—

TRENDS IN BREASTFEEDING RATES AND
LEGISLATIVE AND SOCIAL CHANGES, 1985-1990

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

BREASTFEEDING RATES

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

Breastfeeding rates in the United States, which declined in the 1950s and
1960s, began rising in the 1970s (IOM 1991) and reached a peak in 1982, with
62.0 percent of mothers initiating breastfeeding, and 30.0 percent continuing
to breastfeed at 6 months postpartum (see figure 3) (DHHS 1990a). Since 1982
there has been a continuous decline in both initiation and duration rates. In
1985, 58.0 percent of mothers initiated breastfeeding and 22.1 percent were
still breastfeeding at 6 months postpartum. By 1989 rates had fallen to 52.2
percent and 19.6 percent respectively (DHHS 1990a). Thus, between 1985 and
1989, the proportion of mothers who initiated breastfeeding fell by 10.0
percent and the proportion still breastfeeding at 6 months postpartum fell by
11.3 percent.

Rates of breastfeeding vary among geographic, racial, economic, and social
groups. Rates are highest among women who are white, married, and/or live in
the Western United States, and rates are lowest among women who are black,
single, and/or live in the Southeastern United States (IOM 1991, DHHS 1990a).
Figure 3—Percentage of women breastfeeding, 1971-1989, all races

 

 

 

 

70 +
60 4
50 J In hospital

» |

8 40 5

2 J

g ]

5 30 - 3 months
20 4 5-6 months
10 +
0 +4 oot)

1971 1980 1989

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

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

FEDERAL LEGISLATION AND POLICY
National Health Objectives

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

2
Figure 4—Percentage of women breastfeeding, 1989, by education

80

 

70.7

704

60+

 

@ in hospital
f 3 months
0 6 months

50 4

42.1

40

Percentage

 

 

 

30 +

20~

10-4

   

 

 

 

 

 

 

 

 

College Noncoliege

Source: Ross Laboratories, as reported in: Office of Maternal and Child Health, Public Health Service,

U.S. Department of Health and Human Services. (1990). Child Health USA ‘90. Washington, DC:

U.S. Department of Health and Human Services.

Native women are mentioned as special target populations (the full text of the
objective is reprinted in appendix F, beginning on page 9+).

Title V MCH Program

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

In 1976 the Office for Maternal and Child Health (OMCH—a precursor to
MCHB), in collaboration with the George Washington University and the
March of Dimes Birth Defects Foundation, cosponsored a symposium on
human lactation. Following that, OMCH provided funds to the National
Academy of Sciences to develop an annotated bibliography on breastfeeding,
published in 1978. Because there were few booklets directed to parents-to-be
on the subject of breastfeeding in the 1970s, OMCH published Breastfeeding in
1979, OMCH also provided leadership in 1983 for organizing a subcommittee
on breastfeeding promotion within the Healthy Mothers, Healthy Babies
coalition. One of the first projects was the development of a resource packet for
professionals to improve breastfeeding promotion at the community level.

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

3
Table 2—Breastfeeding of infants born to ever-married mothers 15-44 years of age,
according to selected characteristics of mother, 1981 to 19874

 

 

 

 

 

Percentage breastfeeding Percentage breastfeeding
at all at 3 months or more

1981-83 1984-87 1981-83 1984-87
Total 58.20 59.00 39.00 33.80
Race
White 62.00 62.10 41.90 35.70
Black 30.30 30.20 17.70 16.20
Education
Less than 12 years 30.10 30.70 12.00 16.00
12 years 54.00 50.90 31.90 25.70
13 years or more 71.50 73.30 54.60 45.20
Geographic region
Northeast 65.70 70.50 51.10 44.50
Northcentral 58.10 53.70 38.50 28.30
South 47.40 47.90 26.90 25.10
West 73.10 77.20 51.70 48.30

 

 

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

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

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

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

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

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

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

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

Legislative Changes in the WIC program

In 1986 the Tennessee Department of Health and Environment was awarded
a special projects of regional and national significance (SPRANS) grant from
MCHB for a breastfeeding promotion project targeted at low-income women.

