FOLLOWUP REPORT: THE SURGEON GENERAL'S WORKSHOP ON BREMTFEEDING & HUMAN LACTAnON Presented by lhe U.S. DWARTMEM OF HEALTH AND HUMAN SERVICES Public Health Servtce Healfh Resources and Services Administration Bureau of Health Care Delivery and Assistance Division of Maternal and Child Health DHHS Publkation No. HRS-D-MC 85-2 . . c `Thk report was prepared ivith the assistance of the National Centerfor Educa- tion in Maternal and Chi!d Health. 38th & R-Streets, N. W., Washington; D.C. 20057. The National Center is a resource center that responds to public and professional inquiries in maternal and child health. including human genetics. Established in 1982. the National Center for Education in Maternal and Child Health provides services under a grant from the Divkion`of Mater- nal and Child Health, Department of Health and Human Services. U.S. NATIONAL 1 -\ MEDICINE 1 I : The oiiginal drawing on the cover was done-by Bob Congi of Rochester, N.Y. PREFACE Since the Surgeon General's Workshop on Breastfeeding and Human Lactation last year, there has been a notable renewal of interest and a resurgence of activity in promotion of breastfeeding. This may be attributed to the philosophy of "shared responsibility" which guided the planning com- mittee in organizing the workshop. The workshop participants, represent- ing many professional and voluntary organizations, were actively involved in the workshop process of assessing the current status of breastfeeding pro- . motion in the United States and of developing recommendations and strategies to facilitate progress toward achieving the 1990 breastfeeding ob- jective for the nation. The workshop recommendations have become a na- tional agenda, with participant organizations providing leadership in disseminating the recommendations and encouraging their implementation. The Report of the Surgeon General's Workshop on Breastfeeding and Human Lactation, published in September 1984; has become a valuable reference on the science and art of breastfeeding and a useful planning guide for breastfeeding promotion efforts. The original printing of 35,000 copies was quickly distributed by participant organizations, and a second printing has been done. This Followup Report has been prepared to document efforts emanating from the workshop and to continue to disseminate information related to breastfeeding promotion activies and accomplishments. At the workshop four successful models to promote breastfeeding were presented. In the past year many additional approaches have come to our attention. The purpose of this Followup Report: Surgeon General's Workshop on Breastfeeding and Human Lactation is to recognize other useful ap- proaches, describe these approaches, and identify where they are being im- plemented. It is hoped that policymakers, administrators, educators, health care providers, professional and voluntary organizations, Federal agencies, employers, and others who read this Followup Report will gain new ideas that will inspire them to further action. Information included in this report was submitted in response to requests made to the participants in the workshop; State Directors of Maternal and Child Health; members of the Healthy Mothers, Healthy Babies Coalition; and Department of Health and Human Services Regional Health Administrators. The responses were im- pressive and included descriptions of a variety of efforts such as legislation, policies, resolutions, guidelines, meetings, publications, media campaigns, service delivery models, support systems, and research, all of which are in- cluded in this report. ii We are interested in your response to our ongoing efforts to disseminate information and stimulate action to reduce barriers to breastfeeding. Will you please take a few minutes to complete the question- naire on the back cover of this publication? We recognize and appreciate the new, renewed, and continuing work that is being done in support of improved. health and nutrition for our na- tion's mothers and babies. Progress has been made, but many challenges re- main in our efforts to promote informed decisions by more women to breastfeed their babies. C. Everett Koop, M.D., Sc.D. Surgeon General *.. 111 CONTENTS INTRODUCTION........................................... ACTIVITIES RELATED TO RECOMMENDATIONS OF THE SURGEON GENERALS WORKSHOP ON BREASTFEEDING ANDHUMANLACTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PROFESSIONAL EDUCATION Task Forces/Work Groups/Committees ....................... Policies/Standards/Protocols/Curricula ...................... Continuing Education ...................................... Professional Consultation/Technical Assistance ................ Manuals/Guides/Educational Materials ....................... PUBLIC EDUCATION Media .................................................... Hard-To-ReachGroups ..................................... Promotion/Public Education Campaigns ...................... Education Systems ......................................... Coordination/Sharing of Educational Materials ................ Data Collection ............................................ HEALTH CARE SYSTEM Policies/Standards/Protocols ............................... Laws/Regulations ......................................... Model/Demonstration Programs ............................. Staff/Client Education ..................................... Task Forces/Guides/Materials ............................... SUPPORT SERVICES Telephone Calling Systems .................................. Peer Support Groups ....................................... Breastfeeding Counselors ................................... Nurse Followup/Referral ................................... Clinics/Classes ............................................ Institutional Practices ...................................... Human Milk Banks ........................................ 1 3 8 10 11 12 12 12 14 15 16 17 18 19 20 20 21 21 22 23 iv WORLD OF WORK Data Base ................................................ 24 Information/Education ..................................... Institutional Policies ..................... ; ................. g Breast Pump Loan Programs ................................ Model/Demonstration Programs ............................. z: RESEARCH Trend Data ............................................... 27 Determinants/Behaviors/Practices/Attitudes .................. 28 Physiology/Nutrition/Other Aspects ......................... 29 Interventions/Strategies .................................... 30 NATIONAL AWARENESS .................................. 32 CONTRIBUTORS...............................,,....,..... 34 APPENDIX A-Task Force on Professional Training in Lactation . . 38 APPENDIX B-Research on Human Lactation and Breastfeeding Supported by the National Institutes of Health, Department of Health and Human Services . . . . . . . 40 APPENDIX C-Research on Human Lactation and Breastfeeding Supported by the U.S. Department of Agriculture . . 45 QUESTIONNAIRE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-III V INTRODUCTION The Surgeon General's Workshop on Breastfeeding and Human Lacta- tion was convened in Rochester, NY on June 11-12, 1984. Presented by the Division of Maternal and Child Health in cooperation with the University of Rochester Medical Center, the workshop was directed toward the achievement of the 1990 national objective of increasing the number of women who breastfeed their infants and the duration of breastfeeding. Specific objectives of the workshop were: o To review progress of past efforts, in both public and private sectors, to promote breastfeeding o To assess the state-of-the-art related to factors that enhance and those that inhibit breastfeeding and human lactation o To determine remaining issues o To develop strategies and recommendations in order to facilitate progress toward achieving the 1990 breastfeeding objective Workshop participants included many disciplines serving different ethnic, cultural, and income groups in a wide variety of practice settings. Professional and lay organizations; local, State, and Federal governments; industry; and voluntary groups were all represented. The Report of the Surgeon General's Wotkshop on Breastfeeding and Human Lactation was disseminated in October 1984. Six recommendations with suggested strategies to facilitate progress toward achieving the 1990 objective were presented to the Surgeon General. The recommendations were: o Improve professional education in human lactation and breast feeding o Develop public education and promotional efforts o Strengthen the support for breastfeeding in the health care system o Develop a broad range of support services in the community o Initiate a national breastfeeding promotion effort directed to women in the world of work o Expand research on human lactation and breastfeeding The Division of Maternal and Child Health of the Public Health Ser- vice, in collaboration with other public and private agencies, encourages, supports, assesses progress, and evaluates followup action related to the workshop recommendations. Efforts to increase the incidence and duration of breastfeeding in the United States were underway prior to the Surgeon General's Workshop. However, as a result of the workshop, many of these efforts have been intensified and expanded. In addition, a significant number of other activities have been initiated in direct response to the issues identified at the workshop, and strategies designed to promote breast- feeding, particularly in population groups with low incidence of breastfeeding, have been implemented across the nation. This Followup Report is presented to share information about the wide range of followup action which emanated from the workshop. A large volume of information about followup action was received from a broad spectrum of individuals, agencies, and organizations. In order to ensure a report of reasonable length, it was possible to include only examples or il- lustrations of the scope of activities undertaken, and to present these in ab- breviated or abstract form. The information is organized according to the recommendations listed above. Sections on National Awareness and Con- tributors are also included, as well as Appendices. It is hoped that the report will stimulate the interest and increase the support of all who can have an impact on breastfeeding decisions and op- portunities. The