What are some of the factors which affect exclusive breastfeeding rates--created in a web format

1. Running head: WEB OF A PROBLEM - EXCLUSIVE BREASTFEEDING RATES 1
Web of a Problem - Exclusive Breastfeeding Rates
Denise Breheny
Queens University of Charlotte

2. Web of a Problem - Exclusive Breastfeeding Rates
For my topic I would like to analyze the interrelationships and multiple factors that contribute to
the failure to obtain Healthy People 2010 (HP 2010) goals of breastfeeding initiation and duration. The
current goals of HP 2010 are:
Breastfeeding Rates HP 2010 Goal (U.S. Department of Health HP2010 Actual (Ross Products Division, Abbott
and Human Services [USDHHS], 2000) Laboratories [Abbott], 2003)
• Initiation Rate 75 % 66%
• At Six Months 50% 33%
• At One Year 25% 10%
The HP 2010 initiative was designed to improve the overall health of citizens of the United States,
and established goals for breastfeeding rates. There is abundant evidence that human milk has
nutritional benefits beyond the capacity of formula manufactures to replicate. The intake of human milk
by the baby and the act of lactation by the mother also is helpful in the increased health benefits provided
by these processes. Further, breastmilk is economical by creating less of a drain on individual and
federally funded economic resources. Breastfeeding is less harmful to the environment.
For years breastfeeding an infant fell out of popularity and favor in light of new “scientifically
derived” formula feedings. As formula feeding became more important as the preferred feeding choice
for infants, the choice to breastfeed became more of a lifestyle choice, as opposed to a major health
decision. Over recent decades major health benefits to the infant, the mother and even the community for
families to strongly consider breastfeeding. So much so that many organizations including the World
Health Organization (WHO) guidelines that state in order to achieve optimal growth, development and
health, the infant should be exclusively breastfed for the first six months of life (WHO: Baby-friendly
Hospital Initiative, 2010). The WHO is not alone in their recommendations, they are joined by the
American College of Obstetrician and Gynecologists, the American Academy of Pediatrics, the American
Academy of Family Physicians and the Centers for Disease Control and Prevention, all agree that
breastmilk alone is the preferred and sufficient infant nutrition for the first 6 months of life.

3. In 2009 the CDC conducted a survey of hospitals in the United States to see what policies and
practices were in place, and their effectiveness in the support of exclusive breastfeeding. The findings
were published in a Breastfeeding Report Card 2009. The breastfeeding report card showed how five
“outcome” and nine “process” indicators showed how breastfeeding was being protected, promoted, and
supported nationally and state by state. The nine process indicators were based on the Baby-Friendly
guidelines previously established by the Baby-Friendly Hospital Initiative (BFHI) a global program
sponsored by WHO and the United Nations Children’s Fund (UNICEF). Later that same year, The Joint
Commission (TJC) selected exclusive breastfeeding rate as one of five quality measures towards
addressing the quality and safety needs of perinatal patients. TJC is looking specifically at the number of
exclusively breastmilk-fed infants in a proportion to all term infants.
The topic of exclusive breastfeeding has now been identified by TJC as important, and hospitals
that participate with this quality initiative are able to track and improve their breastfeeding rates. It
would appear from the recently expanded core measure set by TJC that in the United States (U.S.) we are
becoming more aware and moving our hospitals more towards the goals of (BFHI) by recognizing
hospitals and birthing centers that offer an optimal level of care for breastfeeding mothers, based on the
Ten Steps to Successful Breastfeeding for Hospitals (WHO: Baby-friendly Hospital Initiative, 2010).
According to a study published in the Journal of Pediatrics in April, 2010, if new moms would
breastfeed their babies for the first six months of life, it would save nearly 1,000 lives and billions of
dollars each year (Bartick & Reinhold, 2010). With the abundance of information available in support of
breastfeeding and the support of major stakeholders in the improvement of the health of mothers and
children, we are still unable to come close to the goals set by HP 2010. I selected this problem because as
a lactation consultant I would like to logically explore the reasons behind the inability of our U.S.
population to have a higher incidence of exclusive breastfeeding.

