We must identify and reduce barriers which keep women from beginning or continuing to @eastfeed their infants. 42. Everett Koop, M.D., Sc.D. Surgeon General REPORTY OF THE SURGEON GENERAL'S WORKSHOP ON BREASTFEEDING & HUMAN LACTATION Presented by the US. DEPARTMENT OF HEALTH & HUMAN SE&ES PubkHeaiihservice Health Resources and services Administmtbn Bureau of Health Care Dekery and Assistance Dh4skx of Maternal and Chw Health h cooperation with The Uriversilv of Rochester Mediial Center June 11th and 12th. 1964 DHHS Publication No. HRS-D-MC 84-2 The Surgeon General's Workshop on Breastfeeding and Human Lactation was supported by grants from The Daisy Marquis Jones Foundation Medella, Incorporated Parke-Davis The Division of Maternal and Child Health-Public Health Service U.S. Department of Health and Human Services This Report was edited by the Editorial Department of The National Center for Education in Maternal and Child Health: Anthony Waddell, Director of Publications. The original drawing on the cover was done by Bob tinge of Rochester, N.Y. Cover design courtesy of the Publications Office and photos courtesy of the Medical Photo/ Illustrations Unit, University of Rochester Medical Center. PREFACE The Surgeon General's Workshop on Breastfeeding and Human Lactation represents a milestone in our continuing efforts to improve the health of our nation's mothers and infants. Research fmdings have docu- mented the benefits of human milk and lactation for babies and mothers. One of the. "Health. Promotion/Disease Prevention Objectives for the Nation" is that by the year 1990, the proportion of women who breast- feed their babies should be increased to 75% at hospital discharge and 35% at 6 months of age. The last decade has seen a steady increase in breastfeeding, predomi- nantly among middle- and upper-income, educated, white women. We need to identify and reduce the barriers that interfere with breastfeeding, especially in those population groups with low prevalence of breastfeed- ing-among women who are minority, low income, and less educated. The Workshop has provided an opportunity o to review progress of past efforts, in both public and private sec- tors, to promote breastfeeding; o to assess the state of the art related to factors that enhance and those that inhibit breastfeeding and human lactation; o to determine remaining challenges; o to develop strategies and recommendations in order to facilitate progress toward achieving the 1990 Objective. Building on the model of the Healthy Mothers/Healthy Babies Coa- lition, this Workshop involved the participation of representatives of major professional and voluntary organizations. These organizations working in the public and private sectors will play a major role in the dissemination and implementation of the national recommendations. The strategies developed at this Workshop will result in promotion of sound infant feeding practices and in informed decisions by more women about breastfeeding their babies. C. Everett Koop, M.D., Sc.D. Surgeon General . . . 111 PLANNING COMMITTEE Planning Committee for the Surgeon General's Workshop on Breastfeeding and Human Lactation WORKSHOP CHAIRPERSON WORKSHOP CO-CHAIRPERSON Ruth A. Lawrence, M.D., F.A.A.P. Department of Pediatrics University of Rochester Medical Center Henry A. Thiede, M.D., F.A.C.O.G. Department of Obstetrics and Gynecology University of Rochester Medical Center WORKSHOP DIRECTOR M. Elizabeth Brannon, M.S., R.D. Division of Maternal and Child Health U.S. Department of Health and Human Services COMMITTEE MEMBERS Organizational Representatives Jeanne F. Arnold, M.D., F.A.A.F.P. American Academy of Family Physicians Richard H. Aubry, M.D., F.A.C.O.G. American College of Obstetricians and Gynecologists Betty Ann Countryman, R.N:, MN. La Leche League International Judith A. Flanagan, C.N.M., M.S. American College of Nurse-Midwives Fred Holmes, M.D., F.A.A.P. American Academy of Pediatrics iv Mary Hughes, Ph.D. March of Dimes Birth Defects Foundation Jennifer R. Niebyl, M.D., F.A.C.O.G. American College of Obstetricians and Gynecologists Julie Norris, R.N. American Hospital Association Judy Perkin, Dr.P.H., R.D. The American Dietetic Association Nancy Whitley, C.N.M. Nurses Association of the American College of Obstetricians and Gynecologists Federal Representatives Joyce 0. Arango, M.P.H., R.D. U.S. Department of Agriculture Thor&n A. Fjellstedt, Ph.D. National Institutes of Health Vince L. Hutchins, M.D., M.P.H., F.A.A.P. Health Resources and Services Administration Patricia Keamey, R.D,, M.S. The White House Michael McGinnis, M.D. Office of the Assistant Secretary for Health Univemity of Rochester Representatives Bernard B. Keele, Jr., Ph.D. Office of Public Affairs Paul Lamb&e Continuing Professional Education Milton B. Lederman, Ph.D. Office of Public Affairs V WORKSHOP PROGRAM June l&19%4 MO am. - 12:oo noon Presiding Welcome Introduction of the Surgeon General 8:x) a.m. Keynote Address 850 km. Humin Lactation as a physiologic Pmcess 93 a.m. the Unique Values of Human Mi 940 a.m. Bra&feeding Patterns in the United StZ%tCS $55 am. opening menery session The Strong Auditorium University of Rochester Elizabeth Brannon, MS.. RD. Nutrition Specialist Division of hlatemal and Child Health United States Department of Health and Human Services Robert Sproull, Ph.D. P&dent University of Rochester Frank Young, M.D., PkD. Vii President for Health Affairs Dean, School of Medicine and Dentistry University of Rochester Ruth A. Lawrence, M.D. ASSO&XC Professor, Departments of Pediatrics and Gbstetrics and Gynecology University of Rochester Henry A. T&de, M.D. Chairmen, Deprtment of Gbstetrics and Gynecology University of Rochester Michael h&Gin& M.D. Deputy Assistant Secretary for Health Disease Prevention and Health Promotion United Statr, Department of Health and Human Services C. Everett Koop, M.D., Sc.D. Surgean Genertd Ruth A. Lawrence, M.D. Cutbcrto Garza M.D., Ph.D. -iate Director, USDA Children's Nutrition Research zent of Pediitrics Baylor College of Medicine Gilbert Martinez, M.B.A. Director of Marketing Research Ross~Labomtorics Nutrition Break vi 955 a.m. IO:25 a.m. The Cultural Context of Breastfeeding in the United States Nutrition Break 1050 a.m. Successful Approaches to Promote Breastfeeding State-wide Approach City-wide Approach Hospital-based Approach 1 I A0 a.m. Guidelines for Work Groups 12:15 p.m. - 1:45 p.m, Audiovisual Presentation "Outside My Mom" `I& Lay Volunteer in the Mother-to-Mother Program of La Leche League 23Xl p.m. - 430 p.m. Susan Scrimshaw, Ph.D. Asaociite Professor of Public Health Divlalon of Population, Family and International Health University of Caliiomip. Los Angeles Henry A. Thiede, M.D., Moderator Jerianne Heimendinger, D.Sc., M.P.H. Director of Nutrition Services Rhode Island Department of Health Linda Randolph, M.D., M.P.H. Director, Oftke of Public Health New York State Department of Health John E. Alden, M.S., C.N.M. Indian Health Service Poplar, Montana Audrey Naylor, M.D., Dr.P.H. Co-Director, San Diego Lactation Program Mercy Hospital and Medical Center Martin Nacman. D.S.W. Director, Social Work Divison, Strong Memorial Hospital Professor, Department of Health Services University of Rochester Luncheon Bridge Lounge and May Room Wilson Commons Vince L. Hutchins, M.D.. M.P.H. Director, Division of Maternal and Child Health United States Department 4 Health and Human Services Rabbi Judea B. Miller Temple B'rith Kodesh March of Dimes Birth Defects Foundation Viola Lumon Founding Member, La Leche League International Work Groups Medical Education Building vii 7:oO p.m. Master of Ceremonies Invocation Speaker Breastfeeding: New York State's Infant Health Strategy June 12, lwlrl 7~45 a.m. 8:30 a.m. - It:45 a.m. 12:oO noon - 1:45 p.m, Invocation Speaker Breastfeeding and the Medii 2:W p.m. - 4~00 p.m, Presiding Reports from Work Groups 3a4lO p.m. 3:15 p.m. Summary of Recommendations and Presentation to the Surgmn General Response of the Surgeon General Closing Remarks Reception and Dinner Memorial Art Gallery and Cutler Union Prince Street Campus Richard Collins, M.D. Avon, New York Charles T. Lavery. C.S.B. Chancellor, St. John Fisher College David Axelrod, M.D. Commissioner, New York State Department of Health Continental Breakfast Medical Education Wing Work Groups Luncheon Helen Wood Hall Robert E. Hoekelman, M.D. Chairman, Department of Pediatrics University of Rochester Chaplain Thomas Herb& M.Div., M.Ed. Strong Memorial Hospital Robert Bazell NBC Network Closing Plenary Session First Floor Auditorium Medical Education Wing Vince L. Hutchins, M.D., M.P.H. Open Discussion Ruth A. Lawrence, M.D. C. Everett Koop, M.D., Sc.D. Frank Young, M.D., Ph.D. . . . Vlll CONTENTS INTRODUCTION .................................................................................. SURGEON GENERALS KEYNOTE ADDRESS.. ........................ EXCERPTS FROM PRESENTATIONS Human Lactation as a Physiologic Process.. ............................. The Unique Values of Human Milk ........................................... Trends in Breastfeeding in the United States ............................ The Cultural Context of Breastfeeding in the United States .... Successful Approaches to Promote Breastfeeding State-wide Approach ........................................................ City-wide Approach ......................................................... Rural-community Approach ............................................ Hospital-based Approach ................................................. Breastfeeding: New York State's Infant Health Strategy ......... The Lay Volunteer in the Mother-to-Mother Program of La Leche League ................................................................. Breastfeeding and the Media ................................. ..+ .................. Reflection on Breastfeeding ........................................................ WORK GROUP RECOMMENDATIONS ........................................ SUMMARY OF WORKSHOP RECOMMENDATIONS.. .............. RESPONSE OF THE SURGEON GENERAL ................................ CLOSING REMARKS .......................................................................... APPENDICES A-Participants.. ........................................................................... B-Facilitators and Recorders .................................................... C-Key Elements for Promotion of Breastfeeding in the Continuum of Maternal and Infant Health Care.. .......... D-Selected Readings ................................................................. 1 3 9 14 18 23 30 36 39 41 52 55 58 61 63 75 77 81 82 89 90 92 ix 447-700 0 - 84 - 2 1 Doctor Beverly Winikoff feeds her daughter, Lindsay. INTRODUCTION Breastfeeding is believed to provide substantive advantages to both the mother and the infant. The mother's choice to breastfeed is most likely based upon the family's knowledge of breastfeeding and their per- ception of the environment in which the infant will be fed. Certain bar- riers at home, work, or school, or in the health care delivery system or the community can negatively influence both a woman's decision to breastfeed and her breastfeeding experience. The promotion of breastfeeding, a national priority, can be achieved through changing community views. Knowledge and acceptance of breastfeeding by the general public are influenced by not only the media but also cultural and ethnic back- ground, community attitudes, family patterns, and formal education. The community attitude to be fostered is that breastfeeding is a normal part of everyday life. A positive attitude toward breastfeeding must be pro- moted in future parents; public officials and employers must be encour- aged to remove barriers to breastfeeding; the health care system must review its policies and procedures to insure that they facilitate breastfeeding; multi-media approaches to specific target audiences must be developed; the education of health professionals on the physiology of lactation and the management of breastfeeding for optimal infant health must be enhanced. Excellent models of support in initiation and continuation of breastfeeding exist. These models need to be shared for application in a variety of settings. To assess the current status of breastfeeding in the United States and to develop strategies to facilitate breastfeeding, Dr. Koop convened the Third Surgeon General's Workshop at the Univer- sity of Rochester, June 11-12, 1984. The Workshop on Breastfeeding and Human Lactation brought together from a wide range of disciplines and settings health professionals who serve different ethnic and cultural groups throughout the nation. One hundred invited participants included representatives of professional and lay organizations, local, state and fed- eral governments, industry, and volunteer groups. Speakers at the opening session discussed the physiology and proc- ess of human lactation, the composition of human milk, trends in breastfeeding, socio-anthropologic factors, and successful approaches for promoting breastfeeding. The roles of the lay volunteer and of the media in the promotion of breastfeeding were highlighted. Participants con- vened in work groups to consider key issues such as the decision to breastfeed, socio-cultural influences and determinants of infant feeding practices, support services for mothers who breastfeed, roles and respon- sibilities of the health care system in promoting breastfeeding, vocational 1 supports and barriers to breastfeeding, educating health professionals and the public about breastfeeding, and research needs related to breastfeeding and human lactation. Excerpts from presentations and rec- ommendations of the work groups are included in this Report. Presenting the findings and recommendations of the Workshop to the Surgeon General, Workshop Chairperson Ruth Lawrence, M.D., synthesized the deliberations of the participants in her summary. The Surgeon General accepted the report, commented on the general topics, and stated that this Report of the Workshop would be prepared for widespread dissemination. 