/worksite-wellness-toolkit.pdf

Breastfeeding & Working: 

WorkAndPump.com

Web site with practical advice and help for 

mothers who are trying to balance breastfeeding 

and work. 

http://www.workandpump.com
28

Navajo Nation Healthy Start Act

Navajo Nation 

Information about lactation protections in the 

workplace set by the Navajo Nation Healthy 

Start Act.

http://www.usbreastfeeding.org/Portals/0/

Coalitions/2010-NCSBC/BTT-Handouts/

BTT-11-Handout.ppt

Breastfeeding Laws

National Conference of State Legislatures 

Inventory of state legislation related to 

breastfeeding. 

http://www.ncsl.org/issues-research/health/

breastfeeding-state-laws.aspx

Texas Mother-Friendly Worksite Program 

Texas Department of State Health Services 

List of mother-friendly work sites in Texas and 

information for employees and employers. 

http://www.motherfriendly.com

Investing in Workplace Breastfeeding 

Programs and Policies: An Employer’s Toolkit

National Business Group on Health

This tool kit is designed to help employers make 

lactation accommodations and understand the 

benefits to employees and employers. 

http://www.businessgrouphealth.org/pub/

f2ffe4f0-2354-d714-5136-79a21e9327ed
29

Rationale 

In 2012, 57% of all mothers with infants were 

employed.59 As a result, many children are 

regularly cared for by someone other than their 

mother from birth to age 4 years.70 ECE providers 

and teachers influence the lives and health of the 

families they serve and can be an important source 

of support for working mothers who want to 

breastfeed.71

All ECE programs, including those in personal 

homes, can lower a breastfeeding mother’s 

anxiety by allowing her to feed her infant 

on-site, having a posted breastfeeding policy 

that is routinely communicated, making sure 

procedures for storing and handling breast milk 

and feeding breastfed infants are in place, and 

making sure staff members are well-trained in 

these procedures.72

Evidence of Effectiveness

Data from the Infant Feeding Practices Study 

II (IFPS II), a longitudinal study that followed 

mothers from the third trimester until children 

were age 1 year, found that breastfeeding at 6 

months was significantly associated with support 

from child care providers to feed expressed 

breast milk to infants and allow mothers to 

breastfeed on-site before or after work.73 The 

IFPS II used a questionnaire to ask mothers five 

questions about breastfeeding support. Results 

showed that mothers who said they received five 

Infant Feeding Guidelines in 

Caring for Our Children

In 2011, the AAP and the American Public 

Health Association (APHA) published the 

third edition of Caring for Our Children: 

National Health and Safety Performance 

Standards; Guidelines for Early Care and 

Education Programs. This publication provides 

national guidelines on how ECE programs 

should accommodate breastfeeding mothers.

Specifically, the APA and APHA recommend 

the following: “The facility should encourage, 

provide arrangements for, and support 

breastfeeding. The facility staff, with 

appropriate training, should be the mother’s 

cheerleader and enthusiastic supporter 

for the mother’s plan to provide her milk. 

Facilities should have a designated place set 

aside for breastfeeding mothers who want to 

come during work to breastfeed, as well as a 

private area with an outlet (not a bathroom) 

for mothers to pump their breast milk. A 

place that mothers feel they are welcome to 

breastfeed, pump, or bottle feed can create 

a positive environment when offered in a 

supportive way.”72

Strategy 6. Support for Breastfeeding in Early Care and Education

Definition 

Early care and education (ECE) is a term used to describe various types of child care 

arrangements, including prekindergarten (pre-K) programs, Head Start programs, child care 

centers, and in-home care. ECE programs play an important role in supporting breastfeeding 

mothers and their infants by welcoming breastfeeding mothers and making sure staff members 

are trained to handle breast milk and follow mothers’ feeding plans. Increasing access to ECE 

programs that support breastfeeding families will help women start and continue breastfeeding. 

of the supports were three times as likely to be 

breastfeeding at 6 months as mothers who said 

they received fewer than three supports.73
30

• ECE providers often find it difficult to 

attend training. Breastfeeding support 

training can be incorporated into other 

professional development or continuing 

education opportunities. Information 

about breastfeeding support can also be 

included in other annual trainings.

• Support for mothers is not limited to 

feeding an infant breast milk. It can 

include welcoming mothers to breastfeed 

on-site and providing a space. ECE 

providers should let mothers know what 

services are available so they do not wean 

their infants prematurely. 

• Giving out printed materials and resources 

that communicate policies and procedures 

and the benefits of breastfeeding for 

mothers and children is helpful for both 

staff and parents. 

