Guatemala, and Costa Rica. The San Diego Lactation Program is proud
to be participating in this American export.

Summary and Conclusions

This report has described the San Diego Lactation Program, 4
teaching-hospital-based program in operation since September 1977. The
Program functions as an academic subspecialty and is co-directed by a
pediatrician and a pediatric nurse practitioner. Though important serv-
ices are provided for breastfeeding families, the Lactation Program is pri-
marily a teaching resource for health care students and postgraduate
trainees from the perinatally oriented disciplines.

If breastfeeding is to be seriously promoted in this country and if
infants of families from all walks of life are to receive the many benefits
of human milk and breastfeeding, then skilled services from knowledge-
able health professionals are essential. In order to assure the availability
of such professionals, clinical learning opportunities concerning lactation
and breastfeeding must become an unquestioned, standard unit of medical
and nursing education and of postgraduate training in the perinatal
specialties.

Because of the complexity of both the physiology of mother and
infant and their interactive behavior, such clinical training deserves the
same degree of attention, support, and careful direction as given to any
other complex subspecialty. It should be under the direction of knowl-
edgeable and experienced medical faculty with primary training in one of
the perinatal specialties. Teaching-hospital-based lactation programs such
as this can provide ideal clinical learning opportunities for health profes-
sionals and can add a major contribution to the successful promotion of
breastfeeding for all infants and mothers.

51
BREASTFEEDING: NEW YORK STATE’S
INFANT HEALTH STRATEGY

David Axelrod, M.D.

I bring greetings from Governor Cuomo and his wife, Matilda, both
of whom are very interested in the subject of maternal and child health.
The Governor is a strong proponent of initiatives to improve the health
of infants, children, and lactating women, as exemplified by his successful
support of the addition of $15 million to this year’s budget for nutritional
assistance to high-risk populations, many of whom are young mothers
and their children. Mrs. Cuomo has been a tireless worker on behalf of
child health programs in both the public and voluntary sectors.

Our society needs to do more to promote child health, particularly
among the poor, the racial minorities, and adolescent mothers. Ours is a
time and an environment that seems to have turned its back on the needs
of children. We need greater understanding in the White House, in Con-
gress, and in statehouses throughout this country that the future of our
nation is dependent on the physical health and development of our chil-
dren. Their needs cannot be made to wait.

I believe a nation which fails to commit itself to protect the health
and development of its children and the women who bear them is a
nation flirting with social disaster, a nation which has no sense of destiny
in weighing the true determinants of national strength and purpose. It is
neither cliche-ridden nor simplistic to say that children are our most pre-
cious national resource. And it is time we directed our national and local
resources in such a way to prove that we are truly committed to serve
the future of our country.

Our best defense as a nation lies not in weaponry, but in a strong,
healthy, and resilient society, which we cannot have unless we do a
better job of bearing, rearing, and educating our young. And so we
cannot do, unless we address the problem of unwanted adolescent preg-
nancy, unless we recognize that many mothers, their unborn fetuses, and
their newborn infants are being inadequately nourished; and unless we
recognize that, despite all our scientific advances, we still have a long
way to go to achieve our goals in reducing perinatal mortality and
morbidity.

Seventy years ago, one of every ten infants born in this country died
before age one. Last year, the infant mortality rate in the U.S. was the
lowest ever achieved—just over one death per 100 live births. But,
before letting out a loud cheer to celebrate this accomplishment, we
should not forget that the infant mortality rate of Blacks is almost twice
that of Whites in our country. In some ghetto areas, the infant mortality
rate is equivalent to that of some Third World countries.

Nearly two-thirds of the infants who die before their first birthday
have one thing in common, low birthweight, which makes them more
susceptible to disease and developmental defects. All too commonly, low

52
birthweight babies are born to immature, poorly nourished, unwed ado-
lescent mothers. These mothers and their children, if they survive their
common ordeal, usually end up on the welfare rolls, with little prospect
of ever leading independent lives.

I cite these issues because I believe they are critical to our common
goal of encouraging more mothers to breastfeed their young. A glance at
the data on breastfeeding rates gives a rosy picture—between 1971 and
1981, the percentage of postpartum women discharged from U.S. hospi-
tals who were breastfeeding their children increased more than twofold,
from about 25% to over 57%. Indeed, a survey of breastfeeding prac-
tices by mothers discharged from hospitals in most areas of New York
State mirrors the national experience. Here in Rochester, for example,
60% of the maternity patients at Strong Memorial Hospital reportedly
breastfeed their infants.

But it is when we look to hospitals serving poor, minority clientele
that we discover a different picture. In these hospitals, the hospitals of
the Health and Hospitals Corporation in New York City, hospitals serv-
ing the Crown Point and Bedford-Stuyvesant neighborhoods of Brook-
lyn, and hospitals in Harlem or the South Bronx, one discovers that the
percentage of mothers breastfeeding their infants is more likely to be
10% or 15%. In the case of the Harlem Hospital Center, only 5% of
mothers breastfeed.

Our misbegotten marriage with medical technology is not always
consistent with our goals for more breastfeeding mothers. Let me point
out that some of our leading medical centers are not doing an adequate
job of promoting breastfeeding practices for mothers who come under
their care. Their statistics in this regard are little better than those of the
public hospitals in New York City.

Obviously, we need to do more than simply encourage and educate
mothers to breastfeed their young; we need to inculcate belief in the ad-
vantages of breastfeeding among our doctors, nurses, and hospital admin-
istrators.

While we are still gathering evidence for the population being
served by the federal WIC program, early returns are not encouraging.
Only about 15% of this high-risk population are breastfeeders. This evi-
dence suggests failure to reach the audience that stands to benefit the
most from breastfeeding their young.