2 KEYNOTE ADDRESS C. Everett Koop, M.D., Sc.D. Surgeon General and Deputy Assistant Secretary for Health In 1978 the World Health Organization set for itself a goal of health for all by the year 2000. Now this is a tall order, and many of the lesser developed countries-those with limited resources-will have trouble in meeting that goal. Other countries, with help from some of the more de- veloped countries in the western world, will succeed in at least improv- ing health for all in their countries by the year 2ooO only to see those gains slip as support is subsequently withdrawn. The United States is a signatory to "health for all" by the year 2000, but we in this country had previously set ourselves a series of objectives to be realized not by the year 2000, but by 1990. These are largely con- tained in a publication called Healrhy People, the Surgeon General's Report on Health Promotion and Disease Prevention. This volume was subsequently supplemented by Objectives for the Nation Among the na- tional objectives for the United States by the year 1990 is the topic of this Workshop. This objective states: "The proportion of women who breastfeed their babies at hospital discharge should be increased to 75%, and the percentage of those still breastfeeding at 6 months of age should be increased to 35%." In 1978, when this objective was chosen, the pro- portion was 45% at hospital discharge and 21% at 6 months of age. His- torically the federal government has not been idle in the promotion of breastfeeding. During the years 1946-47 Dr. Katherine Bain of the Chil- dren's Bureau conducted the first nationwide survey on the incidence of breastfeeding in hospitals in the United States. This report was published in Pediatrics in September 1948. A symposium on human lactation was held at George Washington University in October 1976 and was co-sponsored by the Public Health Service, the March of Dimes, and George Washington University. The proceedings of that symposium were widely disseminated in public health circles. In 1978, an annotated bibliography on breastfeeding, sup- ported by the Public Health Service, was published by the National Academy of Sciences. Then in 1983, a nationwide video-teleconference on improving nutrition of mothers and babies was co-sponsored by the Department of Health and Human Services and the United States De- partment of Agriculture. "Breastfeeding and Human Lactation" was one of two major topics presented during this 3-hour program viewed at 125 sites coast-to-coast. The program presented an update of new research findings with special emphasis on practical application. Edited videotapes of the teleconference are now being disseminated. The Public Health 3 Service has not been idle in current activities. Breastfeeding promotion is one of the thrusts of the Healthy Mothers/Healthy Babies Coalition. A breastfeeding kit for professionals is now being produced in collaboration with several professional organizations, voluntary associations, the De- partment of Health and Human Services, and the United States Depart- ment of Agriculture. The National Natality Survey of the National Center for Health Statistics provides an ongoing surveillance and report- ing mechanism on educational factors associated with breastfeeding. But let us return for a moment to objectives for the nation. The cur- rent roles of the federal government in promoting breastfeeding to meet the already mentioned 1990 national objective include the following: o establishing and promulgating policy; o offering professional consultation and technical assistance to providers; o supporting professional training; o conducting research; o implementing service delivery; and o sponsoring public education. Let me highlight some of these points. In reference to policy on nu- trition, the guidelines and policies issued by recognized professional or- ganizations such as the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the National Academy of Sciences, and the Associa- tion of State and Territorial Health Officials are used by the Public Health Service in formulating policies and recommendations in maternal and child nutrition. Professional consultation and technical assistance on maternal nutri- tion, lactation, and infant nutrition are made available through guidance materials and technical references developed in concert with professional organizations. For example, recommendations on breastfeeding and other information on infant feeding are addressed in the Pediatric Nutrition Handbook published by the American Academy of Pediatrics with the support of the Division of Maternal and Child Health. An example of a more recently developed technical reference is Guide to Breasfeeding the Infant with PKU. Another federal role is the support of professional training. Breastfeeding is included in the curriculum of graduate training pro- grams in public health nutrition and in the maternal and child health cur- riculum for physicians, nurses, social workers, and other health-care pro- viders. For example, over the last 10 years, 200 public health nutritionists have received Title V/Maternal and Child Health support, and 107 nutri- tionists have received National Health Service Corps scholarships for training leading to a master's degree. As in ah of these endeavors, research and study form the basis for policy and practice. In government, the National Institutes of Health plays a major role in breastfeeding research efforts. A revival of interest in the composition of human milk and the special functions of its many components has been stimulated by the necessity of devising proper nu- trient therapy for premature, growth-retarded, and immunologically 4 compromised babies. The National Institute of Child Health and Human Development has stimulated studies of immunologic and nutrient compo- sition, as well as perhaps undefined components and possible contami- nants of coiostrum and human milk obtained from mothers delivering babies at various gestational ages. In addition, in response to the recom- mendations from workshops held by the Division of Maternal and Child Health, in both 1975 and 1976, the National Institute of Child Health and Human Development is supporting applied studies of human milk-bank- ing in order to develop techniques of collecting, storing, and distributing human milk and colostrum for use- in clinical situations. Currently tech- niques are being developed to combat viral contamination without de- stroying immunologically active cells or denaturing proteins that possess antimicrobial activities. The eventual isolation of special immunologic and nutrient components of human milk which could assist in the care of premature and growth-retarded babies will be the hoped-for outcome of such research. As a matter of fact, a workshop was held in September 1982 on human-milk banking in order to provide further stimulation for this expanding research. The report will be available this summer. The National Institute of Allergy and Infectious Diseases is studying the role of breastmilk as a defense against enteric infections. The National Insti- tute of Environmental Health Sciences is conducting a longitudinal study of 900 children in. North Carolina to see if childhood morbidity is attrib- utable to DDT and PCBs in breastmilk. In response to the controversy over the International Code of Mar- keting of Breastmilk Substitutes, two task forces were established by the Assistant Secretary for Health in November 1981. A Public Health Serv- ice Task Force on the assessment of scientific evidence relating to prob- lems of infant feeding, both in domestic and international context, was chaired by the then-Director of the Centers for Disease Control, Dr. William Foege. These findings will be published as a supplement to Pedi- atrics in October 1984. I chaired the other task force on domestic activi- ties, and the findings have been incorporated into a report that I made to the World Health Assembly last month in Geneva. Education, perhaps the most important aspect of all, should not really be left until the last. Educational materials on nutrition for use in counseling parents and other caregivers of children in community health education programs have been developed by the Public Health Service. Maternal and Child Health funds are frequently used by the states to dis- seminate educational materials. An example of this is Breastfeeding, a publication developed in 1979 and aimed at parents-to-be and new par- ents. Other federal agencies such as the United States Department of Agriculture, voluntary groups such as La Leche League, and practition- ers as well as parents had the opportunity to review the material in draft and make suggestions. Thus, the publication is as practical and useful as possible. To date, over 60,000 copies of the publication have been distributed nationwide. Now you might wonder why we are having this Surgeon General's Workshop on Breastfeeding and Human Lactation. Although the number of breastfed infants has grown in recent years, the increase has not been as great in the highest risk groups. The number of women who start to breastfeed has increased, but many of them do not continue breastfeeding beyond the first few weeks of their infant's life. We know that breastfeeding gives babies complete nutrition plus immunologic benefits to launch them on a healthy life. Breastfeeding also provides its particu- lar benefits at a low cost. We must therefore identify and reduce those barriers which keep women from initiating or continuing to breastfeed their infants. And it is now time to consider what needs to be done. You have already heard a little bit of why we chose the University of Roch- ester, but let me expand on that. The University of Rochester School of Medicine and Dentistry was selected because of its active and unique ef- forts in the support of breastfeeding. Along with the School of Arts and Sciences and the School of Nursing, the School of Medicine and Den- tistry has developed a cluster for the interdisciplinary study of the phys- iologic, psychologic, sociologic, and anthropologic aspects of human lac- tation. Dr. Ruth Lawrence, Associate Professor of Pediatrics and of Ob- stetrics and Gynecology, is the workshop chairperson and a nationally recognized authority on breastfeeding. She is the author of the primary text on the subject entitled Breastfeeding: A Guide for the Medical Profes- sion. The University of Rochester has a strong Obstetrics and Gynecol- ogy Department whose chairman is Dr. Henry Thiede. He is co-chair- person of this workshop. Dr. Thiede, in his prior position as the Chair- man of OB/GYN at the University of Mississippi, was instrumental in the creation of the certified nurse/midwifery training program. Now, let us turn our attention to what will be going on here for the next two days. The luncheon speaker today will highlight the role of the lay volunteer in the mother-to-mother program of the La Leche League. On Tuesday, Bob Bazell, Health and Science Correspondent for NBC, will discuss the use of media in promoting breastfeeding. Speakers this morning will give us an update on the state of the art and the state of science on the physiology of breastfeeding, the unique values of human milk, current trends, and cultural factors related to breastfeeding. This introduction will provide background for the discussions to follow in the , work groups. Models of successful approaches will also be presented this morning, in order that they become part of our knowledge base. This afternoon and continuing through tomorrow morning, participants will convene in 8 work groups to consider and make recommendations on key issues, such as: 6 o the decision to breastfeed; o so&cultural influences and determinants of infant feeding practices; G support services needed for initiation and continuation of breastfeeding; o roles and responsibilities of the health-care system in promoting breastfeeding; o overcoming barriers to breastfeeding in the world of work, o educating health professionals and the public about breastfeeding; and o research needs in breastfeeding and human lactation. My charge to the participants of this Workshop is to report the fol- lowing: which efforts have been successful, which need better applica- tion, what else do we need to know, and what of the above will better promote breastfeeding among high-risk groups in order to realize greater benefits? Now this charge, as I stated earlier, is a tall order, but I know that you will do this, I know that you will do it well, and I will be here tomorrow afternoon to receive your report. Thank you very much. EXCERPTS FROM PRESENTATIONS HUMAN LACTATION AS A PHYSIOLOGIC PROCESS Ruth A. Lawrence, M.D. Lactation is the physiologic completion of the reproductive cycle. The breast, the body, and the psyche are prepared for lactation during pregnancy. The newborn infant is prepared to suckle at the breast at birth. Growth of the mammary gland is a gradual process that starts during puberty under the influence of the sex steroids. The embryonic buds which developed initially in the fetus and have been quiescent since birth are stimulated by estrogen to proliferate and to become multilay- ered. Buds and papillae are formed. The lobuloalveolar development and ductal proliferation depend on the intact pituitary gland. There are three major stages of activity: I) mammogenesis-mam- mary growth, which begins embryonically and culminates during preg- nancy, 2) lactogenesis-the initiation of milk secretion, which begins in pregnancy and increases at delivery, 3) galactopoeisis-maintenance of established lactation, which begins a few days postpartum and continues as long as there is stimulus. The embryonic breast begins its preparation at puberty when the hy- pophyseal-ovarian-uterine cycle is established. Fifteen to 20 primitive ducts arborize extensively and form a compound tubuloalveolar gland. A relatively inactive stage continues through adult life until pregnancy ini- tiates the proliferative stage. Spectacular ductal growth begins in re- sponse to luteal and placental hormones. There is true hyperplasia, but in an orderly fashion, as one alveolus does not overrun another. (Figure I) The hormones-placental lactogen, prolactin, and chorionic gonado- tropin-contribute to the acceleration of growth. At this stage one can observe the complex interaction of the many hormones that function in the development of both the fetus and the breasts during pregnancy. Es- trogen stimulates ductular sprouting, and progesterone stimulates lobular formation. There is a delicate balance of prolactin inhibiting factor in the hypothalamus and prolactin production in the adenohypophysis as the presecretory phase progresses in the second trimester to a secretory phase. In this phase, material resembling colostrum is seen in the alveoli stimulated by placental lactogen. A mother delivering a previable infant at 16-weeks gestation will se- crete colostrum. As early as 24 weeks, lipid droplets can be seen in the 9 A 8 C D E Figure 1. Female breast from infancy to lactation with corresponding cross section and duct structure. A, B, and C, Gradual development of well-differentiated ductular and pe- ripheral lobular-alveolar system. D, Ductular sprouting and intensified peripheral lobular- alveolar development in pregnancy. Glandular luminal cells begin actively synthesizing milk fat and proteins near term; only small amounts are released into lumen. E, With post- partum withdrawal of luteal and placental sex steroids and placental lactogen, prolactin is able to induce full secretory activity of alveolar cells and release of milk into alveoli and smaller ducts. alveolar cells. The composition of the secretion is fairly consistent from 16-17 weeks right up to the time of delivery. With the delivery of the placenta, the source of hormones is lost abruptly and the plasma levels begin to fall. Placental lactogen is gone within hours, progesterone within 2-3 days, estrogen reaches basal levels within 5-6 days, but prolactin levels depend upon the amount of suck- ling. In the non-nursing mother, prolactin drops to prepregnant levels in about 14 days. Observation of nursing mothers with retained placenta in- dicates that lactation is suppressed until the placental fragments are re- moved. This supression is similar to the lack of milk secretion seen in mothers experiencing an intrauterine death. Evidence strongly suggests that it is loss of the placental progesterone with the decline in plasma progesterone which triggers galactogenesis, or milk production. The necessity for adequate levels of prolactin for lactation to begin in humans has been demonstrated. The exact role of prolactin in ade- 10 quate milk production, however, continues under investigation. In the first week postpartum, the high levels of prolactin are only slightly aug- mented by nursing. In the second stage, from 2 weeks to 2 months, base- line levels of prolactin are 2-3 times