Key Considerations

• Setting and enforcing ECE standards 

is the responsibility of individual states 

and territories, although some local 

jurisdictions also have the authority to set 

additional standards. The 2011 Caring 

for Our Children: National Health and 

Safety Performance Standards; Guidelines 

for Early Care and Education Programs is 

based on scientific evidence and expert 

consensus. The document recognizes 

that, “Caregivers/teachers have a unique 

opportunity to support breastfeeding 

mothers, who are often daunted by the 

prospect of continuing to breastfeed as 

they return to work.”72

• As of December 2010, only six states 

had licensing regulations with language 

that fully meets best care guidelines, as 

defined by Caring for Our Children, such as

encouraging and supporting breastfeeding 

and the feeding of breast milk.72 These 

states are Arizona, California, Delaware, 

Mississippi, North Carolina, and Vermont.74

Action Steps 

1. Review state ECE regulations related to 

breastfeeding practices. If licensing or 

regulation change is not appropriate, 

seek to integrate breastfeeding 

standards into statewide Quality Rating 

Improvement Systems. 

2. Consider including breastfeeding 

materials that encourage breastfeeding 

initiation, duration, and exclusivity in 

preservice and professional development 

education and trainings for ECE 

providers.

3. Recognize ECE facilities that meet high 

standards for breastfeeding support.

4. Develop a model breastfeeding policy 

that can be shared with child care 

programs in your state or community.

5. Facilitate training for ECE providers on 

how to support breastfeeding mothers 

and feed breast milk to infants. 

6. Encourage ECE facilities to develop 

breastfeeding policies that support 

breastfeeding employees. 
31

Program Examples

Breastfeeding-Friendly Child Care 

in Wake County

The Breastfeeding-Friendly Child Care in Wake 

County project seeks to improve breastfeeding 

support in child care centers in North Carolina, 

especially those serving low-income families. It 

is a collaboration between the Carolina Global 

Breastfeeding Institute, the Wake County Child 

Care Health Consultants, and Wake County 

SmartStart. 

Activities include identifying the knowledge, 

attitudes, and practices of current child care staff 

in the state and developing a self-appraisal tool 

called the 10 Steps for Breastfeeding-Friendly 

Child Care Centers. Future plans include the 

creation of a Breastfeeding-friendly Child 

Care Award.

How to Support a Breastfeeding Mother: 

A Guide for the Childcare Center

The Mississippi Department of Health’s WIC 

Program developed this training curriculum for 

child care providers. The curriculum includes 

guidelines on how to support breastfeeding 

mothers and how to store and handle expressed 

breast milk. It has been adopted 

by other state health departments 

across the United States. The Texas 

Department of Health houses these 

materials, and the curriculum and 

teaching materials can be downloaded 

free from the department’s Web site. 

Ten Steps to Breastfeeding Friendly 

Child Care Centers

The Wisconsin Department of Health 

Services developed this publication to 

help child care centers develop policies 

and provide an environment that 

supports breastfeeding mothers. 

Resources

Nutrition & Physical Activity in Childcare 

Settings: Breastfeeding

Arizona Department of Human Services

This program aims to empower children to 

make good choices about nutrition, physical 

activity, and tobacco. It includes information 

on breastfeeding.

http://azdhs.gov/empowerpack

Breastfeeding-Friendly Child Care 

in Wake County

Learn about this North Carolina project that 

seeks to improve breastfeeding support in child 

care centers, especially those serving low-income 

families.

http://cgbi.sph.unc.edu/child-care

Caring for Our Children: National Health 

and Safety Performance Standards; 

Guidelines for Early Care and Education 

Programs, Third Edition

Guidance on how to feed infants and prepare for 

breastfeeding infants in child care settings.

http://nrckids.org/CFOC3/index.html
32

Ten Steps to Breastfeeding Friendly Child 

Care Centers

Wisconsin Department of Health Services 

This resource kit includes a self-appraisal 

questionnaire to help child care centers review 

existing practices.

http://www.dhs.wisconsin.gov/physical-activity/

Childcare/BFFChildCare.pdf

Family Checklist for Nutrition in Early Care 

and Education

A checklist on nutrition practices that parents 

can consider when choosing an ECE provider.

http://nrckids.org

Proper Handling and Storage of Human Milk

Centers for Disease Control and Prevention

Instructions on the proper handling and storage 

of human breast milk. 

http://www.cdc.gov/breastfeeding/

recommendations/handling_breastmilk.htm

How to Support a Breastfeeding Mother: 

A Guide for the Childcare Center

Mississippi Department of Health 

Information and resources on this WIC training 

program are available on the Texas Department 

of Health’s Web site.

http://www.dshs.state.tx.us/wichd/bf/

childcare.shtm
33

Rationale 

In the United States, many new mothers do not 

have direct, personal knowledge of breastfeeding. 

