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by Melissa Bartick, MD, MSc AND Marsha Walker, RN

Lack of policy and infrastructure to support breastfeeding in the U.S. means that breastfeeding is made unnecessarily difficult. Breastfeeding is an important public health issue, both for women and children. Arguably, breastfeeding is also a reproductive right. Growing evidence shows that longer durations of breastfeeding are linked with lower risk of obesity in childhood and adolescence [1-4], a national epidemic with major health and cost implications. It therefore makes sense to incorporate the creation of an infrastructure around breastfeeding as part of health care reform. Such investment in breastfeeding is likely to have significant cost-containment benefits and may greatly help stem the spread of many costly chronic diseases.

All major medical organizations in the world recommend six months of exclusive breastfeeding, with continued breastfeeding for at least the first one to two years of life [5-8]. The earlier a woman stops breastfeeding, the higher her risk of breast cancer, ovarian cancer, diabetes [9], hypertension, and cardiovascular disease [10, 11]. Early weaning is linked to higher rates of many diseases in children besides obesity, including acute infections, type 1 diabetes, and leukemia [9]. It has been estimated that two to four billion health care dollars could be saved annually in the United States if all women breastfed their infants for as little as 12 weeks [12], and this does not include costs of time missed from work, or cost of management of expensive chronic diseases in children and women. Lack of breastfeeding has been shown to increase time missed from work to care for sick children [13, 14], and conversely, those companies who have invested in their lactating employees have enjoyed significant returns on their investments [15].

A 2001 study from the US Department of Agriculture (USDA) found that the US could save $3.6 billion a year if breastfeeding rates rose to the levels recommended by the federal government, based on an assessment of just a small fraction of disease in infants [16]. If this analysis were adjusted using the more accurate breastfeeding data now available, adjusted for inflation and raised to the medically recommended rates, the true figure would be over $14 billion per year. If the costs of childhood obesity, maternal diabetes, cancer, and cardiovascular disease were factored in, the true cost would likely be several times that figure.

There is a staggering gap between the medical recommendations and actual breastfeeding rates, despite modest breastfeeding goals set by the federal government as part of Healthy People 2010. Only 12% of U.S. children are exclusively breastfeed for 6 months, and only 21% are still breastfeeding at one year [17]. In addition, Department of Health and Human Services has recognized that there are "alarming" disparities in breastfeeding rates across racial [18] and socio-economic lines. The Centers for Disease Control and Prevention (CDC) has also found that 60% of women cannot even meet their own breastfeeding goals [19].

The countries that have managed to promote breastfeeding most successfully, such as Sweden, have strong central leadership and widespread implementation of the Baby-Friendly Hospital Initiative [20], a WHO/UNICEF certification shown to promote breastfeeding duration and exclusivity. Unlike the US, where fewer than 3% of all hospitals are Baby-Friendly [21], these countries have created a functional, well-funded infrastructure around breastfeeding. Often these countries have single payer health care, and recognize the intrinsic value of breastfeeding as a strategy to promote health and reduce health care expenses.

Both the CDC and HHS have identified the barriers to breastfeeding and ways to overcome these barriers [18]. Several government agencies work on breastfeeding, but not as part of one coordinated vision. The United States Breastfeeding Committee, a coalition of representatives from national organizations and government agencies, has been given the federal mandate to write a national agenda on breastfeeding. Yet, it gets very little funding and contracts with only one individual to provide administrative and support services. The federal budget has only one line item pertaining specifically to breastfeeding, which is the $20 million for peer counselors of the federal Women, Infants, and Children nutrition program (WIC). In short, there is a chasm between what our breastfeeding goals are, and any appreciable funding and infrastructure to meet those goals.

Because there is no big commercial interest involved in breastfeeding, it has few lobbyists to advocate for federal funding or an increased public profile In fact, the powerful $8 billion per year infant formula industry has actively lobbied against breastfeeding. Other barriers to breastfeeding include lack of evidence-based maternity practices, lack of access to lactation care and services, lack of paid maternity leave, and lack of worksite support.

Areas for policy improvement in Health Care Reform

Maternity practice challenges
: Few incentives currently exist to promote and implement the Baby-Friendly Hospital Initiative (BFHI) in the United States. In addition, the CDC has recently found that the average US maternity facility scored only 63 out of 100 possible points in their ability to delivery evidence-based care around breastfeeding [22].

A national infrastructure led by a lead government agency can help with widespread implementation, through training and systemic approaches, which could be funneled through state health departments tied to specific targets for numbers of Baby-Friendly Hospitals. One of the main barriers hospitals cite is the lack of resources to provide the necessary level of training for hospital staff [23].

The top choices of lead agencies would be the CDC, the HHS Office on Women’s Health (OWH), Maternal and Child Health Bureau of HRSA, or the USDA. Of these, the CDC appears to have the most expertise, having conducted the Infant Feeding Practices Surveys, the “mPINC” survey of maternity practices, the breastfeeding component of the National Immunization Survey, and having issued the national “Breastfeeding Report Card.” OWH is best known for the National Breastfeeding Awareness Campaign, and also hosts a public website with breastfeeding information as part of www.4woman.gov. MCHB is best known for launching the “Business Case for Breastfeeding” toolkit. USDA hosts the breastfeeding component of WIC, but the agency’s necessary links to the dairy and infant formula industries may present conflicts of interest.

