The United States Department of Health and Human Services developed specific recommendations for breastfeeding initiation and duration in the United States as part of their Healthy People 2010 national initiative for health promotion and disease prevention. Because the health benefits associated with breastfeeding for both the mother and baby are well documented, a Healthy People 2010 goal recommends that 75% of all women initiate breastfeeding, that 50% are still breastfeeding at 6 months and that 25% are continuing to breastfeed throughout the first year of an infant’s life.  Further, they recommend that exclusive breastfeeding rates be measured at 3 and 6 months after birth.  The American Academy of Pediatrics recommends exclusive breastfeeding for approximately the first 6 months of life with a continuation of breastfeeding for the first year of life or longer. We are far from achieving these goals.

Several interventions are touted as the panacea for increasing breastfeeding initiation and duration rates.  Some suggest the solution should begin in the hospital.  A randomized controlled study by Ball et al. reveals that the placement of the newborn in close proximity to the mother after birth is related to breastfeeding success.  Specifically, newborns who sleep in an adjoining side-car crib during their post birth hospital stay experienced increased frequency of breastfeeding compared to newborns sleeping in the standard rooming-in condition of the stand alone baby cot. These findings suggest that the unhindered access between mother and newborn in the initial postpartum period is correlated to successful night feeds with implications for increased breastfeeding duration rates.

Other studies suggest that the monitoring and follow up by health care professionals after release from the hospital is key to breastfeeding success.  A publication of The American Academy Of Pediatrics Section On Breastfeeding, ”Ten Steps to Support Parents’ Choice to Breastfeed Their Baby – Breastfeeding Promotion in Physicians’ Office Practices”, offers strategies which physicians can utilize in order to better support breastfeeding in the primary care setting.  Other studies look towards the role of the Board Certified Lactation Consultant and the use of this allied health care professional as key staff who can assist with the management of breastfeeding problems and provide ongoing education and support directly to breastfeeding mothers and babies both prenatally and after birth.

Many studies suggest the decision of how a woman will feed her baby is made prior to birth and require earlier interventions.  A study by Gagliardi and Milan reveals that maternal depression during the first trimester of pregnancy is predictive of formula feeding and of a woman not choosing to initiate exclusive breastfeeding.  This study reveals that when looking at socio-demographic variables related to infant feeding choice, maternal depression is the variable most related to a decision to formula feed.  Targeted interventions for specific at risk populations are recommended. 

A 2001 study by Rosenthal et al. suggests it is maternal confidence that needs to be addressed in order to increase breastfeeding duration rates.  This study suggests it is a woman’s lack of confidence that she will continue breastfeeding and her perception of her infant’s feeding preference for formula which is predictive of early discontinuation of breastfeeding even when women are knowledgeable about breastfeeding and have help with breastfeeding management problems. This study recommends a shift in focus from increasing maternal knowledge to enhancing maternal confidence.  Certainly, a psycho-educational approach would allow for attending to the complexities involved in the feeding experience. When providing education about what a woman needs to know about the feeding relationship or when helping with a breastfeeding management problem, reflective listening skills will also allow one to focus on how a woman feels about feeding her baby.

There is no silver bullet to increasing breastfeeding initiation and duration rates in the U.S.  All of the suggested interventions and identified problems will need to be tackled if we are to meet the Health People 2010 goals for breastfeeding. We need to promote breastfeeding prenatally and prior to a woman becoming pregnant.  We must do so in a way that women, their partners, their families and the people in their key supportive network can understand and are comfortable with.  We need to identify barriers to breastfeeding such as maternal depression, returning to work, lack of confidence and lack of support within a variety of venues. We also need to create hospital environments that protect the initial breastfeeding experience and the experience throughout the hospital stay. Finally, it is essential that we provide ongoing support for breastfeeding in the physician office, in the workplace, within the family and throughout our society at large if we are to achieve long term breastfeeding success.

Multi faceted problems require multi faceted solutions. While one set of strategies will facilitate a women’s choice to breastfeed her newborn, additional interventions will be necessary to support a woman’s successful continuation of breastfeeding.  With the proven health benefits associated with breastfeeding, the development of a sound public health plan that can be operationalized will bring us towards realizing the Healthy People 2010 goals for increasing breastfeeding initiation and duration rates in the U.S. 

For more information, visit the two related website links listed at the end of this article -- one to the American Academy of Pediatrics and the other to the Centers for Disease Control.

(Amy Gagliardi is a writer and researcher based at Yale University. She can be reached at amyd.gagliardi@gmail.com. Opinions expressed by Health Commentary guest bloggers do not necessarily represent the views of Health Commentary.)