Public Health

Perspectives in Lactation
PUBHLTH 310, Winter 2020. Carly McCabe, M.S.
Think-pair-share

•  Consider: What does it mean to evaluate or address an issue

from a ‘public health perspective?’
•  Think to yourself for one minute and then share your thoughts
with the person next to you.
Think-pair-share

•  Possible answers:
•  How many people are affected by this issue? How costly is this
issue? How preventable is this issue?
•  Socioecological model
 Differentiate between diverse definitions of breastfeeding

Describe the benefits of breastfeeding that affect the

economy and the environment

Understand the elements of the socio-ecological model that

Learning determine maternal self-efficacy and breastfeeding support

Objectives Describe the common lactation challenges faced by

breastfeeding mothers

Summarize the public health programs available in the U.S.

that support breastfeeding

Understand the degree of support from health care providers

and national guidelines for breastfeeding care
Overall goal of the lecture

•  Evaluate, from many perspectives, the current state of

breastfeeding in the United States and the factors that
contribute to or hinder efforts to improve rates.
Diverse definitions of breastfeeding

•  Dr. Anderson’s lecture alluded to array of definitions

•  Generally a lack of consistency in literature and research of
breastfeeding definitions
•  Important to consider the impact of various patterns of
breastfeeding and/or human milk feeding on a wide variety of
health outcomes for mother and child.
•  Lack of definition = lack of comparability
Definitions of Breastfeeding

Labbok, M. H., & Starling, A. (2012). Definitions of breastfeeding: Call for the development and use of consistent
definitions in research and peer-reviewed literature. Breastfeeding Medicine. https://doi.org/10.1089/bfm.2012.9975
Breastfeeding Rates (US)

Percent of females Percent of females

breastfeeding exclusively breastfeeding
through 6 months through 6 months

Data obtained from: CDC. 2018. Breast feeding Report Card

Breastfeeding Rates (US) National Immunization
Survey. CDC. 2018
 Environmental Cost of Not Breastfeeding

Ecological footprint of Energy for manufacture,

breastmilk substitutes materials, transport &
compared to distribution, water and
breastfeeding cleaning agents.

4,000L of water required In US, 550 million cans,

across production for 1kg 86,000 tons of metal, and
of breastmilk-substitute 364,000 tons of paper
powder used annually to package

Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., … Victora, C. G. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet. https://doi.org/10.1016/
S0140-6736(15)01044-2
 Longer breastfeeding duration associated with 2.6-point
increase in IQ score

Economic
Cost of Not One standard deviation (SD) increase in cognitive scores
associated with 12% and 16% increase in hourly earnings in

Breastfeeding high and low- and middle-income countries

Global loss of gross national income associated with present

levels of any breastfeeding amount to $302 billion dollars
annually

A 10%-point increase in exclusive breastfeeding up to 6 months

or continued breastfeeding up to 1 or 2 years reduced
treatment costs of childhood disorders by at least $312 million
in the USA

Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., … Victora, C. G. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet. https://doi.org/10.1016/
S0140-6736(15)01044-2
Minute-paper

•  Consider breastfeeding in the context of the socio-ecological

model. Name a possible factor for each of the following
levels: structural, community/setting, and individual.
•  What might be a possible intervention to address one of these
factors?
Socio-ecological Model and Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S.,
Lutter, C. K., Martines, J. C., … Victora, C. G.
(2016). Why invest, and what it will take to improve

Breastfeeding
breastfeeding practices? The Lancet. https://
doi.org/10.1016/S0140-6736(15)01044-2
Socio-ecological Model and Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S.,
Lutter, C. K., Martines, J. C., … Victora, C. G.
(2016). Why invest, and what it will take to improve

Breastfeeding
breastfeeding practices? The Lancet. https://
doi.org/10.1016/S0140-6736(15)01044-2
Who is Breastfeeding?