They also may find it hard to rely on family 

members for consistent, accurate information and 

guidance about infant feeding.40 Even though 

many women have a general understanding of the 

benefits of breastfeeding, they may not have access 

to information about how it is done, and they 

may receive incorrect information.33

Evidence of Effectiveness

A 2008 review by the U.S. Preventive 

Services Task Force (USPSTF) found 

formal breastfeeding education alone 

to be ineffective in increasing rates of 

breastfeeding initiation or duration. 

However, when used as part of a 

multicomponent intervention, both 

prenatal and postnatal education 

had an effect on short-term exclusive 

breastfeeding and the duration of any 

breastfeeding.36

A 2005 Cochrane review that looked at 

five studies that involved primarily lowincome women found that education 

resulted in a significant increase in 

the number of women who initiated 

breastfeeding; subgroup analysis 

found education especially effective if it was 

personalized for each woman’s needs.76 An earlier 

2003 review by the USPSTF found that the use 

of printed breastfeeding information alone (such 

as pamphlets, books, and posters) had no effect on 

breastfeeding initiation or duration in the short 

term.77 However, printed materials are often used 

as a component of multifaceted breastfeeding 

interventions, which have been shown through 

a Cochrane review to effectively increase 

breastfeeding initiation and duration.35

Strategy 7. Access to Breastfeeding Education and Information 

Definition 

Breastfeeding education usually occurs during the prenatal and intrapartum periods. It should 

be taught by someone with expertise or training in lactation management. It may be offered 

in a hospital or clinic setting, as well as at libraries, community centers, churches, schools, and 

work sites. Education primarily includes information and resources. First-time mothers report 

that they find books and written information helpful, while experienced women often rely on 

their past experience and doctors.75 Although the audience is usually pregnant or breastfeeding 

women, it may include fathers and others who support the breastfeeding mother. 

The goals of breastfeeding education are to increase mothers’ knowledge and skills, help them 

view breastfeeding as normal, and help them develop positive attitudes toward breastfeeding. 
34

Key Considerations 

• Women have different educational needs 

depending on their stage of pregnancy 

and past experience. Written information 

is sufficient for some women, but others 

need more formal education. 

• For quick answers to many breastfeeding 

questions, education programs can refer 

pregnant and breastfeeding women to 

reputable hotlines, Web sites, and social 

media tools. They also can give out videos, 

pamphlets, tear-off information sheets, 

books, and posters.

• Many classes that include breastfeeding 

instruction are held at community-based 

organizations, community centers, birth 

centers, and hospitals. Many hospital-based 

classes include information about early 

feeding practices and how to prepare for 

the infant’s birth that is directly tied to the 

policies at that particular hospital.

• Breastfeeding education during the intrapartum period is extremely time sensitive. 

It occurs in a hospital setting and is often 

less formal than prenatal education.

• All hospitals that routinely handle births 

should have staff with adequate training 

and knowledge to help with breastfeeding 

education during the intrapartum period 

for all mothers.

Breastfeeding Education

Prenatal breastfeeding education includes 

the following: 

• Guidance for mothers about anticipated 

situations and signs of effective breastfeeding or breastfeeding problems.

• The benefits of breastfeeding to mother, 

baby, and society.

• Correct positioning to help the infant 

latch onto the breast effectively.

• Specific needs in the early days of 

breastfeeding.

• Resources for help with problems. 

• Common fears, concerns, problems, 

and myths.

Intrapartum breastfeeding education 

includes the following:

• Immediate issues such as correct latch 

and positioning.

• Adequate milk removal.

• Stability of the infant.

• Comfort of the mother. 

• Concerns of mothers and family members.

• Referrals for postpartum support.

• Signs of success or potential problems in 

the first few days after hospital discharge. 

