ABM Position on Breastfeeding-Revised 2015

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Recognition of International Board Certified Lactation Consultants by health insurance providers in the United States: results of a national survey of lactation consultants

BACKGROUND

Insurance coverage for lactation management is proposed by the United States Affordable Care Act. International Board Certified Lactation Consultants (IBCLCs) are key providers of lactation services. In order to inform national discussion, this study examines the scope of insurance reimbursement of IBCLC services.

OBJECTIVES

An email survey of US IBCLCs (N = 10 495) in March 2011 was used to explore frequencies of (1) submission--how often lactation consults were submitted to insurance providers for reimbursement and (2) recognition--the proportion of submitted charges recognized by insurance providers.

METHODS

Results (N = 2045) were analyzed to describe patterns of submission and recognition by IBCLC work setting, job classification, and reimbursement strategy.

RESULTS

Many survey respondents did not know their submission (41%) or recognition (57%) levels. Multiple strategies were used for reimbursement of IBCLC services with large variations in recognition between strategies. Overall, less than 15% reported high levels of submissions to insurance providers. Moreover, of submitted encounters, only 4% were consistently recognized by insurance providers. Inpatient hospital IBCLCs were least likely to have consults recognized (3%), and private community IBCLCs were most frequently recognized (32%). Compared with using IBCLC credentials for submitting an encounter, using another clinical license was the most successful strategy for achieving recognition of IBCLC consults (crude risk ratio, 1.44; 95% confidence interval, 1.04-2.01; P = .02).

CONCLUSION

IBCLCs provide key care to a vulnerable population. However, we found that these services are not consistently reimbursed. IBCLCs poorly communicate their health care activities to insurance providers, but insurance providers also inconsistently recognize and reimburse IBCLC care.

Infant feeding practices and determinants of poor breastfeeding behavior in Kinshasa, Democratic Republic of Congo: a descriptive study

BACKGROUND

Although breastfeeding is almost universally accepted in the Democratic Republic (DR) of Congo, by the age of 2 to 3 months 65% of children are receiving something other than human milk. We sought to describe the infant feeding practices and determinants of suboptimal breastfeeding behaviors in DR Congo.

METHODS

Survey questionnaire administered to mothers of infants aged ≤ 6 months and healthcare providers who were recruited consecutively at six selected primary health care facilities in Kinshasa, the capital.

RESULTS

All 66 mothers interviewed were breastfeeding. Before initiating breastfeeding, 23 gave their infants something other than their milk, including: sugar water (16) or water (2). During the twenty-four hours prior to interview, 26 (39%) infants were exclusively breastfed (EBF), whereas 18 (27%), 12 (18%), and 10 (15%) received water, tea, formula, or porridge, respectively, in addition to human milk. The main reasons for water supplementation included "heat" and cultural beliefs that water is needed for proper digestion of human milk. The main reason for formula supplementation was the impression that the baby was not getting enough milk; and for porridge supplementation, the belief that the child was old enough to start complementary food. Virtually all mothers reported that breastfeeding was discussed during antenatal clinic visit and half reported receiving help regarding breastfeeding from a health provider either after birth or during well-child clinic visit. Despite a median of at least 14 years of experience in these facilities, healthcare workers surveyed had little to no formal training on how to support breastfeeding and inadequate breastfeeding-related knowledge and skills. The facilities lacked any written policy about breastfeeding.

CONCLUSION

Addressing cultural beliefs, training healthcare providers adequately on breastfeeding support skills, and providing structured breastfeeding support after maternity discharge is needed to promote EBF in the DR Congo.

Understanding women's interpretations of infant formula advertising

BACKGROUND

Exclusive breastfeeding for 6 months and continued breastfeeding for at least 1 year is recommended by all major health organizations. Whereas 74.6 percent of mothers initiate breastfeeding at birth, exclusivity and duration remain significantly lower than national goals. Empirical evidence suggests that exposure to infant formula marketing contributes to supplementation and premature cessation. The objective of this study was to explore how women interpret infant formula advertising to aid in an understanding of this association.

METHODS

Four focus groups were structured to include women with similar childbearing experience divided according to reproductive status: preconceptional, pregnant, exclusive breastfeeders, and formula feeders. Facilitators used a prepared protocol to guide discussion of infant formula advertisements. Authors conducted a thematic content analysis with special attention to women's statements about what they believed the advertisements said about how the products related to human milk (superior, inferior, similar) and how they reported reacting to these interpretations.

