ACOG Launches Initiative to Increase Breast-feeding

Janis C. Kelly

July 26, 2013

The American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women has revealed a landmark set of recommendations, published in the August issue of Obstetrics & Gynecology, aimed at mobilizing clinicians, hospitals, and other providers to help increase the rate of breast-feeding in underserved women.

"Underserved women, those who are unable to obtain quality health care by virtue of poverty, cultural differences, race and ethnicity, geographic region, or other factors that contribute to health care disparities, may face greater barriers in the initiation and continuation of breastfeeding," according to the committee.

Breast-feeding initiation is lower among black women (58.9%) and women in the Special Supplemental Program for Women Infants and Children (WIC; 66.1%) than among the general population (76.9%). Women younger than 20 years are also less likely to initiate breast-feeding (53.0%) compared with women aged 20 to 29 years (69.0%) or those aged 30 years and older (77.5%). The Healthy People 2020 target is to increase the proportion of infants who are ever breast-fed to 81.9% and those who are breast-fed at 6 months to 60.6%.

Breast-feeding: What Physicians Need to Tell Their Patients

Lack of social support for underserved women about breast-feeding heightens the importance of healthcare providers' and mothers' awareness of other available resources.

"Health care providers should be aware of community resources, including prenatal lactation classes; lactation consultants; home visiting providers; and support groups, such as La Leche League, WIC peer counselors, and phone support. It is helpful for patients to learn about these resources at the time of discharge or during prenatal care," the committee notes.

The report also noted that the US Department of Health and Human Services has developed a campaign to support black women and breast-feeding that includes videos of black mothers discussing their experiences with breast-feeding.

"Counseling to encourage breastfeeding also should involve the patient's partner, a practice shown to improve breastfeeding rates. Acknowledging challenges involved in breastfeeding and the difficulties many women experience while breastfeeding, and recognizing that these experiences are risk factors for postpartum depression, is critical," the committee wrote.

The ACOG committee further recommended that practitioners take advantage of resources such as the American Academy of Pediatrics (AAP) program on breast-feeding, the self-study modules on lactation available from Well Start International, and The Breastfeeding Handbook for Physicians, prepared by ACOG and the AAP.

Choose Gift Packs Wisely

ACOG warned that the "gift packs" containing formula often provided by hospitals to new mothers are a deterrent to breast-feeding because they reinforce the social belief that formula feeding is the norm and carry an implied professional recommendation of the included products. This effect is compounded in hospitals that have not developed programs to provide education and support for breast-feeding. "For this reason, health care providers may conclude that noncommercial educational alternatives or gift packs without health-related items are preferable," the committee writes.

Providing Greater Access to Lactation Consultants, Work Breaks

The committee recommends that lactation consultants be accessible to women both in the hospital and after discharge but notes that because of the cost, and because the cost of lactation visits had been included in the global prenatal fee, access to these services have been unavailable for many women. The Affordable Care Act required many plans to provide coverage without cost sharing in the plan year that began on or after August 1, 2012. "Patients should be educated about this coverage," the report recommends.

Barriers to breast-feeding include socioeconomic status, education misperceptions, social norms, poor family and social support, and the fact that low-income women are more likely to return to work sooner and to work at jobs that make breast-feeding at work more difficult than for more affluent women. The report notes a common misconception among adolescents that breast-feeding "creates dependency."

The ACOG report notes that the Affordable Care Act included an amendment to the Fair Labor Standards Act, effective March 23, 2010, that "requires employers of 50 or more employees to provide reasonable break time and a private place, other than a bathroom, for breastfeeding mothers to express breast milk during the workday for 1 year after the infant's birth."

Hospitals Urged to Put It in Writing

The ACOG report recommended that hospitals maintain a written pro-breast-feeding policy, communicate that policy to all staff, and train staff in the skills needed to carry out this policy. The committee further urged hospitals to inform all pregnant women about the benefits of breast-feeding and offer all mothers the chance to initiate breast-feeding within 1 hour after giving birth.

To encourage continuation of breast-feeding, ACOG suggested that hospitals show mothers how to breast-feed and how to maintain lactation. The report recommended giving breast-feeding newborns only breast milk unless there are medical reasons not to, having mothers and newborns "room in" together during the hospital stay to encourage unrestricted breast-feeding, and encouraging suckling by providing no pacifiers or artificial nipples. Finally, the report recommends that hospitals routinely refer mothers to breast-feeding support groups and services.

Benefits Include Maternal Weight Loss, Lower Diabetes Risk

ACOG supports breast-feeding as the preferred method of feeding newborns and infants until 6 months of age. Among the benefits of breast-feeding cited in the ACOG report are "protection from infections, biologic signals for promoting cellular growth and differentiation, decrease in maternal postpartum blood loss, and a reduction in the risk of ovarian and breast cancer."

According to the report, breast-feeding has also been associated with greater postpartum weight loss in mothers; reduced childhood obesity; reduced incidence of type 2 diabetes in mothers; lower rates of hypertension, hyperlipidemia, and cardiovascular disease in mothers; and increased interval between offspring resulting from delayed ovulation.

The lead authors of the Breastfeeding in Underserved Women document were Leah A. Kaufman, MD, from the Long Island Jewish Medical Center, New Hyde Park, New York, and Veronica Gillispie, MD, from the Ochsner Clinic, New Orleans, Louisiana. Neither have any conflicts to disclose.

Obstet Gynecol. 2013;122:423-428. Full text

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