normal, and increase to 10-20 times normal with suckling. The third phase begins at about 3 months and lasts to weaning. Prolactin levels are almost normal, and no rise is seen with suckling, even though milk production continues. The role of other hormones such as insulin and thyroxine in mammogenesis, lactogenesis, and galactogenesis is well established, but the definition of their roles does not have universal agreement. The breast does not function in isolation, but in synchrony and balance with the maternal endocrine system. The process of milk synthesis is complex. There is a marked alter- ation of the maternal metabolism with a redistribution of the blood supply and an increased demand for nutrients. The mammary blood flow, cardiac output, and milk secretion are suckling-dependent. These changes in turn trigger the hypothalamus to release prolactin to act on the mammary cells. Milk is iso-osmolar with plasma in all species. Al- though milks of different species vary tremendously, each is physio- logic for the growth demands of that species. The biosynthesis of milk involves a cellular site where the metabolic processes occur. Milk is secreted by apocrine and merocrine mechanisms. Protein and fat are synthesized de novo; lactose is synthesized from glu- cose; ions and water diffuse across the membrane so that primary alveo- lar milk is diluted to plasma isotonicity by water extracted from extracel- lular fluid. While the glands prepare for full lactation, other structures of the breast prepare as well. The areolae increase in prominence with the de- velopment and activity of the glands of Morgagni which provide a secre- tion to lubricate and protect the nipple and areolae during suckling. Some of the zealous rituals recommended to mothers during pregnancy (such as scrubbing, buffing, and stretching these tissues) actually interfere with nature's process. During pregnancy, the body stores nutrients that are intended for the manufacturing of milk in the postpartum period. Eight to 10 pounds of added weight (neither fetus, placenta, uterus, or fluid) are carefully stored for future nutrient and energy needs. The body stores reflect the cumulative dietary intake of prepregnancy and pregnancy coupled with the short-term dietary variation to ensure daily sources of both macro- and micronutrients. Thus the daily nourishment provided through the milk is consistent and balanced. Temporary deficiencies of diet are com- pensated by body stores. Lactation also influences the return to prepregnant state for the mother. Getting back "in shape" is facilitated by utilizing the extra weight of pregnancy for milk production. Thus, breastfeeding women return to baseline weight more quickly. The direct effect of the oxytocin released on stimulus of suckling not only contracts the myoepithelial cells for milk ejection but also con- tracts the uterus for faster physiologic involution and increased tone. 11 In most anticipated normal pregnancies, a woman finds that the hor- monal milieu triggers latent maternal instincts leading to anticipation of holding the infant closely to the breast and providing continued nourish- ment. Parenthood potentially provides the opportunity for psychologic growth from the egocentricity of adolescence to an adult self-concept in which the mother cares for and nourishes this new being. The mind, however, is not controlled by body function alone. Many societal, community, family, and individual forces influence attitudes and feelings about breastfeeding. If a woman rejects her own mother as a model, other life experiences prevail. There are other psychodynamic issues and social trends that may lead to negative decisions about breastfeeding. In the meanwhile, the fetus is simultaneously undergoing develop- ment. The infant is prepared to suckle shortly after birth. The newborn already has been making sucking motions in utero. Part of the balance of the amount of amniotic fluid depends upon the fetus sucking and swal- lowing fluid in utero. Until birth, the infant has not had to synchronize this action with breathing, but as Tizzard showed in England some years Hypothalamus Figure 2. Diagrammatical outline of ejection reflex arc. When infant suckles breast, he stim- ulates mechanoreceptors in nipple and areola that send stimulus along nerve pathways to hypothalamus, which stimulates the posterior pituitary to release oxytocin. It is carried via bloodstream to breast and uterus. Oxytocin stimulates myoepithelial cells in breast to con- tract and eject milk from alveolus. Prolactin is responsible for milk production in alveolus. It is secreted by anterior pituitary gland in response to suckling. Stress such as pain and anxiety can inhibit let-down reflex. The sight or cry of infant can stimulate it. Figures by permission of C. K Mosby Cotipany. 12 ago, suckling at the breast is compatible with continuous breathing com- pared to the suck-swallow-breathe pattern of the infant while bottle feed- ing. The infant also has a rooting reflex that helps him turn to grasp the nipple. The normal newborn infant adapts to breastfeeding readily. When the infant grasps the nipple and areola, the sucking stimulates the nerve fibers in the nipple and these, in turn, stimulate the afferent nerve fibers via the spinal cord to the mesencephalon and the hypothalamus in the maternal brain and trigger the pituitary to release two hormones-prolactin and oxytocin. (Figure 2) The prolactin stimu- lates the synthesis and secretion of milk itself. The oxytocin rapidly causes the ejection of milk from alveoli and smaller ducts into larger lac- tiferous ducts and sinuses by stimulating the myoepithelial cells to con- tract. The myoepithelial cells (or basket cells) are wrapped about the ducts, and when they contract, milk is ejected. Milk ejection involves both neural and endocrine stimulation and response. A neural afferent pathway and an endocrine efferent pathway are required, but this stimu- lus is triggered predominantly by touch and not by pressure of a full milk gland. This response may be inhibited by pain or stress. Breastfeeding is not a reflex; it is a learned process. In our present culture, many women have never witnessed an infant at the breast. When a woman is called upon to nurSe her own infant, much of her success depends on a learning process. Successful lactation depends on proper in- formation. As increased numbers of women breastfeed, we need more knowledge to help those who have difficulty in lactating. Another phys- iologic effect of lactation-important, though it receives little notice-is the suppression of ovulation and of menses. There is a temporal differ- ence in the return of menses and ovulation among women who fully lac- tate, who partially lactate, and who have either discontinued breastfeed- ing or never began. The nonlactating woman ovulates within 4-6 weeks of delivery; the lactating woman does not ovulate for 4 months or more. This effect plays a role in general population statistics. Finally, as we look at all the physiologic processes, the interaction of the breast with the mother's other bodily functions, we see that breast- feeding is an art-one based on the science of lactation. We need to con- tinue our explorations, for as Aristotle would have it: "There is a reason behind all these things in nature." 13 THE UNIQUE VALUES OF HUMAN MILK Cutberto Garza, M.D., Ph.D. Introduction Recommendations of human milk as the ideal nutrient source for term infants are common. These endorsements and the growing clinical interest in its use have prompted a remarkable increase in studies of human milk. The results of such investigations have underscored the dual roles played by its constituents: 1) the classic role that is associated with most nutrients, i.e., the provision of enzymatic cofactors or substrates for energy or structural components and 2) a more complex role that is the performance of functions complementing the developing abilities of ma- turing infants. For example, proteins provide amino acids for growth, but they occur in the form of polypeptides that aid in digestion, host defense, and other functions. Lipids provide a major source of energy, but some also have antiviral properties that may impart protection to the develop- ing infant. In addition, this nutrient class provides fat-soluble vitamins and essential fatty acids that are important structural membrane compo- nents, especially in the nervous system. Carbohydrates provide a signifi- cant portion of the energy in milk and also enhance mineral absorption, i.e., calcium; modulate the growth of bacteria, i.e., bifidus factor; and possibly act to prevent the attachment of selected bacteria to retropharyngeal and other epithelial cells found in respiratory and gas- trointestinal surfaces exposed to environmental pathogens. Milk Intake of Breastfed Infants The unique pattern of constituents in human milk and the feeding practices inherent to breastfeeding appear to result in distinctive levels of milk intake between breast- and formula-fed infants. Recent data indicate that the intake of breastfed infants reaches a plateau at approximately 733 g/day through the first 4 months of lactation. Therefore, on a body weight basis, the energy intake falls from approximately 110 to 70 kcal/ kg by the fourth month. These intakes are substantially below those of formula-fed infants and below levels currently recommended for this age group by the National Research Council. Despite these differences between recommended amounts and ob- served intakes, exclusively breastfed infants appear to grow well. Never- theless, the possibility that human milk may become limiting by the fourth month for most infants has been suggested. Current measurements of the intakes of infants whose diets are supplemented ad libitum with solids, however, do not support this view. Results of these recent studies indicate that when the diet of the exclusively breastfed infant is comple- mented with solid foods, intakes remain at approximately 70 k&/kg, and infants continue to grow well. 14 These findings raise interesting points for discussion. They suggest that a child's energy intake is dependent upon the mode of feeding. It is not clear if the differences in intake between formula- and breastfed in- fants represent a more active "gate-keeping" role by mothers of formula- fed infants or represent sound physiologic responses to different nutrient sources.. Formula-fed infants may require "more" food to attain approxi- mately the same endpoint as their human-milk-fed counterparts. Human milk is a highly complex mixture with a nutrient balance that may pro- mote a level of metabolic efficiency unattainable by the formula-fed infant. Yet, if we compare present estimates of the quantities of energy required for growth and maintenance by the Cmonth-old infant, it ap pears that the exclusively breastfed infant would have no energy avail- able for activity. Are the metabolic economies recruited to achieve the apparent high level of efftciency in the breastfed infant accomplished by more conservative uses of energy for growth and maintenance, or are these efficiencies accomplished by a significant curtailment in activity? Are the same levels of efftciency possible under hostile environments? If the energy consumed by bottle-fed infants represents a true excess, are there any positive or negative short-term or long-term consequences? These observations pose questions of significance to the general health of all infants. Functional Components: An Example-Secretory IgA The issues raised by the differences between energy and protein in- takes of formula- and human-milk-fed infants are interrelated with the in vivo roles of milk components with demonstrated functional potentials. Of these components, those with protective functions have been exam- ined most actively. Secretory IgA (SIgA) is the predominant immuno- globulin in human milk and is thought to represent one of its key protec- tive agents. Specific SIgA antibodies are found against a wide array of bacterial and viral organisms. This protein has the ability to adhere to mucosal surfaces and prevent the subsequent attachment, and possibly the inva- sion, of specific infectious agents. Significant data exist indicating that the appearance of these specific antibodies in milk is a response to envi- ronmental challenges. Specific antibodies have been observed in the first few weeks of lactation and are known to persist through 2 years of lacta- tion. Observations made during weaning suggest that these antibodies persist through the period of decreased suckling stimulation. The presence in human milk of SIgA antibodies which act against potential pathogens in the maternal environment provides for "environ- mentally specific" milk. The mechanism by which these antibodies, di- rected against gastrointestinal and respiratory pathogens, appear in human milk has been difficult to identify. In contrast to the gastrointesti- nal and respiratory tracts, where such SIgA is abundant, direct contact with such antigens is unlikely to occur in breast tissue. Experimental data suggest that immune cells travel from gastrointestinal and respiratory-associated immune tissues to multiple mucosal surfaces, in- 15 eluding breast tissue, and thereby effect the same specific immunity to all mucosal surfaces. During lactation, the "homing" of these cells to the breast appears to be activated by hormonal profiles which exist only in lactating women. The concept of a gastrointestinal-respiratory-mammary immune circulation provides an explanation of the means by which anti- gen stimulation at distant sites results in the local production of specific SIgA antibodies in milk. This is one example of a protein with a great degree of specificity. There are other proteins that have more general, potentially protective functions. It is important to emphasize that carbohydrates and fats also have functions which may contribute to the high level of metabolic efft- ciency apparently characteristic of the breastfed infant. Significance of Functional Components Although the potential roles of specific antibodies, nonspecific immunologic factors, and other functional components may be extrapo- lated from laboratory studies, a definitive demonstration of their signifi- cance in free-living populations has been much more problematic. For example, differences in morbidity between bottle- and breastfed infants often are difftcult to interpret because of confounding environmental and demographic variables. Factors such as the degree of preventable con- tamination of artificial formulas, the number of caretakers with whom the child has contact, the behavioral characteristics of the caretaker-in- cluding sanitation practices and other mothering skills, the number of po- tential disease-carrying contacts, etc.