Based on this SPRANS project's experience with breastfeeding promotion in the
USDA's Special Supplemental Food Program for Women, Infants, and Children
(WIC), the American Public Health Association awarded a mini grant to the
Tennessee SPRANS project director for the formation of the National
Committee to Improve Breastfeeding Promotion Strategies in the WIC
program. As a result of the National Committee’s efforts, eight new provisions
were included in the WIC Reauthorization Act of 1989 (Public Law 101-147).
This legislation also earmarked $8 million specifically for breastfeeding
promotion. The new regulations resulting from this legislation require State
WIC programs to:
1. Develop a plan to promote and support breastfeeding and to coordinate
operations with local programs for breastfeeding promotion;

2. Designate a breastfeeding promotion coordinator;

3. Train local agency staff responsible for providing breastfeeding promotion
and support;

4. Authorize the use of administrative funds to purchase breastfeeding aids
(such as breast pumps and nursing supplementers);

5. Evaluate breastfeeding promotion efforts annually, and include views of
participants as part of the evaluation;

6. Develop a policy that creates a positive clinic environment which
endorses breastfeeding as the preferred method of infant feeding; and

7. Provide breastfeeding promotion materials in languages other than
English (Federal Register 1990).

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

National Child Care Legislation

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

SOCIETAL TRENDS
Women’s Labor Force Participation

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

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

Advertising of Infant Formula

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

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

PROFESSIONAL EDUCATION

Recommendation:
Improve Professional Education in
Human Lactation and Breastfeeding

ACTIVITIES REPORTED

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

Education

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

National Activities

The following programs provide training in breastfeeding and human
lactation to health professionals from across the Nation.

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

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

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

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

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

9
lactation developed and provided by Wellstart faculty. Topics included
problem-solving strategies, nutritional risk assessment, jaundice, slow weight
gain, insufficient milk syndrome, AIDS, and drugs.

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

The University of California at Los Angeles Extension’s Division of Nursing
offers two breastfeeding courses. The Lactation Educator Training Program is
intended to prepare health professionals and other interested people to be
lactation educators either in private practice or as part of their clinical
employment. Emphasis is placed on maximizing professional use of scientific
data and understanding problems of clinical management, and the course
includes clinical consultation and community observation as well as written
work and lectures. The Lactation Consultant Training Program, which builds
on the Lactation Educator Training Program, prepares health professionals to
serve as lactation consultants. The didactic portion of this program includes
four 2-1/2-day sessions spaced over 8 months and held at UCLA. Additional
requirements are an apprenticeship with a faculty member in Los Angeles and
a preceptorship and community observation in the student’s local area.

The Lactation Program at Presbyterian-St. Luke’s Medical Center in Denver,
Colorado, provides a variety of professional education services, including a 1-
to 2-week internship program on breastfeeding management for nurses, an
annual conference for health professionals, and a telephone consultation
service.

The Maternal and Infant Care Project at the Grady Memorial Hospital in
Atlanta, Georgia (a Wellstart regional resource team), offers a 1-week lactation
management practicum designed to give health professionals, particularly WIC
program staff, the skills needed to plan and develop a breastfeeding program.
The practicum includes lectures as well as clinical experience in the delivery
room, on maternity floors, and at a breastfeeding clinic.

State and Local Activities

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

10
During 1990, the Hawaii Department of Health implemented a
breastfeeding training program in which seven teams were trained in
breastfeeding management and promotion, and training materials were
developed and adapted. The teams and materials were then utilized to provide
inservice training and technical assistance to clinic prenatal care providers,
hospital staff, and private care providers. The project also provided a
breastfeeding library for use by the teams, as well as a breastfeeding
information, referral, and consultation service.

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

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

The New Mexico Department of Health administered a project to make
appropriate, consistent lactation training available to health care providers in
New Mexico. Activities included training the nutrition education coordinator
of the WIC program, developing an 8-hour curriculum, and holding eight
regional training conferences throughout the State.

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

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

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

11
regional workshops for local clinic staff on topics of current interest.

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

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

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

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

Task Forces and Committees

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

National Activities

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

12
public and private sectors in the promotion of breastfeeding and in working
toward achieving the breastfeeding objective for the Nation. The objectives of
this collaboration have been to assess and monitor breastfeeding promotion
efforts, to exchange information, to share production of materials, and to
disseminate information and materials. The target audiences have been health
providers, hospitals, pregnant and lactating women and their families, and the
general public. This subcommittee has approximately 40 members with
representation from a variety of Federal agencies and professional
organizations, as well as state and local level organizations. Among many other
activities, the subcommittee has developed a breastfeeding promotion packet
which was disseminated to 4,000 leaders in State health agencies and
professional organizations.

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

State and Local Activities

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

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

In February 1990, the Maine Department of Human Services participated in

forming a statewide task force on breastfeeding, which includes representatives
from hospitals, physicians’ offices, public health programs, and lay support
groups. The task force plans to produce a newsletter, compile a resource list for
health professionals, and provide training to a variety of health professionals,
including nurses, WIC staff, and childbirth educators.

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

13
health professionals such as childbirth educators and nutritionists from the
community.

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

Policies and Regulations

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

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

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

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

Professional Consultation and Technical Assistance

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

14
Some of these services, at the national, State, and local levels, are described
below.

National Activities

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

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

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

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

15
findings is through presentations by subcommittee members to professional
meetings; nationwide distribution of this report and a summary of this report
through the National Maternal and Child Health Clearinghouse; news releases;
and making the report widely available as an NAS publication.

