Changing the Breastfeeding Conversation and Our Culture

Introduction

We've seen the headlines in the media: “The Mommy Wars,” “A Woman's Right to Choose (Not to Breastfeed),” and “The Case Against Breastfeeding,” among others. These headlines are focused on the individual mother and the notion of choice, pitting mother against mother, and, in some cases, going so far as demonizing women for not breastfeeding their babies. What's missing in these headlines and stories is the context in which women breastfeed.

Many women start out wanting to breastfeed but face barriers in their communities, healthcare experiences, and workplaces. And, although U.S. breastfeeding initiation rates are on the rise, significant racial disparities persist. For example, African American women have the lowest breastfeeding rates in our country—60% initiation compared with 75% initiation overall ¹ —yet African Americans disproportionately experience health issues that breastfeeding can help prevent. Native Americans also have lower breastfeeding rates than women overall, as well as higher incidences of health problems. For Hispanic women, the data show generational differences: Hispanic women who have become more acculturated in the United States tend to have lower breastfeeding rates.

A Cultural and Societal Shift Is Needed

It is time to move from validating what science tells us and the public knows about the benefits of breastfeeding to figuring out ways in which we can shape a breastfeeding-supportive culture. Fundamentally, this is a public health issue, requiring a cultural and societal shift.

Although breastfeeding will always be up to the mother, our country is doing a poor job of supporting breastfeeding. It's time we focus the conversation on “the breastfeeding system” and the societal and environmental changes needed in communities, hospitals, and workplaces to make it easier for women to breastfeed. It's time we address the racial disparities in breastfeeding, so that every child and mother have the opportunity to benefit from breastfeeding as a First Food experience.

The W.K. Kellogg Foundation is deeply committed to racial equity and addressing the social determinants of health that too often limit opportunities for children. This commitment is at the core of the foundation's First Food program, which aims to build a breastfeeding-supportive society and eliminate racial disparities so that all women and children—regardless of their ethnicity, economic situation, or background—can benefit from the advantages that breastfeeding provides.

The First Food movement has accomplished much over the past several decades. The Surgeon General's “Call to Action to Support Breastfeeding” ² has provided a framework for every one of us to play a role in making it easier for mothers and babies to breastfeed. And thousands of women, fathers, families, community groups, nonprofit organizations, healthcare providers, maternity hospitals, employers, and policymakers have been leading the way. It's time we build on this momentum and leverage 21^st Century tools and resources to truly transform our culture.

Understanding Public Perceptions About Breastfeeding

To inform how we talk about breastfeeding and help shift the conversation from a focus on individual mothers to a focus on the breastfeeding system, the W.K. Kellogg Foundation commissioned LJR Custom Strategies to conduct opinion research on American's perceptions, attitudes, and beliefs about breastfeeding. Key questions for this research were

The research included a national survey of 1,300 U.S. residents 18 years of age and older, sampled by landline and cell phone on January 27 through February 4, 2013. ³ It also involved six focus groups with new mothers, including African American, Hispanic, and white or women of other races, in January 2013; four focus groups and 10 in-depth interviews with employers and human resource executives in July 2013; and three focus groups and 10 in-depth interviews with healthcare professionals, including doctors, nurses, and administrators, in September and October 2013.

Broad Agreement that Breastfeeding Is Best for Both Babies and Mothers

Among focus group participants there was broad agreement that breastfeeding is best, benefiting both babies and mothers. Likewise, the survey revealed 65% of Americans feel very positive toward breastfeeding.

Survey respondents, focus group participants, and interviewees demonstrated a general understanding of the health and bonding benefits of breastfeeding: decreasing babies' risk of asthma, type 1 diabetes, and respiratory infections, as well as lowering the mothers' risk of ovarian and breast cancer, hypertension, and heart disease. The national survey found 59% of Americans strongly agree that breastfeeding benefits mothers too. In addition, the research showed that Americans are starting to believe in the potential economic and societal benefits of breastfeeding.