- are difficult to control unless ap- propriate data are collected and sufficiently large numbers of subjects are recruited. Research designs must account for the "unidirectional" flow of infants from one feeding category to another. A breastfed infant may become exclusively bottle-fed for many reasons. An exclusively bottle- fed infant, however, is unlikely to become exclusively breastfed. Al- though most studies that compare morbidity among children fed human milk or synthetic formula have not controlled adequately for all of the confounding factors, most studies from developed and developing coun- tries have reported significantly fewer illnesses in breastfed infants. A few have found no differences, but there are no reports of increased morbidity among the human-milk-fed groups. Differences in morbidity between feeding groups have been demonstrated more consistently, how- ever, in developing countries than in developed countries. Whereas avail- able data are not conclusive, they generally support the theory that human milk provides components that complement a developing immune system in the infant. Although it is not known whether these comple- mentary components participate in the improved development of active immunoprotective abilities, they may serve as substitutes until the infant matures sufficiently to mount an active immune response. Whether or not the protective effects of human milk components are made real or potential by environmental conditions, such benefits are available only if the infant is breastfed. 16 Conclusion Knowledge of the apparent differences between the ad libitum in- takes of breast- and formula-fed infants, changes in the composition of human milk as lactation progresses, and responses of immunologic fac- tors in human milk which effect environmentally specific protection con- tribute to the consensus that feeding human milk to infants is beneficial. The implementation of this consensus requires the identification of bar- riers that impede successful lactation. The consensus that recommends human milk also poses a significant opportunity to private and public health services to aid in the implementation of a practice which pro- motes health and fosters greater individual responsibility for health. 17 TRENDS IN BREASTFEEDING IN THE UNITED STATES Gilbert A. Martinez, M.B.A. In 1971 the incidence of breastfeeding declined to its lowest level- 25%. Since then, breastfeeding has increased to 61.9% in 1982 and has declined marginally to 61.4% in 1983. (Figure 1) The duration of breastfeeding similarly declined in 1971 to its lowest level of 9% of women who breastfed 3 months or longer. Since then, breastfeeding for at least 3 months has increased to 40% of women giving birth in 1983. Between 1978 and 1983 breastfeeding increased from 47% to 61% nationally, with substantial variation among socio-demographic groups. The highest incidence of breastfeeding occurs among well-educated, rela- tively affluent, somewhat older women living in the Western part of the country. Conversely, the lowest proportion of women breastfeeding is among mothers under 20 years of age, grade-school educated, lower income, black, and living in the East South Central part of the country- Kentucky, Tennessee, Alabama, and Mississippi. (Figure 2; Table 1) The proportion of women breastfeeding their infants at 5 and 6 months of age increased from about 20% in 1978 to 27% in 1983. The 96 70 60 50 40 30 FIGURE l- Incidence of Breastfeeding U&A. % of Infants Breastfed by Year 1970.1983 - In-Hospital (Ross) /- r L- Government 01 I I I I I I I I t I 70 71 72 73 74 '75 76-77 '78-79 '80-81 '82 '83 Savs: Ram bbombxks Naticd Mothas Survey Nati!mal Survey Family Growth, NCHS 18 FIGURE 2. MS3 Incidence of Bread-g by US. Census Regions @@ h than 58.4 m 58.4 - 61.4 ffjJ&Q 61.4 - 75.0 m Above 75.0 Source: Ross Laboratoti National Mothers Survey same differences by socioeconomic groups previously mentioned prevail at 5 and 6 months of age. The most rapid percentage increases in the incidence of breastfeed- ing between 1978 and 1983 occurred among women with the least educa- tion, employed full-time, multiparous, and in the West South Central area-Arkansas, Louisiana, Oklahoma, and Texas. The least rapid per- centage growth occurred among mothers under 20 years of age, the well-educated, the unemployed, and those with lower incomes. The proportion of black women who breastfed their infants in 1978 is unavailable. Hendershot reported 17% of black women breastfed their infants in 1975. For the 2-year period of 1978-1979, 24% of black infants were breastfed. In 1983 that figure had increased to 32%. (Figure 3) The proportion of black women who breastfed their infants in 1983 for 3 months or more was 20%, and was less than half of the 42% of white women who breastfed for 3 months or more. Among black women, as among the whole country, the lowest inci- dence of breastfeeding occurs among young, less educated, low-income women, and, as is true among all women, the highest incidence of breastfeeding occurs among those Blacks with the most education and income. (Table 2) The proportion (54%) of Hispanic women who breastfed their in- fants in 1983 is less than the national rate. 19 FIGURE 3- Incidence of Bred&ding USA. 9% of Infants Breaded by Race 197043 White (Government) r r Black (Government) White 70 71 72 73 74 Souras: Ros Laboratories National Mothers Survey National Survey Family Growth. NCHS 75 `76-77 78-79 `80-81 `82 `83 Rank 1 2 3 4 5 ; 8 9 10 11 12 13 14 15 16 17 18 19 20 TABLE l- Breastfeeding by Demographics: 1983 Characteristic Percent breastfed 1 College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pacific.. .................................................................................... Momltain ................................................................................. > S25,OOO income.. ................................................................... 30 to 34 years of age.. ............................................................ 25 to 29 years of age.. ............................................................ Primiparous ............................................................................. $15,000 to $24,999 income.. ................................................... White ....................................................................................... West North Central.. .............................................................. Not Employed ........................................................................ New England.. ........................................................................ $10,000 to $14,999 income.. ................................................... National.. ................................................................................. Employed.. .............................................................................. 35+ years of age.. .................................................................. East North Central.. ............................................................... Multiparous.. ........................................................................... West South Central.. .............................................................. 20 to 24 years of age .............................................................. 78 78 77 71 67 :: 64 64 63 62 61 61 zi 60 59 58 58 57 Percent of bi*E i 3 33 16 6 32 16 ii 26 80 8 65 5 I5 35 5 18 57 13 33 Rank 20 21 22 23 ;: 26 27 28 29 Characteristic Percent breastfed r South Atlantic. ......................................................................... Hispanic ................................................................................... High School Education ......................................................... Middle Atlantic ...................................................................... East south central ................................................................. <5 lbs. 8 oz. biiweight ....................................................... < $10,000 income .................................................................... <20 years of age.. .................................................................. Grade School Education ....................................................... Black ........................................................................................ 57 54 54 52 49 46 44 43 41 32 I 15 15 63 13 7 7 26 15 4 16 sources: r Ross Laboratories' Mothers' Survey. z Advance Report of Fii Natality Statistics, 198 1. s Population Characteristics, Series P20, No. 386, April 1984 (women 18-44 years of age). TABLE 2- Breastfeeding by Demographics among Blacks: 1983 Rank Characteristic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Pacific ........................................................................ 9 16 Mountain ................................................................... 1 6 >S25,ooO income.. ..................................................... 56 13 32 College.. ..................................................................... 55 22 33 New England ............................................................ 54 2 5 Sl5,OOO to $24,999 income.. ..................................... 45 18 26 Employed .................................................................. 41 33 35 35+ years of age ...................................................... 41 4 5 West North Central.. ................................................ 38 8 30 to 34 years of age ................................................ 38 1: 16 25 to 29 years of age ................................................ 38 24 31 Primiparous ............................................................... 38 40 43 East North Central.. ................................................. 36 17 18 Middle Atlantic.. ....................................................... 33 15 13 Nation01 ..................................................................... 32 SlO,OOO to 814,999 income.. ..................................... 31 13 15 West South Central .................................................. 31 14 13 20 to 24 years of age ................................................ 30 35 33 Multiparous ............................................................... 29 61 57 (5 lbs. 8 oz. birthweight.. ........................................ 28 13 7 South Atlantic.. ......................................................... 27 28 15 Not Employed .......................................................... 27 67 65 Grade School Education ......................................... 27 5 High School Education.. .......................................... 23 73 6': <$lO,tXlO income.. .................................................... 20 55 26 East South Central ................................................... 20 11 7 <20 years of age ...................................................... 15 25 15 Percent Percent Percent breastfed 1 of black of all I births 2 s birthsaS sourcea: t Ross Laboratories Mothers' Survey. * Advance Report of Final Nirtahty Statistics, 1981. 8 Population Characteristics, Series P20, No. 386, April 1984 (women 18 to 44 yeurs of WI. 21 The decision to breastfeed is made by well over half the women prior to pregnancy. In 1981, 55% of breastfeeding women had made that decision before becoming pregnant and, in 1984, that number had in- creased to 63%. An additional 14% of breastfeeders made the decision during their first trimester, and, by the time of delivery, 98% of breast- feeding women had made their decision. In two prospective studies asking women what they intended to feed their infants and subsequently contacting them after the infant was born, 96% had implemented their prenatal decision to breastfeed. In summary, both the incidence and duration of breastfeeding in- creased significantly among all segments of society from 1971 to 1982. These gains did not continue in 1983, with the incidence dipping slightly from 61.9% of mothers in 1982 to 61.4% in 1983. The figure remains a function of socio-demographic variables: older, well-educated, relatively affluent women living in the Western United States are more likely to breastfeed; younger, less well-educated, black women in the East South Central United States have the lowest incidence of breastfeeding. Contin- ued gains will need to come from this latter group. Since the decision to breastfeed is made by more than half of women before pregnancy, three groups-the black, the young, and the poorly educated-need to be reached early if they are to be influenced to breastfeed. 22 THE CULTURAL CONTEXT OF BREASTFEEDING IN THE UNITED STATES Susan C.M. Scrimshaw, Ph.D. Breastfeeding, Etknicity, and Socioeconomic Status Research on breastfeeding in the U.S. reflects two biases frequently found in medical and public health literature. First, ethnicity, and some- times even socioeconomic status are not even mentioned in many reports. Second, reports mentioning ethnicity and socioeconomic status often focus on incidence without discussing correlates such as attitudes, reasons for the observed behaviors, and the influence of sociocultural background. The ethnic groups frequently discussed in the U.S.-Asians, Blacks, Latinos, and Native Americans-are each in fact a complex set of dis- tinct "sub-groups," with varying degrees of acculturation and levels of socioeconomic status. For example, Latinos include major subgroupings of Cubans, Puerto Ricans, Mexicans, and Mexican Americans with small- er numbers of Dominicans, Salvadorans, Guatemalans, and many more people from Central and South America and the Caribbean. Some La- tinos, especially from the Caribbean and circum-Caribbean areas, are Black and reflect influences of African cultures. While few studies make comparisons between subcultures in relation to breastfeeding, important differences exist. For example, in her report on feeding practices among Anglos, Cubans, and Puerto Ricans in Dade County, Florida, Bryant re- ports that most Puerto Ricans think breastfeeding is better for babies, but almost half the Cuban women think bottle feeding is better. Blacks, frequently thought of as one culture in this country, not only divide into obvious groups like Haitians and Panamanian Blacks, but vary in terms of parts of the country and rural or urban residence. A rural southern Black and an urban western Black are as different from each other as their White counterparts from the same region. Individuals in each subcultural group are proud of their heritage; they resent being lumped with others they perceive as dissimilar. Unfortunately, most of the literature that does discuss breastfeeding and ethnicity does not make these subcultural distinctions. Many of these variations are reduced when socioeconomic and edu- cational statuses are considered. Baranowski et al. showed bimodal edu- cational relationships to breastfeeding in a tri-ethnic population. Both the least and the most educated were more likely to breastfeed. Middle- and upper-class women are now more likely to breastfeed, although research comparing middle- and upper-class women with lower-class women within ethnic minority groups is conspicuous by its absence. Studies such as Baranowski's which compared low socioeconomic status Anglo-Ameri- cans, Black Americans, and Mexican Americans show significant differ- ences between ethnic groups. It should be noted that Baranowski et al. do not distinguish between Mexicans and Mexican Americans, although 23 they report that some of their Mexican American sample were inter- viewed in English and some in Spanish. Higher educational attainment is also correlated with breastfeeding. Again, the effect of education within ethnic groups and subgroups has not been adequately documented. Frequency and Duration of Breastfeeding by Ethnic@ The data on frequency and duration of breastfeeding by ethnicity vary greatly by region and by ethnic group. There is relatively little in- formation on Asian populations, and even less on Native American popu- lations. Breastfeeding in all populations declined from the beginning of this century until the early 197Os, and Blacks may have experienced the greatest decline. Prior to 1960, the majority of Blacks and Latinos breastfed their first babies, and nursed longer than Whites. The trend began to reverse in the early 197Os, but this change ap- pears to be occurring more quickly in White than in Latino, Asian, or Black populations. Current figures for Latinos on breastfeeding at dis- charge from the hospital range from 18% in Upper New York State to 60% in Northern California and 74% in Southern California. Asians are poorly represented in the literature, but Samuels reports that 67% of the Asians in her Northern California HMO population were breastfeeding at hospital discharge. The proportion of Blacks breastfeeding at hospital discharge ranges from 20% in Hartford to 26% in Chicago and 52% in Northern California. These discrepancies illustrate regional and perhaps also rural/urban variations, but probably reflect subcultural and socio- economic variations as well. An example of probable variations according to socioeconomic status is that the Blacks studied by Samuels were participants in a Kaiser HMO as an employment benefit. Their socioeconomic status is probably higher than that of the inner-city Blacks studied by Mohrer. The 74% figure for Latinos in Southern California is from our project, which looked at a population of 5 18 women, 96% Mexican in origin, 4% Mexi- can in descent. The relatively recent Mexican origin of most of these women probably accounts for the very high rate, and illust~:es the im- portance of being able to distinguish between subcultures. Duration of breastfeeding also varies, but drops off sharply after the fust two or three months. According to Martinez and Nalezienski, in 1978 47% of all U.S. women were breastfeeding at hospital discharge, 35% were breastfeeding at two months postpartum, and 20% were breastfeeding at six months postpartum. In one of the two Southern Cali- fornia hospitals we studied, 86% of the Latinos (primarily Mexican) planned to breastfeed as of their in-hospital postpartum interview, but by the six-week postpartum visit, only 43% were still breastfeeding. On the other hand, a greater proportion of Whites breastfed and did so longer. 