RESULTS

Participants reported that the advertisements conveyed an expectation of failure with breastfeeding, and that formula is a solution to fussiness, spitting up, and other normal infant behaviors. Participants reported that the advertisements were confusing in terms of how formula-feeding is superior, inferior or the same as breastfeeding. This confusion was exacerbated by an awareness of distribution by health care practitioners and institutions, suggesting provider endorsement of infant formula.

CONCLUSIONS

Formula marketing appears to decrease mothers' confidence in their ability to breastfeed, especially when provided by health care practitioners and institutions. Therefore, to be supportive of breastfeeding, perinatal educators and practitioners could be more effective if they did not offer infant formula advertising to mothers.

Breastfeeding support in child care: an international comparison of findings from Australia and the United States

INTRODUCTION

Many women in industrialized countries return to work while their children are infants. This is often associated with decreased breastfeeding duration or exclusivity. In order to better understand the breastfeeding support activities in childcare settings, studies were undertaken in settings with very different levels of infant mortality, breastfeeding, and breastfeeding support: Adelaide, Australia, and Wake County, North Carolina. The researchers collaborated to explore, contrast, and compare their baseline data.

METHODS

Available data on breastfeeding rates and infant mortality rates were explored for the two settings. In addition, the two childcare datasets were explored for common questions, and descriptive and χ(2) analyses were carried out.

RESULTS

Similarities were found between the response from childcare settings providers in Australia and the United States. Rates of having at least one breastfeeding infant (70.6% vs. 66.3%), a place to breastfeed (90.7% vs. 95%), and a refrigerator for storage (100% vs. 100%) were similar for Adelaide and Wake County, respectively. Qualitative data from Adelaide also mirrored Wake County data in that providers in neither setting were actively promoting breastfeeding. However, the Adelaide data reflected significantly higher rates of encouragement (95.3% vs. 21.7%), written policy (77.8% vs. 20.8%), resource/materials distribution (76.6% vs. 1% and 93.8% vs. 17%), and training (44.4% vs. 13.9%).

CONCLUSIONS

Childcare practices may reflect the environment of support, or lack thereof, for breastfeeding in the society as a whole. The similarities and differences seen in these settings may reflect both official guidance as well as the breastfeeding environment. There is much work to be done in the United States to come up to the same level of support for breastfeeding in child care and in other programs as is seen in Australia.

WIC and breastfeeding support services: does the mix of services offered vary with race and ethnicity?

OBJECTIVE

The U.S. Department of Agriculture's Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition services provides supplemental nutrition and counseling to more than 50% of families with young children in the United States. Given the program's significant reach, as well as large differences in rates of breastfeeding among whites, African Americans, and Hispanics, we explored the associations among breastfeeding initiation, the availability of WIC-based breastfeeding support, and the racial/ethnic composition of WIC clients in North Carolina.

METHODS

An electronic survey gathered data on ongoing breastfeeding support activities from local WIC directors in North Carolina. North Carolina Pregnancy and Nutrition Surveillance System data provided racial/ethnic composition and breastfeeding initiation rates. Linear and logistic regression models were used to examine county-level associations among (1) racial/ethnic composition of clients, (2) breastfeeding initiation, and (3) availability of the identified WIC breastfeeding support services.

RESULTS

Responses were received from 50 of the state's 100 counties and were generally representative of the state. Breastfeeding initiation by site was negatively associated with percentage of African American clients and positively associated with percentage of white or Hispanic clients (p<0.05). The availability and intensity of breastfeeding support services varied widely, with 50% offering clinic-based services, 46% offering home visits, 38% offering peer counseling, and 76% offering some other form of counseling. The WIC sites with larger Hispanic populations were more likely to be providing a broad base of services, including clinic-based services, peer counseling, and home visits (p<0.05); those with higher African American populations were significantly less likely to offer clinic-based breastfeeding support services (p<0.05) and trended toward fewer services in general.

CONCLUSIONS

Results confirmed previous findings of racial/ethnic disparities in breastfeeding rates. We also found that differences in the availability of breastfeeding support services were associated with the racial/ethnic composition of the catchment area. This apparent inequity in the availability of breastfeeding support services at different WIC sites may merit further exploration and may inform implementation of aspects of the U.S. Surgeon General's Call to Action to Support Breastfeeding.

