The Call to Action: Has Anyone Answered? Actions of the AAP
• The strategic healthcare priorities for AAP in the next 10 years are: ∘ Epigenetics ∘ Early brain and child development ∘ Children with special healthcare needs. • These three items will be incorporated into what the AAP addresses on an ongoing basis. ∘ Breastfeeding is integral to epigenetics and early brain development science. • Advocacy opportunities exist around a number of issues of importance to children's health and breastfeeding promotion. • The AAP legislative office can help to advocate on behalf of issues important to the protection of breastfeeding. The AAP national has a chapter legislative office that can help with state legislation.
• Encourage the AAP to incorporate breastfeeding and practices that support it (e.g., early skin-to-skin) into established programs such as helping babies breathe. • Make ourselves heard about: ∘ Paid maternity leave ∘ WIC breastfeeding promotion efforts ∘ Lobbying the Affordable Care Act ∘ Urge State Medicaid officers to incentivize Baby-Friendly: better reimbursement for improved outcomes. ∘ Payment patterns: support to offices to be able to address breastfeeding issues. Currently outpatient offices cannot afford to have this help available.
Is the New AAP Statement on Breastfeeding New?
• Interest in breastfeeding is high. The previous statement from 2005 is the most requested reprint of the AAP. • AAP has made the statement that ABM will be the organization responsible for clinical protocol creation. • The language used emphasizes the disadvantages of NOT breastfeeding as evidenced by the AHRQ1 statement and as a function of duration, exclusivity, and dose-responsiveness. • Duration and exclusivity ∘ Importance of exclusive breastfeeding if solids are started before 6 months to prevent allergies. • Feeding the premature infant ∘ Problems with cow milk–based fortifiers ∘ Need to establish milk banks • Monitoring growth • Public health policies (to address extreme variation in rates associated with sociodemographic, economic, and cultural variables) ∘ Need for public health laws to support the practice broadly and not concentrate all our efforts on individual support.
• Use language that acknowledges that breastfeeding: ∘ Is NOT a lifestyle choice. ∘ Is the normative standard of infant feeding and nutrition: the best, usual, what should be done. ∘ Health benefits depend on duration and exclusivity and are dose-responsive. • Encourage the establishment of an independent national milk bank registry as a first step in assessing where and how donor milk is being provided and used. • Use WHO growth charts when looking at growth in breastfed infants. • Need to address disparities in breastfeeding rates as part of addressing health inequities.
The Call to Action: Has Anyone Answered?
• NYS is using hospital learning collaboratives to change hospital practices and policies around breastfeeding. ∘ There has been a resultant 22% increase in exclusive breastfeeding. • NYS breastfeeding initiatives include public reporting of breastfeeding rates in the hospital, legislation to protect public breastfeeding, support for WIC peer counseling programs, collection and review of hospital policies, business case for breastfeeding legislation, education, and training support. ∘ Translate policy into practice ∘ Change the culture • Early childhood development specialists have worked to develop a consensus around language used when writing or speaking about the topic. They demonstrate consistent use of wording to enhance understanding of important concepts like stress (e.g., acute stress, tolerable stress, toxic stress). ∘ Breastfeeding would benefit from language concordance. • There is a need to address healthcare inequities and to better understand how culture affects the outcomes in underserved populations. • The AAP takes significant support for its activities from the formula industry. How do we change pediatricians' minds about formula marketing?
• Examples of successful strategies to promote change are available and should be used at the state and Federal levels to improve support for breastfeeding. • Work with the AAP Section on Breastfeeding to establish a consensus around language about breastfeeding. • When trying to support mothers, sensitivity to their culture and traditions is vitally important. Attention to healthcare equity should be part of any program or intervention. • The AAP should observe the WHO Code of Marketing. • Use AAP Section on Breastfeeding coordinators to help push a resolution to divest from formula company money again. Until it makes the top 10 resolutions it will not be advisory to the AAP Board.
Empowering Mothers to Make a Difference
• Sensitivity to cultures and traditions are key factors when trying to promote breastfeeding. • Community outreach opportunities exist in nontraditional settings. ∘ Baby showers, expos, Head Start, community groups, health fairs, local women's conferences, church fairs (must go to where women gather) ∘ Black Mothers' Breastfeeding Club: meets monthly. ∘ Partner with WIC, local hospitals, maternal and child health programs, community centers, local nonprofits, departments of health. • Stay-at-home mothers of color call their time off at home “a season” because they may decide to go back to work later. • Many stay-at-home women of color are professional women choosing to stay at home to raise their children. ∘ Recent change and luxury for women of color ∘ Breastfeeding support can be offered as part of a broader vision to provide support to moms raising a child and in support of family and marriage. • Important to change culture of where women deliver • No Baby-Friendly hospitals in areas where women of color reside. • African American women have a much steeper road of challenges; this may go back to the history of wet nursing white children. • African American mothers like Mocha Moms need to be the advocates: reach out to mothers and fathers in church, in community centers, via the Internet, in reading nooks in barber shops and at hair dressers, in African American women breast cancer groups. ∘ Mocha Moms has 10,000 contacts and the power of a collective voice. • What needs to happen: ∘ Community collaborations ∘ Funding grassroots organizations ∘ Grassroots initiatives covering a wide range of activities: “how to” workshops, support groups, community initiatives, educating women, showing role models ∘ Driving up visibility requires showing, not just telling. Planting the seed by seeing an example of what is possible. ∘ Use naturally occurring opportunities, what goes on in a neighborhood (play groups, food sharing, fashion shows for breastfeeding moms), go where the moms are and take the message to them. Open activities to other family members and friends. ∘ Women do not want to be told what to do. Let mothers select the topic for each session and lead it. ∘ Promoting culture change: the use of social media won't work for 50% of audience but is still important. ▪ Suggest a consortium of mothers' support organizations to do a joint social media campaign. Text messaging a group of moms may work well. It is immediate, better than Twitter, phone calls, e-mail, or Facebook.