We in New York State have decided to do something to remedy
this gap in our infant health strategy. We have discovered that despite
extensive documentation of the physical and psychological benefits of
breastfeeding for both mothers and infants, healih-care providers in New
York State are not being appropriately informative or helpful to those
who stand to gain the most from breastfeeding. Indeed, if anything, the
approach in many hospitals has been to encourage artificial feeding
methods at the expense of breastfeeding promotion.

In order to turn this situation around, we in the State Health De-
partment, in addition to supporting model legislation to require hospitals
to inform patients properly of the infant feeding options available to

53
them— including breastfeeding—have drafted new regulations governing
the responsibilities of hospitals with respect to maternity patients who
wish to breastfeed their infants. We anticipate that these regulations will
be adopted later this month by the State Hospital Review and Planning
Council.*

Under these proposed new regulations, hospitals will be required to
provide instruction and assistance to each maternity patient who either
chooses to breastfeed or is undecided about the feeding method for her
infant. Each hospital with a maternity service will be required to desig-
nate at least one person who is thoroughly trained in breastfeeding physi-
ology and management to be responsible for presentation of an effective
breastfeeding instruction program. Among the other policies and proce-
dures that the hospitals will be required to carry out are:

1. prohibition of the application of standing orders for antilactation
drugs;

2. positioning of the infant for breastfeeding immediately following

delivery, unless contraindicated;

3. provision for the infant to be fed on demand;

4. restriction of supplemental feedings to those indicated by the

medical condition of the infant or the mother; and

5. restriction of distribution of discharge packs of infant formula to

an individual order by the attending physician or at the request
of the mother.

The education program, which is to be presented as soon after ad-
mission as possible, must include information on:

1. the nutritional and physiological aspects of human milk;

2. lactation, including care of breasts, frequency of feeding, prob-

lems associated with breastfeeding;

3. dietary requirements for breastfeeding;

4. sanitary procedures to follow in collecting and storing human

milk; and
5. sources for advice available to the mother following discharge.

In order to facilitate implementation of these new regulations, we in
the Health Department intend to develop a curriculum to enhance the
skills and knowledge of maternity staffs in those hospitals that do not
currently have supportive programs for breastfeeding mothers.

These regulations also call for the modification of existing standards
that emphasize procedures and allocation of space for hospital prepara-
tion of infant formulas and for the deletion of regulations that require
pacteriologic monitoring of the feeding unit associated with prepackaged,
presterilized, commercially-prepared formulas. Hospitals should realize
some cost savings as a result of these two changes.

We believe these proposed regulations are indicative of our commit-
ment to increase the number of mothers who provide their infants with
the immunologic, bonding, and other benefits associated with breastfeeding.

We look upon these regulations as an integral part of our strategy to
improve maternal and child health in New York State and to continue

 

* These regulations were adopted in June 1984.

54
our progress in reducing infant mortality and developmental disability. In
a state where the chief executive has tied his entire political philosophy
to the concept of Family, we are sworn to the belief that nothing is more
essential to the promotion of close ties between mother and child than
breastfeeding.

THE LAY VOLUNTEER IN THE MOTHER-TO-
MOTHER PROGRAM OF LA LECHE LEAGUE

Viola Lennon

One of the most interesting aspects of La Leche League is we never
meant to found it. We were all busy young mothers in 1956 and never
dreamed of starting a worldwide organization. None of us had the vision
to see an organization now in 44 countries, having 14,000 qualified lead-
ers in these 27 years.

It all started with a phone call from an old friend, Edwina Froeh-
lich—a person who was a great help to me with breastfeeding of my
children. She invited me to a meeting to discuss breastfeeding and moth-
ering. If she had not mentioned mothering, I would never have accepted
her invitation. I had little trouble with breastfeeding, thanks to the sup-
port and information she had given me. However, mothering interested
me. I wasn’t sure just what it really meant.

In our first meeting we shared our ideas about breastfeeding, its im-
portance, some of the problems in getting started with lactation, and our
real joys in the breastfeeding relationship.

One meeting !ed to others and mothers came. They wanted to know
more about breastfeeding and mothering, and we soon found we had
started reviving the lost art of breastfeeding. When we grew into too
large a group, We broke into several groups. Soon, I was leading a meet-
ing in Chicago.

We then developed an outline for our organization and started to
write a short version of what would eventually be The Womanly Art of

55
Breastfeeding. \ remember not being very enthusiastic about writing a
book. Who needs a book?

When an article appeared in the Readers Digest entitled “They
Teach the Joys of Breastfeeding,” we received hundreds of letters. I was
called and asked to answer a few letters and agreed. Soon we were [e-
ceiving letters by the stack.

In time, I remember one of the husbands suggesting a national con-
ference. Imagine having mothers and babies travel to a convention! The
idea seemed radical to me, but it happened. Eight hundred people ar-
rived for the conference.

We continued to grow because we had uncovered a natural need. I
will always believe that most mothers want what is best for their chil-
dren, and they knew intuitively breastfeeding was best and would lead
them most quickly to a discovery of mothering and all it entails. We had
the help of several doctors and other professionals who made sugges-
tions, stimulated our thinking, and lent us their expertise. Just as at these
meetings, we need each other—professionals and mothers—to give each
mother the solid base she will need.

The discussion in this Workshop about the indecent exposure issue
reminds me of an incident that happened to one of my daughters. The
girls have earned some of their college expenses by waitressing. One day,
one of the other waitresses approached my daughter with the statement,
“You will never guess what the lady in station 17 is doing.”