•  Females receiving support

•  Workplace
•  Partners and family
•  More likely to breastfeed if mother did
•  Culture
•  Age: more likely if 30 years of age or older
•  Higher income: 74% versus 54%

Pediatrics. 2010 and 2008; CDC 2015

Who is
breastfeeding?
Data obtained from: CDC. 2018.
Breast feeding Report Card
Barriers to Breastfeeding

•  Lack of knowledge
•  Lack of professional training and support
•  False notion of inadequate supply
•  Lack of support
•  Social norms
•  Public inconvenience
•  Embarrassment
•  Status of using formula

Chuisano S. and Anderson OS. Journal of Human

Lactation. 2019 (under review); Surgeon General Report.
 •  Study of self-reported reasons mothers stop
Common breastfeeding in the first year, identified seven main
factors
Challenges
Seven Factors of Cessation

•  Lactational •  Medical
•  Latch and nipple/breast problems •  Mother or infant’s sickness, plans
for next pregnancy
•  Psychosocial
•  Breastfeeding attitudes and social •  Milk pumping
support •  Not being able or wanting to
express milk
•  Nutritional
•  Concerns about milk supply •  Self-weaning
•  Infant biting, losing interest, age of
•  Life-style related infant
•  Diet, smoking, personal freedom
Study Results

•  Lactational & nutritional reasons most common during first month

•  Most cited reason for stopping: Perception of their child’s dissatisfaction with
breastmilk alone
•  Maternal confidence and self-efficacy
•  In a study of self-selected mothers who elected to exclusively breastfeed for 3-4 months,
less than 5% of of the mothers were unable to produce enough milk to support infant’s
nutritional needs.

•  Reasons vary with age of infant

•  Psychosocial and milk pumping factors become more prevalent after
first and second month
Public Health Programs and Organizations
The Special Supplemental Nutrition Program for
Women Infants and Children (WIC) Program

•  Pregnant women (through pregnancy and •  Supplemental nutritious foods

up to 6 weeks after birth or after pregnancy
•  Nutrition education and counseling at WIC
ends).
clinics
•  Breastfeeding women (up to infant’s 1st
•  Screening and referrals to other health,
birthday)
welfare and social services
•  Nonbreastfeeding postpartum women (up to
6 months after the birth of an infant or after
pregnancy ends)
•  Infants (up to 1st birthday). WIC serves 53
percent of all infants born in the United
States.
•  Children up to their 5th birthday.
Breastfeeding
Initiatives

•  Surgeon General Call to Action to Support

Breastfeeding
•  Baby-Friendly Hospital Initiative

Surgeon General Report 2011; BFHI Implementation Guidance 2018. WHO and UNICEF
Baby-Friendly Hospital Initiative

•  Launched by UNICEF and WHO in 1991

•  Global program aimed to encourage the broad-scale
implementation of the
Ten Steps to Successful Breastfeeding and the International Code
of Marketing of Breast-milk Substitutes
•  Provide mothers with information, confidence, and skills to initiate
and continue to breastfeed their babies
•  Program that provides special recognition to hospitals that
successfully implement the Ten Steps to support these mothers
Health Care Provider Perspective

Attitudes of health care providers have been proven to influence a woman’s

choice to breastfeed

Better prenatal breastfeeding education is needed

The most effective breastfeeding support interventions include components of care spanning the pregnancy into the postpartum
period
Education by OBs/Midwives during pregnancy Education by pediatricians postpartum Family care physicians can provide continuity
• No continuation of care after delivery • Lack of relationship/trust • Only 6% of prenatal care in the US is provided by family
physicians
Health Care Provider Perspective

Lack of confidence in breastfeeding skills

•  Due to poor training for breastfeeding education
•  Lack of a focus in school and residency

Limited time to address BF issues

•  Difficulty fitting BF education into preventive care visits
•  Lack of training on how to address issues that are
identified during these visits
Thank you!

•  Carly McCabe, M.S.

•  cmccab@umich.edu