4. Identifying Groups at Risk
Although breastfeeding is an important behavior that has been identified as related to the improved
health of mothers, infants and children as well as lower health care costs, breastfeeding initiation and
continuation is not being practiced by the majority of women. There is much research which looks
breastfeeding continuation behavior. The research shows that there are complex relationships to
continuation of breastfeeding which involves not only incentives, but disincentives as well. Often the
disincentives outweigh the advantages for many women. These disincentives form many barriers to
compliance with the breastfeeding recommendations set forth by HP 2010. Common factors associated with
breastfeeding cessation include the mother returning to employment outside of the home, the support of the
father within the home, contraindications to breastfeeding, and the mother’s psychological health. The
groups most at risk have been identified as, mothers experiencing difficulties with breastfeeding, low income
women, and mothers that desire to return to the workplace. The goal of this section is to better understand
why non-optimal infant-feeding practices occur among these groups despite extensive interest and support
by highly respected national and global organizations.
Mothers Experiencing Difficulties
Understanding why mothers decide to stop breastfeeding is important to being able to reach the
goals of HP2010. Past studies suggest a multitude of physical, psychological, and social reasons for cessation
of breastfeeding during the first year. These reasons include:
• Breast discomforts (Neifert, 1999)
• Infant illness
• Mother’s perception of insufficient milk
• Mother’s response to negative familial or health care support
• The contrast between real experience and idealized expectations about breastfeeding
• The need or desire to engage in conflicting activities, such as school or employment
In a study conducted by Williams et al, an additional reason for cessation of breastfeeding in the first
year was due to concern for the baby’s nutrition, and this was the most cited reason for cessation within the

5. first 90 days (Williams, Vogel, & Stephen, 1999). They also cited returning to work and personal choice as
reasons for cessation for mothers’ breastfeeding six months or longer.
• Concern for the baby’s nutrition
• Return to work
• Personal Choice
Kirkland and Fine utilized a survey over 1800 women at 1, 2, 3 and 5 months for reasons
that they stopped breastfeeding (2003). The results of their survey showed that:
Month 1 and 2
• Most common reason for breastfeeding cessation was “breastmilk did not satisfy infant”
• “Infant had difficulties nursing”
• “Mother wanted to leave the infant for several hours”
• “Mother thought she was not producing enough milk”
• “Mother wanted someone else to feed the infant”
Months 3 to 5
• “Infant had difficulty nursing”
• “Infant weaned self”
• “Mother could not feed infant because of work”
The were able to categorize the responses based on Orem’s construct of thriving and found 4 factors
which described responses to the new demands of breastfeeding, these were categorized as follows:
Physical Adjustments Nutritional Factors Psychosocial Distress Lifestyle Patterns
Factors Factors
 Mother became sick  Perception of  BF not worth  Mother wanted
 Breast infected baby not the effort someone else to
 Mother needed gaining enough  BF too tiring feed baby
medications weight  Father wanted  Mother wanted
 Infant sick  HP states mother to quit to leave infant
 Breasts overfull mother not for a few hours
 Breasts leaked making  Mother could
 Nipples sore enough milk not BF because
 HP states of work
infant not  Someone else
gaining enough wanted to feed
weight infant
 Mother  Mother not
perception not present to feed

6. Physical Adjustments Nutritional Factors Psychosocial Distress Lifestyle Patterns
Factors Factors
producing infant (other
enough than work)
 MBM not  Mother wanted
satisfying to diet
infant  Mother had too
 Mother having many
trouble getting household
milk flow to duties
start
 Infant had
difficulty
nursing
Table Abbreviations: BF-Breastfeeding, Breastfeed
HP-Health Professional
MBM-Maternal Breastmilk
Through the identification of the most popular reasons cited by mothers for breastfeeding cessation
earlier than the recommended guidelines, health professionals are able to identify programs and social
marketing directed specifically towards increasing the duration.
Low Income Women
Low-income women and children already have a potential for poorer health outcomes (American
Public Health Association, Food and Nutritional Section, 2007). In addition, low income mothers in the
United States (U. S.) generally are less likely to either initiate or continue to breastfeed than the general
population (American Academy of Pediatrics [AAP], 2005). Because of the potential problems associated
with this population demographic, the risks associated with not breastfeeding are particularly important.
The Supplemental Nutrition Program for Infants, Women and Children (WIC) is a program
specifically targeted to low-income women and children with the mission of supplementation of the
nutritional needs for participants. The income eligibility for this program is at or below 185% of the federal
poverty level and therefore is utilized frequently when looking at low-income populations which include
mothers and infants.