Program Examples 

WIC Baby Behavior Program 

This program helps WIC participants exclusively 

breastfeed their infants longer by making 

sure they understand typical infant behaviors, 

including sleep patterns, cues, and crying. The 

content for the program came from information 

collected during a series of focus groups, which 

revealed that many mothers supplemented 

breastfeeding with formula and cereals because 

they misinterpreted common infant behaviors as 

indicators of hunger. Trained WIC staff members 

teach parents to recognize and respond to the 

range of cues given by infants (not just those 

related to hunger) and to understand that it is 

normal and healthy for young infants to wake 

up often. By promoting realistic expectations 

of infant behavior, WIC staff members give 

mothers options other than the use of formula or 

foods to respond to their infants’ behavior. 
35

Action Steps 

1. Evaluate how breastfeeding education 

may be integrated into public health 

programs that serve new families, such 

as Early Intervention; Early Head Start; 

Success by Six; and family planning, 

teen pregnancy, and women’s health 

clinic programs. 

2. Partner with local community groups 

that support breastfeeding mothers by 

providing educational seminars and 

classes.

3. Work with childbirth educators to 

include evidence-based breastfeeding 

education in their curricula.

4. Promote and support breastfeeding 

classes that are convenient for family 

members to attend.

5. Work with health plans to encourage 

them to routinely offer prenatal classes 

on breastfeeding to all members.

Early Childhood Family Education

The Minnesota Department of Education has 

integrated breastfeeding into its Early Childhood 

Family Education classes, which are part of 

a 35-year parenting program available to all 

Minnesota residents. School districts advertise 

the classes, which are taught by early childhood 

and parenting educators who cover parenting 

topics and child development and health from 

birth to age 3 years. 

Class information is also available on the 

Minnesota Parents Know Web site. Information 

on breastfeeding includes the health benefits 

of breastfeeding, maternity care practices that 

support breastfeeding, basic breastfeeding 

information, signs that your baby is feeding well, 

and where to get help with breastfeeding. 

Kaiser Permanente of Southern California

Kaiser Permanente of Southern California 

offers patients a range of breastfeeding support 

services, including a breastfeeding helpline, 

support groups, and individual and group 

lactation consultations. New mothers also have 

access to general breastfeeding instruction, 

and at some facilities, classes specifically for 

mothers returning to work. Hospital policies 

call for formal education to be reinforced 

with educational materials and one-on-one 

interaction with members of the patient’s health 

care team. These interactions allow mothers and 

family members to ask specific questions about 

breastfeeding or how to deal with social norms 

surrounding breastfeeding in their family or 

community.

La Leche League International 

The LLLI operates a toll-free telephone helpline 

(1-800-525-3243) from 9 am to 5 pm CST. 

It is answered by a person who refers callers 

to specially trained mothers in their area. The 

LLLI also has an online help form that women 

can use to get answers to breastfeeding questions 

(http://www.llli.org/help_form).

Text4baby

This information service sends free text messages 

about maternal and child health to the cell 

phones of pregnant women and new mothers. It 

is supported by the National Healthy Mothers, 

Healthy Babies Coalition. Women sign up 

for the service by texting BABY (or BEBE for 

Spanish) to 511411. They receive free, short text 

messages each week, timed to the baby’s due date 

or date of birth. 
36

Office on Women’s Health

The HHS’s Office on Women’s Health offers a 

telephone support line (1-800-994-WOMAN) 

and online breastfeeding support (http://www.

womenshealth.gov/breastfeeding/index.cfm). The 

specialists who staff the support line are trained 

in breastfeeding management. Other resources 

include a publication entitled Your Guide to 

Breastfeeding, which is available free in three 

languages (English, Spanish, and Chinese) and 

in versions for different audiences (the general 

public, African American women, and Native 

American women). 

Resources

Breastfeeding Made Simple

This interactive, multimedia Web resource 

provides information for breastfeeding mothers. 

http://www.breastfeedingmadesimple.com

Bright Future Lactation Resource 

Centre Ltd.

Guidance and training for people who 

develop and conduct educational seminars 

on breastfeeding. 

http://www.bflrc.info

Kaiser Permanente of Southern California

Information about breastfeeding classes offered 

at Kaiser Permanente facilities. 

https://healthy.kaiserpermanente.org/health/

care/consumer/health-wellness

La Leche League International

Information, resources, and a list of locations 

where breastfeeding mothers can find support. 

http://www.lalecheleague.org

Minnesota Parents Know 

Minnesota Department of Education

Find out more about the state’s Early Childhood 

Family Education classes for parents, which 

include information on breastfeeding.

http://parentsknow.state.mn.us/parentsknow/

Newborn/topicsAZ/PKDEV_000282

Text4baby

Learn more about Text4baby and sign up to 

receive free educational texts and reminders.

http://www.text4baby.org

WomensHealth.gov

U.S. Department of Health and Human Services, 

Office on Women’s Health

Tips and suggestions to help women breastfeed 

successfully.

