Breastfeeding: Promotion & Legislation

1. Breastfeeding: Promotion & Legislation Virginia C. Petrikonis

2. Introduction Upon completion of this PowerPoint, the reader will be able to: • Understand the significance of breastfeeding and why it is a political issue. • Identify the history and evolution of U.S. breastfeeding legislation and understand the need for current policies. • Determine alternatives to legislation action that can potentially influence change. • Identify the role of healthcare providers in influencing the future of breastfeeding policy.

3. Why Breastfeed? • Breast-milk has every vitamin, mineral, and other nutrient that a baby needs whereas formulas do not (Wiessinger, West, & Pitman, 2010). • Breastfeeding decreases a baby’s risk of allergies, dental problems, infections, intestinal upsets, respiratory problems and SIDS (Wiessinger, West, & Pitman, 2010). • Breastfeeding mothers save money, lose weight more readily, miss less work, and are less likely to suffer from postpartum depression or get breast, uterine, or cervical cancer (Breastfeeding, 2011). • Breastfeeding ensures the best possible healthas well as the best developmental and psychosocial outcomesfor the infant (Crase, 2005).

4. Breastfeeding & Society • Recent research shows that if 90% of families breastfed exclusively for 6 months, nearly 1,000 deaths among infants could be prevented. • If 90% of families breastfed, it is estimated that the U.S. would save $13 billion per year because medical care costs are lower for breastfed infants. • Breastfeeding is better for the environment:less trash and plastic waste than formula cans and bottle supplies. • Breastfeeding leads to a more productive workforce since mothers miss less work to care for sick infants. (Breastfeeding, 2011)

5. AAP & Breastfeeding • The abundance of new data about the beneficial effects of breastfeeding influenced the American Academy of Pediatrics (AAP) to update its guidelines, now recommending exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant (Rochman, 2012).

6. Barriers to Breastfeeding • Health professionals lack training, education, and resources to provide appropriate breastfeeding support. • Legislation and policies do not adequately support breastfeeding. The U.S. lacks consistent legislation to support the socioeconomic need for paid maternity leave, necessary for exclusive breastfeeding. This contrasts with Canada, European Union countries, and many other countries worldwide where paid maternity leave is required. • Worksites generally do not support the needs of lactating employees, nor are there national laws to require worksite lactation support. • There is increasing aggressive advertising of human milk substitutes, including widespread hospital distribution. • The cultural emphasis in the U.S. on the sexuality of the human breasthas created significant barriers to the cultural acceptance of breastfeeding. • Breastfeeding rates are lower among mothers who are young, not college educated, or unmarried. • U.S. mothers at high risk for early weaning include first-time mothers, those with less formal education, those who are non-White, and those who are ill postpartum. (A Call to Action on Breastfeeding, 2007)

7. Breastfeeding: A Public Health Issue • Economic, cultural, and political pressures often confounddecisions about infant feeding (Crase, 2005). • The AAP has recalibrated the national dialogue on breast-feeding, deeming it a “public health issue and not only a lifestyle choice” (Rochman, 2012). • Breastfeeding is an important public health issue that merits societal support from the hospital to the workplace (Rochman, 2012). • Data indicate that the rate of initiation & duration of breastfeeding in the U.S. is well below the Healthy People 2010 goals (Crase, 2005).

8. International Treaties & Conventions SupportingBreastfeeding • In May 1981, the International Code of Marketing of Breast-milk Substitutes and its resolutions was overwhelmingly approved by the World Health Assembly by a vote of 118:1. The lone vote against the Code came from the U.S., which was concerned that the Code could have a detrimental effect on U.S. business.  • For more information: http://bestforbabies.wordpress.com/2007/05/09/international-treaties-and-conventions-supporting-breastfeeding/ (Cayetano, 2007)

9. Should Breastfeeding Be Protected Under U.S. Law? Yes! • Breastfeeding mothers sometimes need to feed their babies in public since a baby’s feeding needs cannot be determined by a set schedule. • Indecent exposure and dress code laws need to be adapted for breastfeeding mothers. • Breastfeeding mothers who work need to be ensured reasonable breaks in order to express milk. • The CDC reports that formula marketing has a disproportionately negative impact on U.S. mothers already at high risk for early weaning. (A Call to Action on Breastfeeding, 2007)