7. In a study completed in 2008, Racine et al looked at a study sample of almost 1,600 low-income
families eligible for WIC assistance, and participating in the Healthy Steps for Young Children National
Evaluation (Racine, Frick, Guthrie, & Strobino, 2009). In her research she specifically looked at factors
considered disincentive or barriers which were associated the cessation of breastfeeding. She and her
colleagues we able to identify the following disincentives in their research:
• WIC participation at 2-4 months
• Mother’s returning to work 20-40 hours per week
• Mother’s not attending a postpartum doctor’s visit
• Father not being in the home
• A smoker in the household
• No receipt of breastfeeding instruction at the pediatric office
• The doctor’s not encouraging breastfeeding
• The mother experiencing depressive symptoms
Focus groups were utilized by Heinig et al in 2006, to examine relationships among maternal beliefs,
feeding intentions and infant-feeding behaviors with 65 WIC eligible mothers (Heinig et al., 2006). She and
her colleagues found that although women shared the common beliefs that breastfeeding was beneficial, they
also found the following information when querying the participants:
• Introduction of formula and solid foods was unavoidable in certain situations
• Medical providers and WIC staff were sources of infant-feeding information which was often
ignored if not perceived as working for the family’s circumstances
• Mothers felt that providers world not understand that they were compelled to reject infant-
feeding recommendations, would not ask for assistance when facing difficulties
• Instead, mothers relied on relatives and other for infant-feeding guidance
In follow-up to her previous 2008 study, Dr. Heinig and her colleagues sought to identify factors that
contribute to the acceptance or resistance of breastfeeding advice (Heinig et al., 2009). Several factors were
identified in her research in the acceptance of breastfeeding advice which enabled her subjects to provide
maternal breastmilk feedings for a longer duration, and or impacted cessation of further breastfeeding:
• Mother primarily rely on experienced family and friends for advice
• Mother frequently use their own intuition of find solutions that work to solve real or perceived
infant-feeding problems

8. • Professional advices is perceived a credible when caregivers exhibit characteristics similar to those of
experienced family and friends: confidence, empathy, respect, and calm
Working Women
For another large group of women, the reason to decide to not breastfeed or the early termination of
breastfeeding is due to the fact that these women have made the decision to return to or start employment
outside of the home after the birth of their child. In 2008, 56.4% of mothers with children under one year old
were working outside of the home (Bureau of Labor Statistics, 2008). Often women must return to work due
to their economic situations. Having an income which provides a living with a mother who does not need to
work is a luxury, whereas a generation ago this was typical of middle class. It is usually the woman in the
lower income bracket or one who works casually that does not have the benefit of job protection, and or paid
maternity leave. These jobs often require lower skills and lack flexibility. Often there isn’t access available to
these women for expressing milk while working. There also are relatively few opportunities for negotiation,
or to demand these facilities or access to their infants for breastfeeding.
There are many studies that support the hypothesis that the challenges posed by the disincentives
involved with maintaining full time employment are important reasons for breastfeeding cessation in the
first six months (Kirkland & Fein, 2003). According to Karen Pallarito and reporter for HealthDay with U.S.
News and World Report, full-time workers with short postpartum maternity leaves were more likely to quit
breastfeeding early, those at utmost risk were women in non-managerial and nonflexible positions and
women with higher work related stress levels (Pallarito, 2010). Although the availability of worksite lactation
facilities, and the support of the employer of breastfeeding, pumping etc., does contribute to the longer
success and duration of breastfeeding; according to a study published by Guendelman et al, returning to
work is a strong predictor of cessation of breastfeeding:
• Returning to work within 6 weeks was the strongest predictor of breastfeeding cessation
• Returning to work within 6-12 weeks doubled the probability of cessation
• Having a inflexible job increased the probability of cessation
• Returning to work within 12 weeks had a higher impact on women in non-managerial position
• Postpartum leave had a positive effect on breastfeeding among full-time workers particularly those:
o In non-managerial positions

