A 2017 Update: Centers for Disease Control and Prevention's Contributions and Investments in Breastfeeding

Given that breastfeeding is important to the health of infants and their mothers, ¹ the Centers for Disease Control and Prevention's (CDC) goal is to ensure that new mothers understand the benefits of breastfeeding and, when they choose to breastfeed, have the supports they need to successfully initiate and continue breastfeeding until they reach their goals. CDC has had a long history of supporting breastfeeding and is focusing on three main strategies, including (1) improving hospital support for breastfeeding; (2) improving support for employed women; and (3) improving access to support in the community.

Maternity care practices in the first hours and days after birth can make a difference in whether, and how long, babies are breastfed.^2,3 As such, CDC began to assess the quality of maternity care practices that support breastfeeding in birth facilities. To accomplish this, CDC developed the Maternity Practices in Infant Nutrition and Care (mPINC) survey, a census of all hospitals and birth centers in the United States and Territories that monitors and examines changes in breastfeeding-related practices and policies. ⁴ The first mPINC survey was administered in 2007 and has been administered every 2 years since with a >80% response rate for all cycles. Facility-specific mPINC reports are provided as feedback to each participating facility, and state-specific reports are provided to key stakeholders within each state. In addition, national, aggregate data are reported on the CDC website (www.cdc.gov/breastfeeding/data/mpinc/results-tables.htm) and data are used to answer a variety of research questions.

CDC uses mPINC results to drive investments in assisting hospitals in improving the quality of their maternity practices and policies involving breastfeeding. Examples of this support include the CDC-funded programs: Best Fed Beginnings (2011–2015)^5,6 and EMPower Breastfeeding (2014–2017). ⁷ These programs have facilitated hospitals through the Baby-Friendly Hospital Initiative (Baby-Friendly) designation process, ⁸ which includes implementation of the Ten Steps to Successful Breastfeeding (Ten Steps) and the World Health Organization's International Code of Marketing of Breast-milk Substitutes. A maternity care facility earns the Baby-Friendly designation only after completing a rigorous process, including training on, and demonstration of, the appropriate implementation of the Ten Steps and a thorough on-site assessment.

The Ten Steps are evidence-based maternity care practices that promote and support breastfeeding. The first three steps of the Ten Steps require system changes as well as training and support within the healthcare system, including having a written breastfeeding policy that is routinely communicated to all healthcare staff; training all healthcare staff in the skills necessary to implement this policy; and informing all pregnant women about the benefits and management of breastfeeding. Many providers lack confidence in their ability to manage breastfeeding problems so training provided through the Ten Steps can help fill these gaps.^9,10 Furthermore, these steps help develop healthcare environments where mothers can make informed healthcare decisions about infant nutrition. ⁸ More than 80% of women choose to breastfeed and implementation of the Ten Steps can help support women in achieving their breastfeeding goals after they leave the hospital.^11,12

Steps 4 through 9 of the Ten Steps focus on preparing mothers for successful breastfeeding initiation while they are in the birthing facility. These include the following: helping mothers initiate breastfeeding within 1 hour of birth; showing mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants; giving infants no food or drink other than breast milk, unless medically indicated; allowing for safe rooming-in opportunities so that mothers and infants can remain together as much as possible; encouraging breastfeeding on demand; and giving no pacifiers or artificial nipples to breastfeeding infants during the hospitalization unless required during a painful medical procedure.

The last, but no less critical, step of successful breastfeeding is the transition of new mothers back into their communities. Step 10 has been shown to be influential in sustaining long-term impact of the breastfeeding gains attained through the Baby-Friendly Hospital Initiative. ³ This step involves fostering the establishment of breastfeeding support groups and referring mothers to them during the discharge process from the birthing facility. This requires capacity in the community or through the birthing facility to provide support to new mothers after discharge from the facility. CDC works with state- and local-level grantees, and other national organizations, to improve community support for breastfeeding by increasing access to culturally appropriate lactation support within communities. Community-based support should be equipped to help mothers with a multitude of elements that will influence their opportunity to successfully breastfeed. CDC also works with state grantees to improve work place practices that facilitate improved accommodations for breastfeeding or expressing breast milk.

CDC works to prioritize resources and technical assistance to address existing racial, ethnic, socioeconomic, and geographical disparities that still exist in breastfeeding initiation and continuation rates. Although some progress has been made in narrowing racial disparities, far fewer non-Hispanic black infants start breastfeeding and are breastfeeding exclusively at 6 months compared with non-Hispanic white infants. For infants born in 2013, there was an 18% point difference in breastfeeding initiation and a 12% point difference in breastfeeding exclusively at 6 months between non-Hispanic whites and non-Hispanic blacks. ¹¹

The breastfeeding support efforts of CDC, in combination with the efforts of many others, have contributed to improved breastfeeding rates and maternity practices in the United States. Breastfeeding initiation and duration rates continue to rise in the United States. ¹¹ In addition, the percentage of U.S. hospitals implementing a majority of the Ten Steps increased from 29% in 2007 to 63% in 2015.^13,14 The percentage of U.S. babies born in Baby-Friendly hospitals has increased from 1% in 2005 to 21% in 2017 (Baby-Friendly USA unpublished data) with, as of May 2017, a Baby-Friendly designated hospital in every state, the District of Columbia, and Puerto Rico for the first time. ¹⁵ In short, there has been progress in the United States on breastfeeding because so many national agencies, healthcare providers, medical organizations, individuals, healthcare systems, states, and communities are working together to support breastfeeding mothers and their babies.

Continued efforts to track national- and state-based breastfeeding outcomes, barriers to breastfeeding, public attitudes and beliefs about breastfeeding, and the lessons learned about best practices and policies to support breastfeeding will likely enhance the tremendous progress that has already been made. As evidence and recommendations expand, such as the American Academy of Pediatrics 2016 Clinical Report on safe sleep and skin-to-skin care, ¹⁶ CDC is committed to incorporating new solutions into practice. Even with the focus on tracking national and state progress, and translating science into health system changes, CDC remains committed to the importance of emphasizing that individual mothers are at the center of any successful breastfeeding experience. All of our efforts are intended to maximize each woman's success at safely providing the healthiest nutrition for her infant.