Breastfeeding as a Community Health Imperative

Multiple current initiatives focus on interventions that promote population health. All of these initiatives suggest breastfeeding as an important strategy. Extensive evidence demonstrates that breastfeeding protects infants' health by giving all of the nutrition they need for growth and development. Furthermore, breastmilk reduces the risk for health conditions (e.g., obesity) and for illness (e.g., asthma and multiple childhood infections). Evidence shows that at a population level, these health benefits extend from infancy into adulthood. Although breastfeeding is free and natural and provides complete nutrition, about one in four mothers never initiates breastfeeding. ¹ Duration and exclusivity of breastfeeding are also suboptimal. For example, 86% of infants are no longer exclusively breastfed at age 6 months. ¹ Disparities reflect those seen in other health-related statistics. For example, African-American infants are the least likely to ever be breastfed. ¹

Boosting breastfeeding is a rising national health priority, and community health approaches that reach families in all parts of their lives are the foremost opportunity. First, breastfeeding is prominent in the National Prevention Strategy, a comprehensive plan to increase the number of Americans who are healthy at every stage of life. Its healthy eating component calls on employers, health systems, governments, and other sectors to adopt policies and programs that support breastfeeding. ² Second, community health is a pillar of the National Strategy for Quality Improvement in Health Care, a strategic plan for improving healthcare quality and health outcomes for all Americans. ³ Third, Surgeon General Regina M. Benjamin issued a nationwide call to action to remove barriers to and proactively encourage breastfeeding in clinical and community settings. ¹

All three national strategies represent a growing recognition that health is shaped by multiple influences, of which healthcare services are just one. A community health approach strives to integrate wellness where people live, work, and play by creating the context and circumstances that support health. It seeks to rigorously measure the health of populations (i.e., groups of individuals who share demographic characteristics or health-related exposures) and the impact of interventions. ⁴

A community health approach for breastfeeding would bring together stakeholders from multiple community sectors to establish aligned partnerships. Together, the partners would use data about breastfeeding rates in the community to identify priority populations. Aligned goals, performance measures, and initiatives would then be established. Because women encounter numerous barriers to breastfeeding, the resulting initiatives would be multifaceted. For example, interventions in multiple settings would educate women about and develop skills for breastfeeding, increase social support from peers and others, and create environments that make breastfeeding an easy, supported, and encouraged practice.

Widespread adoption of a community health approach for breastfeeding is hindered by three impediments: Inadequate social support, research gaps about the most influential interventions, and lack of surveillance standards. Social norms have a large influence on breastfeeding initiation and sustainability. Mothers often complain about feeling embarrassed about breastfeeding or describe challenges in finding comfortable, supportive places to breastfeed.

Gaps in the knowledge base are a second major impediment to community-based breastfeeding approaches. Researchers and practitioners have identified some evidence-based best practices, such as for workplaces. There is a need to build on this base by evaluating interventions that promote and support breastfeeding, especially among populations with low breastfeeding rates, and determine which ones work and in which populations.

A third impediment is the lack of adequate surveillance data. Existing surveillance systems provide only a partial picture. Data are available at the national level and for some states, but generally not at the local level. Because action needs to be community and culturally specific, local data are necessary. Gaps exist in capturing breastfeeding initiation, duration, and exclusivity. Also, existing systems do not use standardized terms and robust measures. Uniform definitions of terms need to be adopted, and the validity of measures must be increased.

In conclusion, multiple national strategies have embraced community health approaches as central to improving the health of Americans. Breastfeeding is recognized as a national priority in all communities. In order for community health approaches to take root across the United States, efforts are needed to provide social support, identify effective interventions, and enhance surveillance.