A recent study of maternal disease associated with suboptimal breastfeeding rates quantifies these benefits. The study, titled “Cost Analysis of Maternal Disease Associated with Suboptimal Breastfeeding,” estimates that current low breastfeeding rates in the United States result in 5,000 excess cases of breast cancer, nearly 54,000 cases of hypertension, and almost 14,000 heart attacks each year, costing the United States $17.4 billion annually in premature maternal deaths. ⁴

Barriers to Breastfeeding

The Foundation's commissioned research demonstrated that Americans also understand breastfeeding can be challenging and that there are barriers to breastfeeding. As the World Health Organization states, breastfeeding is a learned behavior. ⁵ Although women's bodies instinctively produce milk and babies instinctively seek breastmilk, the act of latching on—for both mother and child—is a learned behavior and can present several challenges. Both before and after initiating breastfeeding, women encounter obstacles in their communities, in their healthcare experiences, and in their workplaces.

Many expectant mothers don't receive adequate information about breastfeeding from their healthcare providers, and many healthcare providers lack training on breastfeeding to provide the information. Many maternity care and birthing hospitals don't use practices or have policies that encourage breastfeeding, including those serving communities of color, where health disparities are high.

Communities put up barriers to breastfeeding by not providing spaces for breastfeeding in malls, restaurants, and other public areas and by not having supportive policies. Even family members can discourage breastfeeding, as women's mothers and grandmothers often are from generations for whom formula feeding was the norm. Another major obstacle is the workplace. Today the majority of women who have newborn babies work outside the home and must return to work shortly after giving birth. This can be a challenge for women trying to breastfeed or pump breastmilk for their babies, especially if their workplaces don't have supportive breastfeeding policies or practices.

Creating Breastfeeding-Supportive Environments

If we truly understand that breastmilk is the best First Food for new babies—and the research shows Americans do—then communities, healthcare professionals and hospitals, and workplaces and employers need to make it easier for all mothers to nurse. The research highlighted that breastfeeding is not just a woman's issue, but rather a broader family issue. Across gender, race, and age, there was empathy and understanding that we need to change our culture around breastfeeding.

The survey data prove that, as a nation, we believe whether a woman breastfeeds should not be dictated by the quality of health care she receives or her work situation. The majority of Americans agree we all can play a role in building a community of breastfeeding support.

Fathers and Families Are Critical Allies

The national survey revealed that among women who succeeded with breastfeeding, encouragement from family members was high. Likewise, participants in the mother focus groups shared that family support or lack thereof impacted their decision to breastfeed. Healthcare provider focus group participants also noted that lack of support from family members was a barrier to breastfeeding.

Family support—especially from fathers and grandmothers—plays a significant role in women's confidence in and success with breastfeeding. Families can show support by learning alongside expectant mothers and helping new mothers find solutions to breastfeeding challenges that might arise.

Engaging Healthcare Providers

For most women, their prenatal care and hospital birthing experience largely shape their success with breastfeeding. As trusted resources, medical professionals can be highly influential in whether or not a woman breastfeeds. Yet, the focus group and interview research found that few doctors and nurses have formal training on breastfeeding, and they often draw on their own personal experiences when discussing breastfeeding with patients. This means providers without children who were breastfed can be at a disadvantage when talking about breastfeeding with their patients. Still, all of the healthcare providers who participated in the focus groups and interviews understand they have an essential role to play in encouraging and supporting breastfeeding.

Messages that resonated with healthcare providers included “Healthcare providers and hospitals have a key role to play in supporting women in breastfeeding” and “Every breastfeeding mom deserves the best chance for success—healthcare providers can help by sharing the benefits of breastfeeding with expectant mothers, supporting new mothers as they learn to breastfeed and encouraging them to continue nursing through their baby's first 6 months.”