9. o Lacking job flexibility
o Experiencing psychosocial stress
(Guendelman et al., 2009).
One of the problems continually encountered by working mothers and tends to tip the scale towards
the cessation rather than the continuation of breastfeeding is the fact that breastfeeding is sex-specific, and
therefore can not be viewed as gender-neutral in childbearing. The act of breastfeeding from a feminine
perspective becomes even a more difficult problem because many do not consider breastfeeding to be critical
to an infant’s survival. Whereas pregnancy is protected during employment by specific legislation,
breastfeeding, or the right to pump milk up until recent legislation was only specifically protected in 41
states.
• Breastfeeding is sex-specific and not gender-neutral and therefore only impact the female workforce
of childbearing age
• Breastfeeding or the right to pump milk is not protected by Labor Laws in companies with fewer
than 50 employees, and only recent legislation protected and accommodated this health promotion
option
Research has shown that by supporting lactation at work, employers can reduce turnover, lower the
cost of new employee: recruitment, training, absenteeism, and eliminate temporary employees. Supporting
employee lactation can also boost morale and productivity, and reduce health care costs for all employees,
and the babies of employees. Recently Section 4207 of the Patient Protection and Affordable Care Act (also
known as Health Care Reform) mandated that all employers will need to provide a reasonable break time as
well as a private, non-bathroom place to express breastmilk during the workday up until the child’s first
birthday. However, in a personal correspondence with a Breastfeeding Coordinator for WIC services in
Oklahoma, she stated that often cited barriers to breastfeeding for working women are: suspicion, hostility,
or ridicule from bosses and coworkers (Piatak, 2010).
Disincentives to breastfeeding for working women:
• Unavailability of lactation breaks or flexible work schedule for either pumping expressed milk, or
breastfeeding an infant brought into the workplace
• Unavailability of privacy (a locked private office, or lactation room)
• Unavailability of paid maternity leave or disability pay of at least 12 weeks following birth.
• Unavailability of providing workplace support:

10. o Supportive staff attitudes
o Informing co-workers and management about the benefits that lactation support provides
for them
In The Case Against Breastfeeding, a recent article published in Atlantic by Hanna Rosin, she
brought up some very relevant but often ignored criticism of breastfeeding. She states that breastfeeding is
not like taking a vitamin to improve one’s health. Breastfeeding is a “serious time commitment that pretty
much guarantees that you will not work in any meaningful way ((Rosin, 2009, p. 11).” She further argues
that breastfeeding is only free if a woman’s time isn’t worth anything. This is true for the working mother,
who may be taking time away from her busy work schedule to pump milk, and these may be non-paid
breaks.
• Serious time commitment
• Potential decrease in maternal contribution to family income
o Non-paid lactation breaks
o Pumping time taking away from productivity time
o Possible longer maternity break (to breastfeed)
o The time spend breastfeeding must be worth something, unless a woman’s time isn’t worth
anything
Many women may be turned off by the thought of pumping at work due to the physical location of
where they work. Even when breaks to pump are protected, and providing a clean area to pump is required
by her employer, the fact that she has to travel to the space designated for milk expression and bring her own
pumping equipment is a consideration. Also, what is her work situation like? Does she work in a clean
environment, or a dirty one which might require her to remove or add a coverall in order to pump. Pumping
breastmilk is equivalent to preparing food, and requires the same level of cleanness and sanitation. What
about milk storage, is the refrigerator secure, or is it only a shared environment? All women are different in
their needs for time to pump, rest and return to work. Each woman would need an individualized plan
worked out with her employer in order to facilitate her expression of milk in the work place.
• Nursing or pumping room may be inconveniently located for all employees
• Mother’s own vocation may require a change of clothing or protective clothing in order to keep the
expression of milk safe
• An individual plan will need to be worked out for each women, all needs are not the same
• Costs involved for pumping supplies (breastpump, bottles, storage space-freezer)

11. Although there are many obstacles to overcome, providing fair and equitable treatment for
employed mothers to continue breastfeeding or expressing milk once back in the workforce does work in
states where this legislation has been previously mandated. In Oregon for example, State law details that one
30 minutes rest period be provided to express milk for every four-hour period worked. The break should
occur approximately mid the interval, and if possible within her normal break or meal period. The break
area should be private and not be a bathroom. There is a $1,000 penalty for each incident of non-compliance
(Breastfeeding Promotion: Oregon Breastfeeding Law, 2009).

12. Web of Causation
(For a better view you can open the PDF file sent with this paper)
Theoretical basis for the model: Breastfeeding women behave in a manner that maximizes their happiness. Incentives, disincentives and
barriers to breastfeeding will change over time. Barriers are both influenced by and influence disincentives. Incentives influence the
decision to continue with breastfeeding. Overtime when the disincentives and barriers outweigh the incentives the woman will decide to
discontinue breastfeeding in an effort to maximize her happiness.
Cost saving include the money saved by not having to purchase formula or savings in medical costs associated with not breastfeeding
Time saved includes time saved by not shopping for or preparing for formula bottle feeds.
Belief in breastfeeding includes the mindset that breastfeeding is natural and the philosophy that children should be breastfed.
Monetary costs include purchasing a breastpump and any auxiliary equipment for expression of milk.
ity Reources
Abbreviations: BF-Breastfeed, Breastfeeding, HP- Health Professional (Adapted from: Racine, Frick, Guthrie, & Strobino, 2009, figure 1)

