Taking Action to Ensure Breastfeeding through the Health Care System: Childbirth, insurance coverage, parental care, illness of mother and/or baby

La Leche League 18th International Conference
Strength through Diversity - Creating One Breastfeeding World
San Francisco, California, USA
July 3-6, 2003

Saturday, July 5 - Session #221
Global Issues - Taking Action to Ensure Breastfeeding through the Health Care System: Childbirth, insurance coverage, parental care, illness of mother and/or baby

Presenters: Marina Rea and Mary Kroeger
Facilitators: Rae Davis, Raj Anand, Gisèle Laviolle, Beth Styer, Pushpa Panadam and Linda Smith

Mary Kroeger gave a detailed presentation on the evidence and opportunities for expansion of the Baby Friendly Hospital Initiative (BFHI) to incorporate a more holistic friendly care towards the mother and baby. Although the BFHI has brought about numerous positive changes in maternity health care practices, there are areas that need revising and changing to create an even more successful Initiative.

Some areas not covered by the ten steps are:

• Step 3 and step 4 touch on the need for prenatal education on breastfeeding and the importance of early initiation of breastfeeding within 30 minutes after birth. However there is no mention on the effects that intrapartum events can have on breastfeeding.
  
• Step 5 and step 6 refer to feeding practices after birth, such as how to breastfeed if baby and mother are separated, and the importance of only giving the baby breastmilk. However, there is no guidance as to what to do in the case of sick or premature babies.
  
• BFHI is geared towards hospitals and clinics, when in fact more than 50% of births globally occur at home. BFHI needs to include home-based maternity care and the training of Traditional Birth Attendants.

Areas of expansion:

• Continuous labor support -- if the mother receives adequate and continuous support throughout labor the results are better birth outcomes, fewer surgical interventions, better breastfeeding outcomes, and the empowerment of women.
  
• The dangers of episiotomy -- a routine procedure in most hospitals globally, especially among primagravid mothers. There is non-evidence based research that episiotomy has many dangers, such as the risk of extension into rectum, acute pain after delivery, possible delayed early initiation of breastfeeding, and that episiotomy is linked to post partum breastfeeding difficulties.
  
• Mother's choice of position in labor and for delivery -- the most common position used in labor and delivery is not necessarily the best option for mother and baby. There is evidence that an upright position aids the mother to have a faster second stage, reduced assistance in delivery, and less fear, greater control and empowerment.

The following are networks and organizations advocating for an expanded BFHI:

• Coalition to Improve Maternity Services - CIMS (USA based, 1995)
  
• Childbirth and Breastfeeding Foundation of Thailand - CBFT (Thailand, 1998)
  
• Better Births Initiative - BBI (South Africa based, 2000)
  
• Humanizing Childbirth Movement - RELACAHUPAN (Latin America based, 2000)

WABA has already taken on the challenge of linking birthing and breastfeeding through the Global Initiative on Mother Support, an Initiative that includes the humanizing of childbirth; through the World Breastfeeding Week Action Folder of 2002, which addressed birthing and breastfeeding; and during the Global Forum II, by having the topic of birthing practices as one of the core themes.

Kroeger finalized her presentation by referring to the Innocenti Declaration, which addresses the birth and breastfeeding continuum and the importance of eliminating "obstacles to breastfeeding within the health system." (Innocenti Declaration, 1990)

Dr. Marina Rea gave a presentation on the breastfeeding situation in Brazil since 1975 and the steps taken by the Brazilian National Breastfeeding Program (BNBP) to improve this picture. The Brazilian program takes into consideration the WHA Resolution that states that all infants should be exclusively breastfed until six months of age and continue to receive breastmilk until the second year or beyond. To achieve this goal, breastfeeding programs need to be aware that women need support and empowerment.

Some of the challenges faced by the Brazilian National Breastfeeding Program:

• How to keep breastfeeding exclusive until the baby is six months old
  
• How to introduce complementary feeding and at the same time maintain breastfeeding
  
• How to promote the best replacement feeding for special circumstances (HIV, emergencies, etc.) without interfering on breastfeeding practices

1975-1981
Breastfeeding indicators-
- 2.5 months was the average duration of breastfeeding
- Breastfeeding was not a priority among pediatricians
- Pediatricians and Pediatric Schools were highly influenced by the Infant Food Companies

Activities-
- In 1980 PAHO and UNICEF worked together with the Ministry of Health to review the WHO Code and launched the BNBP, with the aim of having a national coordination that could promote social mobilization and design a successful media campaign.

