FOLLOWUP REPORT: THE SURGEON GENERAL S WORKSHOP ON BREMTFEEDING & HUMAN LACTAnON

Transcription

1 FOLLOWUP REPORT: THE SURGEON GENERAL S WORKSHOP ON BREMTFEEDING & HUMAN LACTAnON Presented by he U.S. DWARTMEM OF HEALTH AND HUMAN SERVICES Pubic Heath Servtce Heafh Resources and Services Administration Bureau of Heath Care Deivery and Assistance Division of Materna and Chid Heath DHHS Pubkation No. HRS-D-MC 85-2

2 .. c Thk report was prepared ivith the assistance of the Nationa Centerfor Education in Materna and Chi!d Heath. 38th & R-Streets, N. W., Washington; D.C The Nationa Center is a resource center that responds to pubic and professiona inquiries in materna and chid heath. incuding human genetics. Estabished in the Nationa Center for Education in Materna and Chid Heath provides services under a grant from the Divkion of Materna and Chid Heath, Department of Heath and Human Services. U.S. NATIONAL MEDICINE 1 -\ 1 I : The oiigina drawing on the cover was done-by Bob Congi of Rochester, N.Y.

3 PREFACE Since the Surgeon Genera s Workshop on Breastfeeding and Human Lactation ast year, there has been a notabe renewa of interest and a resurgence of activity in promotion of breastfeeding. This may be attributed to the phiosophy of shared responsibiity which guided the panning committee in organizing the workshop. The workshop participants, representing many professiona and vountary organizations, were activey invoved in the workshop process of assessing the current status of breastfeeding pro-. motion in the United States and of deveoping recommendations and strategies to faciitate progress toward achieving the 1990 breastfeeding objective for the nation. The workshop recommendations have become a nationa agenda, with participant organizations providing eadership in disseminating the recommendations and encouraging their impementation. The Report of the Surgeon Genera s Workshop on Breastfeeding and Human Lactation, pubished in September 1984; has become a vauabe reference on the science and art of breastfeeding and a usefu panning guide for breastfeeding promotion efforts. The origina printing of 35,000 copies was quicky distributed by participant organizations, and a second printing has been done. This Foowup Report has been prepared to document efforts emanating from the workshop and to continue to disseminate information reated to breastfeeding promotion activies and accompishments. At the workshop four successfu modes to promote breastfeeding were presented. In the past year many additiona approaches have come to our attention. The purpose of this Foowup Report: Surgeon Genera s Workshop on Breastfeeding and Human Lactation is to recognize other usefu approaches, describe these approaches, and identify where they are being impemented. It is hoped that poicymakers, administrators, educators, heath care providers, professiona and vountary organizations, Federa agencies, empoyers, and others who read this Foowup Report wi gain new ideas that wi inspire them to further action. Information incuded in this report was submitted in response to requests made to the participants in the workshop; State Directors of Materna and Chid Heath; members of the Heathy Mothers, Heathy Babies Coaition; and Department of Heath and Human Services Regiona Heath Administrators. The responses were impressive and incuded descriptions of a variety of efforts such as egisation, poicies, resoutions, guideines, meetings, pubications, media campaigns, service deivery modes, support systems, and research, a of which are incuded in this report. ii

4 We are interested in your response to our ongoing efforts to disseminate information and stimuate action to reduce barriers to breastfeeding. Wi you pease take a few minutes to compete the questionnaire on the back cover of this pubication? We recognize and appreciate the new, renewed, and continuing work that is being done in support of improved. heath and nutrition for our nation s mothers and babies. Progress has been made, but many chaenges remain in our efforts to promote informed decisions by more women to breastfeed their babies. C. Everett Koop, M.D., Sc.D. Surgeon Genera *.. 111

5 CONTENTS INTRODUCTION... ACTIVITIES RELATED TO RECOMMENDATIONS OF THE SURGEON GENERALS WORKSHOP ON BREASTFEEDING ANDHUMANLACTATION PROFESSIONAL EDUCATION Task Forces/Work Groups/Committees... Poicies/Standards/Protocos/Curricua... Continuing Education... Professiona Consutation/Technica Assistance... Manuas/Guides/Educationa Materias... PUBLIC EDUCATION Media... Hard-To-ReachGroups... Promotion/Pubic Education Campaigns... Education Systems... Coordination/Sharing of Educationa Materias... Data Coection... HEALTH CARE SYSTEM Poicies/Standards/Protocos... Laws/Reguations... Mode/Demonstration Programs... Staff/Cient Education... Task Forces/Guides/Materias... SUPPORT SERVICES Teephone Caing Systems... Peer Support Groups... Breastfeeding Counseors... Nurse Foowup/Referra... Cinics/Casses... Institutiona Practices... Human Mik Banks iv

6 WORLD OF WORK Data Base Information/Education... g Institutiona Poicies... ;... Breast Pump Loan Programs... z: Mode/Demonstration Programs... RESEARCH Trend Data Determinants/Behaviors/Practices/Attitudes Physioogy/Nutrition/Other Aspects Interventions/Strategies NATIONAL AWARENESS CONTRIBUTORS...,,..., APPENDIX A-Task Force on Professiona Training in Lactation.. 38 APPENDIX B-Research on Human Lactation and Breastfeeding Supported by the Nationa Institutes of Heath, Department of Heath and Human Services APPENDIX C-Research on Human Lactation and Breastfeeding Supported by the U.S. Department of Agricuture.. 45 QUESTIONNAIRE C-III V