http://www.womenshealth.gov/breastfeeding/

index.cfm

WIC Baby Behavior Program 

U.S. Department of Agriculture

Web site includes materials and a report on this 

program for WIC participants.

http://www.nal.usda.gov/wicworks/Sharing_

Center/gallery/FitWICBaby.htm
37

Rationale 

Increasing the number of positive messages about 

and images of breastfeeding, as well as the visibility 

of the topic, through social marketing promotes 

breastfeeding and helps mothers and families 

understand the risks of not breastfeeding. This 

strategy can also help to make breastfeeding seem 

normal, which in turn will make it seem a more 

feasible and attainable goal for many women. 

Social marketing seeks to bring about behavior 

change through comprehensive, multifaceted 

approaches that provide coordinated interventions to specific audiences. Examples of these 

audiences include breastfeeding mothers and 

their support systems, health care providers, 

members of a particular community, and the 

general public. Social marketing can be used to 

encourage certain personal behaviors by mothers 

or interpersonal behaviors between a mother 

and others—for example, to encourage nurses to 

support a mother’s choice to start breastfeeding 

within 1 hour of birth. It can also be used to 

educate decision makers—for example, by 

helping a hospital adopt practices or strategies 

to help mothers initiate breastfeeding within 

1 hour of birth. 

Evidence of Effectiveness 

Social marketing has been established as an 

effective behavioral change model for several 

public health issues.79 In Iowa, for example, the

state’s WIC Program participated in a promotional campaign called Loving Support designed to 

increase breastfeeding among WIC participants 

and increase supporting behaviors in relatives, 

friends, health care providers, and WIC staff who 

might influence these women. 

The initial evaluation of the program found 

that after 6 months, in-hospital and 6-month 

breastfeeding rates were higher among WIC 

participants.80 In addition, women in the 

program reported more support from their 

mothers, husbands or boyfriends, friends or other 

relatives, and prenatal health care providers.80

Some social marketing efforts may include media 

campaigns. For several public health issues, such 

as smoking, nutrition, and child survival, media 

campaigns have been found to be effective in 

changing behaviors.81 A 2000 Cochrane review 

suggested that media campaigns, particularly 

television commercials, improve attitudes toward 

breastfeeding and increase initiation rates.14

Strategy 8. Social Marketing

Definition 

Social marketing is an excellent tool for promoting public health activities. It may be used 

to promote breastfeeding practices in community, hospital, and workplace settings; educate 

policy makers about issues related to breastfeeding; and educate the public about healthy infant 

nutrition practices and support programs. Social marketing is a systematic and strategic planning 

process that results in an intended practice or program.78

Many different definitions of social marketing exist, but most have these common components:

• The adoption of strategies used by commercial marketers.

• A goal of promoting voluntary behavior change (not just improved knowledge or awareness).

• An end goal of improving personal or societal welfare.

• The use of pro-health messages (for public health campaigns).
38

Key Considerations 

• Effective social marketing campaigns are 

not confined to television ads and billboards. They may require a variety of 

social media tools.

• Depending on the scope and reach of 

the social marketing campaign, existing 

materials may be sufficient, or new 

materials may need to be developed. 

• Campaigns may run public service 

announcements, which use time and 

space donated by broadcast stations or 

advertisers. Campaigns usually have little 

Components of Social Marketing82,83

Problem: The problem is the health issue of concern. For potential solutions to emerge, the 

problem must be well defined.

Target Audience: The target audience is the individual or group whose behavior should change. 

Social marketers focus on the audience and use a variety of tools to understand it. Formative 

research is used to better understand the target audience and develop insight into the wants, needs, 

daily lives, and behaviors of its members. Insights gained through these processes help strengthen 

program strategies and interventions. 

Target Behavior: The goal of social marketing is always to inform people about voluntary 

strategies they can use to change their behavior. This behavior change should be voluntary, and it is 

the planner’s job to make the desired behavior an easy choice for the target audience. 

Strategies for Change: People who work in commercial marketing use a business tool called the 

marketing mix or 4 Ps, which stands for product, price, place, and promotion. These variables are 

used to create opportunity and motivation for an audience to adopt the desired behavior over the 

existing behavior.

The strategies for change also incorporate two additional concepts:

• Exchange: This concept refers to maximizing the benefits and minimizing the costs of the new 

behavior (or maximizing the costs and minimizing the benefits of the existing behavior). Both 

benefits and costs should be determined from the perspective of the audience.

