Changing the Culture of Breastfeeding Education to Improve Health Outcomes

For the first time in our history, the United States is raising a generation of children who may have sicker, shorter lives than their parents. ¹ Therefore, we must act now to reverse this trend.

The health of a nation is gauged by its infant mortality rate (IMR). Infant mortality in the United States is ranked 12th among developed countries. Historically, the U.S. IMR is higher in blacks compared with whites (340/1,000 versus 217/1,000). African Americans (AA) bear a disproportionate share of the disease morbidity, mortality, disability, and injury. ²

According to data in 2013–2015 reports, ³ five of the nine highest mortality rates for infants of non-Hispanic black Women in the United States were in Midwestern states. Seven states had IMRs significantly higher than the national rate; they were Alabama, Illinois, Indiana, Michigan, North Carolina, Ohio, and Wisconsin. There were eight states (California, Colorado, Iowa, Massachusetts, New Jersey, New York, Texas, and Washington) that had IMRs significantly lower than the national rate for infants of non-Hispanic black women (11.10). Improvement in nutrition, hygiene, living conditions, and health can lead to a decline in infant mortality. While the majority of these really speak to the social determinants of health, improvement in infant nutrition can be addressed with breastfeeding.

According to the American Academy of Pediatrics (AAP) policy statement breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue rather than only a lifestyle choice. The AAP reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer if mutually desired by mother and infant. There are rarely medical contraindications to breastfeeding.

Hospital routines that encourage and support the initiation and sustaining breastfeeding should be based on the AAP-endorsed World Health Organization/United Nations International Children's Emergency Fund “Ten Steps to Successful Breastfeeding.” ⁴ National strategies supported by the U.S. Surgeon General's Call to Action, the Centers for Disease Control and Prevention (CDC), and The Joint Commission are involved in facilitating breastfeeding practices in hospitals and communities. ⁵ Primary care providers, especially pediatricians, obstetric/gynecologists, and family medicine physicians play a critical role in their practices and communities as advocates of breastfeeding. They are very knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and techniques for managing and supporting the breastfeeding dyad.

Breastfeeding rates are only 49% at 6 months and 27% at 12 months, which is lower than the Healthy People 2020 target rates of 61% and 34%, respectively. The Healthy People 2020 targets for breastfeeding aim to increase the proportion of infants who are ever breastfed to 82%; breastfed at 6 months to 61%; breastfed at 1 year to 34%; exclusively breastfed through 3 months to 46%; and exclusively breastfed through 6 months to 26%, according to data for the CDC Breastfeeding Report card. ⁶

According to the U.S. National Immunization Survey data in 2012, 66% AA mothers initiated breastfeeding compared with 83% Caucasian mothers and 82% Hispanic mothers. Gaps in breastfeeding was shown to continue at 6 months with only 35% AA mothers still breastfeeding compared with 56% Caucasian mothers and 51% Hispanic mothers. ⁷

For over 30 years, AA women have had the lowest breastfeeding rates. When it comes to the gold standard of infant nutrition—6 months of exclusive breastfeeding, among AA the rate is only 20% compared with 40% among whites. Cultural issues contribute to this disparity in breastfeeding. Underserved communities have been the targets of aggressive marketing by formula companies. In the 1930s and 1940s, formula feeding was marketed as the choice of the elite, “the substance for sophisticates” for both white and black.

White women have led the charge to infant formula followed by AA women. But, when white women reversed course, led by the celebrity cache and a new ideal of “good mothering,” AA women did not buy-in. There are many factors that negatively impact breastfeeding, for example, being AA, poverty, younger mothers, and being single with less economic and social support. However, the issue is really bigger than breastfeeding, and it is a practice or lack of practice that really is a statement of not feeling empowered or self-worthiness and connectedness to the healthcare world for women of color. ⁸

Several significant associations with breastfeeding have emerged. It reduces stress and supports good mental health; protects mother and child against certain diseases; increases the intelligent quotient in children; and strengthens the bond between mother and child. Ultimately, breastfeeding is associated with enhanced physical and mental health compared with nonbreastfeeding. ⁷

From the medical standpoint, research has documented that breastfeeding for more than 4 months decreases the risk of hospitalization for lower respiratory tract infections significantly (72%). Any breastfeeding is associated with a significant reduction (64%) of nonspecific gastrointestinal infections. A significant reduction in sudden infant death syndrome risk has also been demonstrated. Reduction in the rates of allergy, celiac disease, irritable bowel disease, obesity, diabetes, childhood leukemia, and lymphoma occur with breastfeeding. Neurodevelopmental outcomes are significantly improved in preterm infants who are given breast milk. There seem to be few contraindications to breastfeeding, which include certain metabolic disorders in the baby (galactosemia) and HIV positive mothers, as well as those with active untreated tuberculosis, and mothers receiving certain medications such as chemotherapy agents. ⁹

From a prenatal perspective, it is important to advocate for breastfeeding, this was documented in one study that demonstrated 70% of women who were given probreastfeeding guidance by their obstetrician(s) (OB) were still nursing at 6 weeks postpartum versus 54% who said their OB expressed no preference in feeding method. ¹⁰ There are variations in hospital practices that account for disparities in breastfeeding duration, and that improvement in the quality of antenatal and perinatal support could have a substantial impact on maternal and infant health. Establishing the breastfeeding experience during the childbirth hospitalization is critical for instilling the benefits of breastfeeding to mothers. ¹⁰ There are known innate immune factors present in human breast milk that provide protective agents for some common pediatric pathogens. Without breastfeeding, this is associated health risks for both mother and infant. Epidemiologically the data suggest that women who do not breastfeed may face higher risks of breast and ovarian cancer, obesity, type 2 diabetes, metabolic syndrome, and cardiovascular disease.

What is needed to improve breastfeeding is a combination of Policy, Programs, Peers, and Partners working together to improve health outcomes and a reduction in the IMR in people of color, which can be achieved through addressing the social determinants of health. In addition, breastfeeding in the work place must be addressed for mothers who return to work and the benefits to employers who facilitate this practice.

It really is about more than healthcare. Steps needed to reduce infant mortality is more than access to care, the underlying social, economic, and environmental factors that contribute to health inequities must be addressed at the local, State, and National levels and leaders in public and private sector must work together to achieve success. Partnerships with education, transportation, housing, planning, public health, business, and beyond should join forces with community members to promote health equity as outlined in the National Medical Association's (NMA) National Action Plan for Health Equity.

We exist in an era where healthcare providers must not only be concerned and dedicated to saving lives but must also focus on preventing illness and disease through the use of smart technologies and medical care. It requires a team effort to bring about the necessary changes needed to shift the health paradigm to a new culture of health. The time for change in the health system is now, therefore the urgency is now for the creation of a National Action Plan for Health Equity, which is the action oriented theme throughout 118th NMA presidency, leading to the Creation of a Culture of Health Equity.

Recommendations

There is strong evidence that interventions with a lasting effect on the quality of health and life are effective and should be included in programs that promote early childhood development with support for children and families.

Recommendations are aimed at ensuring that children have the best start in life and health; social advantages and disadvantages; and expand across generations.

Strategies should give children a healthy start and ensure that there are future generations of healthy adults.

High-quality early developmental support, including breast feeding, should be instituted.

Food programs to support the needs of hungry children and families.

Create Public–Private Partnerships to sustain access to healthy food.

Provide healthy food in schools.

Allow time for physical activities for all children in schools (K-12).

Maintain a smoke-free environment.

Create policies and programs that support and promote healthy lifestyles.