7 INTRODUCTION The Surgeon Genera s Workshop on Breastfeeding and Human Lactation was convened in Rochester, NY on June 11-12, Presented by the Division of Materna and Chid Heath in cooperation with the University of Rochester Medica Center, the workshop was directed toward the achievement of the 1990 nationa objective of increasing the number of women who breastfeed their infants and the duration of breastfeeding. Specific objectives of the workshop were: To review progress of past efforts, in both pubic and private sectors, to promote breastfeeding To assess the state-of-the-art reated to factors that enhance and those that inhibit breastfeeding and human actation To determine remaining issues To deveop strategies and recommendations in order to faciitate progress toward achieving the 1990 breastfeeding objective Workshop participants incuded many discipines serving different ethnic, cutura, and income groups in a wide variety of practice settings. Professiona and ay organizations; oca, State, and Federa governments; industry; and vountary groups were a represented. The Report of the Surgeon Genera s Wotkshop on Breastfeeding and Human Lactation was disseminated in October Six recommendations with suggested strategies to faciitate progress toward achieving the 1990 objective were presented to the Surgeon Genera. The recommendations were: Improve professiona education in human actation and breast feeding Deveop pubic education and promotiona efforts Strengthen the support for breastfeeding in the heath care system Deveop a broad range of support services in the community Initiate a nationa breastfeeding promotion effort directed to women in the word of work Expand research on human actation and breastfeeding The Division of Materna and Chid Heath of the Pubic Heath Service, in coaboration with other pubic and private agencies, encourages, supports, assesses progress, and evauates foowup action reated to the workshop recommendations. Efforts to increase the incidence and duration of breastfeeding in the United States were underway prior to the Surgeon Genera s Workshop. However, as a resut of the workshop, many of these efforts have been intensified and expanded. In addition, a significant

8 number of other activities have been initiated in direct response to the issues identified at the workshop, and strategies designed to promote breastfeeding, particuary in popuation groups with ow incidence of breastfeeding, have been impemented across the nation. This Foowup Report is presented to share information about the wide range of foowup action which emanated from the workshop. A arge voume of information about foowup action was received from a broad spectrum of individuas, agencies, and organizations. In order to ensure a report of reasonabe ength, it was possibe to incude ony exampes or iustrations of the scope of activities undertaken, and to present these in abbreviated or abstract form. The information is organized according to the recommendations isted above. Sections on Nationa Awareness and Contributors are aso incuded, as we as Appendices. It is hoped that the report wi stimuate the interest and increase the support of a who can have an impact on breastfeeding decisions and opportunities. The utimate goa is a continuing commitment to the promotion of breastfeeding and improvement of materna and chid heath.

9 ACTIVITIES RELATED TO RECOMMENDATIONS OF THE SURGEON GENERAL S WORKSHOP ON BREASTFEEDING AND HUMAN LACTATION PROFESSIONAL EDUCATION Recommendation: Improve professiona education in human actation and breastfeeding The improvement of didactic and cinica training in actation and breastfeeding, and the deveopment of skis in patient education and management of breastfeeding for a heath care professionas, were major goas of this recommendation. Concerns about the avaiabiity and quaity of professiona education reated to breastfeeding and actation incude: 1) the absence of appropriate curricua which recognizes the diversity of sociocutura and economic groups in the popuation as we as the roes/responsibiities of various heath professionas, 2) the inadequate funding for preparation of facuty to direct and provide training, 3) the unavaiabiity of educationa programs and resources to support the education of practicing professionas, and 4) the ack of appropriate invovement of accreditation and standard-setting bodies to assure the competence of heath professionas and others invoved in materna and chid heath care. Foowup on this recommendation is receiving priority in most parts of the nation, and significant steps have been taken to improve the education of a wide range of providers who can have an impact on breastfeeding decisions. These steps revove around the foowing major types of action: convening task forces, work groups, and committees to focus on professiona education; deveoping and promugating poicies, standards, protocos, and curricua to guide professiona action; offering continuing education to a wide range of heath care providers; providing professiona consutation and technica assistance to upgrade the knowedge and skis of heath professionas; and pubishing manuas, guides, and educationa materias for professiona reference. Seected exampes of each of the above types of action foow. Task Forces/Work Groups/Committees A nationa Task Force on Professiona Training in Lactation was convened in June 1985 by the University of Rochester Medica Center with support from the Division of Materna and Chid Heath, Department of Heath and Human Services to review the activities of professiona groups pursuant to this recommendation and to determine additiona efforts that need to be panned to improve professiona education in the areas of actation and breastfeeding. About 20 major professiona organizations and vountary agencies concerned with perinata heath, education of professionas, and standards of practice were represented. A mode poicy state- 3