Community based participatory research of breastfeeding disparities in African American women

OBJECTIVE: Lack of support for breastfeeding mothers has been consistently identified in the literature as a barrier for breastfeeding across racial and ethnic groups. Using a community-based participatory approach, academic and community-based partners conducted an iterative process to assess barriers, facilitators and potential mediating interventions for breastfeeding in the African-American community in Durham, North Carolina. METHODS: Eight focus groups were conducted with African-American mothers, fathers and grandmothers. Researchers transcribed and coded each focus group and analyzed using Atlas ti. 5.2. Patterns and themes that emerged informed the development of community stakeholder interviews; 41 interviews were conducted with community representatives. These findings informed the development of a support group pilot intervention. The pilot support groups were evaluated for increase in knowledge of attendees. RESULTS: Focus group and community interviews indicate that African Americans may disproportionately experience inadequate support for breastfeeding. This lack of support was reported in the home, the workplace, among peers, and from healthcare providers. The pilot support groups resulted in increased knowledge of breastfeeding among group participants OR=3.6 (95% CI: 2.5, 5.2). CONCLUSIONS: The findings from this research underscore the importance of a multi-level approach to breastfeeding support for African American women to address breastfeeding disparities.

Unintended consequences of the WIC formula rebate program on infant feeding outcomes: will the new food packages be enough?

Approximately half of all mothers of infants born in the United States receive services through the Special Supplemental Nutrition Program for Woman, Infants and Children (WIC). Although WIC promotes breastfeeding, data suggest that, despite advances in the last 2 decades, WIC participants are less likely to initiate breastfeeding, and much less likely to continue, than non-WIC participants, including the non-WIC participants who are eligible for WIC. WIC recently revised their food packages and enhanced the monetary value of the breastfeeding packages. While these changes are an important step in supporting WIC's efforts to promote breastfeeding, other major factors, such as participants' perceptions of the value of the packages and WIC's dependency on rebates from formula companies to fund a portion of the program, may dampen WIC's breastfeeding promotion and support efforts. There is great need for additional research on these issues.

Exploration of guilt among mothers who do not breastfeed: the physician's role

Physicians commonly state the concern that, if they promote breastfeeding, they may "impose guilt upon those who do not breastfeed." This article explores the genesis of this fear, who may benefit from this construct, and the terminology of guilt, shame, and loss. The article also explores the responsibility for both lactation failure and associated shame, considering the roles and responsibilities of physicians, the media, and society as a whole. An alternative construct for the guilt is offered, based on the consideration that the woman experiences lack of breastfeeding as a loss at some level, conscious or subconscious, and whether the choice to not breastfeed is her decision or imposed. Proposed approaches for acting to prevent and to treat shame and guilt are presented.

A descriptive study of Cambodian refugee infant feeding practices in the United States

Background

The purpose of this exploratory study was to examine Cambodian refugee mothers' infant feeding beliefs, practices, and decision making regarding infant feeding in the U.S. and to explore if a culturally-specific breastfeeding program is appropriate for this community.

Methods

A self-administered questionnaire and a 30 minute in-person interview were used to collect information from nine women. The audio-taped interviews were transcribed, answers compiled, and themes from each question identified.

Results

All participants practiced either traditional Cambodian diet (pregnancy and postpartum diet including, tnam sraa, herbs mixed with either wine or tea), traditional Cambodian rituals (like spung, amodified sauna) or both, despite having lived in the U.S. for many years. All nine women initiated breastfeeding, however eight women introduced infant formula while in hospital. Perceived low milk supply and returning to work were the main reasons cited for partial breastfeeding and early cessation of breastfeeding.

Conclusion

While causes of initiation of other foods are similar to those found in the U.S. as a whole, a culturally-specific Cambodian breastfeeding support program may help overcome some breastfeeding problems reported by Cambodian refugee mothers who have immigrated to the United States.

Breastfeeding: a woman's reproductive right

This paper explores the importance of breastfeeding as a women's issue in the health and political contexts, covering the role of global institutions, health practitioners, and national decision-makers in furthering the goals of supporting breastfeeding as a woman's right to health. The roles and responsibilities of the Obstetrician/Gynecologist are highlighted.

The impact of a hospital and clinic-based breastfeeding promotion programme in a middle class urban environment

Hospital interventions in support of breastfeeding have been highly successful in areas where the indigenous population has a well established environment of breastfeeding. However, programmes designed to improve breastfeeding patterns in urban populations have met with mixed success. This paper presents a prospective intervention study with a control group in which a health system-based breastfeeding promotion programme was initiated to support optimal breastfeeding for both child health and child spacing. Following collection of control data, a four-step intervention programme (Breastfeeding Promotion Program) was instituted. This paper reports the process of the development of the intervention programme as well as the comparison of the control and study populations. Major findings include significant increases in duration of full breastfeeding from 31.6 per cent at 6 months in the control group to 66.8 per cent in the intervention group. The duration of lactational amenorrhea was similarly increased: 22 per cent of the control mothers and 56 per cent of the intervention group women were in amenorrhoea at 180 days. The cost-effectiveness of the hospital changes is illustrated.

