The Summit Message: Paradigm Shift Is Necessary

The leaders in governmental affairs, learned professors, bold economists, insightful anthropologists, strong representatives of minority groups, dedicated physicians, outspoken nursing leaders, corporate Chief Executive Officers of health insurance groups, and a representative of the Joint Commission were gathered. This eclectic group launched the second Summit. It was designed to seek new avenues of effort to advance the goal of not only increasing breastfeeding initiation but also extending the duration to the 6-month level at a minimum. Before we began this search, reports were provided by our government agencies on the work accomplished since the last Summit.

High-risk populations had been identified at the previous Summit who did not initiate or continue to breastfeed. Statistically the data were clear. Many who do not breastfeed are Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clients. Does WIC attract non-breastfeeders, or does it cause clients not to breastfeed? We heard from WIC, the National Hispanic Medical Association, the Association of Black Women Physicians, and the Indian Health Service, all of whom support breastfeeding. Community activists reported on their initiatives and their successes. The reports reflected hard work, great enthusiasm, and marginal progress in moving the target populations.

Following the challenges put forth at the first Summit, the business community was asked to present their reflections on “The Business Case for Breastfeeding.” Dr. Bartick reported from her study of the cost savings projected if 90% of babies were breastfed for 6 months. The dollars a year saved in health care without including the cost of substitute feedings was the simple math.

Members of the medical profession shared plans to make changes in management that would extend the duration of breastfeeding. The hospital opportunities for doing a better job of helping mothers and babies were described including the Ten Steps of the Innocenti Declaration, the Baby-Friendly Initiative, and the potential role of the Joint Commission in assuring every hospital providing perinatal care meets the Ten Steps. The charge to nurses was electric. It asserted that perinatal nurses should take back their role as bedside experts in supporting breastfeeding on every shift and in every stage of breastfeeding.

“Sell it” was a session on just that. How do we sell breastfeeding to the public at large, the business community, and disbelieving women? We learned that some terminology could be damaging to a message that was intended to do good. Even the term “exclusive” could be a turn off. Some tricks-of-the-trade in advertising were shared.

At the concluding panel discussion a few points stood out. The economics of health care and the psychosocial issues of domestic life, although distinctly different, were clearly areas that needed further exploration.

Dr. Charles Phelps, our healthcare economist, described the healthcare economy as involving both wholesale and retail. He observed that the breastfeeding community had been providing mainly retail services to change the marketplace. He compared it to hand-to-hand combat. He further suggested that what we needed now was to go wholesale, or to start “carpet bombing”; that is, we need to take on bigger audiences and bigger targets. In health care it means Federal legislation, the U.S. Department of Agriculture, which oversees WIC, and the national insurance system. He also pointed out that a large body of research has resulted in much biomedical evidence to support the efforts to have more infants breastfeed, but there has been almost no social science research to change behaviors.

He suggested that the issues in the workplace needed the keen vision of labor economists and a review of workplace rules because our challenge is the sustained duration of breastfeeding. Labor economists know how to analyze these issues in the workplace.

To “carpet bomb” for social issues, bigger audiences would be the large healthcare providers such as Kaiser, Cigna, Aetna, and United Healthcare. Actually, the largest single healthcare system that provides perinatal care is the Armed Forces, Army, Navy, and Air Force. Dr. Phelps suggested several additional approaches to change the face of breastfeeding and concluded that economics and public policy will be critical parts of the next successful move.

Anthropology added a different view of the issue of duration of breastfeeding while agreeing it was the biggest challenge. Dr. Chin explained that every society had orthodoxies, that is, the practices that everybody considers right and just. Conversely, every society has heterodoxies, the practices that are in opposition to what everybody agrees the orthodoxies are. These were actually identified for the society comprising the Summit. There was discussion about the social ecological model and overcoming cultural bias. Dr. Chin suggested an analysis of the words used frequently.

She noted “money,” “evidence-based,” and a category that included “hospitals, health agencies, and health providers.” She observed that we need a value-driven practice, to value all children equally, and to look for structural violence in families. Dr. Chin urged the audience to screen for domestic violence as a barrier to breastfeeding. The next step after identifying domestic violence where a woman is being abused in her own home needs work. Society must be made safe for women to breastfeed in a social structure, and domestic violence may well be the lynchpin that is obstructing progress in breastfeeding in many families.

The Summit ended with these two major challenges. It is clear the work is not done. We must seek the solutions to extending the duration of breastfeeding. The paradigm must undergo a seismic shift in order to follow the recommendations of the panels.