10 ment, Promotion of Breastfeeding in the Context of Heath Care: Professiona Training Priorities, and a set of objectives were deveoped (see Appendix A). Task Force members agreed to a foowup strategy which caed for each organization to endorse the joint poicy statement or deveop one of its own, and to review the objectives, identifying specific actions to be undertaken by the organization to achieve them. It is expected that the task force meeting wi faciitate networking and resut in cooperative training programs. As wi be noted in the section on Pubic Education, many of the state and community coaitions organized to promote breastfeeding incude a work group or committee specificay concerned with professiona education. For exampe, one subcommittee of the Virginia Task Force on Breastfeeding is investigating continuing education opportunities reated to actation for heath care professionas in that state; the New York City Steering Committee to Promote Breastfeeding has a task group to focus on training of hospita staff; and one of the Montgomery County, MD Breastfeeding Coaition s committees focuses on professiona education of physicians. Poicies/Standards/Protocos/Curricua Not ony are Federa, State, and oca pubic agencies, nationa organizations, and vountary agencies deveoping new or additiona poicy statements, standards, protocos, curricua, and other types of guidance on breastfeeding, but they are aso taking positive action to ensure their dissemination and impementation. Iustrations of specific activities are given beow: The Division of Materna and Chid Heath, Department of Heath and Human Services issued a Regiona Program Guidance Memorandum on Breastfeeding Promotion Efforts to its regiona office staff members in Materna and Chid Heath, Primary Care, and the Nationa Heath Service Corps. The Division of Materna and Chid Heath aso sent copies of the Heathy Mothers, Heathy Babies Breastfeeding Packet to the State Directors of Materna and Chid Heath and to a regiona offices of the Department of Heath and Human Services for reference use of staff and for broad dissemination to their state and oca co-workers. Poicy and position statements reated to breastfeeding deveoped by many professiona organizations remain in effect. These incude issuances from the American Academy of Pediatrics, American Coege of Obstetricians and Gynecoogists, the Nationa Association of Pediatric Nurse Associates and Practitioners, and the American Pubic Heath Association. Other groups report that they are in the process of deveoping new, or additiona, poicy and position statements reated to breastfeeding. These incude the Nationa Perinata Association and The American Dietetic Association. The Tennessee Department of Heath and Environment deveoped 1) a protoco on providing support to breastfeeding mothers for use in oca heath departments, 2) esson pans on breastfeeding management in hospitas for use in training of hospita staff, and 3) guideines for enisting the support of oca heath care providers and heath professiona training programs. 4

11 The Steering Committee to Promote Breastfeeding in New York City deveoped a curricuum which specifies breastfeeding knowedge and skis necessary for hospita staff. It wi be used to train monitors and heath care workers invoved in impementation of New York State s new reguations supporting breastfeeding in hospitas. Their Guide to Promoting Breastfeeding in the Hospita wi be distributed widey by the State Heath Department. Heath Education Associates (PA) issued two new education aids designed to hep impement recommendations of the Surgeon Genera s Workshop. The Breastfeeding Teaching Box for In-Hospita Teaching is a box of teaching cards for instructor use in any setting in which mothers initiate breastfeeding. The Kit for Preventing Breastfeeding Probems and Eary Faiure provides compete instructions and materias for use in deveoping a teephone ca system to assist nursing mothers. Based on the reaization that many give up breastfeeding very easiy, the kit uses a triage mode to differentiate among women with different eves of interest and motivation in breastfeeding and to focus on providing practica hep to each woman as indicated. Famiy Medicine Center, Durham Heath Care, Inc. (NC) has incorporated didactic materia on actation and breastfeeding in the nutrition curricuum deveoped for its residency program. Future pans incude deveopment of a counseing component of the nutrition curricuum to increase competency of famiy physicians in counseing breastfeeding mothers. The first credentiaing exam for actation consutants was given in Juy 1985 in Washington, DC by the Internationa Board of Lactation Consutant Examiners. Continuing Education Positive steps are being taken in many states, oca communities, and agencies across the nation to provide in-service education in actation and breastfeeding to a wide range of care providers. In some states, educationa resources such as the Nationa Chid Nutrition Project (PA) and Heath Education Associates (PA) are utiized for workshops and conferences. These states incude: Caifornia, Idaho, Iinois, Maryand, Mississippi, Montana, New Hampshire, North Dakota, South Dakota, Vermont, and Washington as we as severa states in Department of Heath and Human Services Region VI. Often personne in neighboring states participate; for exampe, Maine sent staff to the New Hampshire workshop. In other states, the state heath agency works cosey with educationa institutions and various agencies to provide continuing education in actation and breastfeeding. Frequenty these continuing education courses invove one or more sessions incorporated into a broader topic on materna and chid heath; often the conference focuses soey on actation. States invoved in these activities incude: Aaska, Coorado, Connecticut, Georgia, Iowa, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, Ohio, Pennsyvania, South Dakota, Utah, Washington, and Wyoming. Both pubic and private community agencies in various ocaities aso conduct in-service training for their own staff as we as that of other agen- 5