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

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

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

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

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

16
State and Local Activities

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

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

BARRIERS TO BREASTFEEDING

Of the 84 respondents who listed barriers to breastfeeding, 51 percent
(43/84) mentioned professional education issues when discussing barriers that
keep women from beginning or continuing to breastfeed (see table 3).

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

 

 

Barriers Percent of Respondents
(N=84)
Lack of support or encouragement from physicians, 32% (27)

nurses, hospital staff, or other health professionals

Inaccurate or inappropriate advice from physicians 17% (14)
and other health care personnel

General lack of education among health professionals 10% (8)
about breastfeeding and lactation management

Lack of access of women to health professionals trained 5% (4)
in lactation management

 

17
SUGGESTIONS FOR FUTURE ACTIVITIES

Forty-three percent (49/113) of respondents mentioned professional
education in their recommendations for future breastfeeding promotion
efforts. Suggestions included the following:

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

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

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

18
———

PuBLic EDUCATION

Recommendation:
Develop public education and promotional efforts

ACTIVITIES REPORTED

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

Hard-to-Reach Populations

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

National Initiatives

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

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

19
Table 4—Programs targeted to specific populations

 

Population

Respondent

 

Minorities (unspecified)

Blacks

American Indians

Non-English speakers

Bilingual/bicultural
groups

Adolescents

Low-literacy groups

Homeless families

Migrant workers

La Leche League International
Franklin Park, IL

Missouri Department of Health
Jefferson City, MO

New Jersey Department of Health
Trenton, N}

Pennsylvania Department of Health
Harrisburg, PA

Indian Heaith Service

Rockville, MD

North Dakota Health Department
Bismark, ND

South Dakota Health Department
Rapid City, SD

Nevada WIC Program

Carson City, NV

University of tllinois School of Public Health
Chicago, it

Massachusetts Department of Public Health
Boston, MA

Rhode Island WIC Program

Providence, Rl

Pennsylvania Department of Health
Harrisburg, PA

Massachusetts Department of Public Health
Boston, MA

Pueblo Community Health Center

Pueblo, CO

Nevada WIC Program
Carson City, NV

New Hampshire Department of Health and Human Services
Concord, NH

University of North Carolina School of Public Health
Chapel Hill, NC

Montana Migrant Council

Billings, MT
State and Local Initiatives

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

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

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

Media Campaigns and Social Marketing Approaches

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

National Initiatives

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

2]
Consortium met again in February 1991 and reviewed a USDA proposal for the
design and implementation of such a breastfeeding promotion campaign. Plans
are also under way by the consortium to conduct a secondary campaign
directed toward health care providers, policymakers, employers, and other
community groups.

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

State and Local Initiatives

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

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

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

22
shopping malls, and television appearances were held across the State.
Newspaper articles appeared in numerous cities. Specialty items including
buttons, balloons, bumper stickers, and banners boasted the campaign’s slogan
and toll-free information phone number. Public opinion surveys were
completed at the beginning and end of the project in an effort to assess the
public awareness campaign. The campaign’s methods and materials have been
used as a model by other States.

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

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

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

Response to Direct Consumer Advertising of Infant Formula

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

23
Association, the American Academy of Pediatrics, the American Academy of
Family Physicians, the Ambulatory Pediatric Association, and the Federation of
Pediatric Organizations.

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

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

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

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

School-Based Curricula

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

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

24
The Community Nutrition Resource Center (formerly Renewable
Technologies, Inc.) in Montana received a SPRANS grant for the project A
Model Approach to Development of Breastfeeding as a Subspecialty Integrated
with Private Sector Maternal/Infant Health Care. As part of this project, several
in-class presentations on breastfeeding were made to second, fourth, and fifth
graders. In addition, information on breastfeeding may be incorporated into
the health education curriculum the State of Montana is currently developing.

BARRIERS TO BREASTFEEDING

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

Table 5—Public education related barriers to initiation and continuation of
breastfeeding

 

Barriers Percentage of Respondents
(N=84)

 

Women's attitudes

Modesty, embarrassment 42% (35)
Interference/incompatibility with lifestyle; 37% (31)
loss of independence

Lack of confidence in ability to breastfeed 23% (19)
Concern that supply of milk is inadequate for baby 11% (9)
Lack of desire, motivation 10% (8)
Concern with figure 7% (6)
Had problem breastfeeding a previous baby 6% (5)
Have negative misconceptions about breastfeeding 6% (5)
Societal attitudes

Breastfeeding is not accepted as the norm; 35% (29)

general lack of societal support for breastfeeding

 

25