Breastfeeding Support in Child Care: An International Comparison of Findings from Australia and the United States

Introduction

Breastfeeding provides the healthiest start in life and a myriad of health benefits for mothers and children. ¹ However, in the United States and abroad, breastfeeding practices continue to lag behind the World Health Organization/UNICEF recommendations of exclusive breastfeeding for 6 months and continued breastfeeding with age-appropriate complementary feeding for up to 2 years and beyond. ²

In industrialized settings, there are multiple and unique barriers to continued breastfeeding, one of which is the separation that often occurs between working mothers and their babies due to formal workplace constraints. Studies have indicated that the anticipation of returning to work or school is associated with lower rates of breastfeeding. ³ In North Carolina, returning to work/school is one of the most commonly cited reasons mothers name for not initiating breastfeeding and for stopping breastfeeding. ⁴ In Australia, one in 10 mothers report weaning before 6 months to return to work. ⁵ There are many reasons why returning to work is associated with reduced breastfeeding, but it is likely that one of the contributing factors is mothers' expectations and experiences related to child care. When mothers place infants in the care of someone other than themselves, they are significantly less likely to breastfeed. ⁶ Therefore, it is not surprising that enrollment in child care is associated with decreased durations of breastfeeding. ⁷ The likelihood of continuing breastfeeding is further reduced by the finding that childcare providers have inadequate knowledge of breastfeeding and other up-to-date recommendations for feeding infants. ⁸

Although many government entities have policies related to breastfeeding in childcare settings, there are limited data available on the breastfeeding knowledge, attitudes, and practices within childcare centers. Therefore, it is especially interesting to find two studies that gathered similar data. In this study, we compared data collected from two very different geographic locations: Adelaide, Australia and Wake County, North Carolina. Adelaide is the urban capital of South Australia with approximately 1.2 million residents, about 74% of South Australians. Wake County contains Raleigh, the capital of North Carolina, as well as surrounding rural areas. It is home to about approximately 0.9 million residents, about 9% of North Carolinians. Australia and the United States are both considered developed countries economically, but they differ substantially in infant mortality rates and breastfeeding rates, with Australia comparatively better for all indicators. North Carolina, however, is below average for the United States for all indicators.^9–13 Also, there are significant differences in the level of Baby-friendly Hospital Initiative designation, an indicator of healthcare system attention to breastfeeding support. In Australia, at least 23% of the hospitals have received this designation, whereas in the United States, this is only about 3%. ¹⁴

The purpose of this comparative study is to ascertain if these environmental differences are reflected in the practices reported by the childcare setting providers.

Materials and Methods

Surveys of childcare providers were carried out, using comparable but differing protocols. In Adelaide, researchers designed a questionnaire based on a previous set of qualitative interviews with childcare centers. An invitation letter to participate and survey questionnaire were distributed to all the childcare centers (limited to long-day centers) in Adelaide (n=293) and were completed either in hard copy or online via SurveyMonkey. Two reminder letters (via post or e-mail) were sent after 2 and 4 weeks. Twenty-two percent (n=65) of the surveys were completed and available for analysis.

In Wake County, data were collected as baseline for an intervention study. The pool of childcare centers was limited to facilities that accept childcare subsidies, and the sample excluded in-home childcare providers. Center directors were contacted by letter and then by phone to request study participation. Those who enrolled were then visited by the researcher to complete a breastfeeding self-appraisal questionnaire. (An additional knowledge, attitude, and practice survey was completed by childcare providers, and is reported elsewhere. ¹⁵ ) Of the 154 eligible childcare centers, 101 enrolled by agreeing to participate and completed self-appraisal and provider surveys. The 101 centers were reasonably representative of the whole, in terms of percentage of clients receiving subsidies, number of children enrolled, and state quality ratings.

Both data collection instruments were reviewed for common questions. Qualitative data, including open comments in both surveys, were also reviewed for commonalities and differences. Descriptive findings from the common questions are presented, and findings are compared using χ² analysis (Epi Info version 3.5.1, National Institutes of Health, Bethesda, MD).