13. Community Resources
In order to meet the HP2010 goals as pointed out in the web problem design, better emphasis should
be placed on interventions that focus on three important domains which include: returning to work and
school, social and professional support, and reducing contraindications to breastfeeding (disincentives and
barriers). In the area of returning to work it is noteworthy that with the initiation of the new Health Care
Reform, employers will now be required to provide breaks and a clean quiet place for mothers to continue
breastfeeding or pumping while at work.
There are many organizations that are assisting in helping reach the goals set by HP 2010. As
emphasized in the web problem design, although this web identifies three groups as: mothers’ experiencing
difficulties; low-income women; and working mothers; as shown in the actual web, any member of one
group may be a member of one or both of the other groups; therefore the disincentives and barriers may be
experienced by any of the mothers in any of the groups, community medical facilities, the local County WIC
offices and the national mother-to-mother support groups which are available locally as well as accessible
through the internet.
The community medical centers at both Carolinas Medical Center and Presbyterian Hospital offer
both inpatient and outpatient lactation services. All of the community’s Medical Centers are affected by TJC
evaluations and accreditation, and this year TJC added exclusive breastfeeding rate reporting as a quality
measure. The local hospitals have been influenced by a few hospitals in this State which have become
designated as Baby-Friendly USA Hospitals by the WHO: Baby-Friendly Hospital Initiative. Recently this
year all hospitals in our local community have discontinued the disbursement of formula gift bags to
breastfeeding mothers. As pointed out in the web problem and in research many times, the distribution of
free formula gift bags has been detrimental to many women in the continuation of breastfeeding.
Another community program available to women locally who are income qualified is the WIC
nutritional programs which are available in every county. The vast majority of low-income women and

14. children in the U. S. are served by the Special Supplemental Nutritional Program for Women, Infants and
Children both prenatally and following birth. The WIC staff has been very supportive of especially in the
past year since the WIC program has placed a higher emphasis on breastfeeding as the preferred infant
feeding method. This past year the program completely changed the food package programs providing a
higher food program for mothers choosing to breastfeed rather than formula feed. Although the WIC
program is the largest distributor of free infant formula in the U.S., a practice which has been consistently
found to be disruptive and a disincentive for breastfeeding; with recent changes they have included more
benefits for mothers who utilize this program and are returning to employment or school, by providing
effective breastpumps (retail value $200) to these mothers. This incentive has encouraged more women to
continue providing their milk even though they need to return to school or a job. They also receive an
enhanced food package which helps economically in these harsh times. They have been very proactive in the
areas of both social and professional support. They have breastfeeding coordinators in all the offices that are
able to explain the benefits of breastfeeding to all participants in these programs. They are also promoting
public awareness campaigns targeted at low-income populations to help increase acceptance of breastfeeding
in those populations.
The La Leche League (LLL) is another both international and local support entity. The LLL’s
“mission is to help mothers worldwide to breastfeed through mother-to-mother support, encouragement,
information, and education, and to promote a better understanding of breastfeeding as an important
element in the healthy development of the baby and mother” (La Leche League, n.d., p. 1). A mother can
search the international web site to find out specific information on breastfeeding difficulties, legal issues,
specific providers for care and local support groups. Currently in the Charlotte area there are several
LLL groups that meet at various times and can assist a new mother with her breastfeeding difficulties and
support.
One resource which should but does not exist in this community is a Baby-Friendly hospital.
Research has shown that being born in a Baby-Friendly hospital gives babies the best possible chance of

15. breastfeeding to 6 months (Merewood et al., 2007). This is particularly true for low-income populations
and for families from backgrounds that traditionally have low breastfeeding rates. In the study
conducted by Merewood et al., they found that women giving birth in a Baby-Friendly hospital increased
initiation rates from 58% to 87% (2007). In their study they found that the “myth” that women feel forced
to breastfeed, was dispelled and that breastfeeding duration rates among infants born in a Baby-Friendly
hospital were at or above national and regional levels at 6 months.
In order to receive the Baby-Friendly USA hospital designation, facilities must embark on journey
which requires them to evaluate their current practices in order to adopt new policies and procedures for
improved breastfeeding outcomes. They must first register with Baby-Friendly USA; and complete all
the requirements; and complete an on-site assessment which shows that their facility has been able to
successfully integrate the “10 Steps To Successful Breastfeeding” into practice. The 10-steps for Baby-
Friendly Hospital USA are:
The Ten Steps To Successful Breastfeeding
The BFHI promotes, protects, and supports breastfeeding through The Ten Steps to Successful
Breastfeeding for Hospitals, as outlined by UNICEF/WHO. The steps for the United States are:
1 - Have a written breastfeeding policy that is routinely communicated to all health care staff.
2 - Train all health care staff in skills necessary to implement this policy.
3 - Inform all pregnant women about the benefits and management of breastfeeding.
4 - Help mothers initiate breastfeeding within one hour of birth.
5 - Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their
infants.
6 - Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7 - Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.
8 - Encourage breastfeeding on demand.
9 - Give no pacifiers or artificial nipples to breastfeeding infants.
10Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
- from the hospital or clinic
In North Carolina the following hospitals have already been accredited with Baby-Friendly:
 Mission Hospital, Asheville, North Carolina