• Interventions should be designed with sensitivity to culture and traditions. • To reach populations of minority women and be effective you must provide appropriate role models and go where the women gather naturally. • Use the power of the collective voice of organizations like Mocha Moms and other organizations like ROSE (Reaching Our Sisters Everywhere) and examples of successful African American breastfeeding women to promote breastfeeding in the larger population. • Assure that the Ten Steps are widely adopted in hospitals throughout the United States. • To reach populations of minority women and be effective we must take advantage of existing organizations like Mocha Moms to provide appropriate role models. • There needs to be a collective effort to address TV portrayal of breastfeeding. • We must be able to envision African American women and the rest of the country becoming culturally receptive to breastfeeding.
Strengthening Support and Leadership in Minority Populations
• We are currently asking children to thrive in adverse circumstances. • Allostatic load: certain individuals bear a disproportionate amount of stress; it impacts birth outcomes. ∘ Controlling for poverty still leaves 38,000 deaths per year or 1.1 million years of life lost among African Americans in the United States.2 Possible cause of health disparities ∘ We need to focus on race. Not just African Americans but also Mexican Americans, Puerto Ricans • Public policy-driven: something happened that was public policy-driven so that 70% of African American infants are now born to single mothers. ∘ Racism makes us assume things about a group of people, and then we make policy around them. ∘ We need to work harder to change systems and environments than individual behaviors, but we need to work hard to change behavior. • State health official ∘ Political appointee, has a “Bully Pulpit” ∘ Interface between power and politics ∘ Not a content expert but someone who works across agencies, public and private sectors, health agency programs. Major things can happen when put together—get them working together to work for public health. • Health equity needs to be a strategic priority. The biggest problem is not that we don't know things, but that we don't implement what we know. • Preconception health and interconception health are huge problems. Unless women are healthy before and during pregnancy we can expect poor pregnancy outcomes and higher infant morbidity and mortality.
• Health equity identified as a strategic priority: build it into every organization working on behalf of women and children, give it visibility, dedicate resources. • Did you hear about the rose that grew from a crack in the concrete? Proving nature's law is wrong it learned to walk with out having feet. Funny it seems, but by keeping its dreams, it learned to breathe fresh air. Long live the rose that grew from concrete when no one else ever cared. —Tupac Shakur • Take advantage of working with state public health officials to garner broad-based support. • Build knowledge of and action to address the root causes of health inequities. • Goodness and fairness; set target for what we want in general: average (the goodness) versus rates in vulnerable groups (the fairness)
Hopes and Fears of Social Marketing
• The conditions are right for a move forward in breastfeeding. ∘ Social networking is powerful. ∘ Breastfeeding initiation is the norm. ∘ Environment to support breastfeeding has improved, although the same barriers exist. ∘ Society's beliefs about breastfeeding have changed little. ∘ How breastfeeding messages are framed is important. ∘ Communication channels have changed rapidly. ∘ Millennial women see themselves as unique. Effective marketing must appeal to the Millennial generation. ∘ Generation Y might be characterized as skeptical and constantly wired and connected; the most trusted source is friends (friends and their friends' friends), skeptical of traditional marketing. • If we are not involved in social media like Twitter and Facebook now, we won't be ready for Generation Z. • Must keep the media relevant and up to date; if posts are not updated or something doesn't work, then it will quickly cease to be used. ∘ No universal recipe for success even within a country.
• Common threads ∘ Human milk the norm ∘ Professional training important • We need Loving Support 2.0 cell phone, texting-based mobile tools. • Social marketing research needs to be conducted to fully understand what should be implemented addressing emotions, experience, and motivation, not just provide information. • Participate in the United States Breastfeeding Committee media campaign in the month of August—“20 Actions in 20 Days.”
Accelerating Our Progress
• What does the new model of the environment look like that supports breastfeeding? ∘ What does insurance look like? ∘ Community ∘ Grocery stores ∘ Medical care ∘ What does the neighborhood look like?
• Movement on our priorities from this Summit should be guided by the idea of the new model. • We are at a tipping point for the work. Efforts need to continue.