12 ties. For exampe, the nutrition staff of the Wiiam F. Ryan Community Heath Center (NY) participated in ongoing professiona conferences on breastfeeding education. In Indiana, the Rura Heath Activities Project and Margaret Mary Community Hospita sponsored a wofkshop. La Leche League reports the continuation of ong-standing professiona seminars for physicians, and the impementation of additiona educationa opportunities for heath professionas and breastfeeding counseors. Medica centers aso pay a key roe in sponsoring professiona education opportunities, often in cooperation with other groups. These incude the University of Rochester Medica Center (NY), Case Western Reserve University and Rainbow Babies and Chidren Hospita (OH), and Georgetown University Hospita s Department of Nursing (DC). Vountary agencies and professiona organizations contribute to upgrading the knowedge and skis of professionas. The March of Dimes Birth Defects Foundation and The American Dietetic Association incude actation and breastfeeding as important topics in their nationwide series of symposia for dietitians, nurses, and physicians, designed to address nutrition in perinata heath care incuding the short- and the ong-term support of critica and convaescing premature infants. Papers and sessions on breastfeeding are incuded in the annua meeting programs of such professiona organizations as the American Medica Women s Association, American Coege of Obstetricians and Gynecoogists, and the Nationa Association of Pediatric Nurse Associates and Practitioners. The twefth and thirteenth annua Seminars for Physicans on Breastfeeding sponsored by La Leche League nternationa were hed in Montrea, Canada in 1984 and in Washington, DC in Professiona Consutation/Technica Assistance In order to hep heath care providers deveop skis in patient education and management of breastfeeding, many agencies continue or are expanding their professiona consutation and technica assistance services to staff in a wide variety of practice settings. For exampe, the three-year demonstration project sponsored jointy by the Departments of Pediatrics, Obstetrics, and Community Heath of the Abert Einstein Coege of Medicine (NY), and supported as a Tite V Specia Project of Regiona and Nationa Significance, is designed to improve the incidence and duration of breastfeeding among ow-income women in the Bronx. A actation consutation team consisting of a nutritionist, nurse, and obstetrician provides consutation and education services in the three municipa hospitas in the Bronx and the eeven community heath centers that constitute the Bronx Committee for the Community s Heath. Whie members of the team provide consutation to mothers with breastfeeding probems, primary emphasis is given to education and training activities directed toward providers of care. The San Diego Lactation Program continues to provide intensive training and consutation to professiona care providers. For exampe, the Popuation Counci of New York utiized staff from the San Diego program for a day-ong workshop for key staff members of the municipa hospita system. This workshop consisted of on-site visits to seected hospitas to meet with staff and conduct bedside demonstrations of techniques to assist 6

13 mothers with breastfeeding. A foowup visit one year ater was made to the target hospita to address specific concerns of staff. Manuas/Guides/Educationa Materias A significant number of educationa materias designed for professiona reference and use were avaiabe prior to the Surgeon Genera s Workshop. Since the Workshop a renewed effort has been made to improve their dissemination and to deveop additiona materias to meet specia needs and fi existing gaps. Exampes of activities reated to this effort incude: The Heathy Mothers, Heathy Babies Coaition s Breastfeeding Promotion Packet was assembed with eadership from the American Academy of Pediatrics and contributions from seected Federa and State agencies and professiona organizations. Amost 2,000 copies of this educationa packet on breastfeeding have been disseminated nationwide. The packet incudes reprints of scientific artices on actation and breastfeeding; bibiographies of seected technica references and resource materias; sampe materias for cient education; a how-to guide to assist individuas, agencies, and communities to promote breastfeeding; and a ist of key organizationa contacts by state. In some states, materias in the packet have been made more widey avaiabe to heath professionas working within the state. The Nationa Chid Nutrition Project (PA) pubished A Guide 10 Breastfeeding - Principes, Practices and Probems. It is intended as a guide for medica professionas and others who work with expectant and new mothers. The Popuation Counci s Program for Appropriate Technoogy in Heath has deveoped Breastfeeding: A Nurse s Guide for use in conjunction with two cient bookets, A Mothers Guide to Breastfeeding and Su Guia de a Lactancia Materna. Intended for use by hospita staff and mothers, the bookets are designed to hep them initiate and maintain breastfeeding. Drawings and simpy stated messages are used to iustrate and expain breastfeeding. The United States Department of Agricuture, Food and Nutrition Service, with support from the Infant Formua Counci, pubished and disseminated Promoting Breastfeeding: A Guide for Heath Professionas Working in the WIC and CSF Programs. The guide is intended to provide a variety of ideas and successsfu approaches to hep staff be more effective in their efforts to promote breastfeeding among owincome women. The Nationa Center for Education in Materna and Chid Heath continues to make avaiabe the video-tape on breastfeeding from the nationwide teeconference entited Improving Nutrition for Mothers and Babies: A Research Update - Breastfeeding and Human Lactation. 7

14 PUBLIC EDUCATION Recommendation: Deveop pubic education an4 promotiona efforts There is a need to improve the avaiabiity and quaity of information and education about actation and breastfeeding as a norma process, a part of everyday ife, and the preferred method of infant feeding. Important aspects of this recommendation incude the deveopment and dissemination of accurate and consistent messages about breastfeeding, increased use of the educationa system and the media; coordination with professiona education; recognition and targeting of various economic, cutura, and ethnic groups; and encouragement of pubic officias and other eaders who can infuence community support for breastfeeding. A wide range of efforts have been stimuated by the workshop and impemented to improve pubic information and education about breastfeeding and actation. Incuded are activities designed to make more effective use of various media, improve targeting of hard-to-reach groups, deveop state and community promotion and pubic education campaigns, integrate breastfeeding information into education systems, coordinate and share educationa materias, and coect data to monitor changes in attitudes and behavior. Iustrations of these various activities foow. Media Increased use has been made of teevision, radio, newspapers, magazines, posters, fims, dispay ads, educationa materias, and other media to enhance awareness of breastfeeding as the norm and to encourage the deveopment of attitudes and behaviors that support it. For exampe, the Pubic Education Task Group, New York City Steering Committee to Promote Breastfeeding, competed a three-pronged strategy as the basis of a pubic information campaign. Incuded were a media effort composed of a subway poster, press conference, caravan of mothers breastfeeding on the subway with teevision, radio, and press coverage; a teephone information effort which provided counseing and referra; and an informationa pamphet for use in heath cinics and other service settings. A speakers bureau was organized, and resource materias were deveoped for use in pubic presentations during a city-wide Prenata Care Week program. An estimated four miion New Yorkers had some exposure to the two-month pubic information campaign in the fa of The Wisconsin Nutrition Project, Inc., deveoped two radio and two teevision pubic service annoucements to promote breastfeeding. The Tennessee Breastfeeding Task Force deveoped a pubic service annoucement to educate the pubic and encourage pregnant women to contact the heath 8