My daughter knew what the woman was doing. The waitress con-
tinued, “Wouldn’t you think she would nurse the baby in the bathroom?”
My daughter confided to me that years ago she would have said nothing.
In those early days the children had problems describing their mother’s
involvement. Now, breastfeeding has come out of the closet, and my
daughter responded, “No one else in this restaurant is eating lunch in the
bathroom.”

Now back to the story. We just kept on growing and soon we had a
few State meetings and a State Coordinator. Then Canada and New Zea-
Jand joined us, and we changed to areas.

The usual followed—starting to employ a few people, setting up an
official office, writing a constitution. Many of you in the voluntary
sector know the steps.

We started out as a breastfeeding support system. Like all of you
who have your vision focused on the ultimate health and happiness of
families, we made startling discoveries. Breastfeeding is important. A
positive birthing experience adds immeasurable support to a mother’s
confidence, but she needs all this and more to complete her education as
a parent for the lifelong job of raising 4 family. We together must give
parents this belief in themselves. That whole process is what La Leche
League is all about.

La Leche League is a much broader oganization than we, the found-
ers, first anticipated. La Leche League is first a breastfeeding information
and support network, usually based on the mother-to-mother approach.

La Leche League is really the only organization that speaks to the
needs of the baby and is a spokesperson for the baby.

La Leche League International is a witness to the importance of

56
motherhood, a model for mothering. LLLI is also a comfortable place to
row in mothering. The mother who becomes attentive to the real needs
of her infant and is sensitive to the rhythm of a little body soon learns
real discipline is loving guidance. The mother who sees growth in her
infant through her own milk soon begins to take a real interest in her
own and her family’s diet.

La Leche League International is becoming a worldwide resource
for minority, employed, and professional mothers.

The ingenuity displayed by employed mothers will always fascinate
me. Their determination to breastfeed makes me pause in respectful ad-
miration. They come home for lunch for two. They pump their milk on
coffee breaks. By prior arrangement, some mothers bring their babies to
work.

The WIC program and La Leche League are cooperating in offer-
ing breastfeeding information and support to the clinic mother. We had
often wondered if our mother-to-mother approach and our materials
would work for this group of mothers. Happily it does work, if our lead-
ers develop a real sensitivity to cultural differences in any group. In Chi-
cago we have had several seminars on Black culture to sharpen our own
insights. We also offer many of our materials in Spanish. In the Watts
district in California, our inner city program is thriving and our member-
ship has real interest in other cultures.

For the pregnant professional, we are planning a series of lectures
on breastfeeding complete with a package of information and an appro-
priate charge. This scheme is a departure from our meeting series, but
we realize that some women will not attend a La Leche League Series
meeting. We are not locked into any one format. Our philosophy is para-
mount. The eighties present new life-styles, and we mean to be as sup-
portive as possible—always depending on you good professionals for
guidance and cooperation.

We need you, but you need us. When a new mother is confronted
by a crying, seemingly unmanageable infant, she doesn’t need a diagram
of the construction of the breast. She needs an experienced nursing
mother. When there is a medical problem, the diagram may point to the
solution, and a doctor’s experience is vital. We never give medical
advice.

The following story is true and says what we really are. One day an
overwrought and tired new mother called me. She was haying problems
with breastfeeding. Since she lived close by, I suggested that she drop in.
She did—and started asking questions. Martin Lennon was 3 months old
and behaving just his age. I nursed him and we talked. I put him on my
lap, then I put him on a blanket on the floor as I made some coffee. Fi-
nally I noticed my visitor was not paying any attention to my answers.
She was watching and finally blurted out, “Do you think that child is
normal?” Remember, this was my son! I said “yes” and she seemed to
smile and relax. “I guess I don’t have any problems. I just didn’t know!”

There it is: La Leche League.

37
BREASTFEEDING AND THE MEDIA

Robert Bazell, NBC News

After I was asked to speak at this conference of distinguished par-
ticipants, I read a press release that said I would be talking about what
television is doing to promote breastfeeding. I then went to our comput-
er to see what NBC News has done on the subject of breastfeeding. In
researching the 7 years since tape has replaced film as the primary video
storage element, I found that NBC News had done 7 pieces on breast-
feeding, 3 of them in a period of a few days in 1981. Using these pieces
as a framework, I would like to talk about how news is made, and why
something becomes newsworthy. Breastfeeding, although it involves cru-
cial health issues, is unfortunately “old hat.” It is not news. It is true that
the news media certainly stresses educating the public, but we in the
media don’t always function as if that were our primary role.

Let me enumerate the NBC News stories on breastfeeding in chron-
ological order. The first was aired on June 8, 1977. There was a report
of a Senate hearing in which some environmentalists showed that toxic
substances had been found in human milk. How will such a story be
treated? We must remember that the network evening news program is
22 minutes and 40 seconds long after the commercials. Frequently a
story is sandwiched between a commercial touting a headache remedy
and another selling a hemorrhoid remedy, and conveying health informa-
tion in that perspective is difficult. Furthermore, a typical story on the
evening news is 90 seconds long, including the sound bites (the 15-18
second quotation from the subject of the story) as well as the 1% min-
utes of reporter’s commentary. This amount of space/time doesn’t allow
for much of a balanced perspective on two sides of a complicated issue.
There is usually time for only one impression to be conveyed in this
visual medium, and in the story in point, probably the one idea that came
across was that there was something dangerous in mother’s milk. The
public takes away the idea that there is something to worry about.

Why did we do that story? It was startling, and therefore it was
news—and viewers paid attention. Breastfeeding was suddenly suspected
as potentially harmful to children; thus it became newsworthy.

The decisions concerning news content are made by relatively few
people and almost all of them are men. Certain subjects simply evoke
squeamishness. A story on the benefits of breastfeeding unfortunately
seems to be considered by some as unfit material for the evening news.