24 Barriers to Breastfeeding UNDERLYING FACTORS Few of the underlying factors associated with bottle-feeding rather than breastfeeding can be directly related to ethnicity, but relate instead to socioeconomic status or are reported by women in all ethnic groups. Cultural values, however, are likely to influence how these factors are interpreted by women. These factors include: general perceptions of the value of breastfeeding (mostly positive), the baby's father's feelings, embarrassment at the exposure of the breasts, concerns about interfer- ence with sexuality, questions about mother's temperament and suitability for breastfeeding, anxieties about the mother's ability to produce high quality and sufftcient milk, perception of bottles as convenient, percep- tion of breastfeeding as old-fashioned, concerns about breastfeeding ruin- ing the figure, and work intentions. In addition to socioeconomic and educational status, marital status provides another underlying factor. Several studies show that married women are more likely to breastfeed. The proportion of married women giving birth varies by ethnicity, as do socioeconomic status and educa- tional level. One factor identified by Bryant is the husband's role. She found that husbands were more often against breastfeeding in the Cuban and Puerto Rican families she studied, and that Anglo husbands varied from beiig very supportive to indifferent and sometimes negative. The husbands in both Latin0 groups were concerned about exposure of the breasts, inter- ference with sexual activity, and the perceived "old-fashioned" nature of breastfeeding. This finding may appear to contradict the previously men- tioned finding that married women are more likely to breastfeed, but other factors such as the need to work and social isolation may influence single women. One perception often found in Latin0 populations is that of "bad milk" due to maternal stress or tendency to have a temper. Mexicans, Hondurans, Puerto Ricans, and Cubans have all described concern that maternal anger and stress would produce bad milk, which would make the baby sick. This concern was cited as a reason not to initiate lactation. Another interethnic difference identified by Baranowski is the role of the support person. The male partner was the most important breast- feeding support person for the Anglo woman, the woman's mother was most important to Latinos, and a close friend was most important to Blacks. In this study, it was asserted that the woman's mother actually had a negative effect on Anglo women. Despite these interethnic differences, one major underlying obstacle to breastfeeding in all groups is the woman's need to work postpartum. While many women never even initiate breastfeeding because of postpar- tum work plans, others simply stop sooner in order to return to work. In our sample of 518 Mexican women, significantly fewer women planned to breastfeed if they intended to return to work soon. The proportion breastfeeding increased with a later return to work. The highest propor- 25 tion planning to breastfeed did not have any immediate plans to return to work. Women were more likely to return to work soon if they did not have economic support from the baby's father and if they were neither married nor planning to be. Duration of breastfeeding was also influ- enced by work plans, the variable most predictive of breastfeeding dura- tion. Factors such as educational level and social support did not predict intended duration. Embarrassment at feeding in public is more difficult to address than some of the other obstacles, particularly since women are occasionally arrested for indecent exposure while breastfeeding. In this society, women are often told to go to the restroom to breastfeed, where (implic- itly) excretory acts belong. Influences During Pregnancy During pregnancy, family and friends may discuss breastfeeding with the woman, and their influence is reflected in some of the data al- ready described. At this point, the health care providers enter, and can either encourage or discourage breastfeeding by their attitudes and by the information conveyed to the pregnant women. Some studies mention that women did not breastfeed because "it did not occur to them." Many others fmd that hospitals and clinics encouraging breastfeeding report a higher incidence. An intervention study at Roosevelt Hospital in New York revealed that prior to the onset of a prenatal breastfeeding education program, only 11% of a large Hispanic patient population in- tended to breastfeed. At the time of the evaluation of the program, 40% intended to breastfeed, and the majority (70%) followed through with their intentions. Hospital-Based Influences: Delivery and the Early Postpartum Period Regardless of ethnicity of the mother, the hospital experience strongly influences both initiation and duration of breastfeeding. Obsta- cles reported in the literature include: medications given during labor and delivery, delivery complications, cesarean section, baby complica- tions, lack of early mother-infant contact and opportunity to nurse, use of stilbesterol for the suppression of lactation, offering water and formula to the breastfed newborn, restricting maternal access to the baby, re- stricting feedings to every 4 hours, lack of support for overcoming en- gorgement, sore nipples, not giving nursing mothers enough food or liquid, not allowing mothers access to supportive family members during hospital stay, and encouraging breastfeeding mothers to give babies for- mula after nursing to "fill them up." Postpartum contact was associated with breastfeeding duration. Hos- pitals differ significantly in the location and timing of the first attempt to breastfeed, with some encouraging nursing in the delivery or recovery room, some in the mother's room, and some not providing the opportu- 26 nity for nursing at the time of the postpartum interview (approximately 24 hours postpartum for normal births, 48 hours for cesarean sections). Staff attitudes and behaviors are also important. Several researchers point out the different constituencies of nurses. Maternity nurses focus on the mother, and can be either more likely to encourage breastfeeding or may ignore the concept of a mother-baby dyad and focus solely on the mother. Pediatric nurses focus on babies and may be more likely to give babies bottles even when they are supposed to be breastfed. Nurses sometimes encourage the mother to give bottles after breastfeeding. This practice serves to undermine the mother's confidence in her milk, and may influence her milk production as well. Duthie demonstrated that breastfeeding success was significantly associated with not feeding babies sterile water after nursing. Physicians' attitudes toward and knowledge of breastfeeding also need to be addressed. Hollen found that more pediatricians (58%) than obstetricians (38%) thought breastfeeding was important. Among the nearly 200 physicians he studied, only 22% had children who had been breastfed. Halpern et al. also found that pediatricians indifferent to breastfeeding had significantly fewer nursing mothers in their patient populations than pediatricians favoring breastfeeding. Similarly, Acosta- Johnson comments that the barriers to breastfeeding are not so much the women's desires, but the organization of maternity services. We also found that most deviations from "normal" recovery inter- fered with breastfeeding. Cesarean patients had a harder time getting access to their infants, women with fever or on medication were not per- mitted to nurse, and baby complications such as elevated bilirubin levels were cited as reasons not to nurse. Clearly, good research is needed on the validity of these and other medical practices, and staff must be taught to encourage breastfeeding rather than to discourage it. Figure 1 outlines encouraging and discouraging hospital practices. Hospital practices and health care provider attitudes can be discouraging to women in all ethnic groups, but cultural norms can influence factors such as assertiveness, at- titudes toward medical authority, and feelings of autonomy. For some women, language can create an additional barrier. Conclusions and Recommendations The research on breastfeeding attitudes and behavior is inconsistent, particularly in its attention to variations between ethnic "subgroups" and in socioeconomic and educational level variations within ethnic groups and subgroups. Nevertheless, a great deal is known about attitudes toward breastfeeding, barriers, and the reasons for not initiating breast- feeding or for early discontinuance. Many of these reasons, such as the need to work and hospital practices, present problems for women from all ethnic groups, although cultural values and institutions will influence the way these barriers are managed. Attitudinal research and research on incidence remain important, but are of greater value when combined with research aimed at reducing hospital barriers and developing and testing high quality intervention programs. 27 Cultural norms guide decisions about breastfeeding and influence support for breastfeeding. Cultural attitudes must be taken into account in the design of intervention programs. Despite the importance of ethnic- ity, education, and socioeconomic status, other factors need serious atten- FIGURE l- Hospital Practices Which Influence Breastfeeding Initiation o baby put to breast immediately in delivery room e d o baby not taken from mother after delivery o staff sensitivity to cultural norms 8 and expectations of woman u -z o woman helped by staff to suckle baby in recov- .I! R ery room 2 o rooming-in, staff help with baby care in room; not only in nursery o staff initiates discussion re: woman's intention to o appropriate language skills of 8 breastfeed pre- and intrapartum staff, teaching how to handle `G s breast engorgement and nipple `c' problem i o staff encourages & reinforces breastfeeding im- o staff's own skills & comfort re: 3 mediately on labor and delivery art of breastfeeding and time to 3 teach woman on one-to-one basis >z o staff discusses use of breast pump & realities of separation from baby re: breastfeeding o pictures of woman breastfeeding 8 o literature on breastfeeding in understandable terms `S 8 .- 8 o staff (doctors as well as nurses) give reinforce- 2 ment for breastfeeding (respect; smiles; aHirma- s tion) 2 o nurse (or any attendant) making mother comfort- g able and helping to arrange baby at breast for 8 nursing z o woman sees others breastfeeding in hospital, o closed circuit TV show in hospi. tal on breastfeeding o if breastfeeding not immediorely successful, staff z continues to be supportive t .g & o previous success with breastfeeding experience in d hospital 28 tion: postpartum participation in the work force; general U.S. attitudes about breastfeeding in public; hospital practices; and health care provid- ers' knowledge, attitudes, and behaviors. These areas must be addressed in order to facilitate breastfeeding for women in all ethnic groups. 9 mother-infant separation at birth o scheduled feedings regardless of mother's breastfeeding wishes o mother-infant housed on sepa- rate floors in postpartum period o mother separated from baby due to bilirubin problem o no rooming-in policy o staff instructs woman "to get good night's rest and miss the feed" o woman told to "take it easy," "get your rest" impres- sion that breastfeeding is effort- ful/tiring o strict times allotted for breast- feeding regardless of mother/ baby's feeding "cycle" * woman told she doesn't "do it right," staff interrupts her ef- forts; corrects her re: positions, etc. o pictures of woman bottle-feeding * woman given infant formula kit & infant food literature o stafT interrupts her breastfeeding session for lab tests, etc. o woman doesn't see others breast- feeding o sees official-looking nurses au- thoritatively caring for babies by bottle-feeding (leads to woman's insecurities re: own ca- pability of care) o previous failure with breastfeed- ing experience in hospital 29 SUCCESSFUL APPROACHES TO PROMOTE BREASTFEEDING A State-Wide Breastfeeding Program: Rhode Island Jerianne Heimendinger, DSc., M.P.H. Information Provided If you want to encourage the practice of breastfeeding in a state, where do you begin? Who is the target audience? Do you approach the pregnant woman most likely or least likely to breastfeed? Teenagers before they become pregnant? Grandmothers? Physicians? Nurses? Hus- bands? All of the above? And what message do you deliver? Where to begin? With commitment to the effort-a top-level deci- sion to act. The impetus for action within the Rhode Island Department of Health came from several sources. Top-level management decided that there was sufficient evidence of the positive benefits of breastfeeding to promote actively the practice as good preventive health care. The Di- vision of Family Health had recently adopted the Office of Nutrition Services and viewed breastfeeding as a part of the nutritional agenda of maternal and child health. Of greater human interest, two administrators within the Department had recently become fathers of breastfed babies and experienced first-hand the realities of breastfeeding and the institu- tional and community resistance to the practice. Finally, a 1981 press release from Ross Laboratories' survey cata- lyzed action. The survey indicated that Rhode Island had the lowest in- cidence of breastfed newborns in the U.S. The U.S. average reported was 55%, and the rate for Rhode Island was 36%. Even if the data are questionable, Meyer's report of surveys from 1946 to 1966 also indicated low incidences for the state. The first obvious question was: Why were fewer mothers breast- feeding in Rhode Island? No hard data were available to answer the question, but a variety of cultural and economic elements were postu- lated as answers. Rhode Island is a small, densely populated, urban industrial state with a long history of working mothers. Currently, 50.4% of Rhode Island women work, compared to 50.8% for New England and 47.8% for the U.S. The industries in which many women work, such as jewelry and other manufacturing and cottage industries, often lack time and space flexibility to accommodate breastfeeding women. Consequently, even grandmothers and great-grandmothers may not have breastfed; thus, there is no legacy of breastfeeding practice or exposure. In this situ- ation, health professionals become even more important as sources of in- formation and support. 