Insurance Industry Leadership and Possibilities
• All Kaiser Permanente hospitals have agreed to either become Baby-Friendly or a participant in the Joint Commission perinatal core measures. ∘ Kaiser Permanente is planning to publicly share tools of the initiative. ∘ Use of performance Improvement Model ▪ Small tests of change “Plan, Do, Study, Act” ∘ Services and supports for duration ▪ Pediatric visits as support for duration ▪ Continuing Medical Education ▪ Role modeling support for employees
• We must get other insurers to recognize importance of this work.
Where Can We Do More? Medical Schools, Hospitals, Workplaces, Clinics, Community-Based Organizations?
• WHO Code ∘ Requires information and education about health hazard of formula. ∘ No gifts or samples to health workers or their families. ∘ Prohibits company contact of pregnant women. ∘ Public education • 50% of the problem is lack of compliance with the Code. • Data on duration and exclusivity of breastfeeding are compromised by incomplete records and variable terms. • The business case for breastfeeding has been made; however, employees need to be empowered. • Nevada's Infant at Work Program is an example of a program that has been successful.
• Advocate for compliance with the Code. • Work to establish more standardized questions and reporting of breastfeeding-rated information. • Are the workplaces of ABM members lactation-friendly? If not, we should change that. • Identify and make visible successful workplace lactation programs/baby at work and breastfeeding support programs.
Recommendations • To Federal Agencies • To Governors and Commissioners • To Hospitals, Clinics, and Communities • To Mayors and Moms • To Advocates
• Effectively communicating with members of different communities is a challenge. ∘ There is not language concordance among groups. Note the culture and language usage of the group in question. Make sure the images and messages are a cultural match. ∘ The Y Generation wants individual responses, and new moms in general want someone to listen. ∘ The needs, wants, and communication styles of different groups vary. Messages need to be tailored to the audience. ∘ Correctly tailoring messages is further complicated by a lack of understanding of the subgroups within racial and ethnic groups. ▪ Community representatives from the targeted group need to be part of the messaging process. ▪ Recent immigrants from different groups have similar levels of acculturation. Acculturation level versus race or ethnicity may be a better metric for messaging. • Breastfeeding is a very personal topic. The challenge is in moving the discussion to the community level. • More education for doctors. Partner with nurses, home healthcare workers, and other health professionals to get the word out and support moms. • The focus should shift from in the hospital to postpartum support. ∘ Breastfeeding should be discussed during prenatal care and as part of the birth plan. Motivational interviewing with pregnant women shows promise as an intervention. ∘ The provisions in the Affordable Care Act for breastfeeding are the subject of a blogging campaign. • Support for workplace lactation programs is needed. ∘ The business case for breastfeeding has been made; however, employees need to be empowered. • Duration and exclusivity of breastfeeding remain issues. ∘ Data on duration and exclusivity of breastfeeding are compromised by incomplete records and variable terms. • Advocacy of breastfeeding issues needs to be strengthened. ∘ Clear action steps are needed to advance goals ∘ Both contacts and collaborations with key players and grassroots support need to be nurtured.
• Create a national repository of breastfeeding images and videos. • Address populations in a culturally sensitive and meaningful way. Borrow tools from commercial advertising to reach people. • Look at how to integrate doctors, moms, community advocates, and others in breastfeeding promotion. • Funding agencies should make understanding how and why certain programs and interventions work a priority for study. • Community agency and academic partnerships like those supported by the National Institute on Minority Health and Health Disparities should be encouraged. • Effective peer-to-peer support for breastfeeding should be identified and funded. • Work with the AAP to make sure breastfeeding is a part of Continuing Medical Education classes and recertification modules. • Breastfeeding duration remains problematic. Funding priorities should shift to interventions that enhance breastfeeding duration. • Work to educate physicians on billing and practice setup to support breastfeeding. Older physicians should be targeted. • Obstetricians should not ask “Do you want to breastfeed or bottle feed?,” but rather “How can we support you in breastfeeding?” • Quality metrics for breastfeeding should be established. • Recommend reduced insurance rates for women who breastfeed. • Are the workplaces of ABM members lactation-friendly? If not, we should change that. • Work to establish more standardized questions and reporting of breastfeeding-rated information. • Support opportunities for advocates to come together and align strategies. • Check with community transformation grantees to learn what they are doing to support breastfeeding.
AAP, American Academy of Pediatrics; ABM, Academy of Breastfeeding Medicine; AHRQ, Agency for Healthcare Research and Quality; NYS, New York State; WHO, World Health Organization; WIC, Special Supplemental Nutrition Program for Women, Infants and Children.
References
1.
IpS, ChungM, RamanGet al.A summary of the Agency for Healthcare Research and Quality's evidence report on breastfeeding in developed countries. Breastfeed Med, 2009; 4,Suppl 1:S17–S30.
2.
FranksP, MuennigP, LubetkinEet al.The burden of disease associated with being African-American in the United States and the contribution of socio-economic status. Soc Sci Med, 2006; 62:2469–2478.