• Competition: This concept refers to understanding what factors compete for the time and 

attention of the target audience and why the target audience prefers the current behavior.

control over when these announcements 

run. Paying for time and advertising space 

allows greater control and may ensure 

better reach to the target audience. 

• Framing is important to consider when 

using social marketing. Frames are mental 

structures or filters that are used to integrate new information in our brains in a 

meaningful way.84 A well-framed message 

incorporates values held by and information 

relevant to the target audience and excludes 

information the audience finds irrelevant. 
39

Action Steps

1. Identify local experts who can pitch 

stories that promote breastfeeding to 

the media.

2. Provide materials from Loving Support, 

the USDA’s national breastfeeding promotion and support campaign for the 

WIC Program, to local doctors, schools, 

clinics, hospitals, and child care centers.

3. Ask local media outlets (television, 

radio, and print) to air or feature public 

service announcements from the Office 

on Women’s Health’s Babies Were Born 

to Be Breastfed campaign.

4. Develop and implement a public health 

campaign on breastfeeding that uses 

social marketing. 

Program Examples

Loving Support Makes Breastfeeding Work

Loving Support is the USDA’s national 

breastfeeding promotion and support campaign 

for the WIC Program. This campaign was 

launched in 1997 as a result of Public Law 

102-342, which required the Secretary of 

Agriculture to create a national program to 

promote breastfeeding as the best method of 

infant nutrition and to foster wider public 

acceptance of breastfeeding in the United States. 

Loving Support uses a social marketing approach 

to promote breastfeeding to WIC participants 

and their families by emphasizing that the 

support of family and friends, the health care 

system, and the community are all essential for a 

breastfeeding mother to be successful.

The goals of the campaign include increasing 

breastfeeding initiation and duration among 

WIC participants, increasing referrals to the 

WIC Program for breastfeeding support, 

increasing general public acceptance and 

support of breastfeeding, and helping WIC staff 

at state and local levels promote and support 

breastfeeding. These goals are addressed through 

various components, including consumer 

research, an extensive media campaign, and 

resources for WIC staff. 

Mother-Friendly Worksite Program

The Texas Department of State Health Services 

conducted a social marketing campaign to 

promote its Mother-Friendly Worksite Program. 

The campaign focused on educating Texas 

employers about mother-friendly policies in the 

workplace. As part of the campaign, in-depth 

telephone interviews were conducted with 

breastfeeding promoters across the country, Texas 

businesses that participate in the Mother-Friendly 

Worksite Program, and businesses that do not 

participate in the program. Focus groups were 

also conducted with business leaders, mothers, 

and fathers in six Texas cities. 
40

The results were used to develop messages for 

businesses, working mothers, and the partners 

of working mothers. They were also used to 

strengthen the Mother-Friendly Worksite 

Program and the state’s Every Ounce Counts 

Campaign, which provides resources to pregnant 

women and new mothers.

Fathers Supporting Breastfeeding

The USDA’s Fathers Supporting Breastfeeding 

program uses a video, poster, and brochures 

to reach African American fathers so that they 

may positively influence a woman’s decision 

to breastfeed. It is part of national efforts to 

increase breastfeeding initiation and duration 

rates among African American women. Project 

materials can also be used with men in other 

racial and ethnic groups.

Best for Babes: Champions for Moms 

The Best for Babes’ Champions for Moms 

campaign shares information from high-profile 

mothers about how they overcame obstacles to 

childbirth and breastfeeding. These stories are 

meant to encourage and support pregnant and 

breastfeeding mothers. 
41

Resources

Best for Babes: Champions for Moms

A foundation with a mission to help women 

overcome breastfeeding obstacles. 

http://www.bestforbabes.org

Talking about Breastfeeding: Why the 

Health Argument Isn’t Enough 

Berkeley Media Studies Group and California 

WIC Association

A report that explores ways to frame 

breastfeeding issues for public audiences.

http://www.bmsg.org/pdfs/BMSG_Issue_18.pdf

Babies Were Born to Be Breastfed

Materials from this national breastfeeding 

campaign. 

http://www.womenshealth.gov/breastfeeding/

government-in-action/national-breastfeedingcampaign/index.cfm#materials

Loving Support Makes Breastfeeding Work

U.S. Department of Agriculture

Find out more about this social marketing 

campaign designed to support WIC Program 

recipients who want to breastfeed. 

http://www.nal.usda.gov/wicworks/Learning_

Center/loving_support.html

Social Marketing Resources 

Centers for Disease Control and Prevention

Training for public health professionals on how 

to use social marketing to plan nutrition, physical 

activity, and obesity prevention programs.

