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Turning the Tide

These 10 steps can improve breastfeeding rates

The promotion of breastfeeding has become a significant public health issue. The World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) have focused on promoting breastfeeding worldwide.1 These two organizations, along with the American Academy of Pediatrics and the Healthy People program, have worked to increase the rates of breastfeeding initiation and duration through public awareness campaigns for more than a decade.1 Data from 2007 through 2009 showed that 74% of infants were breastfed, but only 43.5% continued to be breastfed until 6 months of age.2 The need for improvement is clear.

Many facilitators affect a mother's decision to initiate breastfeeding and to continue it. Maternal social support and knowledge about breastfeeding are the most influential factors affecting breastfeeding.1

Benefits of Breastfeeding

Adequate nutrition during infancy is essential to ensure a child's growth, health and development to full potential.3 Breast milk is the most appropriate nourishment for an infant and offers benefits to both the mother and her infant.4

Mothers who choose to breastfeed benefit in multiple ways. When a mother begins to breastfeed her infant shortly after birth, she experiences a more rapid involution of the uterus and a decrease in blood loss.5 Breastfeeding can also enhance weight loss and help the mother quickly return to her prepregnancy weight.6

Lactation can serve as a means of contraception through the lactation amenorrhea method (LAM), which suppresses the menstrual cycle and therefore prevents ovulation postpartum.4 LAM is an inexpensive approach to contraception in the first 6 months after delivery. LAM is 98% effective, but it requires that three criteria are met: postpartum amenorrhea; complete or nearly complete breastfeeding in which the infant is breastfed every 4 hours during the day and every 6 hours during the night; and the infant is younger than 6 months old.7 LAM also improves child spacing, reducing the risk of birth of a preterm infant.6

Breastfeeding also has long-term health benefits for mothers, including a decrease in the risk for breast, endometrial and ovarian cancer.8 A 2012 study by Schanler8 found that breastfeeding for longer than 12 months is correlated with a 28% decrease in ovarian cancer (OR: 0.72; 95% CI; 0.54-0.97) and breast cancer (OR: 0.72; 95% CI: 0.65-0.8).

The mother who chooses to breastfeed may also have a decreased risk for osteoporosis, cardiovascular diseases, diabetes and postpartum depression.8 Women who breastfed have bone mineral density levels 5% to 10% higher than women who did not breastfeed.8 These levels are deterrents to hip fractures in the postmenopausal period.8

Breastfeeding also provides the emotional benefit of enhancing the maternal-infant bond. It provides the mother with a sense of fulfillment.9 Oxytocin, the hormone responsible for milk let down, can cause a state of calmness and reduce stress. The release of oxytocin and prolactin, along with skin-to-skin contact with the infant, can also facilitate bonding between the mother and infant.3

Unlike formula, breast milk changes to meet the unique needs of each infant. Breast milk changes in makeup during a feeding, as well as day to day, in the forms of colostrum, transitional and mature milk. The amount of energy and fat the infant receives is dependent on the length of the breastfeeding session because nutrients increase as the feed progresses.10

The nutritional components of breast milk provide bacteriostatic and anti-inflammatory properties that provide protection against acute illness or infection. The lymphocytes in breast milk contribute to cytokine production and antimicrobial activity through macrophages capable of phagocytosis, chemotaxis and intracellular killing.5

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According to a research synthesis,11 breastfed infants are less likely to develop gastrointestinal infections, atopic dermatitis, acute otitis media, lower respiratory illnesses, asthma, urinary tract infections and sudden infant death syndrome. Breastfeeding also provides long-term benefits to the infant after breastfeeding has ceased. These include a reduction in the risk for acute illnesses, chronic diseases such as obesity and cancer, childhood leukemia, cardiovascular diseases, type 1 and type 2 diabetes, and allergies.11

Facilitators of Breastfeeding

The success of breastfeeding depends on many factors, including support and education. Familial and social influences strongly contribute to a woman's decision to breastfeed. A review completed by Clifford and McIntyre12 found that fathers are most influential on breastfeeding, but that friends and other family members can also provide advice and support. Women who have friends and family with positive opinions about breastfeeding are more likely to initiate breastfeeding and to breastfeed for a longer duration.12

Generally, breastfeeding support is directed to the mother and infant. This focus may lead some fathers to feel excluded and resentful of breastfeeding, which can cause negative perceptions that lead to formula feeding. NPs must be prepared to educate fathers and other family members about the benefits of breastfeeding and to dispel myths and misperceptions they may have.13

Education also influences breastfeeding success. The combination of prenatal and postnatal breastfeeding educational programs with ongoing support through posters, books, videos and pamphlets is recommended to facilitate breastfeeding.14 Lactation consultants who provide education to mothers experiencing difficulties with breastfeeding can contribute to a longer duration of breastfeeding.12 WHO and UNICEF developed the Baby-Friendly Hospital Initiative (BFHI) 10 Steps to Successful Breastfeeding to promote and support breastfeeding (Table 1).9 This initiative recommends educational classes, support, advice, counseling and encouragement to improve the initiation and duration of breastfeeding.9

A systematic review determined that institutional changes in hospitals to promote breastfeeding, such as implementing the BFHI 10 Steps, can increase the initiation and duration of breastfeeding.15 However, the application of the steps remains low. Only 6% of maternity facilities in the United States practice all 10 steps. Data from the 2011 Centers for Disease Control Maternity Care Practices Survey suggest that 50% of facilities practice only three to five of the steps, a decrease from 2009, when 54% did so.16 The survey found that 43% of facilities practice more than six steps, which is an increase from 37% in 2009. The least followed interventions are step 1 (model policy) at 19% of facilities, step 6 (supplements) at 23%, step 10 (post-discharge support) at 28.4%, step 9 (pacifiers) at 36.4%, and step 7 (rooming in) at 37%.16

A study by DiGirolamo et al17 found a relationship between the number of baby-friendly practices experienced and the mother's breastfeeding success. Mothers who experienced fewer practices were more likely to terminate breastfeeding before age 6 weeks. Additionally, the cumulative effects of these practices were more important in breastfeeding outcome than each individual practice. Mothers who encountered none of the 10 steps during their stay were eight times more likely to stop breastfeeding before 6 weeks compared to those who experienced six steps.