The subject is a visual one, and showing a picture of a woman nursing
her baby, no matter how tastefully done, makes some people nervous.
Those who decide what will be shown seem to prefer to do a story on
another health topic—almost any other.

The second story aired by NBC in this 7-year period was in January
1978. Jane Pauley on the “Today Show” interviewed Dr. Jean Lockhart
of the American Academy of Pediatrics. The Academy had just come

58
out with a recommendation strongly in favor of breastfeeding. The pre-
sentation was a one-on-one interview and did not involve showing pic-
tures. This type of presentation, 4 to 6 minutes long, does give more of
an opportunity for questions and answers and explanations. | believe
such a format is better for conveying information, and I am surprised
that there have not been more presentations of this kind. There is the
conviction that health issues are important, and breastfeeding is certainly
one of these issues. This interview also reinforced the concept of the
voice of authority. The physician or the medical organization will make
us pay attention to an issue—in this case, breastfeeding. When the Amer-
ican Academy of Pediatrics highlights an issue, people listen. Even So,
the press and the public are ambivalent toward physicians and the medi-
cal establishment as authority figures. On one hand, we look to them as
experts with all knowledge; on the other, there is enormous skepticism
running through the country. In this context, breastfeeding, or the return
to breastfeeding, first started as a popular movement and then received
the establishment’s blessing through scientific research. There are both
the popular and the establishment currents at work, and we in the media
always wonder which current we should swim with.

The next story to appear on NBC was on the nightly news on Janu-
ary 26, 1979, and I am sure it is familiar to you. Linda Eaton, a fire fight-
er in Iowa City, was dismissed from the fire department because she in-
sisted on the right to nurse her baby in the firehouse. Now a story like
this one gets on the news because it’s quirky, and in fact it does raise
some very crucial issues like the questions of breastfeeding and women
working and women’s rights. Even though this case was regarded as bi-
zarre, it could have been a focus to discuss those issues. I think that one
of the reasons it got so much attention was that she was a fire fighter. If
she had been a secretary and had been fired for insisting on bringing her
child to the office, there would have been a small paragraph in a news-
paper someplace. It was only because she was a fire fighter, a job which
obviously is commonly male, that the story received so much attention.
That is the reason some stories become news. I hope that some people
go beyond seeing it as more than just a weird story about a woman in a
firehouse, and see the real issue. But certainly when I look back over the
way the scripts were written, or even the way newspapers (which have
much more space) treated it, I don’t think it was treated in a way to
bring out the substantive issue.

The next time that a story about breastfeeding appeared on NBC
was two years later in May 1981. There were three stories in a period of
a few days. Officials in the Agency for International Development
threatened to resign because the Reagan administration did not support
the World Health Organization’s infant formula code. Television news

sed the issue very quickly and then just dismissed it. If I am listing the
Its of television, this is the area where we fail the most. Middle-class
ymen and men who make decisions about breastfeeding don’t need a
igthy discussion on the “Today Show.” If they are educated or if they
Jl consult their doctors for the right information, they will get the in-
rmation. But the issue of infant formula sales in Third-World countries

59
and formula promotion in poverty areas of the United States is a crucial
news issue, and it is one that has been almost ignored by both newspa-
pers and television. It only came up in this one instance because two men
threatened to resign. It happened, and then it was just forgotten. There
was never an in-depth report. There was never a “why is it so impor-
tant?” The reasons are astounding in terms of the implications for nutri-
tion, the implications for birth control in those countries, and all those
things which you know so well. We should have done 20 news stories OF
documentaries about breastfeeding, because the issue really matters. But
it was not done. We did not cover it because American television would
much rather cover a story about the sex life of gorillas.

The last story on the-list illustrates another reason why things get
on the air. On December 6, 1982, in Boston, 150 women donated breast-
milk to save the life of an infant whose mother couldn’t produce enough.
That’s wonderful! That is a nice heartwarming story, and got on the air
for that reason . . . not because it instructs people about anything, not
because it informs us about the issues, but because it is a “Gee whiz,
aren’t those people nice” story.

There you have the limitation of our coverage. I think it should be
different.

One of the fascinating things on the subject of breastfeeding is its
lack of media history. I always associate breastfeeding with bricking up
the fireplace. After World War II, many people bricked up their fire-
places because why in the world would you want to have a fireplace in
your living room anymore with all the new technology? Who would
want to see an old-fashioned thing burning? Now we are rediscovering
that it is a good thing.
REFLECTION ON BREASTFEEDING
Rabbi Judea B. Miller

Some participants asked if there were any references in the Bible to
nursing and lactation. I want to point out that aside from the most obvi-
ous bonding and nurturing references to the mother mentioned in one
portion of the service, Moses is described as a nursing father. He carried
Israel through the desert like a nursing father. And when I see the young
fathers today holding their children and sharing in the nurturing and
raising of children (as in my generation they did not do), I can under-
stand what was meant by Moses as a nursing father.

In Jewish tradition, a woman is not ordained (according to our Or-
thodox brethren), not because she is unworthy of ordination, but just the
opposite. There is a hierarchy of values, and from those mitzvot or com-
mandments that have to do with time and place, a woman is automatical-
ly exempt. She can take them on, but she is exempt from the responsibil-
ity of fulfilling them. Because of a higher order of priorities, her respon-
sibility is to be available to nurse and nurture the children. Of vourse,
women don’t nurse children all their lives. After they finish their nursing
responsibilities, they can become rabbis or priests, or anything else they
care to be.

