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Melissa Bartick's picture

The budget debates currently paralyzing Washington include proposals that significantly cut funding for public health initiatives, all while our nation fights an exploding epidemic of obesity, diabetes, and chronic preventable illness that cost our nation billions of dollars a year in medical costs and lost productivity.

The Surgeon General recently identified breastfeeding as one our most efficient health promotion strategies. Private industries have repeatedly found that supporting their breastfeeding employees has provided a significant return on investment-- $3 returned for every $1 spent.1 Federal funding for breastfeeding is one initiative that Republicans and Democrats should agree on- it just makes fiscal sense.  And that’s why over 120 organizations, including the American Academy of Pediatrics, have just asked Congress to appropriate $15 million for breastfeeding for the 2012 fiscal year.

Research has consistently found that breastfeeding is associated with decreased infections and many chronic diseases in children, including obesity2 —which is why the First Lady is promoting breastfeeding as part of her campaign to end childhood obesity. Now there is a growing body of evidence linking longer breastfeeding durations with lower risk of many costly diseases in mothers: breast cancer,2 ovarian cancer2, diabetes,2 and cardiovascular disease.3 And we get all this for one single health intervention. As the Surgeon General said, “Rarely are we given the chance to make such a profound and lasting difference in the lives of so many.”4

Yet, U.S. breastfeeding rates fall far short of the medical recommendation for breastfeeding for at least year, exclusively so in the first six months. Seventy-five percent of new mothers in 2007 initiated breastfeeding, but only 13% exclusively breastfed for six months and less than 23% were still breastfeeding at one year.5

One reason for our poor breastfeeding rates is that families face many “booby-traps” which actively undermine a woman’s ability to breastfeeding successfully. Some of the biggest booby-traps of all are the practices in our own maternity hospitals, practices which make it difficult for an infant to learn basic breastfeeding skills and for his mother’s body to make enough milk. One booby-trap is the routine separation of mothers and babies, especially in that precious first hour of life, which is so important for the baby to imprint proper suckling.  Another hospital booby trap occurs when hospitals give breastfeeding infants formula without a medical reason – a practice that is highly predictive of early breastfeeding failure. When the CDC recently scored maternity hospitals on their practices that impact breastfeeding, the average US hospital scored only a 63 out of a possible 100 points,6, 7- a failing grade by any standard. It’s no wonder that the sharpest decrease in breastfeeding rates occurs within the first month after hospital discharge.8

The World Health Organization and UNICEF have clearly described the maternity practices important for the successful establishment of breastfeeding, all based on scientific evidence. These practices make up the WHO/UNICEF Baby-Friendly Hospital Initiative, and include the Ten Steps to Successful Breastfeeding. The steps include keeping mothers and babies together, initiating breastfeeding in the first hour of life, avoiding pacifiers in the newborn period, and avoiding formula without a medical reason. These steps have been shown to markedly improve exclusive breastfeeding rates and breastfeeding duration in the months after hospital discharge.7, 9, 10And yet, out of nearly 3000 maternity facilities in the US, only 105 carry the official Baby-Friendly designation, less than 4%.11

But changing hospital practice is often very challenging. For example, hospitals have to completely redesign how they do nearly everything related to newborn care. Their existing workflows may make life easier for staff, but are often not good for mothers and babies. Hospitals who want to go Baby-Friendly face many other barriers, including training of staff. Appropriate training courses exist for nurses, but hospitals often consider paying for education time and fees to be too costly.12 They also need technical assistance to learn how to implement all these changes in the most strategic ways.

Incredibly, Congress currently dedicates no government funding specifically for breastfeeding, outside of the Special Supplemental Nutrition Program for Women, Infants, and Children, better known as the WIC Program. Yet the WIC Program serves only a portion of the population. Wisely, the Affordable Care Act has set aside a Prevention Fund. For FY 11, that’s funded for $750 million.

The Baby-Friendly Hospital Initiative has proven efficacy. In California, for example, the number of Baby-Friendly hospitals has tripled, but these evidence-based reforms have not yet reached hospitals serving the state’s poorest families. A recent report shows that when hospitals improve their newborn feeding policies and practices, however, they dramatically increase their breastfeeding rates. As the report notes, “with growing state and federal emphasis on achieving health equity, outdated institutional policies that create disparities in health are no longer acceptable.”13 Research has shown that the greater the number of the Ten Steps a woman experiences, the more likely she is to still be breastfeeding two months later.7, 9

Investment in improving evidence-based maternity practices would be a highly effective way to increase breastfeeding duration and exclusivity. With 40% of infants on Medicaid, suboptimal breastfeeding rates cost the federal government nearly $1 billion per year in direct medical costs for pediatric disease alone.14 So, if $15 million for breastfeeding sounds like a smart way to spend our tax-dollars, click here to let your legislators know how you feel. It’s going to take a lot more than a village to beat these booby-traps.


1. Slavit W, editor. Investing in workplace breastfeeding programs and policies: An employer's toolkit. Washington, DC; 2009.

2. 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. Rockville, MD: Agency for Healthcare Research and Quality; 2007.

3. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol 2009;113:974-82.

4. US Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. In. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2011.

5. Breastfeeding among U.S. children born 1999-2007, CDC National Immunization Survey. Centers for Disease Control and Prevention, 2010. (Accessed October 21, 2010, at

6. 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.

7. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics 2008;122 Suppl 2:S43-9.

8. American College of Obstetricians and Gynecologists. Breastfeeding: Maternal and infant aspects. 2007.

9. DiGirolamo A, Grummer-Strawn L, Fein S. Maternity care practices: Implications for breastfeeding. Birth 2001;28:94-100.

10. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase breastfeeding duration: results from a population-based study. Birth 2007;34:202-11.

11. BFHI USA. Baby Friendly USA, 2011. (Accessed January 22, 2011, at

12. Bartick M, Edwards RA, Walker M, Jenkins L. The Massachusetts Baby-Friendly Collaborative: lessons learned from an innovation to foster implementation of best practices. J Hum Lact 2010;26:405-11.

13. California WIC Association, US Davis Human Lactation Center. One hospital at a time: Overcoming barriers to breastfeeding. Davis, CA: California WIC Association and UC Davis Human Lactation Center; 2011.

14. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010;125:e1048-56.

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