An Update to A Call to Action to Support Breastfeeding: A Fundamental Public Health Issue

Related APHA Policy Statements

APHA Policy Statement 200714 – A Call to Action to Support Breastfeeding:
A Fundamental Public Health Issue^[1]
APHA Policy Statement 201115 – APHA Endorses the Surgeon General’s Call
 to Action to Support Breastfeeding^[2]
APHA Policy Statement 8126 – Nestle Boycott^[3]
APHA Policy Statement 8226 – Breastfeeding^[4]
APHA Policy Statement 200114 – APHA Supports the Health and Human
Services Blueprint for Action on Breastfeeding^[5]

Abstract
The American Public Health Association published a comprehensive policy on breastfeeding in 2007 (Policy No. 200714: A Call to Action on Breastfeeding: A Fundamental Public Health Issue). While breastfeeding rates have improved, they are still short of medical recommendations, and significant disparities in US breastfeeding rates persist, especially among African Americans. Access to lactation support provided by accredited professionals is limited, contributing to disparities. Formula marketing continues to undermine breastfeeding, especially in vulnerable populations. Stronger performance-based incentives in health care settings may improve breastfeeding outcomes. In addition, although maternal transmission of HIV is significantly less prevalent among exclusively breastfed infants of HIV-positive mothers than among infants who are not exclusively breastfed, progress in increasing exclusive breastfeeding worldwide remains slow. 

Problem Statement
Breastfeeding rates continue to fall far short of medical recommendations owing to persistent social, political, and economic barriers, and alarming racial and geographic disparities persist in breastfeeding rates in the United States.^[6] Since 2007, the United States has achieved small but steady increases in rates of any and exclusive breastfeeding^[7] and in the proportion of births that occur in “baby-friendly” hospitals; however, these and other measures still fall short of Healthy People 2020 goals.^[6] 

The Affordable Care Act of 2010 spawned regulations designed to close disparities in women’s health, mandating that new private health insurance plans provide coverage for breastfeeding counseling and supplies without a copayment. However, breastfeeding counseling and supplies are not defined, and this omission is complicated by the lack of any state licensure for lactation professionals. In addition, some insurers have not covered the types of breast pumps that are required for a mother’s particular clinical situation. The Affordable Care Act also amended the Fair Labor Standards Act to require employers to allow hourly employees time and space (other than a bathroom) to express milk, but the law does not cover all employees.

Alarming disparities in breastfeeding rates persist in the southeastern United States and among African Americans. There is a shortage of African American breastfeeding professionals.[8] International board-certified lactation consultants (IBCLCs) are currently the only independently accredited lactation professionals. The Centers for Disease Control and Prevention (CDC) uses the number of IBCLCs per live birth as a quality metric.^[6] However, because there is no state licensure for lactation professionals in the United States, reimbursement for IBCLCs has been generally limited to those who hold other health care licenses as well, such as physicians and nurses. The United States Breastfeeding Committee and the National Breastfeeding Center have published guidelines to support payment for independently accredited providers of these services under the Affordable Care Act.^[9] According to a 2013 clarification rule from the Centers for Medicare & Medicaid Services on preventative services allowed under the Affordable Care Act (§440.130), the providers of preventative services do not need to be licensed, and “physicians and other licensed providers may recommend these services.” It is up to each state to determine whether to reimburse an unlicensed provider, and reimbursement of IBCLCs is not mandated. In states where implementation includes IBCLCs, the rule could reduce inequities in access to skilled lactation care. There are a number of evidence-based strategies designed to reduce disparities in breastfeeding rates, some of which involve use of performance measures and improvements in reimbursement for lactation care.^[10,11]

To obtain certification as an IBCLC, an individual is required to complete both extensive coursework and clinical training, as is common with most clinical health professionals. Although this training can be costly, the breadth of the classroom and clinical work required for certification results in improved outcomes; indeed, IBCLCs have been shown to improve breastfeeding as well as health outcomes.^[12] Without a guarantee of reimbursement from Medicaid or private insurers, there has been little incentive for individuals to pursue this training. 

Other less expensive training programs for lactation counseling do exist; however, these programs generally provide fewer hours of education than IBCLC training and require little or no experience. None of these other programs are independently accredited. The lower costs associated with attaining these alternative counseling credentials (e.g., with respect to financial expense, hours of education, and hours of experience) may increase the number of credentialed professionals providing lactation support; however, these credentialed counselors’ training is significantly less specialized than that of IBCLCs. Access to care from these lower-tiered counselors plays an important role but does not suffice when women require more specialized, professional care, which may result in inequities in health care access. In addition, because these providers are not independently accredited, there is no mechanism for consumer protection, reimbursement, and/or licensure, nor is there a sustainable career path for such individuals, which contributes to inequities in access to culturally sensitive care.