10. The Constitutional Right To Breastfeed Dike v. Orange County School Board, 650 F.2d 783 (5th Cir., 1981) • A teacher wanted to nurse her baby on her lunch break, but the school claimed that insurance provisions prohibited teachers from bringing their children onto school property& also prohibited teachers from leaving the school grounds during the day. The trial court ruled that the mother had no right to breastfeed. In Dike, the appeals court reversed the case, stating that breastfeeding is a protected constitutional right. (Baldwin, 1999)

11. History of U.S. Breastfeeding Legislation • HR 2490, with a breastfeeding amendment, was signed into law on September 29, 1999. It stipulated that no government funds may be used to enforce any prohibition on women breastfeeding their children in federal buildings or on federal property. • U.S. Public Law 106-58, Sec. 647 was enacted in 1999. It states that "a woman may breastfeed her child at any location in a federal building or on federal property, if the woman and her child are otherwise authorized to be present at the location.” • Breastfeeding in public is now legal in all 50 states & DC. (Breastfeeding Laws, 2011)

12. State Breastfeeding Laws • 45 states have laws that specifically allow women to breastfeed in any public or private location. • 28 states exempt breastfeeding from public indecency laws. • 24 states have laws related to breastfeeding in the workplace. • 12states exempt breastfeeding mothers from jury duty. • 5states have implemented or encouraged the development of a breastfeeding awareness education campaign. For more information on specific state breastfeeding laws: http://www.ncsl.org/issues-research/health/breastfeeding-state-laws.aspx (Breastfeeding Laws, 2011)

13. (Existing Legislation, 2011)

14. (Existing Legislation, 2011)

15. ACA & Breastfeeding • Section 4207 of the Patient Protection and Affordable Care Act (ACA) amended the Fair Labor Standards Act (FLSA). The amendment requires employers to provide reasonable break time and a private, non-bathroom place for nursing mothers to express breast-milk during the workday, for one year after the child’s birth. The new requirements became effective when the ACA was signed into law on March 23, 2010. (Existing Legislation, 2011)

16. Recent Legislation:HR 2758 HR 2758: Breastfeeding Promotion Act of 2011 • Breastfeeding Promotion Act of 2011 amends the Civil Rights Act of 1964 to include lactation as protected conduct. It amends the Fair Labor Standards Act of 1938 to extend the requirement that certain employers provide reasonable break time for an employee to express breast-milk for her nursing child to bona fide executive, administrative, or professional capacity employees or outside salesmen who are exempt from federal labor laws that limit the number of hours in a workweek. • The bill is currently in the House Subcommittee on Health, Employment, Labor, and Pensions. (HR 2758, 2011)

17. How Healthcare Affects Breastfeeding • Health professionals have inadequate training, education, and resources to provide appropriate breastfeeding support. • Maternity & birthing practices that are not medically indicated interfere with the establishment of breastfeeding. • Infant formula marketing, particularly hospital discharge packs, discourages breastfeeding. • The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) is a package of 10 evidenced-based steps shown to increase sustained breastfeeding rates, but it has been achieved by fewer than 3% of maternity hospitals and birth centers in the United States. (A Call to Action on Breastfeeding, 2007)

18. Breastfeeding Report Card:2011 is its 5th year. It provides perspectives on state and national trends in breastfeeding data. Percent of births at Baby-Friendly facilities in 2011, by state (Breastfeeding Report Card-United States, 2011)

19. Stakeholders • American Academy of Pediatrics (AAP) • American Public Health Association (APHA) • Centers for Disease Control & Prevention (CDC) • La Leche League International (LLLI) • International Baby Food Action Network • International Code of Marketing of Breast-milk Substitutes • National Initiative for Children’s Healthcare Quality (NICHQ) • National Prevention, Health Promotion, and Public Health Council • National Women’s Health Information Center • United Nations Children’s Fund (UNICEF) • United States Breastfeeding Committee (USBC) • U.S. Department of Health & Human Services • U.S. Surgeon General • World Health Organization (WHO)

20. Stakeholders:Supporting Breastfeeding • The WHO & grassroots non-governmental organizations such as IBFAN have played a large role in encouraging governmental departments to promote breastfeeding& the development of national breastfeeding strategies. • There continues to be an ongoing struggle between corporations promoting artificial substitutes and grassroots organizations & WHO who promote breastfeeding. • Breastfeeding legislation aims to increase the incidence and duration of breastfeeding by helping to change the public opinion about breastfeeding. (Existing Legislation, 2011)