30 The state has assimilated several waves of immigrants over the past thirty years, and these immigrants are eager to trade their breastfeeding legacy for the more "American" practice of bottle feeding. Physicians and hospital nurses did not actively encourage breastfeeding. Hospital routines were not designed to incorporate breastfeeding. Finally, hospital administrators did not encourage the practice because formula companies finance many hospital educational and social activities. Although these last few elements are not peculiar to Rhode Island, they add substantially to bottle-feeding's entrenched status. With some of these concepts in mind, the staff of the Health Depart- ment organized a planning committee to develop a statewide breastfeed- ing campaign. The committee represented physicians, nurses, nutrition- ists, hospital administrators, media and public relations experts, nursing mothers, and the La Leche League. A media consultant was employed to help direct the committee's efforts. The campaign's goal was to increase the incidence and duration of breastfeeding by addressing 3 major target groups: professionals, patients, and the larger community. The committee was correspondingly divided into 3 subcommittees. The Professional Education Subcommittee developed a strategy for motivating professionals to encourage breastfeeding in their practices. Public endorsement of the campaign was obtained from the local chap- ters of the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the Perinatal Committee of the Medical Society, the American Academy of Family Physicians, the Hospital AS- sociation, and the La Leche League. The committee also developed edu- cational materials and counseling standards for physicians, nurses, nutri- tionists, and other hospital and health center personnel. The Patient Education Subcommittee discussed the targeting of their efforts and decided to address both the pregnant women in Rhode Island who obtained care from private physicians and the prenatal population served directly through the Department's programs, such as the maternal and infant care projects and WIC. The Community Education Subcommittee attempted to create a more supportive atmosphere by educating the community at large about the practice of breastfeeding. Specific target groups were fathers, grand- mothers, aunts, uncles, brothers, and sisters. A function of this committee was to address cultural and lifestyle issues through the media. The campaign was officially inaugurated in April 1982 at a press conference held at Women and Infants Hospital, the major maternity hospital in the state. Easelback posters and brochures inviting requests for additional information were mailed to obstetricians, gynecologists, pediatricians, and general practice physicians. Brochures were also dis- tributed to clinics, hospitals, Visiting Nurse Associations, and community organizations statewide. Materials were also available in Portuguese, Spanish, and Vietnamese. Local diaper services and maternity clothing stores distributed brochures to customers. Public service announcements of 10 and 30 seconds were developed for use by major Rhode Island TV and radio stations. Through these an- 31 447-700 0 - 84 - 6 nouncements, the community was invited to call the Division of Family Health or the Nutrition Hotline to request brochures and additional in- formation. Special feature articles and editorials appeared in the Provi- dence Journal and local town newspapers. Members of the Committee discussed breastfeeding issues on radio and TV talk shows, some of which were broadcast in Portuguese and Spanish. A library of breastfeeding films and slide-tapes was established at Women and Infants Hospital and made available to professional and community organizations. A videotape was developed for patient educa- tion within the hospital. Two audiotapes on why and how to breastfeed a baby were devel- oped for Tel-Med, the community service which makes tape-recorded health messages available to the community by phone. A breastfeeding manual for mothers was made available, and a speaker's bureau was organized. The nutritionists in the WIC program made a concerted effort to educate their clients and gave them reasonable expectations and anticipa- tory guidance on such matters as breast engorgement and weight gain. The nutritionists felt that factors which made breastfeeding difficult for mothers were: the presence of other small children in the household; lack of support from health professionals, family, and friends; anxiety that the breastfed infant was not getting enough to eat; and the ready availability of formula both from the WIC program itself and in the hos- pital setting. Informed discussions about the latter issue led to a decision by the administration of Women and Infants Hospital to establish a policy of not offering formula packs to breastfeeding women. The message we delivered was: "When feeding your newborn, the natural way is best . . . A popular `new' way to feed babies is sweeping America . . . Breastfeeding is nature's own way of giving the best to your baby . . . and it's something only you can give." Our messages ad- dressed special attention to the issues of working, worrying about wheth- er babies get enough to eat, and nutrition. Information Collected While we were providing information, we were also collecting data. Several small surveys done prior to the campaign indicated that the inci- dence of breastfeeding ranged from 16% to 48%. I would like to share some of the details of the survey done several months after the campaign was underway. At the request of the Centers for Disease Control, the Division of Family Health conducted a breastfeeding pilot survey (July/August 1982) designed to serve as a model for other states by providing a simple instrument for sampling from birth certificates and assessing the inci- dence of breastfeeding nationwide. Although the survey was not de- signed as part of the breastfeeding campaign, it immediately followed the major media blitz; its design and preliminary results are quite pertinent to the issues of this Workshop. 32 To allow states flexibility, the survey was designed in 2 parts: a simple one-page mail questionnaire and a telephone interview follow-up. The mail survey recorded data on the incidence and duration of breastfeeding, other food supplements given to breastfed infants, birth weight, and the mother's participation or lack of participation in WIC or Food Stamp programs. The survey also identified whether the mother was given formula by a hospital and whether she was willing to be con- tacted by telephone. Information obtained on this questionnaire could be linked with demographic information available on the birth certificate. It was thus unnecessary to ask respondents any socio-demographic information. The reverse side of the mail survey contained an explanatory letter from the Health Department with a name and number to contact if the recipient had any questions. In addition, the letter contained short notes in Spanish and Portuguese. The notes requested non-English speaking re- cipients to secure help in translating the survey. The purpose of the letter was to assure people of the legitimacy and confidentiality of the survey and to attempt to address the problem of language barriers. En- closed with the survey was a stamped self-addressed envelope. The second part of the survey was the telephone interview in which data were obtained on the reasons a mother chose to breastfeed or bottle-feed, why she stopped breastfeeding, what types and amounts of food were fed, at what ages various solids were introduced, and what the weight of the child was. The telephone interview also provided an opportunity to verify the mail-survey questions, such as participation in WIG. A representative data sample of infants 3 months of age was ob- tained from 2 sources: 1) a list of April births as recorded by the Divi- sion of Vital Statistics and 2) lists of WIC infants born in April and of women known or expected to deliver in April. Two major factors af- fected the choice of sampling sources and the sampling process. First, it was not possible to obtain a truly representative sample because state confidentiality laws prohibited inclusion of births of unwed mothers in the vital statistics sample. Secondly, the WIC program was interested in obtaining information on the feeding practices of its clients. By sampling from its participant list, we were able to obtain some information on unwed mothers-a fact that we think enhances the value of our survey. A few pertinent points from the preliminary results follow. Women were very eager to talk to us. In fact, 70% of them indicated they would not mind being contacted. Both breastfeeding and bottle-feeding mothers seemed pleased that someone was still interested in them so long after delivery. Even women without telephones provided us with numbers of family and friends through whom they could be contacted. The conclu- sion we draw is that women with infants 3 to 4 months of age provide an informative sample population, They are not only eager to talk, but they are likely still to be breastfeeding, carefully measuring the amounts of other foods given their infants, and knowledgeable about the reasons behind their behaviors. Preliminary analysis indicates that 52% of the total sample of 283 33 women breastfed at least once; 37% of the sample were still breastfeeding at 3 months of age. Of the WlC sample of 123 women, 40% breastfed at some point; 21% were still breastfeeding at 3 months of age. Comparable figures for the vital statistics sample of 160 women were 62% and 49%. Although these rates may be a little high (respond- ents tended to be the better educated women of higher socioeconomic status), it is unlikely that even our adjusted rates could be as low as the Ross Survey indicates. Although we would like to think our campaign has had an impact on the incidence and duration of breastfeeding, we cannot draw that conclusion from this survey at this time. Most surveys on breastfeeding behavior have been limited to legiti- mate births. Seventeen percent of the infants in our sample were born to unwed mothers. Since the prevalence of single mothers is increasing, we were happy to be able to include a few in our sample. We look forward to further analysis of the data on this cohort. Finally, we plan to delineate the following reasons given for breast- feeding: health-healthier for the baby; intrinsic reasons such as bonding; extrinsic ones such as encouragement by physicians, relatives, or friends; and practical ones such as ease and economy. Preliminary anlaysis shows that choices were made in the order of: health, health and closeness, health and practical considerations, and health and extrinsic encourage- ment. Thus, the initial decision to breastfeed by women in our sample was based on concerns about the health and well-being of the child. In- terestingly, even in Rhode Island, returning to work was not the most important reason given for stopping breastfeeding; anxiety about whether the baby was getting enough to eat was the major concern. In summary, we think the simple mail survey linked to vital statistics records is a quick and inexpensive means for states to use to estimate the incidence of breastfeeding. Sampling from programs such as WIC can provide information about the characteristics and infant-feeding behav- iors of single mothers, a growing portion of the population. Preliminary analysis indicates that in our sample, health and nurturing factors are the most important determinants of the choice to breastfeed. We still think, however, that creating a supportive environment is a priority. We think we were correct in our ambition to address all target groups-professionals, patients, and the community at large. We did the best job of communicating with health professionals, largely-I sup- pose-because we are used to talking to ourselves. The key groups of professionals to enlist are: 1) professionals who interact with women prior to or early in their pregnancies-obstetricians, gynecologists, nutri- tionists, and childbirth educators and 2) professionals whose support is crucial in initiating the actual practice of breastfeeding-hospital nurses and pediatricians. As for the patient population, we would target the subgroups mo.st likely to adopt breastfeeding who tend to be the better educated women of higher social status. Social norms etablished by higher status groups are eventually adopted by lower income groups. Thus a small amount of effort on the margin can reap large benefits in terms of increased num- 34 bers of women in a social group who not only lend support to eacu other but ultimately influence other social groups. However, it is also important to address the needs of lower income groups. Is it cost effective for us in public health to address the popula- tions most accessible, or should we aggressively seek out the population hardest to reach? The groups most accessible to us are those involved in public programs on the basis of low income or medical or nutritional need; within these groups are subgroups more likely to breastfeed. For example, it is more productive to target married older women than unwed teenagers. The most difficult population for us to reach is low-income women who are not eligible for our services, work in low-wage jobs, and re- ceive services from private physicians. For this population, we suggest focusing on strategies addressed to the health-care providers and the work place. The consumers we would target are husbands and grandmothers, since they form the major support around the breastfeeding mother. If we had this campaign to do again, we might hire an advertising agency to do a better job of reaching the community through the media. We have been pleased that our campaign produced some good mate- rials and initiatives. We have suffered, however, from not providing ade- quately for continuity of our efforts. A coordinator, committed to main- taining the momentum of this effort, needs to be designated within the Health Department. This initiative, along with others, has suffered from the funding and staffing constraints common in state governments in the past several years. On the more positive side, some residuals of our efforts are im- proved inservice education programs for nurses in the maternity hospi- tals and improved educational materials for both professionals and preg- nant women. We have also given people broader access to information through the Nutrition Hotline. In addition, the Department has strength- ened its emphasis on breastfeeding through its request for proposal proc- ess, which it uses for contracting direct services. Three nutrition-related innovative projects were recently funded. The purpose of one of these is to develop breastfeeding support groups for low-income women. Finally, we hope the ideas generated in this Workshop will re-energize and redi- rect our efforts to finalize the analysis of our survey and to continue to create a more supportive environment for breastfeeding among women in Rhode Island. 