ultimate goal is a continuing commitment to the promotion of breastfeeding and improvement of maternal and child health. ACTIVITIES RELATED TO RECOMMENDATIONS OF THE SURGEON GENERAL'S WORKSHOP ON BREASTFEEDING AND HUMAN LACTATION PROFESSIONAL EDUCATION Recommendation: Improve professional education in human lactation and breastfeeding The improvement of didactic and clinical training in lactation and breastfeeding, and the development of skills in patient education and management of breastfeeding for all health care professionals, were major goals of this recommendation. Concerns about the availability and quality of professional education related to breastfeeding and lactation include: 1) the absence of appropriate curricula which recognizes the diversity of sociocultural and economic groups in the population as well as the roles/responsibilities of various health professionals, 2) the inadequate funding for preparation of faculty to direct and provide training, 3) the unavailability of educational programs and resources to support the educa- tion of practicing professionals, and 4) the lack of appropriate involvement of accreditation and standard-setting bodies to assure the competence of health professionals and others involved in maternal and child health care. Followup on this recommendation is receiving priority in most parts of the nation, and significant steps have been taken to improve the education of a wide range of providers who can have an impact on breastfeeding deci- sions. These steps revolve around the following major types of action: con- vening task forces, work groups, and committees to focus on professional education; developing and promulgating policies, standards, protocols, and curricula to guide professional action; offering continuing education to a wide range of health care providers; providing professional consultation and technical assistance to upgrade the knowledge and skills of health pro- fessionals; and publishing manuals, guides, and educational materials for professional reference. Selected examples of each of the above types of action follow. Task Forces/Work Groups/Committees A national Task Force on Professional Training in Lactation was con- vened in June 1985 by the University of Rochester Medical Center with sup- port from the Division of Maternal and Child Health, Department of Health and Human Services to review the activities of professional groups pursuant to this recommendation and to determine additional efforts that need to be planned to improve professional education in the areas of lacta- tion and breastfeeding. About 20 major professional organizations and voluntary agencies concerned with perinatal health, education of profes- sionals, and standards of practice were represented. A model policy state- 3 ment, "Promotion of Breastfeeding in the Context of Health Care: Profes- sional Training Priorities," and a set of objectives were developed (see Ap- pendix A). Task Force members agreed to a followup strategy which called for each organization to endorse the joint policy statement or develop one of its own, and to review the objectives, identifying specific actions to be undertaken by the organization to achieve them. It is expected that the task force meeting will facilitate networking and result in cooperative training programs. As will be noted in the section on Public Education, many of the state and community coalitions organized to promote breastfeeding include a work group or committee specifically concerned with professional educa- tion. For example, one subcommittee of the Virginia Task Force on Breastfeeding is investigating continuing education opportunities related to lactation for health care professionals in that state; the New York City Steering Committee to Promote Breastfeeding has a task group to focus on training of hospital staff; and one of the Montgomery County, MD Breastfeeding Coalition's committees focuses on professional education of physicians. Policies/Standards/Protocols/Curricula Not only are Federal, State, and local public agencies, national organizations, and voluntary agencies developing new or additional policy statements, standards, protocols, curricula, and other types of guidance on breastfeeding, but they are also taking positive action to ensure their dissemination and implementation. Illustrations of specific activities are given below: o The Division of Maternal and Child Health, Department of Health and Human Services issued a Regional Program Guidance Memorandum on Breastfeeding Promotion Efforts to its regional office staff members in Maternal and Child Health, Primary Care, and the National Health Serv- ice Corps. The Division of Maternal and Child Health also sent copies of the Healthy Mothers, Healthy Babies Breastfeeding Packet to the State Directors of Maternal and Child Health and to all regional offices of the Department of Health and Human Services for reference use of staff and for broad dissemination to their state and local co-workers. o Policy and position statements related to breastfeeding developed by many professional organizations remain in effect. These include is- suances from the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, the National Association of Pediatric Nurse Associates and Practitioners, and the American Public Health Association. Other groups report that they are in the process of develop- ing new, or additional, policy and position statements related to breastfeeding. These include the National Perinatal Association and The American Dietetic Association. o The Tennessee Department of Health and Environment developed 1) a protocol on providing support to breastfeeding mothers for use in local health departments, 2) lesson plans on breastfeeding management in hospitals for use in training of hospital staff, and 3) guidelines for enlisting the support of local health care providers and health profes- sional training programs. 