16.  Women’s Birth and Wellness Center, Chapel Hill, North Carolina
Currently there are 100 hospitals that have been designated as Baby-Friendly USA in the United
States; there are more than 15,000 in 134 countries worldwide. Participation in the BFHI provides many
benefits to the hospital or birthcenter. It can easily become a major quality improvement measure, and
many of the ten steps are adaptable as quality improvement projects. Increased breastfeeding rates can
impact health care costs through improved health care outcomes for the mother and the baby. This is a
prestigious international award and achievement for any hospital or birth center.
To date, human milk is the only substance available to provide complete nutrition and
immunologic protection to the human infant. Infant health outcomes from receiving human milk
correlate with both immediate and lifelong effects on children's lives. Added outcomes of human
lactation are the physical and psychological benefits for the lactating woman. Additionally, lactation and
breastfeeding have the potential to save money for families, tax payers, employers, and the health-care
system. There are many long term consequences for not providing maternal breastmilk and our
continued failure to reach the goals set by HP2010. Long-term consequences include the following
([AAP], 2005):
Breast Cancer
Treatment of breast cancer is approximately $30,000 annually/patient. Breastfeeding reduces the
incidence of breast cancer. (Lee 1997)
Diabetes
Breastfeeding reduces a diabetic mother's need for insulin and a two-fold reduction or delay in
the onset of subsequent diabetes for a gestational diabetic. Treatment of diabetes takes one of
every $7 of health care dollars, and costs the US $130 billion annually. This is for direct treatment
and does not factor in the high incidence of kidney disease, peripheral vascular disease and
blindness which accompany diabetes.
Emotional Stability
Oxytocin, a hormone released each time a mother breastfeeds, decreases blood pressure, stress
hormone level and calms the mother. A 38-fold difference in the frequency of domestic violence
and sexual abuse was found between the group that breastfed and the group which did not.
(Acheston 1995)
Infertility
Breastfed women were 25% less likely to have hyperprolactinemia, galactorrhea and menstrual
disturbances according to Dr. Shafig Rahimova. He also feels that males not breastfed are at
greater risk of developing genito-urinary difficulties.
Ovarian and Endometrial Cancer