15 department for breastfeeding information, whie the North Jersey Community Union in Newark aso conducted a media campaign about breastfeeding. Actress Linda Kesey has formed a non-profit, organization, Metanoia (a Greek work meaning change of heart ), to foster a change on the part of miions of mothers around the word to choose breastfeeding. Metanoia has produced a 30-second pubic service announcement in Engish and Spanish to promote breastfeeding and wi have a to-free 800 teephone number which viewers wi be abe to ca for information. The pubic service announcement wi be avaiabe for use by states in their Heathy Mothers, Heathy Babies pubic information efforts. Posters and eafets for use in a wide variety of settings were deveoped by the New York State Heath Department in cooperation with the New York City Heath Department and the New York City Medica and Heath Research Association. The Heathy Mothers, Heathy Babies Coaition has continued to emphasize breastfeeding in its pubic education effort. Breastfeeding is the topic of one of a series of six posters and information cards deveoped for use in cinics serving ow-income pregnant women. Over a miion breastfeeding information cards in Engish and Spanish have been distributed to ow-income women. A student in the Department of Heath Education at Hunter Coege, New York City, is conducting a survey of women to evauate the effectiveness of different types of posters in getting the breastfeeding message to women. Videotapes to present information to cients were prepared by the Jackson County, IL pubic heath program and by Charity Hospita in New Oreans, LA. The atter tape was fimed in a cient s home, and a cient narrated the fim. Cosed-circuit teevision is made avaiabe to patients at the Kapioani Women and Chidren s Medica Center in Hawaii, and breastfeeding fims are shown daiy. Fims were aso prepared and disseminated to increase pubic education about breastfeeding. In Kansas, the State Department of Heath and Environment and the Kansas University Medica Center produced Breastfeeding in the 1980 s. The producers of a three-part educationa fim series on breastfeeding, Motion, Inc., offered a specia discount on fim orders received before March 31, 1985, in recognition of the Surgeon Genera s commitment to promote breastfeeding. The New Jersey State Department of Heath, with support from the Ford Foundation, deveoped a fim entited Liy s Choice for use with ow-income popuations. Outside My Mom: The Story of a Breastfed Baby is an 1 -minute audiovisua presentation avaiabe from the March of Dimes Birth Defects Foundation. It is avaiabe in coor sides or fimstrip with audio-cassette and comes with a teaching guide and pamphets for viewers. Other innovative activities reated to the use of media incude the deveopment of a guide, Starting a Teephone Support System for Breastfeeding Mothers, by the Wisconsin Nutrition Project, Inc., and the Aabama State Heath Department s use of speciay designed postcards. Maied to mothers of breastfed infants when infants are ten days, three weeks, and six weeks of age, the cards provided information designed to encourage continuation of breastfeeding. 9

16 New or additiona educationa materias on breastfeeding were deveoped by numerous organizations and agencies, and many took steps to expand the dissemination and use of existing materias. For exampe, the Missouri Division of Heath deveoped an information packet on breastfeeding for diabetics, whie the Naturist Society and the State Heath Departments in Aaska, Coorado, Iinois, Indiana, Minnesota, New York, Wisconsin, and Wyoming deveoped or provided for new materias on breastfeeding. The Utah State Heath Department initiated a periodic newsetter for a new mothers in the state, and it wi incude information on breastfeeding. The American Academy of Pediatrics, the Department of Heath and Human Services/Division of Materna and Chid Heath, the United States Department of Agricuture/Food and Nutrition Service, the Bayor Coege of Medicine/Department of Pediatrics, and The American Dietetic Association cooperated in the deveopment and dissemination of two pubications on breastfeeding-a Gift of Love and Breastfeeding: Baby s Best Start. The atter is written in both Engish and Spanish. Hard-To-Reach Groups Some of the educationa materias on breastfeeding described above were pubished in severa anguages to meet cient needs and in simpified formats for cients with imited reading skis. For exampe, the Popuation Counci of New York deveoped a new set of educationa mater,ia for women with imited reading abiity. Heping Mothers to Breastfeed, Program Strategies for Minority Communities, a guide edited by Judith D. Gusser and Caro A. Bryant, was pubished by the Lexington-Fayette County Heath Department (KY) and the University of Kentucky Coege of Medicine. Based on a breastfeeding promotion workshop supported by Ross Laboratories, the pubication incudes reports from peope directing successfu breastfeeding programs for ow-income mothers in severa rura communities and ethnic groups in widey scattered geographic areas. Forida has deveoped a poster to promote breastfeeding among its new refugee popuations. Many immigrants from deveoping countries view botte-feeding as the accepted method of infant feeding in the United States. The poster in Engish, Spanish, and Haitian Creoe versions says Discover the New American Way of Infant Feeding. In New York City, the Expanded Food and Nutrition Education Program aides acceerated their activities to promote breastfeeding among owincome women. Emphasis is given to recruitment of pregnant women, particuary pregnant teens, use of vounteers to provide a support network, and use of eafets and brochures adapted to cient needs. To provide prenata education for young parents in rura areas, the University of Wyoming deveoped tweve side-tape modues, one of which is on breastfeeding. Recognizing that grandmothers and other cose kin can be important support persons for new parents, the Internationa Chidbirth Education Association, Inc., has deveoped a eafet entited To the Grandmother of the Breastfed Baby. Grandmother casses offered during the prenata and postnata periods to hep cose kin earn current concepts of materna and infant care and nutrition are aso recommended. Such casses can update 10