4 o The Steering Committee to Promote Breastfeeding in New York City developed a curriculum which specifies breastfeeding knowledge and skills necessary for hospital staff. It will be used to train monitors and health care workers involved in implementation of New York State's new regulations supporting breastfeeding in hospitals. Their Guide to Pro- moting Breastfeeding in the Hospital will be distributed widely by the State Health Department. o Health Education Associates (PA) issued two new education aids de- signed to help implement recommendations of the Surgeon General's Workshop. The "Breastfeeding Teaching Box for In-Hospital Teaching" is a box of teaching cards for instructor use in any setting in which mothers initiate breastfeeding. The "Kit for Preventing Breastfeeding Problems and Early Failure" provides complete instructions and materials for use in developing a telephone call system to assist nursing mothers. Based on the realization that many give up breastfeeding very easily, the kit uses a "triage" model to differentiate among women with different levels of interest and motivation in breastfeeding and to focus on providing practical help to each woman as indicated. o Family Medicine Center, Durham Health Care, Inc. (NC) has incor- porated didactic material on lactation and breastfeeding in the nutrition curriculum developed for its residency program. Future plans include development of a counseling component of the nutrition curriculum to increase competency of family physicians in counseling breastfeeding mothers. o The first credentialing exam for lactation consultants was given in July 1985 in Washington, DC by the International Board of Lactation Consul- tant Examiners. Continuing Education Positive steps are being taken in many states, local communities, and agencies across the nation to provide in-service education in lactation and breastfeeding to a wide range of care providers. In some states, educational resources such as the National Child Nutrition Project (PA) and Health Education Associates (PA) are utilized for workshops and conferences. These states include: California, Idaho, Illinois, Maryland, Mississippi, Montana, New Hampshire, North Dakota, South Dakota, Vermont, and Washington as well as several states in Department of Health and Human Services Region VI. Often personnel in neighboring states participate; for example, Maine sent staff to the New Hampshire workshop. In other states, the state health agency works closely with educational institutions and various agencies to provide continuing education in lacta- tion and breastfeeding. Frequently these continuing education courses in- volve one or more sessions incorporated into a broader topic on maternal and child health; often the conference focuses solely on lactation. States in- volved in these activities include: Alaska, Colorado, Connecticut, Georgia, Iowa, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Dakota, Utah, Washington, and Wyoming. Both public and private community agencies in various localities also conduct in-service training for their own staff as well as that of other agen- 5 ties. For example, the nutrition staff of the William F. Ryan Community Health Center (NY) participated in ongoing professional conferences on breastfeeding education. In Indiana, the Rural Health Activities Project and Margaret Mary Community Hospital sponsored a wofkshop. La Leche League reports the continuation of long-standing professional seminars for physicians, and the implementation of additional educational opportunities for health professionals and breastfeeding counselors. Medical centers also play a key role in sponsoring professional educa- tion opportunities, often in cooperation with other groups. These include the University of Rochester Medical Center (NY), Case Western Reserve University and Rainbow Babies and Children Hospital (OH), and Georgetown University Hospital's Department of Nursing (DC). Voluntary agencies and professional organizations contribute to upgrading the knowledge and skills of professionals. The March of Dimes Birth Defects Foundation and The American Dietetic Association include lactation and breastfeeding as important topics in their nationwide series of symposia for dietitians, nurses, and physicians, designed to address nutrition in perinatal health care including the short- and the long-term support of critical and convalescing premature infants. Papers and sessions on breastfeeding are included