The most influential practices on breastfeeding outcomes include exclusivity of breastfeeding and breastfeeding initiation within 1 hour of birth. The importance of working with and supporting hospitals to increase the adoption of these practices is demonstrated by a decreased risk for early breastfeeding termination with each added practice.17

NPs have a role in providing support and encouragement to mothers who choose to breastfeed, and to emphasize the maternal and infant benefits.14 NPs have an influence on a mother's decision to initiate and continue breastfeeding because women hold their knowledge and opinions in high regard and look to them for breastfeeding advice.12 NPs should encourage mothers to attend breastfeeding support and education classes.

Implications for Practice

Given the documented benefits for mother and infant, it is the responsibility of any healthcare provider who encounters pregnant women to promote breastfeeding. Providers who work with women during and after pregnancy are in an ideal position to have a positive influence on breastfeeding duration.

NPs should address both the personal and interpersonal facilitators of breastfeeding. Specific ways to address the personal factors include discussing the benefits of breastfeeding: how breastfeeding can facilitate bonding, provides the best nutrition possible for the infant, and provides maternal health benefits. Because breastfeeding can be overwhelming for a new mother, providing handouts as a component of education will help reinforce the information.18 Personal follow-up is also needed. Referrals can be provided to outside resources such as prenatal breastfeeding workshops that are based on self-efficacy theory, to help prepare and support women who want to breastfeed.

The mother needs to know that breastfeeding can be difficult and discouraging in the beginning, but that the rewards are significant. It is important to have a strong support system in place. Education should be provided to both the mother and her partner or closest support person. Suggest support groups and classes. Table 2 provides a list of web-based resources.

NPs should be active advocates for breastfeeding within the healthcare community. One way this can be achieved is by supporting the Baby Friendly Hospital Initiative to promote, protect and support breastfeeding. We should encourage breastfeeding to all mothers at every encounter, and provide the education and resources necessary for mothers to be successful.

Breast Pump Coverage Now Mandatory

The Affordable Care Act requires most health insurance plans to cover the costs of breastfeeding equipment such as breast pumps, as well as charges for lactation support and counseling. Many health plans began implementing this coverage on or after Aug. 1, 2012.

This part of the healthcare reform law removes a common barrier to breastfeeding for working mothers in particular, since many face challenges to nursing their infants after they return to work. It also puts breast pumps and lactation counseling within reach for women who cannot afford to rent or purchase pumps.

Step-by-step guidance for patients who want to find out about insurance coverage for breast pumps and lactation support is available from pump manufacturers. Medela created a document called "Breastfeeding Insurance and Reimbursement." It is available for download at

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Table 2

• Academy of Breastfeeding Medicine:

American Academy of Pediatrics:

Baby-Friendly USA:

International Lactation Consultant Association:

La Leche League International:

National Alliance for Breastfeeding Advocacy:


1. Schulze PA, Carlisle SA. What research does and doesn't say about breastfeeding: A critical review. Early Child Dev Care. 2010;180(6):703-718.

2. U.S. Department of Health and Human Services. Maternal, infant, and child health: Infant care. Healthy People 2020: Objectives for improving health (Focus area 21, Maternal, Infant and Child Health).

3. World Health Organization. Breastfeeding.

4. Deneris A, Huether SE. Structure and function of the reproductive systems. In: McCance KL, Huether SE, eds. Pathophysiology: The biologic basis for disease in adults and children. 6th ed. St. Louis, MO: Elsevier Mosby; 2010: 781-951.

5. Schanler RJ, Potak DC. Physiology of lactation. Available with subscription at

6. AAP Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.

7. Sipsma HL, et al. Lactational amenorrhea method as a contraceptive strategy in Niger. Matern Child Health. 2013;17(4):654-660.

8. Schanler RJ. Maternal and economic benefits of breastfeeding. Available with subscription at

9. Leung AK, Sauve RS. Breast is best for babies. J Natl Med Assoc. 2005;97(7):1010-1019.

10. American Academy of Pediatrics. Committee on nutrition. Pediatric Nutrition Handbook. Kleinman RE, ed. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics: 2009: 55-85.

11. Ip S, et al. A summary of the Agency for Healthcare Research and Quality evidence report on breastfeeding in developed countries. Breastfeed Med. 2009;4(Suppl 1):S17-S30.

12. Clifford J, McIntyre E. Who supports breastfeeding? Breastfeeding Rev. 2008;16(2):9-19.

13. American Academy of Family Physicians. Breastfeeding, family physicians supporting: Position paper.

14. Schanler RJ, Potak DC. Breastfeeding: Paternal education and support.

15. Fairbank L, et al. A systematic review to evaluate the effectiveness of interventions to promote initiation of breastfeeding. Health Technol Assess. 2000;4(25):1-171.

16. Centers for Disease Control and Prevention. Breastfeeding: Data and Statistics: mPINC results.

17. DiGirolamo AM, et al. Maternity care practices: implications for breastfeeding. Birth. 2001;28(2):94-100.

18. Levy J, Overfield M. Nurse practitioners can advocate for breastfeeding in so many ways! Triangle Breastfeeding Alliance.

Michele Woltman is a recent graduate of the family nurse practitioner program at the University of North Florida in Jacksonville.


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