21. Stakeholders: Resources • Resources include mothers and families, communities, healthcare, employers, research & surveillance, & public health infrastructure. (Breastfeeding: Promotion & Support, 2011) • The National Breastfeeding Policy Conference in 1998 was a major resource for stakeholders. The conference helped identify policies &strategies to move the U.S. forward towards setting a national policy agenda to promote breastfeeding. • The conference brought together new members to a partnership of stakeholders to support breastfeeding. The mandate from the conference was transferred to the USBC. • The federal government, through the Maternal &Child Health Bureau, Health Resources and Services Administration, asked the USBC to provide a strategic plan to protect, promote, &support breastfeeding in the U.S. (National Breastfeeding Policy Conference, 2008)

22. Role of Policymakers & Stakeholders • Support small nonprofit organizations that promote breastfeeding in African-American communities. • Support compliance with the International Code of Marketing of Breast-milk Substitutes. • Increase funding of high-quality research on breastfeeding. • Support better tracking of breastfeeding rates as well as factors that affect breastfeeding. (Fact Sheet, 2011)

23. Current Policies & Initiatives:NICHQ: Best Fed Beginnings • The CDC supports NICHQ in leading Best Fed Beginnings, an effort to help U.S. hospitals make quality improvements to maternity care to better support mothers and babies to be able to breastfeed. • This project addresses the need to improve hospital practices to support breastfeeding & help hospitals move toward Baby-Friendly status. (Existing Legislation, 2011)

24. Current Policies & Initiatives:National Prevention Strategy • The National Prevention Strategyis a comprehensive plan that will help increase the number of Americans who are healthy at every stage of life. • The National Prevention Strategy was released on June 16, 2011, by the National Prevention, Health Promotion, &Public Health Council. • The strategy identifies seven Priorities: Tobacco Free Living, Preventing Drug Abuse and Excessive Alcohol Use, Healthy Eating, Active Living, Injury and Violence Free Living, Reproductive and Sexual Health, & Mental and Emotional Well-Being. • Breastfeeding is included under Healthy Eating& specifically calls to "Support policies and programs that promote breastfeeding.” (Existing Legislation, 2011)

25. Current Policies & Initiatives: Surgeon General’s Call to Action to Support Breastfeeding • TheSurgeon General’s Call to Action to Support Breastfeeding outlines steps that can be taken to remove some of the obstacles faced by women who want to breastfeed their babies. • Identification of 20 key actions to improve support for breastfeeding. • Calls for a commitment to ensure that breastfeeding support is consistently available for every mom and baby. • Visit www.surgeongeneral.govfor more information. (Fact Sheet, 2011)

26. Current Policies & Initiatives:Let’s Move! Campaign • Let’s Move! is a comprehensive initiative launched by First Lady Michelle Obama. It is dedicated to solving the problem of childhood obesity. • Under its 5 pillars is pillar #1: Creating a healthy start for children. • 4 recommendations under the 1st pillar outline the support of breastfeeding by healthcare providers, health departments, community-based organizations, insurance companies, & early childhood settings. (Existing Legislation, 2011)

27. Current Policies & Initiatives: Healthy People 2020 • Healthy People provides research-based, 10-year national objectives for improving the health of all Americans. It is managed by the U.S. Department of Health and Human Services. • Healthy People 2020 objectives on breastfeeding are under the Maternal, Infant, and Child Health Topic Area, under the section on "Infant Care.” • Seeks to increase the proportion of infants who breastfeed, increase worksite lactation support programs, increase lactation support in hospitals, and reduce infant supplementation in breastfed newborns. • Goals include: 82% ever breastfed, 61% at 6 months, and 34% at one year. (Existing Legislation, 2011)

28. Current Policies & Initiatives: CDC Guide To Breastfeeding Interventions • CDC Guide To Breastfeeding Interventions provides state &local communities information to choose the breastfeeding intervention strategy that best meets their needs. • Support for breastfeeding is needed in many different arenas, including worksites, medical systems, and family settings. • The Guide builds upon the research that demonstrates effective interventions as well as the expertise of the nation's leading scientists and experts in breastfeeding management and interventions. (Existing Legislation, 2011)