in the annual meeting programs of such professional organizations as the American Medical Women's Association, American College of Obstetricians and Gynecologists, and the National Association of Pediatric Nurse Associates and Practitioners. The twelfth and thirteenth annual Seminars for Physicans on Breastfeeding sponsored by La Leche League ln- ternational were held in Montreal, Canada in 1984 and in Washington, DC in 1985. Professional Consultation/Technical Assistance In order to help health care providers develop skills in patient educa- tion and management of breastfeeding, many agencies continue or are ex- panding their professional consultation and technical assistance services to staff in a wide variety of practice settings. For example, the three-year demonstration project sponsored jointly by the Departments of Pediatrics, Obstetrics, and Community Health of the Albert Einstein College of Medicine (NY), and supported as a Title V Special Project of Regional and National Significance, is designed to im- prove the incidence and duration of breastfeeding among low-income women in the Bronx. A lactation consultation team consisting of a nutri- tionist, nurse, and obstetrician provides consultation and education services in the three municipal hospitals in the Bronx and the eleven community health centers that constitute the Bronx Committee for the Community's Health. While members of the team provide consultation to mothers with breastfeeding problems, primary emphasis is given to education and train- ing activities directed toward providers of care. The San Diego Lactation Program continues to provide intensive train- ing and consultation to professional care providers. For example, the Population Council of New York utilized staff from the San Diego program for a day-long workshop for key staff members of the municipal hospital system. This workshop consisted of on-site visits to selected hospitals to meet with staff and conduct bedside demonstrations of techniques to assist 6 mothers with breastfeeding. A followup visit one year later was made to the target hospital to address specific concerns of staff. Manuals/Guides/Educational Materials A significant number of educational materials designed for profes- sional reference and use were available prior to the Surgeon General's Workshop. Since the Workshop a renewed effort has been made to improve their dissemination and to develop additional materials to meet special needs and fill existing gaps. Examples of activities related to this effort in- clude: o The Healthy Mothers, Healthy Babies Coalition's Breastfeeding Promo- tion Packet was assembled with leadership from the American Academy of Pediatrics and contributions from selected Federal and State agencies and professional organizations. Almost 2,000 copies of this educational packet on breastfeeding have been disseminated nationwide. The packet includes reprints of scientific articles on lactation and breastfeeding; bibliographies of selected technical references and resource materials; sample materials for client education; a how-to guide to assist in- dividuals, agencies, and communities to promote breastfeeding; and a list of key organizational contacts by state. In some states, materials in the packet have been made more widely available to health professionals working within the state. o The National Child Nutrition Project (PA) published A Guide 10 Breastfeeding - Principles, Practices and Problems. It is intended as a guide for medical professionals and others who work with expectant and new mothers. o The Population Council's Program for Appropriate Technology in Health has developed "Breastfeeding: A Nurse's Guide" for use in con- junction with two client booklets, "A Mothers Guide to Breastfeeding" and "Su Guia de la Lactancia Materna." Intended for use by hospital staff and mothers, the booklets are designed to help them initiate and maintain breastfeeding. Drawings and simply stated messages are used to illustrate and explain breastfeeding. o The United States Department of Agriculture, Food and Nutrition Serv- ice, with support from the Infant Formula Council, published and disseminated Promoting Breastfeeding: A Guide for Health Profes- sionals Working in the WIC and CSF Programs. The guide is intended to provide a variety of ideas and successsful approaches to help staff be more effective in their efforts to promote breastfeeding among low- income women. o The National Center for Education in Maternal and Child Health con- tinues to make available the video-tape on breastfeeding from the nation- wide teleconference entitled "Improving Nutrition for Mothers and Babies: A Research Update - Breastfeeding and Human Lactation." 