17 grandmothers on new concepts and practices that have changed during the ast generation and can hep them deveop supportive attitudes and techniques. Many of the breastfeeding promotiona campaigns described ater in this section focus considerabe attention on hard-to-reach groups. The District of Coumbia s campaign, for exampe, is targeted for ow-income minorities who reside in the District as we as for oca professiona and paraprofessiona providers who deiver heath and socia services to these groups. Promotion/Pubic Education Campaigns One of the most interesting foowup activities was the initiation and expansion of coaition-type organizations in states and communities across the nation to mobiize community interest and support for breastfeeding. Foowing are a few iustrations of these organizing efforts. The Virginia Task Force on Breastfeeding currenty incudes representatives from heath departments and hospitas and wi be expanded to incude individuas from primary care centers and other interested groups. Three subcommittees are invoved in obtaining baseine data about breastfeeding promotion and education, investigating opportunities for continuing education avaiabe for heath care professionas, and reviewing the avaiabiity of support services and systems. The Georgia Breastfeeding Promotion Steering Committee incudes representatives from medica organizations, nationa foundations, and educationa institutions. Pans are underway to convene breastfeeding workshops for professionas and sponsor other promotiona activities. The District of Coumbia s Breastfeeding Promotion Campaign was aunched in September Individuas and organizations from the private and pubic sectors are cooperating to address barriers that interfere with the initiation and continuation of breastfeeding. Tennessee s Breastfeeding Promotion Task Force was organized to deveop a statewide breastfeeding education and promotion campaign. It is composed of representatives from the nursing, nutrition, and materna and chid heath divisions of the State Department of Pubic Heath. A technica advisory committee has been organized and incudes two private-practice obstetricians, the chairman of the Perinata Advisory Committee of the state chapter of the American Academy of Pediatrics, two university nursing professors, and a hospita nurse and actation counseor. A poicy etter stressing the importance of providing services that support breastfeeding has been issued to a oca heath departments in the state. A workshop, entited Promoting Breastfeeding in Massachusetts: Research Issues, Poicy Impications and Practica Strategies, was hed to set the groundwork for a statewide campaign. Organized by the Massachusetts Breastfeeding Promotion Task Force, the workshop was cosponsored by the Massachusetts Department of Pubic Heath, Boston University Schoo of Pubic Heath, Boston Area Heath Education Center, Department of Heath and Hospitas, and the Erna Yaffe Foundation. Numerous state, professiona, and vountary organizations were invoved. Conference proceedings wi be avaiabe in December Cities and counties in various geographic areas were aso active in promoting breastfeeding. For exampe, the La Crosse, WI Breastfeeding Task 11

18 Force, organized in 1982, has continued its efforts to work with oca hospitas, cinics, socia services, and Women, Infants, and Chidren programs to increase the incidence and duration of brgastfeeding. The Las Vegas, NV Perinata Coaition is working to invove the La Leche League in staff training and to modify hospita poicies which have discouraged breastfeeding. The Montgomery County, MD Breastfeeding Coaition has deveoped Guideines for Enisting Support of Loca Heath Care Providers and Heath Professiona Training Programs. Four committees have been estabished: Patient Education, Professiona Eduction for Physicians, Community Outreach, and Literature. The Steering Committee to Promote Breastfeeding in New York City continues to impement specific strategies to promote breastfeeding. The work of six task groups is we underway, and reports of some of their activities are discussed in other sections of this report. In addition to a of these state and oca coaition activities, Heathy Mothers, Heathy Babies state coaitions in Arizona, Caifornia, Maryand, and Montana reported a focus on the promotion of breastfeeding. Education Systems Limited efforts to integrate breastfeeding information into existing secondary schoo curricua and educationa programs and systems are being reported. The New York State Heath Department reported oaning fims on breastfeeding free of charge to schoos for famiy ife education courses. In Arizona, La Leche League members are invited to speak in some schoos. Primary care projects such as North Jefferson Heath Systems, Inc., Cayton, NY provide fims, informationa materias, and staff to ecture on breastfeeding in schoos. In addition, prenata and parenting casses conducted by a wide variety of heath agencies incude information on breastfeeding. Such agencies incude Cinica Sierra Vista (Lamont, CA), Northern Oswego County Heath Services, Inc. (Puaski, NY), San Juan Department of Heath and the Conciia De Saud Integra De Loiza, Inc. (PR), and the Anchorage Heath Department (AK). Coordination/Sharing of Educationa Materias Educationa materias on breastfeeding deveoped by such organizations as La Leche League, Internationa Chidbirth Education Association, the American Academy of Pediatrics, and The American Dietetic Association are utiized nationwide. In addition, information and materias avaiabe from industries such as Ross Laboratories, Mead Johnson, Wyeth Laboratories, and Gerber are aso used and adapted as necessary. Many oca heath departments report that they utiize materias from their respective state heath agencies. Data Coection It appears that more effort is being made to coect baseine data usefu in monitoring changes in attitudes and behavior reated to breastfeeding. States utiizing the automated data system of the Women, Infants, and Chidren program to monitor the incidence of breastfeeding are Aabama, Arizona, Coorado, Connecticut, Iowa, Kentucky, Maine, Montana, 12