Access to lactation care and services: Health Care reform can mandate coverage of lactation care and services on a national level. Lactation consultants are valuable in helping diagnose and solve breastfeeding problems. Insurance companies vary widely as to what kinds of services they will pay for, if any, including Medicaid. Such problems with access further compounds the disparities already seen across racial and economic lines with respect to breastfeeding.

WIC has a significant breastfeeding component, including some peer counselors. However, breastfeeding rates among WIC recipients are even lower than in the general population, for a variety of reasons, including worksite issues and lack of social support. A federal infrastructure could evaluate expanding successful WIC strategies to the general population.

Worksite issues: Research from California, which has worksite protection legislation, shows that even the WIC mothers there have impressive records of breastfeeding duration [24]. This demonstrates that worksite legislation is an effective way to improve breastfeeding duration. National legislation modeled on California's can be rolled into health care reform or passed separately. In addition, health insurance plans proposed around health care reform can consider discounts to those employers who have lactation programs, on-site daycare, and babies-at-work programs.

Paid maternity leave would help all families, regardless of how their babies are fed. The US joins only Papua New Guinea, Swaziland, and Lesotho as the world's only countries without any form of paid maternity leave. Paid family leave has been shown to reduce infant mortality by as much as 20% [25]. As noted in the Motherhood Manifesto, having a baby is a leading cause of "poverty spells" in the U.S. -- when income dips below what's needed for basic living expenses. In countries with national health insurance, such as Costa Rica, such leave may be paid for out of a general disability fund paid into by the citizenry, along with employer contributions. Thus, the opportunity exists to roll in at least a limited form of paid leave with health care reform.

Conclusions:

The ideal infrastructure around breastfeeding in the US would involve a central lead government agency for breastfeeding, with adequate line-item funding to sustain it, starting with at least $10-$20 million. In concert with the US Breastfeeding Committee, other government agencies would work in concert with this lead agency, with one goal of achieving widespread implementation of the Baby-Friendly Hospital Initiative. In addition, paid maternity leave and/or worksite protection and workplace insurance incentives could possibly be rolled into a health care reform measure.

It is in the best interest of the United States to fund and build an infrastructure to support breastfeeding. Our nation faces epidemics of obesity, breast cancer, diabetes, and cardiovascular disease. Funding an infrastructure around breastfeeding should be a priority that likely will reap significant returns on investment in form of reduced health expenditures and reduced health disparities.

References:
1. Bergmann KE, Bergmann RL, Von Kries R, et al. Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. Int J Obes Relat Metab Disord 2003;27:162-72.
2. Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics 2004;113:e81-6.
3. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol 2005;162:397-403.
4. Shields L, O'Callaghan M, Williams GM, Najman JM, Bor W. Breastfeeding and obesity at 14 years: a cohort study. J Paediatr Child Health 2006;42:289-96.
5. Family physicians supporting breastfeeding (position paper). 2008. (Accessed January 20, 2009, at http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositi....)
6. American College of Obstetricians and Gynecologists. Breastfeeding. Washington, DC; 2003 July.
7. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.
8. WHO/UNICEF. WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Geneva: WHO; 2003.
9. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. In: Evidence Report/Technology Assessment Number 153: Agency for Healthcare Research and Quality; April 2007.
10. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of Lactation and Risk Factors for Maternal Cardiovascular Disease. Obstet Gynecol 2009;113:974-82.
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12. Department of Health Services Breastfeeding Promotion Policy, MO-07-0067 BFP. 2007. (Accessed May 26, 2009, at http://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Pages/DHSBre....)
13. Ball T, Wright A. Health care costs of formula-feeding in the first year of life. Pediatrics 1999;103:870-6.
14. Cohen R, Mrtek M, Mrtek R. Comparison of maternal absenteeism and infant illness rates among breast-feeding and formula-feeding women in two corporations. Am J Health Promot 1995;10:148-53.
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17. Breastfeeding Among U.S. Children Born 1999—2005, CDC National Immunization Survey. Department of Health and Human Services, 2008. (Accessed August 12, 2008, at http://cdc.gov/breastfeeding/data/NIS_data/index.htm.)
18. US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: US Department of Health and Human Services, Office on Women's Health; 2000.
19. Infant Feeding Practices Survey II. 2007. (Accessed May 18, 2009, at http://www.cdc.gov/ifps/.)
20. Hofvander Y. Breastfeeding and the Baby Friendly Hospitals Initiative (BFHI): organization, response and outcome in Sweden and other countries. Acta Paediatr 2005;94:1012-6.
21. US Baby-friendly hospitals and birth centers as of April 2009. 2009. (Accessed April 8, 2009, at http://www.babyfriendlyusa.org/eng/03.html.)
22. DiGirolamo A, Manninen D, Cohen J, al e. Breastfeeding-related maternity practices at hospitals and birth centers -- United States, 2007. MMWR 2008;57:621-25.
23. Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics 2005;116:628-34.
24. Whaley SE, Meehan K, Lange L, Slusser W, Jenks E. Predictors of breastfeeding duration for employees of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). J Am Diet Assoc 2002;102:1290-3.
25. Grant J, al e. Expecting better: a state-by-state analysis of parentla leave programs. Washington, DC: National Partnership for Women and Families; 2005.


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