Abstract
Implementation of the International Code of Marketing of Breast-Milk Substitutes
The International Code of Marketing of Breast-Milk Substitutes (the Code), passed by the World Health Assembly/World Health Organization in 1981 to protect mothers and babies, continues to be one of the most hotly debated international recommendations ever. 2 It requires that parents and healthcare providers be informed about the health hazards of unnecessary and improper use of infant formula. The main points of the Code focus on the areas that advocates today are often most challenged by, that is, the continued advertisement and promotion of formula as a product equivalent to breastmilk. The Code clearly states (1) that no gifts or personal samples are to be given to health workers or their families, (2) it protects artificially fed infants through its demand for product quality control, accurate scientific information, and hazard warnings on labels that should take account of the climatic and storage conditions of the country in which they are to be used, (3) there is to be no advertising, offering free samples to parents, idealizing artificial feeding, and comparing products with breastmilk, (4) a prohibition of company personnel from contacting pregnant women, mothers, or their families, whether directly or indirectly, and (5) a prohibition of all promotion for any product that replaces breastmilk, whether suitable or not. The United States was the sole country that voted against the Code in 1981. In 1994 we signed on; however, the tepid approval that the United States has related to the Code has no consequences for formula companies, which continue to advertise their product using these approaches and practices. We need to adhere to the code.
Improved Healthcare Practices—Instituting the “Ten Steps” Is Fundamental
Sufficient evidence exists for the effectiveness of the 10 Steps to Successful Breastfeeding. 3 The most clearly effective of the 10 Steps relate to education (Step 3, antenatal education), guidance (Step 5, showing mothers how to breastfeed), and support for mothers before and after delivery, including after discharge from hospital (Step 10, continuing support after discharge). However, too many healthcare providers remain poorly prepared to provide even routine support. They are even further challenged to manage the mother who experiences delay or failure of lactogenesis. 4 Improving education of medical students, residents, practicing physicians, and nurses (Step 2) continues to be a challenge. Many curricula exist for healthcare providers. However, there is no consistency in educating medical students or residents about breastfeeding benefits as well as management of challenges. In the medical field the American Academy of Pediatrics 5 has a breastfeeding curriculum available to any residency program; also, Wellstart has excellent training modules, 6 and there are others. However, none of them will mean much to the student or resident until substantive questions are placed on our certifying examinations. It is not until the student or resident either becomes a parent or a practicing physician that he or she recognizes how much more education is needed in this area.
Locally, the D.C. Breastfeeding Coalition established the District of Columbia Perinatal Lactation Quality Care Collaborative in October 2010 in an attempt to improve the implementation of the 10 Steps across maternity units in the District of Columbia. This collaborative brought leaders together from the seven general hospitals, one children's hospital, and one free-standing birthing facility in the District to review evidence-based best practices and learn from each other's successes and challenges addressing breastfeeding-related maternity care practices. Major challenges were identified with provider knowledge, getting mothers to truly do 24-hour rooming-in, addressing request for supplementation, and identifying postdischarge breastfeeding support services. Ninety percent indicated that the meetings were helpful in improving their breastfeeding support services, and 100% indicated that they would continue to attend in the future. This experience indicated to us that healthcare providers at birth institutions are interested in providing this breastfeeding support and recognize that provider education and support are essential to accomplishing the Ten Steps optimally.
Employment Legislation
In 2008, the Maternal Health Branch of the U.S. Department of Health and Human Services produced an outstanding training process and manual for the business case for breastfeeding. 7 This led the way for helping worksites understand the importance of breastfeeding for the health of the mother and baby and how breastfeeding could benefit business. Subsequent to that many workplaces have improved support of breastfeeding. More important laws are being put in to place to afford accommodation of breastfeeding mothers. As of March 23, 2010 the Affordable Healthcare Act and laws in many local jurisdictions exist that can help promote breastfeeding in the workplace by requiring appropriate accommodations in time and space. Federal requirements do not preempt a state law that provides greater protections to employees.
However, coverage of lactation support, supplies, and counseling varies widely among the individual states and insurance plans. As of August 1, 2012 the Affordable Healthcare Act will require healthcare plans to provide lactation support services.
Much more education about the laws is needed for the public. Also, real substantive consequences need to be in place to address instances when the law is broken.