A Jewish child, like every other, is introduced to the world with a
whack. That is quite an introduction, but at least we grow up knowing
that there are loving, nurturing arms and breasts to receive us into a
world that is sympathetic and hospitable. Let me recall to those of you
who know Hebrew that one of the words for God in the Bible is El
Shaddai. The word shaddai has the same root as shaddayim, which means
breasts. God is compared to a nurturing, nourishing mother, taking care
of believer and unbeliever alike.

One last thought is that according to the laws of kashrut, you shall
not boil the kid in its mother’s milk. And from that law, the rabbinical
tradition builds up our whole system separating milk from meat. The
thought behind it is not merely one of taboo, but (long before the days
of Freudian psychology) one of symbolism and of metaphor. It seems in-
sensitive and brutal to eat flesh and then immediately to drink milk that
was given out of love. The giving of the milk is the height of human
compassion. In Jewish thinking the highest. order of priorities for a
woman and for a man, like the nurturing father Moses, is the care and
nurture of the young. God could not be everywhere. That is why God
created mothers; that is why God created parents.

61
 
VORK GROUP
RECOMMENDATIONS

NTRODUCTION TO WORK GROUPS

Each interdisciplinary work group of approximately 12 persons was
issigned to examine in detail one of 8 specific issues related to human
actation and breastfeeding. Each work group included participants with
special knowledge of the issue being addressed as well as participants
with unique perspectives on the issue by virtue of their discipline, work
setting, cultural and ethnic orientation, and organizational affiliation.
Each work group had as its core a nurse/nurse-midwife, a nutritionist/
dietitian, a pediatrician, and an obstetrician. Each work group focused on
a different topic that was well delineated. The tasks of the work groups
were to identify issues, prioritize and discuss them, and then to generate
recommendations and develop strategies to address them.

Although the broad scope of information and the range of views
and perspectives exchanged in the work groups cannot be covered ade-
quately in this document, some of the more urgent issues, needs, and
strategies are synthesized and presented in capsule form. To provide a
convenient framework for follow-up discussion and action, the delibera-
tions and recommendations were categorized into common themes and
are reported under the following 6 headings:

World of Work

Public Education
Professional Education
Health-Care System
Support Services
Research

Awe wnm

CATEGORY 1: WORLD OF WORK

A national breastfeeding promotion initiative directed to all those who
influence the breastfeeding decisions and opportunities of women involved
in school, job training, professional education, and employment is needed.

63
DEFINITION OF THE ISSUE

Many barriers currently exist at work and school which can nega-
tively influence a woman’s decision to breastfeed and/or her breastfeed-
ing experience. These barriers include:

¢ Lack of information on the part of the lay public (including
women themselves), employers, health providers, and other sup-
port persons to whom the mother may turn for assistance and/or
advice.

¢ Logistic elements such as how, when, how often, and where to
nurse her baby or to empty her breasts when separated from the
baby and to store milk for later use.

* A social, psychological, and political climate which significantly
separates the worlds of work and home and their related roles.
The working breastfeeding mother often receives negative mes-
sages about her efforts, specifically, that she is attempting to
combine mutually incompatible roles and threatening the deci-
sions others have made to keep the worlds of work and home
separate and unrelated to one another.

In addition, adequate data necessary to direct effective promotional
efforts to working women and to those who influence them are not
available. Also lacking are the appropriate support systems, €.8-, prenatal
care, paid maternity leave, and flexible work arrangements, which are es-
sential for the success of programs designed to promote breastfeeding by
working mothers.

SUGGESTED STRATEGIES

1. Develop a Public Health Service initiative which would help to
insure the rights of all mothers to make and implement an informed
choice about infant feeding. This effort should be targeted (but not
limited) to employers, unions, educational institutions, health care
providers, and social service agencies. Particular attention should be
directed to employers of certain job categories, €.g., domestic
employees, in which minority and low-income women are often
over-represented. The initiative should include at least the following:

a. Development and distribution of informational packets for
prospective breastfeeding mothers, major employer groups,
health professionals, and agencies serving women and infants.
These packets should specifically address logistical and support
elements relating to employment/school and breastfeeding.

b. Collection and dissemination of current information about
existing programs for employed breastfeeding mothers.

c. Allocation of funds for:

* data collection on populations potentially affected;
* studies of employed breastfeeding women; ,
evaluation of program components;

* projects to demonstrate how to facilitate breastfeeding for
working women, including some with emphasis on minority
and low-income women.

d. Exploration of legislation related to federal, state, and local tax
incentives for those who successfully implement breastfeeding
programs in work/school settings.

2. Examine institutional policies which interfere with culturally appro-
priate choices of infant feeding in work/school and other institutional
settings.

3. Encourage the development and/or accessibility of appropriate
support services in the world of work, e.g. prenatal care, social and
nutritional services, paid maternity leave, child care, and alternate
types of work arrangements such as flexitime and job sharing.

CATEGORY 2: PUBLIC EDUCATION

Public education and promotional efforts should be undertaken
through the education system and the media. Such efforts should recognize
the diversity of the audience; should target various economic, cultural, and
ethnic groups; and should be coordinated with professional education.

DEFINITION OF THE ISSUE

Information and education about lactation and breastfeeding as a
normal process, a part of everyday life, and the preferred method of
infant feeding are not universally available. In those instances where edu-
cational programs do exist, they frequently lack sensitivity to cultural
differences, life styles, and socioeconomic levels. Often messages and in-
formation about breastfeeding and lactation conveyed to women, fami-
lies, care providers, community officials, and the public are conflicting
and not based on fact. The resulting confusion often leads to the perpet-
uation of myths, attitudes, laws/regulations, and other barriers which

impact negatively on the initiation and/or continuation of breastfeeding.