29. Group Theory & Breastfeeding Policy • The interaction among groups is central to the development of breastfeeding policies (Cox, 2010). • An ongoing struggle exists between corporations promoting artificial substitutes and grassroots organizations & WHO who promote breastfeeding(Existing Legislation, 2011). • Breastfeeding public policy results from an equilibrium reached in the group struggle (Cox, 2010). • Policy moves in the direction desired by the groups gaining influence and away from desires of groups losing influence (Cox, 2010). • WHO & grassroots organizations have gained influence, yet issues remain regarding the Baby-Friendly Hospital Initiative due to marketing of formulas and concerns about U.S. business (Existing Legislation, 2011).

30. Group Theory & Breastfeeding Policy • The political system has managed group conflict by arranging compromises & balancing interests as well as enacting compromises in the form of public policy (Cox, 2010). • Mothers may breastfeed in public in all 50 states. • Development of indecent exposure &dress code laws have been adapted for breastfeeding mothers in many states. • Breastfeeding mothers who work must be provided with reasonable breaks in order to express milk. (Existing Legislation, 2011)

31. Development: The Future of Breastfeeding Policy • In order to effectively make changes in breastfeeding laws and public policy, powerful group involvement and increased public awareness are needed. • As more research has come out and public awareness has increased, groups such as AAP & WHO have gotten involved to make U.S. breastfeeding rates a matter of public health rather than lifestyle choice (Rochman, 2012). • Currently, fewer than 12% of U.S. babies are exclusively breastfed for 6 months, despite recommendation from UNICEF and WHO. • A multi-faceted, multi-disciplinary approach to infant feedingis needed in order to significantly increase breastfeeding rates. (Breastfeeding: A Vision for the Future, 2011)

32. Alternatives to Policy • Create widespread knowledge of the importance of breastfeeding and the risks of not breastfeeding. • Educate mothers and families so they can make informed choices about feeding children. • Allow & encourage women to begin and continue breastfeeding for as long as they wish. • Educate healthcare providers on evidence-basedbirth practices and breastfeeding care. • Encourage more hospitals to become Baby-Friendly. (Breastfeeding: A Vision for the Future, 2011)

33. Policy Recommendations:Breastfeeding: A Vision for the Future • USBC created the Vision that sets 9 specific objectives that must be met in order to fully address the barriers to breastfeeding: 1. Meet and exceed the Healthy People objectives to increase the proportion of mothers who breastfeed. • Important to implement, but difficult to monitor. 2. Implement maternity care practices that foster normal birth and breastfeeding in every facility that cares for childbearing women. • May be difficult to get providers to adhere to these practices. 3. Ensure that healthcare providers provide evidence-based, culturally competent birth and breastfeeding care. • Effective way to ensure breastfeeding needs of new mothers are met. 4. Create and foster work environments that support breastfeeding mothers. • Difficult to quantify but is appropriate and effective. (Breastfeeding: A Vision for the Future, 2011)

34. Policy Recommendations:Breastfeeding: A Vision for the Future 5. Ensure that all federal, state, and local laws relating to child welfare and family law recognize the importance of breastfeeding and support its practice. • Ensures equity throughout the U.S. and is an efficient means of awareness. 6. Implement curricula that teach students of all ages that breastfeeding is the normal and preferred method of feeding infants and young children. • Will promote responsiveness and effectively decrease stigma. 7. Reduce the barriers to breastfeeding imposed by the marketing of human milk substitutes. • Will be difficult to implement due to U.S. economic climate. 8. Protect a woman’s right to breastfeed in public. • Effective and appropriate means of increasing the incidence of breastfeeding. 9. Encourage greater social support for breastfeeding as a vital public health strategy. • Appropriate in order to increase responsiveness and increase the incidence & duration of breastfeeding. (Breastfeeding: A Vision for the Future, 2011)

35. How Health Professionals Can Help • Lobbying: give examples from patients in your practice or individuals you know and how the legislation would impact them. • Support legislation &programs to help women to succeed with breastfeeding. • Include lactation consultants on patient care teams. • Help write hospital policies that help every mother be able to breastfeed. • Patient education can promote breastfeeding& help legislation succeed. • Support compliance with the International Code of Marketing of Breast-milk Substitutes. • Increase funding of high-quality research on breastfeeding. • Support better tracking of breastfeeding rates as well as factors that affect breastfeeding. (Fact Sheet, 2011)