7 PUBLIC EDUCATION Recommendation: Develop public education an4 promotional efforts There is a need to improve the availability and quality of information and education about lactation and breastfeeding as a normal process, a part of everyday life, and the preferred method of infant feeding. Important aspects of this recommendation include the development and dissemination of accurate and consistent messages about breastfeeding, increased use of the educational system and the media; coordination with professional education; recognition and targeting of various economic, cultural, and ethnic groups; and encouragement of public officials and other leaders who can influence community support for breastfeeding. A wide range of efforts have been stimulated by the workshop and im- plemented to improve public information and education about breastfeeding and lactation. Included are activities designed to make more effective use of various media, improve targeting of hard-to-reach groups, develop state and community promotion and public education campaigns, integrate breastfeeding information into education systems, coordinate and share educational materials, and collect data to monitor changes in attitudes and behavior. Illustrations of these various activities follow. Media Increased use has been made of television, radio, newspapers, magazines, posters, films, display ads, educational materials, and other media to enhance awareness of breastfeeding as the norm and to encourage the development of attitudes and behaviors that support it. For example, the Public Education Task Group, New York City Steer- ing Committee to Promote Breastfeeding, completed a three-pronged strategy as the basis of a public information campaign. Included were a media effort composed of a subway poster, press conference, "caravan" of mothers breastfeeding on the subway with television, radio, and press coverage; a telephone information effort which provided counseling and referral; and an informational pamphlet for use in health clinics and other service settings. A speakers' bureau was organized, and resource materials were developed for use in public presentations during a city-wide Prenatal Care Week program. An estimated four million New Yorkers had some ex- posure to the two-month public information campaign in the fall of 1984. The Wisconsin Nutrition Project, Inc., developed two radio and two television public service annoucements to promote breastfeeding. The Ten- nessee Breastfeeding Task Force developed a public service annoucement to educate the public and encourage pregnant women to contact the health 8 department for breastfeeding information, while the North Jersey Com- munity Union in Newark also conducted a media campaign about breastfeeding. Actress Linda Kelsey has formed a non-profit, organization, Metanoia (a Greek work meaning "change of heart"), to foster a change on the part of millions of mothers around the world to choose breastfeeding. Metanoia has produced a 30-second public service announcement in English and Spanish to promote breastfeeding and will have a toll-free 800 telephone number which viewers will be able to call for information. The public serv- ice announcement will be available for use by states in their Healthy Mothers, Healthy Babies public information efforts. Posters and leaflets for use in a wide variety of settings were developed by the New York State Health Department in cooperation with the New York City Health Department and the New York City Medical and Health Research Association. The Healthy Mothers, Healthy Babies Coalition has continued to em- phasize breastfeeding in its public education effort. Breastfeeding is the topic of one of a series of six posters and information cards developed for use in clinics serving low-income pregnant women. Over a million breastfeeding information cards in English and Spanish have been distributed to low-income women. A student in the Department of Health Education at Hunter College, New York City, is conducting a survey of women to evaluate the effec- tiveness of different types of posters in getting the breastfeeding message to women. Videotapes to present information to clients were prepared by the Jackson County, IL public health program and by Charity Hospital in New Orleans, LA. The latter tape was filmed in a client's home, and a client nar- rated the film. Closed-circuit television is made available to patients at the Kapiolani Women and Children's Medical Center in Hawaii, and breastfeeding films are shown daily. Films were also prepared and disseminated to increase public education about breastfeeding. In Kansas, the State Department of Health and En- vironment and the Kansas University Medical Center produced "Breastfeeding in the 1980's." The producers of a three-part educational film series on breastfeeding, Motion, Inc., offered a special discount on film orders received before March 31, 1985, in recognition of the Surgeon General's commitment to promote breastfeeding. The New Jersey State Department of Health, with support from the Ford Foundation, developed a film entitled "Lily's Choice" for use with low-income populations. "Outside My Mom: The Story of a Breastfed Baby" is an 1 l-minute audiovisual presentation available from the March of Dimes Birth Defects Foundation. It is available in color slides or filmstrip with audio-cassette and comes with a teaching guide and pamphlets for viewers. Other innovative activities related to the use of media include the development of a guide, Starting a Telephone Support System for Breastfeeding Mothers, by the Wisconsin Nutrition Project, Inc., and the Alabama State Health Department's use of specially designed postcards. Mailed to mothers of breastfed infants when infants are ten days, three weeks, and six weeks of age, the cards provided information designed to en- courage continuation of breastfeeding. 