65
SUGGESTED STRATEGIES

66

_ Issue to the national media a Surgeon General’s public policy

message emphasizing the positive aspects of breastfeeding and re-
porting the annual progress made toward the 1990 national ob-
jective related to breastfeeding.

. Develop, implement, and evaluate a public-education campaign

to encourage the development of attitudes and behaviors which

support breastfeeding. Such a campaign should target women of

child-bearing age, their supporters, and the community at large,
with highest priority given to lower-income/less-educated
women. Important elements include:

a. An on-going media campaign which utilizes public service
announcements, features, display ads, posters, printed mate-
rials, and role modeling to portray breastfeeding as a com-
munity norm and a part of everyday life.

b. A mechanism to exchange and share educational materials
developed in various parts of the country.

c. A coordinated effort of organizations concerned with pre-
natal care to achieve the universal provision of education
and counseling on breastfeeding and other goals of the
public education campaign.

d. Materials developed and tested for applicability to specific
target groups.

. Develop an educational campaign for public officials to identify

and address community attitudes and to remove and prevent
laws restricting the practice of breastfeeding in public (e-2-
public nudity, indecent exposure). Organizations of elected offi-

cials (e.g., national associations of attorneys general) and legisla-
tors should be utilized.

. Integrate breastfeeding information early and throughout the

educational system through a cooperative effort of State Depart-
ments of Health and State Departments of Education. Such an
effort should include:

a. Development of model education curricula and materials;

b. Integration of breastfeeding information into existing cur-
ricula for science, family life education, home economics,
and health.

_ Use the Healthy Mothers/Healthy Babies Coalition as a clearing-

house for educational materials related to breastfeeding.

_ Encourage community support for breastfeeding by health-care

systems, businesses, religious organizations, volunteer organiza- .
tions, and the media. These efforts should focus on:

a. Removal of physical and attitudinal barriers to
breastfeeding, e.g., providing an appropriate place and fos-
tering postive public attitudes by provision of educational
materials;

b. Development of support systems to nurture nursing moth-
ers such as support groups, telephone hotlines, and the uti-
lization of existing community resources, €.g., churches, so-
rorities, and ethnic community organizations.

7. Collect information and data to monitor changes in attitudes and
behavior related to breastfeeding.

CATEGORY 3: PROFESSIONAL EDUCATION

It is imperative for all health care professionals to receive adequate
didactic and clinical training in lactation and breastfeeding and to develop
skills in patient education and the management of breastfeeding.

DEFINITION OF THE ISSUE

Education of professionals in this important aspect of maternal and
child health care is too often inadequate, ineffective, and—in some situa-
tions—unavailable. A national plan for the education of professionals in
lactation and breastfeeding does not exist. Current concerns are related
to the following aspects and issues of educational programs:

¢ The need for appropriate curricula which recognize the diversity
of sociocultural and economic groups in the population as well
as the roles/responsibilities of various health professionals;

¢ The inadequate funding for the preparation of faculty to direct
and provide training related to lactation and breastfeeding;

¢ The unavailability of educational programs and resources, in-
cluding faculty and funds, to support the education of practicing
professionals;

° The lack of appropriate involvement of accreditation and
standard-setting bodies to assure the competence of health pro-
fessionals and others involved in education and counseling
related to lactation and breastfeeding.

67
SUGGESTED STRATEGIES

68

10.

11.

. Charge the Healthy Mothers/Healthy Babies Coalition to estab-

lish an interdisciplinary sub-committee to develop strategies for
the education of professionals regarding lactation and breastfeed-
ing; provide the Coalition with the necessary funding and admin-
istrative support.

Encourage the federal Maternal and Child Health agency to pro-
vide leadership for education of professionals, including guide-
lines for curriculum, evaluation, and accreditation.

Encourage state, county, and municipal health departments to in-
clude breastfeeding and lactation in in-service training programs.
Encourage local health professional societies, universities, and
perinatal outreach programs to give priority to continuing edu-
cation regarding breastfeeding and lactation to practicing profes-
sionals.

Request the Department of Health and Human Services and
non-profit foundations to provide additional funding for pro-
grams for faculty development and for education of health pro-
fessionals in breastfeeding and lactation.

Include training modules on breastfeeding in curricula of health
care professional students (particularly in medicine, nursing, and
nutrition) to cover contemporary scientific knowledge, influence
of social factors, practical techniques, and roles in multi-chan-
neled promotion programs.

_ Stimulate national professional societies to educate their mem-

bers regarding breastfeeding and lactation through policy state-
ments, articles published in their journals, and continuing educa-
tion programs.

Encourage editorial boards of professional journals to accept for
publication appropriate articles dealing with scientific knowl-
edge, influence of social factors, and practical techniques regard-
ing breastfeeding and lactation.

Include questions on breastfeeding/lactation on certification
exams for health professionals serving families in the perinatal
period, e.g. nurses, nurse-midwives, dietitians, nutritionists,
physicians.

Develop guidelines concerning training and accreditation of lay
lactation advisors in relation to selection criteria of trainees; de-
tails of. practical and theoretical training; examination system,
nomenclature.

Develop accreditation guidelines for health care facilities that
specifically include a requirement of staff education in lactation
and breastfeeding.
CATEGORY 4: HEALTH-CARE SYSTEM

The health-care system needs to be better informed and more clearly
supportive of lactation and breastfeeding.

DEFINITION OF THE ISSUE

How best to support and encourage lactation and breastfeeding as
the natural and preferred method of infant feeding is a major overall
issue of the health-care system. Concern for lactation and the promotion
of breastfeeding are not always reflected in the practices of the health-
care team and in the policies of health-care institutions. Support for
breastfeeding needs to be conspicuous in primary care, prenatal care, and
postpartum care provided in a wide variety of ambulatory-care settings
as well as labor, delivery, postpartum, and infant care provided in hospi-
tal settings. The current organization and delivery of maternal and child
health services and attitudes of health-care team members frequently
negate support for breastfeeding. The problem is compounded by the sig-
nificant numbers of health-care providers who are not adequately edu-
cated about the process and advantages of lactation in human reproduc-
tion and in infant health.