Results

Discussion

Given the differences in child health and breastfeeding rates between Adelaide, Australia, and Wake County, North Carolina, significant differences in breastfeeding support in child care were expected. Those identified are most likely a reflection of the overall breastfeeding environments of the two countries, rather than a reflection of guidance or rules, per se. There are other important policy differences by setting: Women in Australia now have up to 18 weeks paid at federal minimum wage, ¹⁶ whereas in the United States there is none mandated. (Australia has introduced a comprehensive Paid Parental Leave scheme for new parents who are the primary caretakers of a child born or adopted after January 1, 2011. An eligible person receives taxable payments at the federal minimum wage, currently $543.78 a week, for a maximum period of 18 weeks. In most cases, the person will receive the payment through his or her employer. The Paid Parental Leave was not in place when the data analyzed in this document were collected.) Once they leave maternity care, Australian women receive home visits and lactation support free of charge through the national health system; in the United States, home visits are rare, and most lactation support in the United States is not covered by private or public insurance agencies.

Other differences that may impact childcare practices include aspects of national infant feeding strategies. In Australia there is a national breastfeeding strategy ¹⁷ that has led to implementation of supportive interventions. One such activity is the Australian Breastfeeding Association helpline, which receives about 6,000 calls per month. ¹⁸

The new U.S. Surgeon General's Call to Action to Support Breastfeeding ¹⁹ recommends action on many of the same issues addressed in the Australian document, but it is unclear at this stage how many of the 20 actions suggested will be implemented in the near future. Furthermore, the U.S. national strategy, as reflected in the Women, Infants and Children program, offers free formula to many women, which may influence parental feeding plans.

As a consequence, perhaps, the contents of the national childcare guidance documents reflect different priorities. The Australian Quality Improvement and Accreditation System Quality Practices Guide, published by the National Childcare Accreditation Council, states that breastfeeding is beneficial and encourages providers to have the training and knowledge to support the choice of parents. ²⁰ This contrasts with the U.S. “Caring for Our Children,” ²¹ which takes a stronger position that breastfeeding is a public health imperative and that childcare providers should take the role of advocating for breastfeeding. The differences may reflect that breastfeeding is normative in Australia and therefore is not seen to merit the strength of language used in the U.S. documents.

Given the above, it is not surprising that the direction of the differences seen in breastfeeding supportive activities in the childcare centers studied seems to be reflective of the national environment of breastfeeding support.

The United States has no guarantee of paid maternity leave, or of breastfeeding support in the health system, as evidenced by the rarity of third-party reimbursement for board-certified lactation consultants. The United States might benefit from the recognition that these national and state policies ²² are less supportive of breastfeeding than those of other industrialized countries. This is especially salient as the documented impact of breastfeeding on infant survival may account for some of the differences seen in infant mortality rates in the two settings. Children born in North Carolina are nearly twice as likely to die in infancy as Australian children and are about half as likely to be breastfed at 6 and 12 months or to be exclusively breastfeeding at 3 months of age, and many of these deaths are caused by illnesses that are reduced in incidence and severity by breastfeeding. Although, certainly, other factors contribute to these mortality figures, given current estimates of the impact of breastfeeding on infant survival, increasing breastfeeding in the United States has the potential to decrease the disparity between settings in infant mortality.^23,24

In terms of recommendations for action, perhaps it is of note that the most striking commonality across the two settings is the rather passive support, reflected in the fact that child care in both settings (1) provides a place and refrigeration for expressed milk feeding and (2) feels that their role is to support the parent's choice, which is generally made prior to child care accommodation. We posit that, in fact, childcare settings may be an appropriate site for breastfeeding intervention in terms of education and accommodation of breastfeeding families because supportive activities for other healthy behaviors are already considered appropriately placed in the childcare settings. ²⁵

Conclusions

Despite similar GDP and level of development, Australia and the United States present very different pictures of breastfeeding support. Given the U.S. Surgeon General's Call to Action to Support Breastfeeding action point 16, “Ensure that all child care providers accommodate the needs of breastfeeding mothers and infants,” ¹⁹ perhaps it is time to recognize the need for increased breastfeeding support throughout the social structures that support mothers in the United States and consider not only how they might support breastfeeding, but also what barriers they create for those who wish to more optimally feed their children.