http://www.cdc.gov/nccdphp/dnpao/

socialmarketing/training.html
42

Mother-Friendly Worksite Program 

Texas Department of State Health Services 

Information about a Texas program that 

recognizes businesses that have made special 

efforts to accommodate breastfeeding mothers 

in the workplace. 

http://www.motherfriendly.com

Every Ounce Counts Campaign

Media and print resources and breastfeeding 

information for pregnant women and new 

mothers in Texas.

http://www.breastmilkcounts.com/our-newcampaign.html

Fathers Supporting Breastfeeding

U.S. Department of Agriculture

Program information and materials. 

http://www.fns.usda.gov/wic/fathers/

supportingbreastfeeding.htm

Massachusetts Breastfeeding Coalition

Provides social marketing materials in Spanish 

and English that emphasize the importance of 

exclusive breastfeeding. 

http://www.cafepress.com/massbfc
43

Rationale

The Code was developed with manufacturers 

of infant formula. It provides guidelines for the 

marketing and distribution of breastfeeding 

substitutes and limits direct marketing to 

pregnant women and new mothers. Until the 

late 1980s, infant formula was not marketed 

directly to consumers in the United States.86

Instead, marketing efforts focused on the 

relationship between health care professionals 

and parents in making decisions about infant 

feeding. However, there has been a movement 

toward the use of direct-to-consumer marketing 

in recent years.86,87

Evidence suggests that the effect of the marketing practices used to promote breastfeeding 

substitutes is of particular concern because of its 

disproportionately negative effect on mothers 

in the United States who are known to be at 

high risk for early termination of breastfeeding. 

These groups include WIC participants, firsttime mothers, and women who are less educated, 

nonwhite, or ill during the postpartum period.23,88

Evidence of Effectiveness

One common way that infant formula is 

marketed is by giving women gift bags with free 

formula samples when they are discharged from 

Strategy 9. Addressing the Marketing of Infant Formula

Definition

Monitoring how infant formula is marketed to ensure that potential negative effects on 

breastfeeding are minimized can help reduce barriers to breastfeeding for women who choose 

to do so. The negative association between the marketing of breast-milk substitutes and 

breastfeeding rates was the basis of the World Health Organization’s International Code of 

Marketing of Breast-milk Substitutes (the Code).85

Developed with infant formula manufacturers, the Code is a set of guidelines that apply to the 

marketing of breast-milk substitutes. It reaffirms the role that key entities—such as governments, 

health care systems, health care workers, and manufacturers and distributors of breast-milk 

substitutes—play in making sure infant formula is marketed in ways that minimize its negative 

effects on breastfeeding. 

the hospital. In 2006, the U.S. Government 

Accountability Office reviewed 11 studies to 

determine the effect of distributing discharge 

bags with formula samples on breastfeeding.88

Seven of the 11 studies found lower breastfeeding 

rates among women who receive discharge bags 

with formula samples than among women who 

did not receive bags with formula samples. More 

recently, the results of a study in Oregon found 

that receiving a commercial hospital discharge 

bag was associated with shorter duration of 

exclusive breastfeeding.24
44

International Code of Marketing of 

Breast-milk Substitutes 

The Code* includes the following guidelines:

• No advertising of breast-milk substitutes 

directly to the public.

• No free samples to mothers.

• No promotion of products in health 

care facilities.

• No commercial product representatives 

to advise mothers.

• No gifts or personal samples to health 

workers.

• No words or pictures idealizing artificial 

feeding, including pictures of infants on 

the products.

The Code states that

• Information to health workers should be 

scientific and factual.

• All information on artificial feeding, 

including product labels, should explain 

the benefits of breastfeeding and the 

costs and hazards associated with 

artificial feeding.

• Unsuitable products, such as 

condensed milk, should not be 

promoted for babies.

• All products should be of high quality 

and take into account the climatic and 

storage conditions of the country where 

they will be used.

* The Code is currently voluntary in the United States.

In addition, the results of a randomized 

controlled trial of 547 women found that 

educational materials on breastfeeding produced 

by manufacturers of infant formula and 

distributed to pregnant women who intended to 

breastfeed had a substantially negative effect on 

the exclusivity and duration of breastfeeding.89

Key Considerations

• The Code individually addresses the roles 

of health care systems, health workers, 

and people who manufacture, market, and 

distribute breast-milk substitutes. It also 

covers issues of labeling and quality, and it 

monitors compliance with the guidelines. 