35 City-wide Approach: New York Linda Randolph, M.D., M.P.H. New York City has a high proportion of both ethnic minorities and the poor. In 1980, the White population in New York City was 36.5%, the Black population 30.8%, those of Hispanic origin 27.9%, and the Native American-Asian 3.6%. Twenty-seven percent of the New York City population were below the poverty line in 1980 compared to the New York State percentage with 16% and the U.S. with 13%. In 1970, 19.5% of all children under 18 years of age in New York City lived with a female head of household. By 1980 the percentage had grown to 30.9%. The city's poor increased by 10% between 1969 and 1982. In 1982, the New York City Department of Health conducted a survey of infant feeding practices in municipal, voluntary, and private hospitals. According to this survey, 15.1% of infants discharged from municipal hospitals were breastfed compared to 37.7% discharged from private hospitals and compared to the overall U.S. rate of in-hospital breastfeed- ing of 57.6% in 1981. In the survey of the New York City Health De- partment Child Health Stations, 3% to 6% of babies were breastfed during the period of 1980-1982. In January 1982, the Steering Committee to Promote Breastfeeding in New York City was formed, with the goal of instituting a comprehen- sive program to increase the breastfeeding rate of women, with specific emphasis on low-income women. The Committee is sponsored by the New York State Department of Health, and I have been its chairperson for the last two years. The State Health Department's Bureau of Mater- nal and Child Health has had breastfeeding promotion as one of its goals, and this effort in New York City has reflected a local implementation of that goal. Originally, 25 individuals were called together from medical and public health schools, city and state health departments, voluntary and research organizations, foundations, and maternity service providers to discuss methods of procedure. Based upon the copious literature avail- able and the considerable experience of the various members, the com- mittee developed a comprehensive program to address the barriers to successful breastfeeding. The Steering Committee's total agenda is built around 6 coordinated programs, each administered by a task group. Each group targets a barrier to breastfeeding and works simultaneously to achieve the overall program goal. A multidisciplinary membership on the committee has evolved as interests increased throughout the 5 boroughs of the city. Today it consists of over 40 active members, including pedia- tricians, obstetricians, nutritionists, nurses, nurse-midwives, public health administrators, social workers, a lawyer, legislative aides, a journalist, health educators, a foundation representative, and public health students. 36 A brief description of the 6 task groups and their activities to date follows. The first task group is concerned with research and surveys. The intent is not so much to conduct research, but rather to identify ex- isting material to be used by all of the other task groups. Six research background papers are being developed to assess the following areas re- lating to breastfeeding: 1) trends and patterns of infant feeding practices by socioeconomic and ethnic groups; 2) factors influencing the pattern and incidence of breastfeeding-especially cultural and social influences (this background paper will also analyze the role of existing health serv- ices such as prenatal, maternity, and postpartum care, and WIC); 3) the impact of the media and business interests in breastfeeding practices with particular emphasis on the media effects on different ethnic groups; 4) examination of the impact of government, legislation, reim- bursement patterns, maternity leave, child-care facilities, government and business support networks available for the lactating mother; 5) the eco- nomic value of breastfeeding as it relates to cost of formula versus the increased cost of providing a lactating mother with an enriched diet; and 6) the influence of alcohol, smoking, and drugs on mother's milk. The professional education task group, our second group, has devel- oped a slide presentation to be used for grand rounds in the city's hospi- tals. The slides are designed to address lack of knowledge of both breastfeeding physiology and techniques. Since many pediatricians, ob- stetricians, and even some nurses have never during their training seen a baby being breastfed, they will not necessarily be as informed as they should be in order to provide assistance to a lactating woman. Members of the Steering Committee will be available to conduct the rounds on request of hospitals, and we are beginning to receive those requests. The third group looks at hospital practices. It addresses barriers of facility design, rigid feeding schedules, supplemental feeding, gift packs, and lack of information on the part of hospital support staff. Guidelines for changes in hospital practices in order to encourage breastfeeding and to create an atmosphere of acceptance at the site of delivery have been prepared with participation of representatives of the Health and Hospital Corporation and the voluntary hospital sector. One task of the fourth group, the pre- and postnatal care group, has been the development of a handbook for promoting breastfeeding in am- bulatory-care facililities. The handbook was done in conjunction with our Office of Health Promotion in the New York State Health Depart- ment. In addition, a project developed by a member of the Steering Committee and endorsed by it is the Bronx-based Lactation Consultation Team. This project has received federal MCH funding. It is designed to provide a team of health professionals to institutions for breastfeeding consultation in the Bronx. The entire health care system in the borough will be affected. The fifth task group is concerned with public policy and legislation; it has been monitoring existing legislation and assisting in the develop- ment of new policy and legislative efforts related to the promotion of breastfeeding in both the city and the state. The major emphasis has been the analysis of trends in labor force participation rates among mothers of children under 3. Existing legislation, maternity benefits, and employer policies have not adequately addressed the difficulties faced by pregnant working women or by those wanting to breastfeed while maintaining their job. A background paper presenting an overview of these trends is in draft form, and it gives an analysis of maternity benefits, including health insurance and maternity leave. The paper also discusses the poten- tial benefits unions and employers might derive from promotion of pre- natal care and breastfeeding. In addition, 2 sets of sample guides have been drafted to provide recommendations for the development of prena- tal care and breastfeeding promotion programs at the worksite. A third paper will analyze maternity benefit packages and provide recommenda- tions of strategies for change. During 1984, this group also plans to im- plement a continuing education program for occupational health nurses. The Public Information Group has developed a 3-tiered program to counter the perception of breastfeeding as aberrant behavior. The first level is a blanketing of the city with visual images of breastfeeding, in- cluding a subway poster campaign, TV public service announcements, and engagements for Steering Committee members on talk shows. The second level is individualized support, information, and referrals pro- vided by counselors to callers on an information line. Data will be col- lected and follow-up on a sample of those calls will be conducted. The third level is written information mailed to callers, community groups, and lay health advocates. One interesting phenomenon about the Steering Committee is that we have learned how to make a little money go a long way. The funding for the committee projects has come from very small contributions from the New York State Department of Health, the New York City Depart- ment of Health, the Columbia University School of Public Health- Center for Population and Family Health, the Health Education Fund, the New York Community Trust, and the Division of Maternal and Child Health-DHHS. All of the organizations represented on the com- mittee allowed staff to provide significant amounts of time for task group efforts and for Steering Committee meetings which we held approxi- mately every 2 months for the past 2% years. Recently we saw the end of a long gestation. The Committee con- ducted for approximately 200 persons an invitational workshop wherein the materials that had been developed by the task groups were presented, shared, and discussed. We were fortunate to have Dr. Lawrence as our keynote speaker and Jane Brody, the personal-health columnist for the New York Times, to provide some of her personal insights on the breast- feeding of twins. Where do we go from here? The public information campaign will be launched in the early fall. Further dissemination of materials and com- pletion of an evaluation design and its implementation are on the agenda. Concomitantly, the State Health Department is revising its hospital code in order to facilitate maternity patients' ability to breastfeed. In conclusion then, I think the Steering Committee in New York City is an example of government and the public and private sectors working together with professional organizations, voluntary organiza- 38 tions, and individuals to try to put together a comprehensive, interre- lated, multidisciplinary approach to promotion of breastfeeding. We have just gotten off the ground, and I hope to have another forum at a later date to let you know what our impact has been. Breastfeeding Promotion in Three Rural Indigent Populations John E. Alden, M.S., C.N.M. Breastfeeding in an Indigent Rural County in Florida Jackson County, Florida is predominantly rural and has a population of approximately 40,000. The two largest communities contain 12,000 and 5,000 persons. About 30% of families in this agriculture-based econ- omy have annual incomes below levels established for federal assistance programs. Approximately one-quarter of the county residents are Blacks, and the remainder are Caucasians of English-speaking origin. The indi- gent population is primarily Black. Many families in this poor rural society are comprised of younger mothers raising children in their mothers' (or parents') homes, as in a ma- triarchal society. Young mothers receive considerable child-care support from their mothers, grandmothers, and sisters. Until the past decade, breastfeeding has been commonly practiced. Supplementation has been usual even during the first few months, but bottle-feeding from birth appears to have become common with the availability of formula through assistance programs such as WIC. Most young women now having children were breastfed as infants. Breastfeeding Promotion Project In 1979 a focused effort to promote breastfeeding among the low income rural population began. The program was coordinated by the pri- mary care provider (a nurse-midwife) with the special assistance of the public health nutritionist and support of the clinic and hospital nursing staffs. The project consisted primarily of modification of patient-teaching 39 447-700 0 - 84 - 7 practices during the prenatal period and of patient management during the intrapartum and postpartum periods. The project was conducted through the county health department in the context of a maternity-care program for low-income families. Ap- proximately 20% of mothers delivering in the community hospital re- ceived their obstetrical care through the Low Income Clinic Program. Data Collection The basic means of data collection was to have mothers and infants return to the clinic frequently "to see how you and the baby are doing." It was not difficult to get them to return at least once a week during the first month and subsequently at least monthly. During these visits, the infant was generally weighed and perfunctorily examined. The mother was questioned about feeding and supplementation, her well-being, and the baby's activity. Either the woman was encouraged to show how the baby fed or the baby was "tested" with a bottle or finger to evaluate the sucking pattern. By this means, the evaluators could be reasonably sure that the baby was being predominantly breastfed. Women's statements about feeding were generally consistent with the babies' responses. For the purpose of this study, the infant was no longer considered to be breastfed if he/she received more than 8 ounces of supplemental feeding a day (for the first week, 4 ounces). Data collection at each visit included the number of weeks through which the woman continued to breastfeed predominantly and some anec- dotal information (comments, reasons for stopping, problems, etc.). Data were updated with each contact. If the woman did not return to the clinic, attempts were made to contact her by telephone, public health nurses, or relatives. If satisfac- tory contact could not be made, she was assumed to have discontinued breastfeeding. Discussion of the Project Initiation of Breastfeeding. Figure I presents data for the percentage of women initiating breastfeeding. Shown are rates for women who re- ceived maternity care through the public low-income clinic and by pri- vate physicians. During the 6-month period before the project began, breastfeeding rates for the two groups were similar. During the term of the project, the percentage of women initiating breastfeeding among the low income clinic (project participants) more than doubled. The increase in breastfeeding by other women in the community occurred after the project began providing breastfeeding education to prepared childbirth groups, nurses groups, and the community at large. The first increase during January-June 1979 over the control period (July-December 1978) appeared to occur after a more consistent encour- agement to breastfeed. The increases after July 1979 occurred as a more well-developed teaching program, distribution of selected written materi- als, and use of films were adopted. 