Achievement of the goal to increase the incidence and duration of
breastfeeding will require thorough education of all members of the
health-care team. The result should be a clearer recognition of support
for lactation and breastfeeding as an important and valuable component
of family-centered maternity/newborn care. Furthermore, the application
of this knowledge will require on the part of all members of the health-
care team a positive attitude, based upon the conviction that lactation has
specific and significant advantages for both mother and baby. According-
ly, all providers and facilities should adopt a posture of advocating lacta-
tion as the natural and preferred means of infant feeding. This attitude
should include institutional policies clearly supportive of lactation and
breastfeeding.

At the present time, some of the federal programs serving women
and children include disincentives to breastfeeding. The federal govern-
ment should address these barriers and become committed to the elimina-
tion or modification of such policies. .

Elements important for the promotion of breastfeeding in the vari-
ous phases and settings of health care are detailed in Appendix C.

SUGGESTED STRATEGIES

Recommendations and strategies are outlined according to the inter-
action of the individual with the various levels of the health-care system.

69
National Level

_ Assign the Division of Maternal and Child Health the responsi-

bility to determine national policy related to lactation and breast-

feeding and to convene periodically a national group to advise
on and monitor national policy on breastfeeding.

. Improve the support for lactation in the Women, Infants, and

Children (WIC) Program, including the possible formation of
task forces at both federal and state levels to examine ways in
which WIC can develop incentives to promote breastfeeding,
eliminate existing disincentives, and increase the flexibility of the

program in certain aspects such as cultural foods.

. Request professional organizations including the American Hos-

pital Association, the American College of Obstetricians and
Gynecologists, the American Academy of Pediatrics, the Ameri-
can Academy of Family Physicians, the American College of
Nurse-Midwives; the American Dietetic Association, the Ameri-
can Nurses Association, and others to develop policies and ac-
tivities which more clearly support breastfeeding.

. Request the Joint Commission on Accreditation of Hospitals to

develop guidelines for hospital policies which will promote fully
informed choice about infant feeding and which will support a
mother’s decision to breastfeed, e.g., rooming-in and feeding on
demand.

. Explore the potential for third-party coverage for lactation coun-

seling and breastfeeding support through the Health Care Fi-
nancing Administration, the National Association of Insurance

Carriers, and other appropriate groups/agencies.

State Level

70

6. State health departments working cooperatively with state pro-

fessional societies and voluntary agencies, regional perinatal pro-
grams, hospitals, and others should establish state task forces to
review state laws and regulations with a view to eliminating
laws/regulations which inhibit breastfeeding and make recom-
mendations regarding 1) policies, procedures, and standing
orders of hospitals and ambulatory settings; 2) implementation of
recommendations of this Surgeon General's Workshop; 3) staff
education; 4) continuing education; 5) education materials on
breastfeeding; 6) funds for support of demonstration projects;
and 7) incentives for women to initiate and continue breastfeed-

ing.

_ Encourage state health departments and regional perinatal cen-

ters to become resources for training and consultation and to
serve as models for the promotion and support of breastfeeding.
g. Develop a model for a continuum of postpartum care involving
immediate follow-up with integration of medical and social sup-
port to avoid the present fragmentation of services.

Regional Level

9, Encourage regional perinatal centers to become regional re-

sources for training and consultation regarding breastfeeding and
models for promotion and support of breastfeeding. These cen-
ters would relate to each hospital’s breastfeeding coordinator,
stimulate and initiate research, provide centralized information
and referrals, and provide direct services to high-risk popula-
tions, as appropriate.

10. Make equipment and facilities of the regioanl perinatal centers
available for teaching purposes throughout the region.

Local Level

11. Encourage and assist hospitals to:
a. Explore the development of facilities for parents of hospitalized
infants;
b. Designate breastfeeding coordinators to serve patient needs and
to be the contact with regional lactation resources;

Provide materials, equipment, and facilities for rooming-in;

Meet other needs of breastfeeding mothers;

e. Provide information about La Leche League and other such
support groups;

f. Create special programs supportive of breastfeeding for high-
risk groups such as pregnant adolescents;

g. Recognize the marketing value of an effective lactation pro-
gram.

12. Organize in the community a continuum of postpartum care
which will facilitate immediate follow-up and referral, including
medical and support services, as the matrix for breastfeeding sup-
port.

a9

71
CATEGORY 5: SUPPORT SERVICES

The successful initiation and continuation of breastfeeding will require
a broad spectrum of support services involving families, peers, care provid-
ers, employers, and community agencies and organizations.

DEFINITION OF THE ISSUE

It is essential to have a model of care which focuses on the strengths
of the family, respects the variations found within different cultural/
ethnic and economic groups as well as life styles, offers a continuum of
care for the mother and child throughout the reproductive cycle, and ef-
fectively utilizes community resources to support breastfeeding. Yet, far
too often, many of these attributes are missing. Even those mothers and
families who may have received appropriate education and counseling
for breastfeeding prior to and during hospitalization, do not always have
access to the follow-up support necessary to cope with problems and
questions frequently arising after discharge. Although health-care provid-
ers may do a good job of promoting an informed choice about infant
feeding, the important involvement and support throughout the process
by the family members, peers, employers, and community resources may
be lacking and unrecognized.