36. Implications of Supporting Breastfeeding • As the largest healthcare profession in the United States, totaling 3.1 million professionals, nurses play a critical role in breastfeeding education and support & should be the first level of intervention for breastfeeding mothers and their babies. • Health professionals need to support patients’ intentions to breastfeed as well as health system changes to improve patient satisfaction and breastfeeding outcomes. • Support of breastfeeding legislation will help remove obstacles to breastfeeding and help increase breastfeeding rates in the U.S. (Spatz, 2011)

37. Summary • WHO & AAP recommend that infants be exclusively breastfed for the first six months of life (Spatz, 2011). • According to U.S. Surgeon General Dr. Regina M. Benjamin, the lack of breastfeeding in the United States is a public health crisis(Spatz, 2011). • APHA reports that hospital-based practices are key to the success of breastfeeding, and the education of healthcare workers can increase the success of breastfeeding (A Call to Action on Breastfeeding, 2007). • Breastfeeding legislation aims to increase the incidence and duration of breastfeeding by helping to change the public opinion about breastfeeding (Existing Legislation, 2011).

39. Resources • A Call to Action on Breastfeeding: A Fundamental Public Health Issue (2007, November). American Public Health Association. Retrieved from http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360. • Baldwin, J.D. (1999) A look at enacting breastfeeding legislation. Retrieved from http://www.llli.org/law/lawenact.html#BREASTFEEDING%20LEGISLATION:%20AN%20OVERVIEW. • Breastfeeding (2011, September). Womenshealth.gov. Retrieved from http://www.womenshealth.gov/breastfeeding/why-breastfeeding-is-important/. • Breastfeeding: A Vision for the Future (2011). United States Breastfeeding Committee. Retrieved from http://www.usbreastfeeding.org/LegislationPolicy/BreastfeedingAdvocacyHQ/BreastfeedingAVisionfortheFuture/tabid/214/Default.aspx. • Breastfeeding Laws (2011, May). National Conference of State Legislators. Retrieved from http://www.ncsl.org/issues-research/health/breastfeeding-state-laws.aspx. • Breastfeeding: Promotion and Support (2011, August). Centers for Disease Control & Prevention. Retrieved fromhttp://www.cdc.gov/breastfeeding/promotion/index.htm.

40. Resources • Breastfeeding Report Card-United States (2011). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard.htm. • Cayetano, P. (2007, May). International treaties and conventions supporting breastfeeding. Retrieved from http://bestforbabies.wordpress.com/2007/05/09/international-treaties-and-conventions-supporting-breastfeeding/. • Crase, B. (2005). AAP policy statement: breastfeeding and the use of human milk. Pediatrics 115 (2), 496-506. • Cox, K.B. (2010). Models for Policy Analysis Part 1. (Unpublished dissertation). University of Virginia, Charlottesville, VA. • Existing Legislation (2011). United States Breastfeeding Committee. Retrieved from http://www.usbreastfeeding.org/LegislationPolicy/ExistingLegislation/tabid/233/Default.aspx. • Fact Sheet (2011, January). Office of the Surgeon General. Retrieved from http://www.surgeongeneral.gov/topics/breastfeeding/factsheet.html.

41. Resources • HR 2758: Breastfeeding Promotion Act of 2011(2011). GovTrack.us. Retrieved from http://www.govtrack.us/congress/bill.xpd?bill=h112-2758. • National Breastfeeding Policy Conference (2008). United States Breastfeeding Committee. Retrieved from http://www.usbreastfeeding.org/LegislationPolicy/FederalPoliciesInitiatives/NationalBreastfeedingPolicyConference/tabid/122/Default.aspx. • Rochman, B. (2012). Why pediatricians say breastfeeding is about public health, not just lifestyle. Retrieved from http://healthland.time.com/2012/02/29/why-pediatricians-say-breast-feeding-is-about-public-health-not-just-lifestyle/. • Spatz, D. (2011, June). Call to Breastfeeding Action – Policy and Practice for Nurses. Retrieved from http://www.newswise.com/articles/call-to-breastfeeding-action-policy-and-practice-for-nurses. • Wiesenger, D., West, D., & Pitman, T. (2010). The womanly art of breastfeeding. New York: Ballantine Books.