17. A WHO Collaborative Study found the relative risk of endometrial cancer decreased significantly
with increased duration of breastfeeding; women whose lifetime lactation was 72 months or
greater, had the greatest protection. Those breastfeeding for less than one year did not accrue this
benefit. (Rosenblatt, 1995)
Lactation has a preventative effect on ovarian cancer. The American Cancer Society estimates
26,888 new cases of ovarian cancer will be diagnosed this year. Among women studied, there was
a ratio of 1 breastfeeding woman vs. 1.6 non-breastfeeding women who developed ovarian
cancer (= a 60% higher risk factor for non-breastfeeding moms)(Gwinn, 1990)
Osteoporosis
Lactating protects women against osteoporosis; not breastfeeding is a risk factor in its
development. Bone mineral density decreases during lactation but after weaning showed higher
bone mineral density than those who did not breastfeed. A mother's bone mineral density
increases with each child breastfed; lumbar spine density increased 1.5% per child breastfed.
Thus a decrease in the risk of a fracture of the hip, vertebrae, humerus or pelvis. (Kalwart and
Specker 1995; Hreschyshyn 1988)
In 1983 osteoporosis and osteoporotic fractures cost an estimated $6.1 billion dollars; an adult
white woman who lives to the age of 80 has a 15% lifetime risk of a hip fracture. (Cummings
1985)
Rheumatoid Arthritis
In Norway, 63,090 women with rheumatoid arthritis were followed for 28 years. The total time of
lactation was associated with reduced mortality; the protective effects of breastfeeding appear
dose related. (Brun 1995)
Weight Loss
During the first year postpartum, lactating women lose an average of 2 kg more than non-
breastfeeding women, with no return of weight once weaning occurs. The impact of overweight
impacts health by increasing chances of cardiovascular disease and diabetes. (Dewey 1993)
Allergies
Allergy protection is one of the most frequently cited reasons mothers choose to breastfeed.
Premature infants are also protected from allergies; breastfed preemies had less than one-third of
the allergies, particularly atopic disease, in the first 18 months of life. (Lucas 1990)
There has not been a documented case of anaphylaxis to human milk. (Baylor, 1991; Ellis 1991)
Estimated treatment cost of allergy diagnosis and treatment is $400; acute reaction treatment
costs about $80-100 per episode. (Hoey at 1996 ILCA Conference)
Anemia
In 1995, one study showed "none of the infants who were exclusively breastfed for 7 months or
more....were anemic." (Piscante, 1995)
Communicable Childhood Diseases
Antibody response to oral and parental vaccines is higher in the breastfed infant. Formula-
feeding, particularly soy formula, may interfere with the immunization process. (Zoppie 1989;
Hahn-Soric 1990)
Death
Breastfeeding protects against sudden death from botulism. In one study, all of the infants who
died were not breastfed. (Arnon 1982) Globally, breastfeeding has been identified as one element
of protection against SIDS. (Mitchell, 1991) One study identified the risk of SIDS increasing by
1.19 for every month the infant is not breastfed. (McKenna 1995) Breastfed infants are one-fifth to
one-third less likely to die of SIDS. SIDS is a leading cause of US infant death, impacting nearly
7,000 families per year. (Goyco 1990)
Diarrhea
Breastfeeding for 13 weeks has been shown to reduce the rate of vomiting and diarrhea by one-
third and reduce the rate of hospital admissions from GI diseases. (Howie 1990)

18. Breastfed infants are protected against salmonellosis; breastfed infants are one-fifth less likely to
develop this. (Stigman-Grant 1995) Breastfed babies are also protected from giardiasis. (Nayak
1987)
Gastrointestinal Disease
Children with acute appendicitis are less likely to have been breastfed for a prolonged time.
(Piscante 1995) Breastfeeding may reduce the risk of pyloric stenosis. (Habbick, 1989)
Hospitalization
Breastfed infants are less likely to be hospitalized if they become ill and were hospitalized for
respiratory infections less than half as much as formula-fed infants. (Chen 1988)
Formula-fed infants are 10-15 times more likely to become hospitalized when ill. (Cunningham
1986) Breastfed babies are half as likely to be hospitalized for RSV infections; in 1993 about 90,000
babies with RSV were admitted to hospitals at a cost of about $450 million. (Riordan, 1997)
Breastfeeding reduced re-hospitalizations in very low birth weight babies. (Malloy 1993) In a
Honolulu hospital, readmission rates were reduced 90% following the initiation of a lactation
program. The drop was seen in dehydration, hyperbilirubinemia and infection. (Lee, 1997)
Necrotizing Enterocolitis
Premature infants fed their own mother's milk or banked human milk were one-sixth to one-
tenth as likely to develop NEC, which is potentially fatal. The incidence of NEC in breastfed
infants is 0.012; in formula-fed infants it is .072. In Australia, one study has calculated that 83% of
NEC cases may be attributed to lack of breastfeeding. (Drane 1997)
NEC adds between one and four weeks to the NICU hospital stay of a preemie. At a cost of
$2000/day, this translates to $14,000 to $120,000 per infant. (Lee 1997) Even when infants survive
NEC, the disease can leave life-long costs via the development of short-gut syndrome and
chronic malabsorption syndromes. A Pennsylvania physician has estimated the cost of at-home
IV nutritional support treatment for a child with chronic malabsorption to be $50-100,000/year.
(Lee 1997)
Otitis Media
Conservative estimates of savings for this disease alone range from one-half to two-thirds of a
billion dollars if women were to breastfeed for 4 months. The savings estimate for Ohio if half of
the mothers on WIC were to breastfeed was $1 million. (Riordan, 1997) Based on these figures,
health care provider agencies could, conservatively, save two-thirds of what it spends to treat
otitis media. More than one million tympanoslomies are performed yearly in the US; at a cost of
$2 billion. By reducing the ear infections which cause the need for tubes for ear drainage, two-
thirds to one billion dollars could be saved.
Respiratory Infections
Breastfeeding protects against respiratory infections, including those caused by rotaviruses and
respiratory syncytial viruses. (Grover 1997) Breastfed babies were less than half as likely to be
hospitalized with pneumonia or bronchiolitis. (Pisacane 1994)
Breastfed infants had one-fifth the lower respiratory tract infections when compared to formula-
fed infants. (Cunningham 1988)
Sepsis
Infants receiving human milk while patients in the intensive care nursery were half as likely to
develop sepsis, a reason for increased length of hospital stays and provider expenditure. (El-
Mohandes 1997)
Urinary Tract Infections
Breastfeeding protects babies against UTI and subsequent hospitalization. (Pisacane 1992)
LONG TERM EFFECTS OF BREASTFEEDING
Breastfeeding prevents or lessens the severity of the following conditions.
 Allergies
 Asthma
 Childhood Cancer