Breast-feeding and child health in the United States

This paper evaluates the influence of breast-feeding on infectious and allergic diseases in infants and children through an analysis of data from a large national sample of US children. It controls for a large number of maternal and child health, demographic, and socioeconomic variables which have been shown to affect feeding patterns, and it includes several aspects of the feeding pattern in addition to breast-feeding. The results suggest that breast-feeding provides some protection against pneumonia and otitis media in the United States while early introduction of formula may have a separate and negative effect.

Who is breast-feeding? Implications of associated social and biomedical variables for research on the consequences of method of infant feeding

The objective of this paper is to identify social and biomedical variables that influence the selection of methods of infant feeding in the United States and to provide guidelines for the choice of control variables in the design and interpretation of studies that examine the influence of breast-feeding on infant and child health. Data were drawn from a national household survey, the Child Health Supplement of the 1981 Health Interview Survey conducted by the National Center for Health Statistics. Relationships between demographic, socioeconomic, and health variables were studied for the total sample of children under age 5 y as well as for black and white women separately. The data provide evidence for the importance of both social and health variables as selection factors for breast-feeding in the United States.

Toward consistency in breastfeeding definitions

On 28 April 1988, the Interagency Group for Action on Breastfeeding met to develop and agree upon a set of definitions that could be used as standardized terminology for the collection and description of cross-sectional information on breastfeeding behavior. The schema and potential framework suggested at the meeting were reviewed extensively by breastfeeding researchers and program personnel, revised at subsequent meetings by a variety of organizations, and compared against published research on patterns of breastfeeding and their effects on infant nutrition, health, and fertility. This schema and framework: (1) acknowledge that the term "breastfeeding" alone is insufficient to describe the numerous types of breastfeeding behavior, (2) distinguish full from partial breastfeeding, (3) subdivide full breastfeeding into categories of exclusive and almost exclusive breastfeeding, (4) differentiate among levels of partial breastfeeding, and (5) recognize that there can be token breastfeeding with little to no nutritional impact. The schema and framework should assist researchers and agencies in their efforts to accurately describe and interpret breastfeeding practices.

Use-effectiveness of the ovulation method initiated during postpartum breastfeeding

Between April 1981 to March 1984, 419 urban middle class postpartum women entered the Natural Family Planning (NFP) program of the Pontificia Universidad Catolica de Chile. This NFP program teaches the Ovulation Method (Billings). Only 1.9% of the women did not learn how to recognize the mucus pattern of fertility awareness. The sample of 378 women who were practicing the method to avoid a pregnancy completed 4,935 months of use of the OM. The cumulative life table unplanned pregnancy rate at the 12th postpartum month was 11.1 +/- 1.9 and the Pearl Rate was 12.1 per 100 woman-years. The Pearl Rate calculation of method-related failure was only 2.1 pregnancies per 100 woman-years. The breastfeeding group showed a significantly lower rate of unplanned pregnancies than the nonbreastfeeding group and there was no significant increase in unplanned pregnancy at the time of menstruation among previously amenorrheic women as compared to later intervals. The protection against unplanned pregnancy shown in this study should be viewed as the combination of two factors: breastfeeding and the Ovulation Method (OM) of NFP.

Characteristics of ovulation method acceptors: a cross-cultural assessment

Five programs of instruction in the ovulation method (OM) in diverse geographic and cultural settings are described, and characteristics of approximately 200 consecutive OM acceptors in each program are examined. Major findings include: the religious background and family size of acceptors are variable, as is the level of previous contraceptive use. Acceptors are drawn from a wide range of socioeconomic and religious backgrounds; however, family planning intention was similarly distributed in all five countries. In sum, the ovulation method is accepted by persons from a variety of backgrounds within and between cultural setting.

Contraceptive usage during lactation in the United States: an update

National Surveys of Family Growth data showed that as of 1982, most lactating women who were sexually active used a contraceptive method; barrier methods were most frequently used. Black women and women of higher parity and lower educational level were more likely to be sexually active and not using a method.

Contraceptive usage during lactation: analysis of 1973 and 1976 National Survey of Family Growth: I. Age and race

Data from the National Survey of Family Growth are analyzed to estimate the prevalence of contraceptive use during lactation. Approximately 20 per cent of lactating women were sexually active and did not use a method in months two through six, postpartum. Among method users, the largest proportion chose barrier methods but 14 per cent used oral contraceptives in the early postpartum period. Between 1973 and 1976 there was an increase in the percentage of women who utilized a contraceptive method during lactation and a decrease in the per cent using oral contraceptives.