19 Nebraska, New Jersey, North Caroina, Rhode Isand, Tennessee, and Wisconsin. Over 300 materna and chid heath agencies and primary care programs in the Department of Heath and Human Services Region VI have surveyed knowedge, attitudes, and practices among their cients. Maine, Caifornia, and Oregon report use of their state-wide newborn screening program data base to determine incidence of breastfeeding. In Maine, for exampe, a recenty initiated Newborn Breastfeeding Surveiance Program provides information on breastfeeding rates in Maine hospitas and about feeding practices of at east 90 percent of the newborns in the state. The Ross Laboratories Nationa Mothers Survey is conducted on an annua basis to track infant feeding practices in the United States. The data from the 1984 survey are schedued to be pubished in the December 1985 issue of Pediatrics. Surveys to assess practices and poicies were aso conducted by Aaska s State Department of Heath and Socia Services; Arizona s State Department of Heath; St. Louis, Missouri s County and City Women, Infants, and Chidren Advisory Counci; and Tennessee s State Department of Pubic Heath. The surveys obtained information from mothers, birth certificates, hospitas, heath programs, and other data sources. 13

20 HEALTH CARE SYSTEM Recommendation: Strengthen the support for breastfeeding in the heath care system Practices of the heath care team and poicies of heath care institutions do not aways refect concern for actation and the promotion of breastfeeding. In fact, frequenty they negate support for it. This recommendation deas with the need for breastfeeding promotion in ambuatory heath care settings as we as hospitas. The need for education for a members of the heath care team about the process and the advantages of actation in human reproduction and infant heath was emphasized. Adoption of institutiona poicies supportive of actation and breastfeeding and remova of disincentives to breastfeeding were recommended. Many supportive actions are aso reported under Professiona Education and Support Services. Five different strategies appeared frequenty to be used to strengthen the heath care system s support of breastfeeding. These incude: deveopment and promugation of institutiona poicies, standards, and protocos; modification or enactment of aws and reguations; impementation of mode or demonstration programs; education of staff and cients; and deveopment of task forces, guides, and materias. Exampes of each of these strategies foow. Poicies/Standards/Protocos Federa, state, and oca agencies report the deveopment, adoption, and dissemination of poicies, standards, and protocos designed to increase support for breastfeeding in the heath care system. Some exampes are given beow: The United States Department of Agricuture revised Efforts To Promote Breastfeeding in the Suppementa Food Programs, a fact sheet which describes federa requirements, pubications, and guidance avaiabe from the United States Department of Agricuture, cooperative efforts, and other usefu information. The Division of Materna and Chid Heath/Department of Heath and Human Services incuded breastfeeding promotion as a priority area for competitive grant appications for Fisca Year 1985 funding under the Materna and Chid Heath Improvement Projects category of Specia Projects of Regiona and Nationa Significance. In New Mexico, nutrition recommendations for actating women and infant feeding were incuded in a state nutrition manua. Breastfeeding: A Probem Soving Manua was aso deveoped by the nutrition staff of the state heath agency for use by nurses, nutritionists, and other heath professionas. 14

21 8 The Women, Infants, and Chidren and the Commodity Suppementa Foods Program State Pans and Poicies continue to emphasize breastfeeding as a priority among program goas. Connecticut, Minnesota, and Wisconsin Women, Infants, and Chidren programs require each oca agency to incude measures to promote breastfeeding in its annua pan. A poicy and procedure manua on breastfeeding for babies requiring newborn intensive care and other specia care was deveoped at the University of Kansas Medica Center. Poicy changes have been instituted to support breastfeeding of preterm and sick infants. Six Steps to Breast Feeding Promotion: A Handbook for Heath Care Professionas in Materna and Infant Care Faciities was deveoped by the Prenata and Postpartum Ambuatory Care Task Group of the Steering Committee to Promote Breastfeeding in New York City. The Suggested Guideines and Standards for Materna and Perinata Nutrition Care, which incudes breastfeeding, continues to be promugated by the Michigan Heath Department in cooperation with the Michigan State Medica Society and the Michigan Dietetic Association. A Mode Breastfeeding Poicy for Fu-Term Norma Newborn Infants was deveoped by the San Diego Lactation Program (CA), and a simiar poicy is in preparation by the Greater Southeast Community Hospita (DC). A Breastfeeding Promotion Poicy, issued by the Tennessee Department of Heath and Environment, is posted in every heath department cinic statewide. A Breastfeeding Promotion Handbook to assist oca heath departments with panning and impementing such efforts is being competed. The Arkansas Pubic Heath Association adopted the American Pubic Heath Association resoution on Breastfeeding Encouragement. 0 The Georgia Division of Pubic Heath, Office of Nutrition deveoped a position paper on breastfeeding. Guideines are aso being prepared and wi be distributed statewide as part of a practice manua. Quaity assurance standards for actation were deveoped by the Materna and Chid Heath Division, Indiana Department of Heath, and made avaiabe for use in a oca heath services. Laws/Reguations This particuar strategy has not been used extensivey, but severa states have undertaken activities reated to either changing existing aws and reguations, or deveoping new ones in order to infuence the heath care system to faciitate breastfeeding. Some of these activities are given beow: In New York State, breastfeeding reguations were issued as an amendment to the New York Hospita Code (see Support Services). In Massachusetts, there is a proposed amendment to the patients bi of rights to inform prenata and maternity patients about the heath benefits and techniques of breastfeeding and actation. The bi (S2269) is in the Senate Steering and Poicy Committee. In the Pacific Basin, a mode bii supporting the promotion of breastfeeding and adaptabe to each jurisdiction is being prepared for incusion in a breastfeeding packet, This effort is part of the focus on breastfeeding, a priority of the Pacific Basin Materna and Chid Heath Resource Center IS