19.  Diabetes
 Gastrointestinal Disease
 Heart Disease
 Inguinal Hernia
 Multiple Sclerosis
 Juvenile Rheumatoid Arthritis
The Nursing Profession
The nursing profession can help support the efforts of HP2010. By the continuation of promoting
and utilizing evidence based practice, we as a profession must embrace the evidence provided. The evidence
is overwhelming in the support of breastfeeding as the best form of nutrition. The nursing profession can
increase public acceptance of breastfeeding by increasing public awareness of the health risks associated with
not breastfeeding, and promote the behavioral changes that result in increased rates of breastfeeding
initiation and duration. Through our own self education, and education in the nursing school programs
specific to lactation and breastfeeding as a part of our nutritional studies and care of mother and baby. We
can professionally contribute to a supportive and accepting social environment with respect to mothers and
babies who are breastfeeding. As nursing leaders we can model policies and practices that promote and
support breastfeeding in all sectors of the health care system. We can advocate for public and private
insurance coverage for breastfeeding support services and equipment. We can continue to advocate,
promote and educate for HP 2010 breastfeeding goals. We can support the establishment of model policies
in work sites, childcare facilities, and schools that will foster a supportive and positive environment for
breastfeeding. And finally, we can encourage key leaders and stakeholders and others who can influence
these individuals or groups to take action and develop concrete policies in support of breastfeeding.
Primary Prevention
As a human being, a mother, a nurse and a lactation consultant I have spent the last two decades
dedicated to the promotion of breastfeeding, and to assist mothers in achieving their goals. I have personally
taken action in my community by seeking grants which can help mothers continue to receive support and
services which will enable them to continue with breastfeeding for a longer duration. I have actively been
involved in the lactation community, by joining and participating in professional organizations locally and

20. nationally. I helped to author the first professional guidelines for practice and the establishment of lactation
during the first two weeks by the International Lactation Consultants Association our professional
organization.
Secondary Prevention
As a lactation consultant concerned over the continuation of breastfeeding working in both in-
patient and outpatient lactation I am instrumental in the direct management of problems, and the referral
for problems beyond my scope of practice for follow-up before problems can continue which could cause
a mother to discontinue breastfeeding.
Tertial Prevention
Although breastfeeding or lack of breastfeeding is not a chronic disease, an example of tertiary
prevention would be with outreach programs that monitor and assist the mother with continuation of
breastfeeding. Currently I provide telephone follow-up for discharged mothers who were breastfeeding
during their hospitalization. This encounter is provided to praise mothers who are continuing
breastfeeding, and more importantly for those mothers who are experiencing difficulties, to provide
appropriate referrals.
There needs to be a lot more work in the area of tertiary prevention, especially as it applies to
low-income mothers and working mothers. In the Charlotte area, there are many places where mothers
that are having problems can receive assistance; they can seek the mother-to-mother support available
from the local LLL meetings, or calling to chat with a league leader. They can seek support at most of the
larger pediatric clinics which include a lactation consultant on staff. If they are enrolled in WIC there are
lactation consultants available to help with any difficulties. There are many “warm-line” which can
address their needs by telephone and make appropriate referrals.
For working mothers there still exist many difficulties which need to be addressed. Most
problems are not going to be resolved quickly, for one the need for extended time with their babies, with

21. pay, is an issue which may never be resolved in this Country. The decision to use formula rather than
often being an individual decision is a structural problem related largely to the economic needs of
families. It is clear that many changes to promote breastfeeding have the deep potential to cost women a
great amount in terms of career advancement. Breastfeeding rates can be improved—perhaps
substantially—but our society will not be able to solve the problem fully until we make substantial
changes in the socio-economic divisions and gender inequality.

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