Healthcare providers recognized that, in addition to a lack of support from family members, one of the greatest barriers to breastfeeding faced by their patients was returning to work shortly after giving birth. The focus group discussions helped galvanize healthcare providers' interest in talking with expectant mothers not only about the health benefits of breastfeeding, but also about planning ahead with their family and employers to address obstacles.

Making Hospital Environments Baby-Friendly™

Hospitals also have a critical role in helping women get off to a strong start with breastfeeding. The national survey found 68% of Americans strongly agree that hospitals should be Baby-Friendly (World Health Organization, Geneva, Switzerland), meaning they provide new moms the support and encouragement they need to breastfeed. However, the focus groups and interviews revealed that doctors and nurses not familiar with Baby-Friendly perceive it to be a public relations effort, not fully appreciating the practices that are required for the designation as important to support breastfeeding.

To become designated as Baby-Friendly, hospitals must follow the “10 Steps to Successful Breastfeeding” established by the World Health Organization and UNICEF, which are evidence-based practices to increase breastfeeding rates. The 10 Steps include having a written breastfeeding policy, training staff on the policy, promoting skin-to-skin contact (where the baby rests on the mother's bare chest immediately after birth), and showing mothers how to breastfeed within the first hour after birth, among other practices. ⁶

The focus groups and interviews underscored the importance of education about Baby-Friendly and following the 10 Steps. Those at Baby-Friendly hospitals or at hospitals in the process of becoming Baby-Friendly talked about the positive impact of following the 10 Steps on both patient care and the workplace environment. Additional areas for building supportive healthcare environments included making lactation consultants more available as a resource to new mothers, increasing training opportunities for doctors and nurses, and providing community support groups for women and families.

Talking with Employers, Changing Workplaces

With the majority of today's women working outside the home, workplaces are another key area for building supportive breastfeeding environments. The national survey found 66% believe it would be very helpful for workplaces to support breastfeeding by giving women time and space to pump breastmilk and a place to store it.

The good news is that many employers recognize the importance of breastfeeding and, for the most part, are willing to do their part. They just need guidance and encouragement. It is surprising that men in the focus groups and interviews perceived fewer barriers to accommodating breastfeeding employees than women managers, who expressed more concerns about fairness across staff. Having the space to create a private, non-bathroom place for mothers was seen as the biggest challenge, not financial costs.

The key takeaway from the research is that employers and managers need to know about workable solutions to common issues for accommodating breastfeeding mothers in the workplace, such as finding private, clean, non-bathroom space and addressing fairness questions from other staff. Another opportunity is making breastfeeding part of the human resources process and training managers to talk with expectant mothers prior to maternity leave about options for accommodating their needs to pump breastmilk when they return to work. In focus groups with mothers, many women shared that returning to work after giving birth was a significant barrier to breastfeeding, although they felt uncomfortable asking their managers about accommodating their needs.

The employers interviewed were receptive to accommodating breastfeeding at work. For instance, employers appreciated messages like “Helping breastfeeding moms succeed can be as simple as providing break time and a private space to pump breastmilk at work.” At the same time, employers acknowledged that the service industry and certain other fields—agriculture, manufacturing, and transportation, to name a few—face significant challenges to providing clean, private, non-bathroom space and appropriate break time to accommodate breastfeeding mothers.

Building a Breastfeeding-Supportive Society

The barriers to breastfeeding faced by hospitals, employers, and women themselves are real, and we must continue to discuss them in order to address them. Above all, we must broaden the scope of our discourse on breastfeeding support—in the public sphere and in the healthcare field—so that we're talking about systems of support for breastfeeding and about the larger cultural context for breastfeeding.

The economic and health imperatives are too great to be ignored. To give all mothers and babies the opportunity to breastfeed, we must change our culture around breastfeeding and build support in communities, hospitals, and workplaces. We must strive to become a breastfeeding-supportive society. And our research shows that a majority of healthcare professionals, employers, and individuals are eager to do just that. Every one of us can contribute to shifting our culture, one conversation at a time.