Recently, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) released updated and revised materials on the Baby-Friendly Hospital Initiative and its 10 steps to successful breastfeeding.^[13] In comparison with women who had completed 6 of the 10 steps, women who had completed none of the steps were 13 times more likely to stop breastfeeding by 6 weeks.^[14] Women in the southeastern United States are less likely to give birth in facilities providing maternity practices that optimally implement these steps.^[15] The Southeast also has fewer IBCLCs per live birth than the US average.^[6] CDC’s Best Fed Beginnings initiative is designed to markedly increase the numbers of baby-friendly hospitals in the United States, particularly in geographic areas where health and breastfeeding disparities are most severe. 

In 2011 the surgeon general released Call to Action to Support Breastfeeding,^[10] and APHA policy 201115 endorsed this document, which includes 20 action steps necessary to help improve US breastfeeding rates.^[2] Moreover, the US Department of Health and Human Services (DHHS) outlined 10 action steps to support breastfeeding in Appendix E of its 2013 report on infant mortality.^[16] However, current US government data^[17,18] show that 60% of women do not reach their own personal breastfeeding goals. 

Performance measures and incentives used to promote appropriate maternity practices with respect to infant feeding and care are improving but can be strengthened. In 2010 the Joint Commission, which accredits most US hospitals, introduced an elective quality measure on exclusive breast milk feeding. According to the measure, hospitals should limit formula supplementation for breastfeeding newborns without a medical recommendation. Such supplementation is one of the biggest predictors of subsequent breastfeeding failure.^[14,19,20] In late 2012, the Joint Commission announced that it will be mandating this metric effective January 2014, but only for hospitals with at least 1,100 births per year.^[21]

Increased attention has been focused on hospital-based marketing of infant formula. At present, only about 20% of hospitals have stopped distributing commercial discharge packs.^[22] Formula marketing continues to be prevalent in hospitals, driven in part by the common practice of brand-name formula manufacturers entering into contracts with maternity facilities to provide formula either at no direct cost or at below-market rates (however, these contracts often require facilities to purchase other items, such as bottles, from the formula manufacturer at above-market costs). This situation, in turn, encourages staff to distribute formula when it is not medically necessary and to send breastfeeding families home with free formula samples and other products that may inhibit breastfeeding. Recent research shows that 91% of maternity hospitals distributed commercial formula sample packs in 2006–2007.^[23] US Department of Agriculture (USDA) researchers have found tremendous infant formula brand loyalty among mothers, which appears to drive the intensive marketing of brand-name formulas (which cost more than store brands), especially in health care settings (24). Only a tiny fraction of formula sold in the United States is not brand name.^[24] 

Nearly all formula sold since 2007 is supplemented with decosahexoenoic acid and arachadonic acid (DHA/ARA).^[24] However, there are insufficient data to show any benefits of these costly formula additives for healthy term infants.^[25] It has also been found that some women perceive formula with DHA/ARA as actual powdered human breast milk, or “the breast milk formula.”^[25] Other recent qualitative research has shown adverse effects of formula advertising in a sample of relatively educated pregnant and postpartum women in the United States.[26]

In addition, there is growing use of donor human milk and expressed mothers’ milk among preterm infants, owing to better health outcomes associated with its use as compared with outcomes among formula-fed preterm infants. However, there is no requirement that insurers pay for human milk, and reimbursement for use of human milk can be problematic. In 2011, WHO issued a “strong” recommendation that low-birth-weight infants be fed their mother’s own milk and a “strong situational” recommendation that banked human milk be used in cases in which safe and affordable milk-banking facilities are available.^[27] Among preterm infants fed human milk, there is a decreased risk of necrotizing enterocolitis,[28] and these infants have been shown to have significantly decreased rates of hospitalization after discharge.^[29] Donor milk also helps hospitals achieve improved exclusivity rates on the Joint Commission’s perinatal care core measure for term infants.

As a result of mounting evidence that exclusive breastfeeding (relative to mixed feeding) helps prevent maternal-infant transmission of HIV,^[30–33] in 2012 WHO revised its 2006 recommendations for infant feeding by HIV-positive mothers.^[34] WHO now explicitly states that “health authorities should endorse either breastfeeding while receiving antiretroviral drugs (to the mother or infant), or avoidance of all breastfeeding.” WHO recognizes that, in countries with low infant and child mor¬tality rates, “replacement feeding may remain the best strategy to promote HIV-free survival among HIV-exposed infants.”^[35] Nonetheless, progress toward improvements in exclusive breastfeeding practices continues to be slow.^[36]

A growing body of research highlights significant effects of breastfeeding on maternal health.^[37–46] Evidence also continues to accumulate on the impact of breastfeeding (particularly exclusive breastfeeding) on the health of children,^[47–49] and many of the studies providing this evidence have been cited in recent policy statements by the American Academy of Pediatrics^[50] and the American Academy of Family Physicians.^[51] 

Proposed Recommendations Statement
We recommend that maternity services be improved throughout the United States, with special attention to hospitals serving populations with poor breastfeeding rates, such as in rural and urban communities in the Southeast, and those serving large African American populations. Appropriate reimbursement of independently accredited lactation professionals will ensure a sustainable career track and help increase the numbers of lactation professionals from and serving underserved populations. APHA recommends consistent reimbursement strategies for independently accredited lactation professionals both to reduce inequities among lactation care providers and to reduce inequities in access to care. Creating other tiers of independently accredited credentials will also improve access to skilled care. Reimbursement should include breastfeeding supplies appropriate for a mother’s circumstances.