22 at the University of Guam. This center is supported by Division of Materna and Chid Heath funds. Mode/Demonstration Programs Many agencies impemented a variety of mode or demonstration programs which provide continuous support, professiona consutation, cient counseing, and education. Descriptions of a number of these programs are mentioned beow: The Lactation Project at Oregon Heath Sciences University Hospita serves women who deiver their babies there as we as those referred by private physicians. The project incudes a actation cinic, inservice training of staff, consutation to staff and private physicians, teephone foowup of cinic cients, and prenata education which incudes breastfeeding. The Mode Breastfeeding Program of Tacoma-Pierce County Heath Department is supported by the Washington State Office of Materna and Chid Heath. Detais of this project are discussed under Support Services. The project Overcoming Constraints to Breastfeeding in Lower Socioeconomic Urban Groups has been continued by the Popuation Counci (NY). Focusing on factors over which hospita staff coud exert some contro, a Nursing Department Lactation Committee was deveoped in the hospita. Functions of the Committee reate to staff and patient education, reporting techniques, and deveopment of more consistent, quaity nursing care throughout the period of pregnancy, actation, and infancy. An interdiscipinary group meets on an ad hoc basis to examine impediments to breastfeeding as they reate to medica and nursing issues. Pans incude empoyment of a part-time actation counseor, a teephone hotine for nursing mothers, and training of a mutidiscipine staff. The three-year SPRANS Breastfeeding Project at Abert Einstein Coege of Medicine (NY) is described under Professiona Education. In addition to activities cited esewhere, a curricuum outine, Art and Science of Breastfeeding, and a form for prenata pediatric interviews have been deveoped. A joint breastfeeding promotion project of the Washington State Office of Materna and Chid Heath Services and the Seatte-King County Department of Pubic Heath is deveoping a system to promote breastfeeding that can be repicated statewide. Supported as a Tite V Materna and Chid Heath Improvement Project, the goas of the project are: to estabish a mode for increasing the incidence and duration of breastfeeding among ow-income and minority women that incorporates support for breastfeeding into the existing heath care deivery system; to provide breastfeeding education to pubic heath professionas throughout Washington; and to deveop breastfeeding education materias for statewide use. A mode of service wi be deveoped, impemented, and evauated at two sites that currenty have very ow rates of breastfeeding. A manua to assist others in the deveopment of simiar projects wi aso be written. A breastfeeding promotion project conducted by Renewabe Technoogies, Inc., in Butte, MT aims to deveop breastfeeding counse- 16

23 ing and support in the existing private materna and infant care system where virtuay a such care is provided in Montana. Heath care professionas (nurse, nurse-midwife, dietitian) wi function as breastfeeding subspeciaists who wi become sef-supporting independent practitioners in the existing private system. The cost of providing breastfeeding support services by a breastfeeding subspeciaist and the potentia for any reimbursement for payment of these services wi be determined. The piot project Materna and Chid Heath Modue has been initiated at Shady Grove Adventist Hospita (MD). The focus incudes change in hospita poicies, staff education, and a strengthening of referra and foowup. The Breastfeeding Promotion Program at Yeatman, Union-Sarah Medica Heath Centers, St. Louis, MO, invoves promotion, education, counseing, and support activities. An ad hoc task force was organized to expore the feasibiity of such a program and assist in its impementation. A prenata counseing protoco was estabished. A series of etters to the cient s famiy, incuding grandparents and fathers, was deveoped and many other actions impemented. A project reated to promotion of breastfeeding in the hospita setting was conducted by the Division of Chid and Famiy Heath, Department of Heath and Wefare, Canada. Another project invoved the deveopment of a counseing guide, Feeding Babies in the Eighties, for heath professionas. Staff/Cient Education A diverse group of heath care agencies took positive steps to improve the knowedge and skis of staff and cients invoved in the heath care system. Activities directy reated to this recommendation are aso discussed under Professiona Education, Pubic Education, and Support Services, and some are mentioned in the paragraphs that foow: The first step in a mutifaceted program for Aabama s heath department personne is in-service training on aspects of breastfeeding promotion. Five of the ten heath districts are focusing on increasing the incidence of breastfeeding. Significant numbers of community heath centers have stepped up their efforts to provide individua counseing and patient education, and to use prenata and chidbirth preparation casses effectivey for education regarding breastfeeding. Among such heath centers were the Oak Orchard Heath Center and Coney Isand Community Heath Center (NY), East Orange Famiy Heath Center (NJ), Cinica Adeante, Inc. (AZ), and Neponset Heath Center (MA). Nurses in the area of Ceveand Metropoitan Genera and Highand View Hospitas (OH) received training on the promotion of breastfeeding of high risk infants from the neonata nutritionist. The Hudson Headwaters Heath Network, Warrensburg, NY, provides a free pediatric visit for coupes before their baby is born. During this visit the pediatrician stresses the importance of breastfeeding. Information about breastfeeding is aso presented during the Lamaze casses sponsored by the Network. 17