SUGGESTED STRATEGIES

1. Encourage cooperation and referral between breastfeeding sup-
port groups and providers of health and social services.

2. Provide for culturally appropriate peer-support Broups who can
offer assistance and counseling for such lifestyle conflicts as
breastfeeding in public and/or while working.

3. Explore the availability of insurance coverage and other sources
of funding for support services and for materials and supplies to
facilitate breastfeeding, especially for mothers and infants with
special needs, e.g., infants in day care and mothers with chronic
illness.

4. Advocate for infant-care centers which provide breastfeeding fa-
cilities in the workplaces, schools, and other locations serving
“working women.”

5. Develop support services in the community which help to nur-
ture nursing mothers, e.g., telephone hotlines, community or
public health nursing follow-up, and volunteers who are experi-
enced in breastfeeding.

6. Seek commitment from national voluntary organizations to stim-
ulate support for breastfeeding among their membership. Include

72
voluntary organizations which reach various cultural/ethnic
populations, economic groups, and women of different ages.

4. Collect information about successful models of support for initi-
ation and continuation of breastfeeding and disseminate this
knowledge nationwide through the Healthy Mothers/Healthy

Babies Coalition.

CATEGORY 6: RESEARCH

An intensified national research effort, including a broad range of re-
search studies, is needed to provide data on the benefits and contraindica-
tions of breastfeeding among women in the United States. Research is also
needed to evaluate strategies/interventions and to determine progress in
achieving goals related to the promotion of breastfeeding.

DEFINITION OF THE ISSUE

Basic studies, clinical studies, evaluation of information studies, and
prospective, longitudinal studies related to breastfeeding are all needed to
improve the information base, establish policy, improve and target strate-
gies, and assess program effectiveness. Areas of concern which need to
be investigated are:

¢ Epidemiologic studies on the outcome of breastfeeding in com-
parison to other types of feeding among diverse groups of Amer-
ican women,

¢ Infant outcome with respect to morbidity, physical growth, and
both physical and behavioral development of the child;

¢ Physiology and pharmacology of the lactation process, including
better data on the medical contraindications to breastfeeding;

* Behavioral and social-scientific aspects of lactation in particular
segments of our society, including barriers to initiation and con-
tinuation of breastfeeding, resistance of health care providers,
and need for—as well as effectiveness of—support services for
lactating mothers.

e Evaluation of strategies designed to motivate and foster a change
in breastfeeding behavior.

* Cost-benefit research which would provide a scientific basis for

development of national policy on breastfeeding.

73
SUGGESTED STRATEGIES

74

_ Develop a national data base on initiation and duration of lacta-

tion.

. Initiate multi-center studies that focus on the physiologic, phar-

macologic, medical, psychosocial, and cultural aspects of breast-
feeding.

. Encourage and support longitudinal and cross-sectional studies.
. Improve coordination among federal agencies with responsibil-

ities for research relating to breastfeeding and among federal,
state, and local governments in order to provide a unified ap-
proach to research questions.

. Request the Public Health Service, including the National Insti-

tutes of Health, as well as the U.S. Department of Agriculture,
to increase funding support for research related to breastfeeding.

. Develop a multi-cultural task force responsible for collecting

available interdisciplinary research on cultural differences related
to lactation and breastfeeding and for disseminating research
findings to health care providers.

_ Establish a national clearinghouse on research findings, demon-

stration projects, and baseline data related to breastfeeding and
human lactation. '

. Design and implement a national evaluation effort to determine

the degree to which strategies recommended at this Workshop
have been implemented and goals have been achieved.
SUMMARY OF WORKSHOP
RECOMMENDATIONS

Ruth A. Lawrence, M.D.

Common themes emerge from all the work groups. Many of the
groups made similar recommendations focusing on the same issues, but
perhaps from different perspectives.

The importance of endorsement of the positive aspects of breastfeed-
ing by federal agencies, professional organizations, and voluntary groups
ran throughout the reports. We need to insure an informed and free
choice for all women with regard to feeding their infants. In order to
remove or prevent the passage of laws detrimental to breastfeeding,
public officials should be educated about the normalcy of breastfeeding.
In other words, let us insure the right to breastfeed.

We need to establish breastfeeding as the community norm; in order
to accomplish this goal, we need universal education—early and continu-
ous. An unceasing effort should be directed to educating all segments of
society, levels of the education system, and cultural subgroups.

A professional information base should be determined and standards
established for training all health-care professionals. In addition, profes-
sional education for specific health-care areas should be developed in
order to train consultants within the health-care structure to understand
human lactation and to facilitate breastfeeding.

The health-care system should deal with breastfeeding issues within
the continuum of comprehensive perinatal care. Support for breastfeed-
ing families should be available from health-care facilities and from com-
munity-based resources.

With respect to employment, the opportunity should be available for
women to continue breastfeeding when working or when completing
their education or training. ,

All of these efforts should be sensitive to cultural values and should
be initiated and implemented with the involvement of members from the
targeted cultural groups.

With respect to research, the needs are great and the potential un-
limited. We need a national data base on the initiation and the duration
of lactation. Multicenter, longitudinal, and cross-sectional studies are
needed to investigate benefits and contraindications of breastfeeding and
to evaluate strategies and interventions to promote it. Interagency COo-
ordination of projects would insure a unified approach to research ques-
tions and timely dissemination of research findings.

In summary, we need to continue to communicate among ourselves
and also to involve other colleagues to begin to implement these recom-
mendations in our own programs, regions, and states. We all stand ready
to assist the Surgeon General in this effort. We realize it cannot all be
done in Washington. Thus, it will be the responsibility of each of us to
initiate efforts from our own vantage points to enhance and magnify the
national effort to make breastfeeding the norm.

75