40 FIGURE I- Percentage of Women hitiathg Breastfeedmg of Newborns Delivered by Private Physicians vs. Those Cared for in Low Income Clinic (Community Hospital - July 78 through June 80) Low Income Clinic Private Medical Practice N=l2 N=80 N=20 N=75 N=42 N=ll6 N=40 N=l02 July-Dee 1978 Jan-June 1979 July-Dee 1979 Jan-April 1980 Over the term of the project, a progressive improvement in the du- ration of breastfeeding was observed at all intervals. During the control period, half of the women initiating breastfeeding discontinued the prac- tice during the first week, with none continuing through 16 weeks. During the last 6 months, almost half of the study participants breastfed through 16 weeks. (Table I) Of 23 women known to discontinue breastfeeding between 4 and 16 weeks during 1979, only 5 did so upon returning to work or school. The majority expressed dissatisfaction with breastfeeding or the demands it placed on their lives. The most easily discernible difference between women who contin- ued breastfeeding and those who did not was their family situation. Not surprisingly, most of the women who continued were those in stable marital relationships. Few women who were single, divorced, or in peri- ods of marital conflict continued. Returning to work or school was a more frequent (though not universal) occurrence among single mothers. Subjective Evaluation of Influencing Factors Prenatal Instruction. Of all factors considered in promoting selection of breastfeeding, unhurried discussion of infant feeding appeared most productive for this group. Many women seemed to want to breastfeed 41 but were inhibited by stories they had heard or anxieties they were harboring. The primary-care provider is generally a person with whom the woman is developing a trust relationship and seems the ideal person to provide counsel on breastfeeding. Additionally, during prenatal care visits, the woman is a captive audience. Prenatal care should include, Table I Percentage of Women Continuing to Breastfeed through Selected Intervals After Delivery (Low-Income Clinic-July 1978 through June 1980) Duration July- January- December June 1978 1979 July- December 1979 January- June 1980 1 week 50 62 81 88 W=) 6 10 34 35 4 weeks 33 62 79 75 (N=) 4 10 33 30 8 weeks 25 44 63 68 @=I 3 7 26 27 12 weeks 8 38 38 56 (N=) 1 6 16 22 16 weeks 0 25 36 48 W=) 0 4 15 19 whenever possible, the woman's significant others. Most husbands reti- cent about breastfeeding usually responded readily to open discussion. This form of breastfeeding education also encouraged the woman to feel free to call the care provider if problems were encountered. Considerable effort was made toward deftning the breast as a nutri- tive organ rather than as a sexual one. A successful technique was to take time during the prenatal physical exam to "explore" with the woman the anatomy of the breast in relation to infant feeding. Most women appreciated films about breastfeeding. "Promotional films" were shown prior to delivery and "how-to" films were reserved for after delivery when breastfeeding was started. Within this lower socioeconomic group, written material was of less value; many did not read it. Hospital Management. The primary-care provider may insure that hospital management of the mother and infant promotes breastfeeding. Most important aspects (not commonly practiced by hospital maternity departments) are early and frequent (demand) feedings, avoidance of sup- plementation, and avoidance of mother-infant separation. During the hos- pital stay, "hospital rounds" were generally made twice each day, ideally when the infant was with the mother. During these visits, previous 42 teaching was reinforced, and anticipatory guidance and encouragemenr were provided. Post-Hospital Management. Women were given appointments for a follow-up visit within a few days of hospital discharge. This early visit provided early problem intervention for many women. Of women breast- feeding at one week, 91% continued through at least one month (during the last year of this study). Most breastfeeding problems developed in the first few days at home. Although formula companies provided free formula samples upon discharge from the hospital, these samples were not distributed to breastfeeding mothers. Sterile water was provided for "emergency" supplementation until professional assistance could be obtained. Community Follow-Up Two Years After Discontinuance of Breastfeeding Project As demonstrated in Table II, the discontinuance of the special breastfeeding promotion project was accompanied by a prompt decline in the number of women initiating breastfeeding. Within 2 years, breast- feeding initiation rates were similar to pre-project levels. Careful analysis of this observation was not possible. Table II Percentage of Women Initiating Breastfeeding (Community Hospital-l 978 through 1982) 1978 1979 1980 1981 1982 43% 50% 60% 48% 46% (Breastfeeding Promotion Project) Breastfeeding Promotion on the Papago Indian Reservation (Arizona) The Papago Reservation's community is a rather closed, traditional Indian society. The reservation population is approximately 10,000 per- sons, with very few non-tribal members. The largest community contains 3,000 persons, and the nearest large non-Indian community (Tucson) is 60 miles distant. The native language is used in commerce. Many prob- lems common to Indian reservations exist, including high infant morbidi- ty and mortality and other nutrition-related problems-probably originat- ing in alteration of traditional dietary practices. Elements of the Papago Breastfeeding Education Project In 1981, the U.S. Department of Agriculture granted funding for a breastfeeding demonstration project on the Papago Reservation. The 43 project functioned with the assistance of an advisory board made up of representatives of the Indian Health Service, WIC, tribal programs, Meals for Millions Foundation, and other interested individuals. Overall function and administration of the project was local and native. The project developed high quality audiovisual aids to increase community awareness and understanding of breastfeeding. The theme of this material focused on breastfeeding as "the Papago Way." Native lay women were recruited, trained, and paid as "breastfeeding helpers," both to assist the new mother and infant directly and to act as liaison for her with other services. A free nursery for breastfeeding babies was estab- lished in a location central to school and major work places so that new mothers could, with the cooperation of employers, feed their infants during the day. The project also sought to develop rapport with and im- prove services from the health-care system. Outcome As noted in Table III, a marked increase in breastfeeding initiation was occurring in the time immediately preceding the grant funding of the project. This change occurred as individual program efforts devel- oped and became coordinated. . . Table III Breastfeeding Initiation and Duration (Papago Reservation-1979 through 1983) Percentage of New Mothers Initiating Breastfeeding 1979 6/81 7/81-6/82 4/83-9/83 23 44 59 49 Percentage Breastfeeding at 6 weeks 4 months Percentage Utilizing Formula Supplementation (Age: Birth to 4 months) 50 48 33 42 21 37 Summary of Papago Breastfeeding Project With this multi-level approach, improvements in breastfeeding initi- ation and duration were noted. While the percentage of mothers initiat- ing breastfeeding has decreased somewhat following the ending of the USDA grant-funded program, the percentage of infants breastfeeding during the first months of life remains similar to that during the program. Formula supplementation during breastfeeding has increased. The factors contributing to the apparent post-project declines are not fully under- 44 stood; however, decreased direct support of the breastfeeding mother may be an influential factor. Breastfeeding on the Fort Peck Indian Reservation (Montana) Description of Reservation Unlike the Papago Indian Reservation, the Fort Peck Indian Reser- vation is not homogeneous. The reservation population is approximately 12,000; the largest community has fewer than 4,000 persons. The reserva- tion is the assigned home of two unrelated and, historically, sometimes antagonistic tribes. The reservation was opened to homesteading in 1911, and currently, less than one-half of the residents are tribal members. Intermarriage with non-Indians and members of other Indian tribes is common. The native languages are used infrequently and are generally unfamiliar to younger tribal members. Largely agriculture-based, the local economy is augmented by oil production, federal-agency salaries, and tribal light industry (receiving minority-preference federal contracts). Unemployment is relatively high. Women of child-bearing years comprise a substantial portion of the work force. The health-care needs are met by both the Indian Health Service and private medical practices. Two small hospitals have limited services; referral and transport to outside specialists and facilities are common. The Recent Practice of Breastfeeding As anticipated from the rapid assimilation into a non-Indian society, many traditional ways have been lost. Cultural and family disruptions have brought about major changes in child-care practices, including mothering and feeding of infants. Breastfeeding has been infrequent for two generations. Traditional family ties have been altered, and women are increasingly dependent on their male partners for breastfeeding sup- port. Native male attitudes toward breastfeeding as well as other aspects of child care reflect the relatively greater role alteration of the aboriginal male produced by assimilation. Many males are strongly opposed to breastfeeding. Breastfeeding Promotion on the Fort Peck Indian Reservation It is the policy of the Indian Health Service to encourage breastfeeding. The tribal WIC program reaches almost all pregnant women (WIC reaches approximately 80% of eligible families in Mon- tana). Few Indian families have contact with prepared childbirth pro- grams, nor is there an active breastfeeding mother support group (such as La Leche League). Almost all pregnant women receive some prenatal care, although often less than optimal. Approximately 60% of pregnant women receive maternity care from one provider (the author), who pro- 45 vides prenatal, inpatient obstetrical, and postpartum care. A limited amount of commercially produced written material is available. During the course of prenatal care, breastfeeding is discussed at least twice, literature is distributed, and a short film is shown. The pregnant women are encouraged to talk with other women who they know have breastfed. The WIC program staff tells all pregnant women that breast- feeding is best for the baby and encourages them "at least to try." The outpatient nursing staff encourages breastfeeding. The inpatient nursing staff is generally supportive, and the inpatient hospital routine is general- ly conducive to breastfeeding. The infant is usually allowed only sterile water as a supplement, and formula samples are not sent home with the mother. Post-hospital discharge follow-up is within two or three days and generally one week later. Telephone or personal consultation is always available. Montana rates of breastfeeding initiation fit the general characteris- tics of urban vs. rural, educational, and economic patterns. With promo- tional efforts, the Fort Peck Reservation-among those served by the Poplar Community Hospital/Indian Health Service (PCH/IHS) pro- gram-has a percentage initiating and continuing breastfeeding among the highest in the state, even with the previously mentioned negative fac- tors. Summary Results of breastfeeding promotion efforts in these three rural areas indicate potential for success in increasing both initiation and duration of breastfeeding. Data available following the ending of the promotion projects suggest that infant-feeding practices will tend to revert to prac- tices similar to those before promotion. Two programs (Florida and Arizona) were among populations less affected by cultural change-where breastfeeding was recently practiced and where indigenous support was present. In the Montana community (Fort Peck Indian Reservation- PCH/IHS), both of these factors are lacking, and breastfeeding promotion has made slower progress. Breastfeeding mothers in rural areas encounter several problems. Often these women lack frequent contact with other new mothers, and thus basic information and peer support are less available than in urban areas. The media (audiovisual and written) are limited and not always in accord with the culture. While many breastfeeding promotion efforts take place outside of the formal health-care system, groups such as La Leche League and prepared childbirth programs are less frequently available in rural areas. Although some assert that the free infant formula available through the WIC program acts as a disincentive, WIC program personnel actively encourage breastfeeding. When promotional efforts address these rural problems, the incidence of breastfeeding can dramati- cally increase. 46 The San Diego Lactation Program: A Teaching Hospital- Based Resource to Promote Breastfeeding Audrey J. Naylor, M.D., Dr.P.H. The transformation of maternal blood into milk and successful deliv- ery of this complex nutritional and immunologic substance in the correct quantity and quality to assure infant growth and development, though "natural," is not simple. As with other complex physiologic functions and behaviors, both lactation and breastfeeding are at risk for a variety of problems which can and often do lead to early weaning. This risk can be greatly reduced when perinatal health care professionals understand the complexities of breast function and suckling and when they are trained to apply this understanding to the clinical management of breast- feeding. During the past 30 years, while other areas of medical and nursing education underwent vast revisions in response to medical advances, at- tention to lactation and breastfeeding declined. Obstetrics taught students how to inhibit lactation and speed the postpartum involution of the breast, while pediatrics concentrated on the fine points of providing in- fants with an artificial formula. The breast became a topic discussed pri- marily in pathology classes and surgical clerkships. Students and house officers were taught details about how to eliminate its basic function either temporarily or permanently, but learned little about how to en- courage and enhance its normal processes, or how to prevent, diagnose, or treat deviations from normal function. During the past 5 to 10 years, the basic science information provided for students of the health professions about lactation and breast milk has significantly increased; however, instruction regarding clinical eval- uation and management of breast function is rare. Many perinatal health care providers enter practice unprepared to assist the nursing mother and often give advice and carry out procedures leading to breastfeeding problems and failures. The San Diego Lactation Program Until September 1977, training programs available at the University of California, San Diego Medical Center (UCSDMC), and Mercy Hospi- tal and Medical Center, an academically affiliated teaching hospital, were typically deficient in this area. While 50% to 65% of new mothers were initiating nursing, less than half continued beyond 8 to 10 weeks. To pro- mote breastfeeding while simultaneously providing appropriate clinical teaching opportunities, the San Diego Lactation Program was launched. The Lactation Program was designed with multi-departmental guid- ance. The consortium of departments contributing to the early planning included Reproductive Medicine (OB/GYN), Pediatrics, and Community and Family Medicine, as well as Nursing and Social Service. Within a short time, the Program developed its own distinct identity and now functions independently and essentially like other academic subspecialty 47 services within the teaching-hospital setting. In July 1983, the Program's base of operations was moved to nearby Mercy Hospital and Medical Center. Both the