Restriction of marketing of infant formula in ways that disproportionately affect vulnerable women will help improve disparities. Reimbursement standards for donor human milk will promote preterm infant health and help hospitals meet performance outcomes related to breastfeeding exclusivity. International attention to improving breastfeeding exclusivity will help lower rates of HIV transmission to infants in developing countries. 

Opposing Arguments/Evidence
One opposing argument is that limiting paid lactation support to accredited lactation professionals may result in some mothers not obtaining any help. This is a separate but unequal solution. All mothers deserve care from quality providers, and all those aspiring to be lactation professionals deserve a sustainable reimbursable career path. Career promotion for minority IBCLCs should be encouraged,^[52] or the formation of other independent accredited providers should be promoted. 

Another argument is that increasing the numbers of independently accredited lactation professionals may not lead to increased access to care in areas where it is most needed and may not result in improved breastfeeding outcomes among residents of these areas. While increasing the numbers of lactation professionals alone may not eliminate disparities in breastfeeding support and outcomes, strengthening accreditation pathways and reimbursement may make it more possible for individuals from underserved populations to pursue careers in lactation and thus diminish inequities in access to care and breastfeeding outcomes.

Finally, it has been argued that formula marketing is free speech. The Federal Trade Commission restricts deceptive marketing, and evidence shows that consumers are indeed misled by manufacturers’ advertising. In cases in which a product may cause harm, labeling that ensures consumers are aware of associated risks is in the interest of public health and has precedent with other products, such as tobacco. Health care institutions that distribute free samples are engaging in product marketing, and this represents a conflict of interest.^[23] 

Action Steps
Considering these facts, APHA:

1. Urges the US Congress and state legislatures to pass laws ensuring that all breastfeeding employees have reasonable break times and a private place (that is not a bathroom) to express milk, as well as laws protecting breastfeeding women from being fired or discriminated against in the workplace.
2. Supports state and federal legislators and regulators in restricting infant formula marketing practices that interfere with breastfeeding. This includes restriction of formula marketing practices by health care providers such as provision of free samples of formula without staff accountability, acceptance of free formula supplies from manufacturers, and distribution of marketing materials in hospitals and doctors’ offices. To promote breastfeeding and public health, APHA urges state and local governments and related organizations to refuse donations from infant formula companies, as this is an obvious conflict of interest (e.g., the Association of State and Territorial Health Officials and the National Association of City and County Health Officials could direct its members in this regard.) Health providers and the Food and Drug Administration (FDA) should better inform women of the risks of non-indicated formula feeding to the establishment of breastfeeding, which might include new labeling practices. APHA urges the FDA to study DHA/ARA additives to infant formula with respect to their safety and efficacy, and the FDA should ensure that labeling and advertising of these and other additives does not imply a benefit or equivalence to human breast milk. 
3. Urges public and private insurers (including the Centers for Medicare & Medicaid Services, the National Association of Insurance Commissioners, and America’s Health Insurance Plans) to cover appropriately trained and qualified lactation counseling and consultation, which is independently accredited and thus protects consumers; recommends that third-party payers institute reimbursement scales commensurate with training credentials and state licensure where possible; urges insurance companies to cover breastfeeding supplies that are appropriate for a mother’s clinical situation; and urges state Medicaid offices to include reimbursement for IBCLCs and other independently accredited lactation providers who offer lactation care and services within their appropriate scopes of practice. 
4. Urges national governments, nongovernmental organizations, and the World Health Organization to continue measures to improve exclusive breastfeeding in resource-poor countries as a means of decreasing HIV transmission as well as child morbidity and mortality.
5. Urges public and private insurers and health care accreditation bodies such as the Joint Commission to use performance measures to encourage implementation of evidence-based practices that support breastfeeding.
6. Urges the Joint Commission to expand mandated breastfeeding performance measures to include maternity facilities of all sizes, which will help diminish inequities in rural areas.
7. Endorses the action steps to support breastfeeding outlined in Appendix E of the 2013 DHHS report on infant mortality.^[16]

References

1. American Public Health Association. Policy No. 200714. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360. Accessed December 14, 2013.
2. American Public Health Association. Policy No. 201115. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1422. Accessed December 14, 2013.
3. American Public Health Association. Policy No. 8126. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=998. Accessed December 14, 2013.
4. American Public Health Association. Policy No. 8226. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1030. Accessed December 14, 2013.
5. American Public Health Association. Policy No. 200114. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=253. Accessed December 14, 2013.
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21. Specifications Manual for Joint Commission National Quality Core Measures, Version 2013A1. Oakbrook Terrace, IL: Joint Commission; 2012.
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