1981-1986
Breastfeeding indicators-
- The median duration of breastfeeding increased in 1986
- Mean duration of predominant breastfeeding increased from 15 days to 32 days
- However, exclusive breastfeeding in the DHS in NE-Brazil was around 3%

Activities-
- The Ministry of Health launched social mobilization and the 1st media campaign
- UNICEF supported quantitative research to assess the impact of the BNBP, and qualitative research on effective messages for the campaign
- IBFAN effectively monitored the marketing of breastmilk substitutes
- The 2nd media campaign was implemented with the slogan "Breastfeeding: all mothers can do it"
- From 1984-86 the BNBP was weakened by the decision from the Ministry of Health to integrate breastfeeding with other primary healthcare actions
- In 1986 the WHA Resolution on the rejection of donations of breastmilk substitutes in maternity hospitals was approved

1987-1996
Activities-
- Human Milk banks elaborated rules to become centers for breastfeeding support
- In 1991 the BFHI was implemented and formula companies were prohibited to donate supplies
- WHO and UNICEF designed training courses for different target groups: 18 hours course for BFHI teams, 12 hours intensive course for policy makers and administrators to launch BFHI, a hands-on 40 hour counseling course for participants and 80 hours for trainers

1996-2002
Activities and results:
- Used the training courses for all target groups
- In 2002 there was a total of 250 Baby-Friendly Hospitals in Brazil
- 150 Human Milk Banks (in collaboration with the firefighters, who fetch the milk and take it to the hospitals)
- Code training and monitoring- in collaboration with IBFAN, trained sanitary workers, consumer associations and judiciary defense personnel

The BNBP has successfully increased breastfeeding rates in the country. In 1975, the median duration of breastfeeding was around two or three months, in contrast the most recent survey shows that the median duration of breastfeeding is now around 10 months. The success of this program has been due to a good coordination, planning and training of health workers, with the support from public policies that protect and promote breastfeeding. In the future the aim of BNBP is to reach a higher rate of exclusive breastfeeding and to continue promoting breastfeeding until the second year or beyond.

Following are the actions presented during the session:

A. Mother support group at a hospital
Facilitated by Rae Davis

This group created an outline for a mother support group meeting to take place in a hospital. The meeting is intended for two hours and is designed to include birth and breastfeeding practices.

Outline:

Successful Breastfeeding Begins Before Birth

Meeting from 7-9 PM

I. Introduction:
a) Icebreakers -
- How do birth practices affect breastfeeding?
- What are the ingredients of formula milk?

II. Show a video titled "Delivery Self-Attachment"
a) Effects of birth practices on breastfeeding
b) Importance of the mother/baby dyad

III. Provide the opportunity for mothers to talk about their ideal picture of birth
a) Discuss the elements that might interfere with this ideal picture

IV. List benefits of breastfeeding and risks of industrial milk

BREAK - provide nutritious snacks

V. First hour after birth
a) Attachment/contact with the baby
b) Positioning- use dads to get used to helping
c) Frequency of feeds- create playdoh stomachs to illustrate the process
d) Talk about the don't's

VI. Support system (make sure they know where they can go for help)
a) Doulas during birth and post-partum
b) Child birth education
c) Mother-support groups
d) In-house Lactation Consultants

Materials used:

• breast model
  
• note cards
  
• playdoh
  
• doll
  
• video

Handouts:

• Information on location/schedule of LLL meetings
  
• Lansinoh
  
• Comic books published by LLLI

After the meeting it is important to do an evaluation to measure the effectiveness of the topics presented.

B. Reaching out to the American Dental Association
Facilitated by Mary Kroeger and Gisèle Laviolle

The American Dental Association (ADA) does not recommend nighttime feeding, so this group decided to write a letter to the Pediatric Dentistry Association (PDA) requesting them to contact the ADA in an effort to change their recommendation. The letter to the PDA will be signed by numerous dentists representing many countries around the world.

Letter:

Dear (find individual's name):

Currently, the American Dental Association has an official recommendation that night breastfeeding is not recommended. Current research does not support this recommendation (cite studies). Suggesting that mothers refrain from night breastfeeding, when many babies receive 30% or more of their daily calories, is counter productive to breastfeeding and to the mother-baby bond. It sends mothers the message that breastmilk may be inferior to artificial/complementary foods, and is likely to contribute to early and unnecessary weaning, as well as less responsive nighttime parenting practices. We therefore respectfully request that the P.D.A. communicate with the A.D.A in an effort to effect a replacement recommendation in support of night breastfeeding.