• In addition to the guidelines in the Code, 

many doctors belong to professional 

organizations that also provide standards 

on similar issues. For example, in 2010, 

the Council of Medical Specialty Societies 

(CMSS), which represents 32 leading 

medical professional societies, including the 

AAP, adopted its own Code for Interactions 

with Companies. This code, which was 

revised in 2011, provides guidance for 

appropriate interactions with for-profit 

companies in the health care sector to 

ensure that interactions benefit patients 

and lead to improved care. 

The CMSS code ensures that interactions 

with companies, such as manufacturers of 

breast-milk substitutes, meet high ethical 

standards. These standards may include 

disclosing any company sponsorship or 

support to CMSS members and the public 

and not accepting company sponsorship 

of items or programs unless they are 

aligned with the CMSS’s strategic plan and 

mission.90
45

Action Steps 

1. Establish guidelines for how public 

health clinics and facilities can display 

and distribute materials that do not 

deter breastfeeding initiation, duration, 

and exclusivity. 

2. Provide educational materials that 

do not deter breastfeeding initiation, 

duration, and exclusivity to the offices 

of pediatricians, family practitioners, 

obstetrician-gynecologists, and nursemidwives and to public health clinics 

and facilities.

3. Work with local associations of health 

care professionals such as pediatricians, 

family practitioners, obstetriciangynecologists, and nurse-midwives to 

encourage the use of informational or 

educational materials that do not deter 

breastfeeding initiation, duration, and 

exclusivity.

Program Examples 

Six Steps to Achieve Breastfeeding Goals 

for WIC Clinics 

The National WIC Association developed the Six 

Steps to Achieve Breastfeeding Goals for WIC 

Clinics to increase breastfeeding and support 

mothers in WIC Programs who breastfeed. Step 

2 is to “Provide an appropriate breastfeedingfriendly environment.” The first objective of 

this step is to “meet the International Code of 

Marketing of Breast-milk Substitutes.” 

National Alliance for Breastfeeding Advocacy: 

Research, Education, and Legal Branch 

(NABA REAL)

NABA REAL is the nonprofit organization 

that monitors compliance with the Code in the 

United States. NABA REAL trains volunteers 

to monitor compliance and publishes and 

distributes information about the Code.

New Mexico Breastfeeding Task Force 

Honor Roll Project

The task force set up the Honor Roll project to 

identify and recognize hospitals in New Mexico 

that have eliminated the use of marketing 

materials from companies that make infant 

formula. Identified hospitals receive an award, 

and a list of awardees is posted on the task force’s 

Web site.
46

Resources 

Infant Formula Q&A

U.S. Food and Drug Administration 

Answers to consumer questions about infant 

formula. 

http://www.fda.gov/ForConsumers/

ConsumerUpdates/ucm048694.htm

INFACT (Infant Feeding Action Coalition) 

Canada

INFACT is a national, nongovernmental 

organization that works to protect infant and 

maternal well-being through the promotion 

and support of breastfeeding and optimal infant 

feeding practices.

http://www.infactcanada.ca

National Alliance for Breastfeeding Advocacy: 

Research, Education, and Legal Branch 

(NABA REAL)

This nonprofit organization monitors compliance 

with the Code in the United States. 

http://www.naba-breastfeeding.org/nabareal.htm

International Code of Marketing of 

Breast-milk Substitutes

World Health Organization 

Online link to this publication. 

http://www.who.int/nutrition/publications/

infantfeeding/9241541601/en

New Mexico Breastfeeding Task Force

Information about the task force’s Honor 

Roll project, which recognizes hospitals in 

New Mexico that have eliminated the use of 

marketing materials from companies that make 

infant formula.

http://www.breastfeedingnewmexico.org/

Hospital_Awards.html

Marketing Breastfeeding—Reversing 

Corporate Influence on Infant Feeding 

Practices

This journal article describes the strategic 

approach taken by the New York City 

Department of Health and Mental Hygiene 

and its partners to change hospital practices and 

educate health care providers and the public on 

the benefits of breast milk. 

http://www.ncbi.nlm.nih.gov/

pubmed/18463985

Six Steps to Achieve Breastfeeding Goals 

for WIC Clinics

National WIC Association

Six steps that WIC clinics can take to increase 

exclusive breastfeeding, initiation, and duration 

among program participants.

http://learning.mihealth.org/Mediasite/WIC

Coordinator_02102011_Resources/SixSteps

toAchieveBreastfeedingGoalsforWICClinics.pdf
47

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