Abstract
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Is there anything more primary in life and the care of an infant than breastfeeding? The American Academy of Family Physicians recently embarked on a campaign to advocate for the values of family medicine and primary care—Health is Primary. The aim of this patient-centered education campaign is to improve the health and healthcare access of all Americans. Borrowing from this campaign theme and with all due attribution—Breastfeeding is Primary!
Significant attention is paid to supporting breastfeeding in hospitals. Baby-Friendly Hospital Initiatives have highlighted the importance of the breastfeeding care that must occur in hospital settings. Significant strides have been made in human milk research, epigenetics, milk banking, and breastfeeding in neonatal intensive care units. The Academy of Breastfeeding Medicine has supported the education of physicians worldwide and has advocated for and represented our members in many venues worldwide. I am speaking to the choir, but are we doing enough to incorporate breastfeeding and lactation support into the training and care provided by primary care physicians?
It is generally known that most medical students, residents, and practicing primary care physicians lack training and experience in the support and promotion of breastfeeding. Much of what we do in primary care offices is now dictated by quality measures. Prevention and disease management is actively promoted to primary care physicians. Vaccinations, proper nutrition, depression and alcohol screening, colon cancer prevention, smoking cessation, cardiovascular disease, and diabetes prevention are all part of our training and daily practice. Insurance companies, governments, and credentialing agencies promote and incentivize primary care physicians for quality achievements in these areas. The American Academy of Pediatrics states that breastfeeding should be considered a public health issue and not only a lifestyle choice. 1 However, breastfeeding and human milk get little attention as the ultimate primary care prevention activity that should be promoted by physicians. It is time that insurance companies, governments, and other agencies emphasize breastfeeding as an important quality measure on par with all the others.
The works of Barbara Starfield, MD, MPH, highlight the benefits of primary care physicians to countries and communities. An increase in primary care physicians is associated with healthier outcomes and especially in areas of high social disparities, and is negatively associated with infant mortality and low birth weight. “The evidence strongly shows that it is in primary care that preventive interventions are best when they are not related to any one disease or organ system. Examples of these ‘generic’ (i.e., not limited to a particular disease or type of disease) measures are breastfeeding, not smoking, using seat belts, using smoke detectors, being physically active, and eating a healthy diet.” 2
Primary care physicians and teams have the opportunity and I believe an obligation to discuss and educate patients, families, and communities on breastfeeding. Family physicians, pediatricians, internists, and obstetricians generally speak the same language on other public health issues such as smoking, seatbelt use, safe sleep, and vaccines. It makes sense that we should be doing the same for breastfeeding.
Fewer primary care doctors are practicing in hospitals. Because of this, they don't appreciate the continuum of preconception, prenatal, delivery, and postpartum care and the events that sabotage breastfeeding. They have little knowledge of Baby-Friendly Hospital practices or the Ten Steps. Most students and many residents have never witnessed the “golden hour,” the magic of self-attachment, and are never taught to examine the breastfeeding dyad or observe the latch. Without this primary care breastfeeding knowledge, physicians will have difficulty with the challenge of helping to support, educate, and develop confidence in their patients to breastfeed. Out of ignorance, lack of time, or lack of training, they give in to what they think is the easy way out.
Most primary care physicians practice in communities that they have influence in. They understand the social, cultural, and economic patterns that affect their patients' desires and ability to breastfeed. Primary care physicians can advocate to prevent barriers that disrupt breastfeeding. Primary care teams of physicians, nurses, medical assistants, and physician extenders also need to be educated to support breastfeeding in their communities. Primary care physicians can make their offices breastfeeding friendly and take time to educate the extended family about the importance of breastfeeding. 3 They can write letters to community newspapers or offer their breastfeeding expertise to local news services. They can also invite and teach students and residents about breastfeeding prenatally, at delivery, and in the office.
A call to action for primary care physicians—Breastfeeding is Primary!