Widespread Public Education
Extensive public education needs to occur in order to increase public acceptance of breastfeeding. This education should begin with inclusion of breastfeeding in K–12 curricula so that young people understand that for a mammal to breastfeed its offspring is an expectation of the species—that includes the human species. 8 Targeted programs will be needed to improve acceptance of breastfeeding in public places and to achieve placement of nursing mothers' lounges in public areas. Childcare facilities will need focused interventions so that mothers can be assured that their expressed breastmilk will be used appropriately and that their breastfeeding on site is welcomed. Public education would help to combat negative social norms and poor family/social support as well as lessen embarrassment.
Community Support
Long-standing duration of breastfeeding is best achieved with robust community support. That support consists of knowledgeable physicians, lactation specialists, hospital support groups, supportive Special Supplemental Nutrition Program for Women, Infants and Children (WIC) programs, and grass root support groups (La Leche League International, Mocha Moms, and African American Breastfeeding Alliance). Breastfeeding support centers like the BLESS (Breastfeeding Lactation Education Support Services) Initiative at Howard University Hospital and the East of the River Breastfeeding Support Center (a collaborative program among Children's National Medical Center, the D.C. WIC Program, and the DC Breastfeeding Coalition). Both centers attempt to improve breastfeeding through prenatal breastfeeding education and postpartum breastfeeding support. Externally funded, they are always challenged with continued funding issues that might be addressed if insurances uniformly and adequately reimbursed services for breastfeeding support.
How Do We Do More?
Focusing on the areas mentioned above individually or in combination will not be sufficient—we have been doing that. There needs to be a requirement with consequences introduced into this process for it to be successful—a carrot with a stick, if you will. The introduction of the Joint Commission's Perinatal Core Measure of exclusive breastmilk feeding has inadvertently provided such an avenue. 9 Breastfeeding advocates across the country have indicated that they have been approached by hospital leadership with new interest since this measure was first published. The Joint Commission acknowledged that exclusive breastmilk feeding for the first 6 months of neonatal life has long been the expressed goal of the World Health Organization, the U.S. Department of Health and Human Services, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists. They further noted that the exclusive breastmilk feeding rate during the birth hospital stay has been shown to be unacceptably low. The Joint Commission will be measuring how many non–neonatal intensive care unit babies, without a contraindication to breastfeeding, were exclusively breastmilk fed. The Joint Commission defines exclusive breastmilk feeding as: “a newborn receiving only breastmilk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.” Breastmilk feeding includes expressed mother's milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast. The Joint Commission's core measures are a national, standardized performance measurement system providing assessments of care delivered in specific focus areas. Quality measures required by the Joint Commission engage the entire hospital organization to accomplish the goals being measured and compared across the nation. Finally, the hospital-wide engagement implied in the 10 Steps for Successful Breastfeeding will have to be implemented by hospital organizations in order to achieve the desired outcomes of exclusive breastfeeding expected of hospitals by the Joint Commission.
The Perinatal Core Measure Set was available for voluntary implementation beginning with April 1, 2010 discharges. If the Joint Commission abides by its usual processes, then by 2014 implementation of the new perinatal core measures will be mandatory for all hospitals that provide maternity services. This quality measure of exclusive human milk feeding for infants born in a Joint Commission Accredited Hospital in the United States will go a long way to furthering promotion, protection, and support of breastfeeding needed for breastfeeding success. This perfect storm (Fig. 1) could help prompt us to address all the areas where we can do more: (1) enforce the code and end promotion of breastmilk substitutes to pregnant and postpartum women, their families, their healthcare providers, and their community; (2) improve breastfeeding practices in hospitals, which will by necessity demand better healthcare provider education and competency; (3) employee legislation will become more accountable because more breastfeeding women entering the workforce will expose the gaps in legislation so that challenges to breastfeeding will be more apparent and can be readily addressed; (4) widespread public education will have to be done as more mothers come home breastfeeding, so that the demand for public knowledge and more acceptance will increase; and (5) community support will be needed and expected with more breastfeeding families presenting themselves to stores, restaurants, and public events. Community sites where mothers can turn to for mother-to-mother support and meet comfortably will evolve by necessity. All of this will indeed be more work for us—the stick, but it will clearly result in optimal health for infants—the carrot. We can do more on all fronts—expectations, regulations, and requirements will help us get there. Breastfeeding is the single intervention that confers a lifetime of health benefits in infancy and beyond; we must do everything possible to see that every child is afforded the opportunity to be breastfed.
Quality measures required by the Joint Commission around exclusive breastmilk feeding in hospital maternity settings offer the opportunity to get breastfeeding off to a great start, which by necessity should generate better provider education, increase employee legislation, improve public education, and engender community support.
Footnotes
Disclosure Statement
No competing financial interests exist.