We suggest the following wording:

• include detailed citing/summarizing of current research re:
  a) breastfeeding and dental caries
  b) breastfeeding and oral hygiene
  c) breastfeeding and oral/facial development
  
• briefly describe overall benefits of breastfeeding
  if exists, any research showing detrimental effect of ADA recommendation
  
• risks of weaning (formula, nipples, pacifiers)-- for dental caries, orofacial development

Sincerely, coalition of (signatures of dentists from all over the world, started by 2 at this session)

Note: The session attendee who committed to finalizing this action (Kathy Engleman) has made the following request: "If anyone who reads this Web site has information that might be of help to me (relevant research about breastfeeding and dental caries; prominent dentists supportive of breastfeeding; board members or other decision makers of the AAPD; attorneys who are willing to work pro bono for breastfeeding causes, etc.) please send it to me at khengleman@noos.fr. I appreciate any information that anyone may have that can help me in this cause!"

C. Breastfeeding Friendly Clinical Practice
Facilitated by Raj Anand

This is an action similar to the BFHI, but called the 10 steps for breastfeeding friendly clinical practice. It will be disseminated by approaching WABA, and it can also be used locally as talking points with doctors.

10 Steps for Breastfeeding Friendly Clinical Practice

1. Hang breastfeeding posters in visible areas.
2. Display non-formula co-produced reading materials about breastfeeding in the waiting room.
3. Give every mother accurate, up-to-date written information on breastfeeding and good birthing practices. Include information on establishing and maintaining milk supply.
4. Breastfeeding specialist on staff, where possible.
5. All staff trained in breastfeeding counseling (to be developed by Academy of Breastfeeding Medicine).
6. Provide current list of local resources/support groups.
7. Provide care during first week post-partum.
8. Promote exclusive breastfeeding for the first 6 months and complementary feeding thereafter.
9. Promote breastfeeding into the 2nd year.
10. Respect the MOTHER and respect the mother/baby dyad (including emotional aspects).

D. Utilizing Insurance Companies
Facilitated by Beth Styer and Pushpa Panadam

Goal: to develop actuary tables usable by Insurance Companies that would demonstrate lowered risks of various diseases for mother and baby from breastfeeding

Action: Find organizations or graduate schools interested in funding the research project

Research project:

• Gather studies on the costs of illnesses:
  a) Child: Otitis media, NEC, Childhood diabetes, Resistance to colds and flu, Respiratory infections, Childhood cancers, Obesity, Dental health, Food allergies, Hypertension
  b) Mother: Breast Cancer, Ovarian Cancer, Diabetic motives, Postpartum depression, Weight loss
• Compare to costs of a breastfed child
  
• Gather studies about health benefits for the mother
  
• Summarize data into savings for families
  
• Publish as actuarial table
  
• Talk to insurance companies in order to create breastfeeding discounts for families
  
• Educate the insurance companies about breastfeeding as a life-saving intervention and the need to reflect this in policies

E. Involving Insurance Companies
Facilitated by Linda Smith and Marina Rea

1. Send out information to insurance companies and policy makers on the cost-savings of breastfeeding.

2. Form a coalition of LLL Leaders, Lactation Consultants, MDs and nurses to provide skill-based education, covering topics such as cupfeeding, positioning and latch-on, how to help mothers without alienating them. Reach out to health professionals by hosting brown-bag lunches, resident training programs, provide breastfeeding books at doctors' offices, and send out a feedback letter (see below).

3. Send good information to providers such as Breastfeeding Briefs by IBFAN, Breastfeeding Abstracts by LLLI, Breastfeeding Review by the Australian Breastfeeding Association, breastfeeding books such as Pure and Simple and the Breastfeeding Answer Book, and invite doctors to become La Leche League Members

Letter:

Dear Dr. ,

The Local La Leche Group has received ____ number of calls in the past year. We have donated ___ hours to help mothers and babies get off to a good start.

Our Local Leaders are available to provide training for your staff and answer questions about baby-friendly and mother-friendly techniques. How can we help educate your staff in medical practice? We'd love to schedule some time to talk at one of your staff meetings.