9 New or additional educational materials on breastfeeding were developed by numerous organizations and agencies, and many took steps to expand the dissemination and use of existing materials. For example, the Missouri Division of Health developed an information packet on breastfeeding for diabetics, while the Naturist Society and the State Health Departments in Alaska, Colorado, Illinois, Indiana, Minnesota, New York, Wisconsin, and Wyoming developed or provided for new materials on breastfeeding. The Utah State Health Department initiated a periodic newsletter for all new mothers in the state, and it will include information on breastfeeding. The American Academy of Pediatrics, the Department of Health and Human Services/Division of Maternal and Child Health, the United States Department of Agriculture/Food and Nutrition Service, the Baylor College of Medicine/Department of Pediatrics, and The American Dietetic Association cooperated in the development and dissemination of two publications on breastfeeding-A Gift of Love and Breastfeeding: Baby's Best Start. The latter is written in both English and Spanish. Hard-To-Reach Groups Some of the educational materials on breastfeeding described above were published in several languages to meet client needs and in simplified formats for clients with limited reading skills. For example, the Population Council of New York developed a new set of educational mater,ial for women with limited reading ability. Helping Mothers to Breastfeed, Program Strategies for Minority Com- munities, a guide edited by Judith D. Gussler and Carol A. Bryant, was published by the Lexington-Fayette County Health Department (KY) and the University of Kentucky College of Medicine. Based on a breastfeeding promotion workshop supported by Ross Laboratories, the publication in- cludes reports from people directing successful breastfeeding programs for low-income mothers in several rural communities and ethnic groups in widely scattered geographic areas. Florida has developed a poster to promote breastfeeding among its new refugee populations. Many immigrants from developing countries view bottle-feeding as the accepted method of infant feeding in the United States. The poster in English, Spanish, and Haitian Creole versions says "Discover the New American Way of Infant Feeding." In New York City, the Expanded Food and Nutrition Education Pro- gram aides accelerated their activities to promote breastfeeding among low- income women. Emphasis is given to recruitment of pregnant women, par- ticularly pregnant teens, use of volunteers to provide a support network, and use of leaflets and brochures adapted to client needs. To provide prenatal education for young parents in rural areas, the University of Wyoming developed twelve slide-tape modules, one of which is on breastfeeding. Recognizing that grandmothers and other close kin can be important support persons for new parents, the International Childbirth Education Association, Inc., has developed a leaflet entitled "To the Grandmother of the Breastfed Baby." Grandmother classes offered during the prenatal and postnatal periods to help close kin learn current concepts of maternal and infant care and nutrition are also recommended. Such classes can update 10 grandmothers on new concepts and practices that have changed during the last generation and can help them develop supportive attitudes and tech- niques. Many of the breastfeeding promotional campaigns described later in this section focus considerable attention on hard-to-reach groups. The District of Columbia's campaign, for example, is targeted for low-income minorities who reside in the District as well as for local professional and paraprofessional providers who deliver health and social services to these groups. Promotion/Public Education Campaigns One of the most interesting followup activities was the initiation and expansion of coalition-type organizations in states and communities across the nation to mobilize community interest and support for breastfeeding. Following are a few illustrations of these organizing efforts. The Virginia Task Force on Breastfeeding currently includes represent- atives from health departments and hospitals and will be expanded to in- clude individuals from primary care centers and other interested groups. Three subcommittees are involved in obtaining baseline data about breastfeeding promotion and education, investigating opportunities for continuing education available for health care professionals, and reviewing the availability of support services and systems. The Georgia Breastfeeding Promotion Steering Committee includes representatives from medical organizations, national foundations, and educational institutions. Plans are underway to convene breastfeeding workshops for professionals and spon- sor other promotional activities. The District of Columbia's Breastfeeding Promotion Campaign was launched in September 1985. Individuals and organizations from the private and public sectors are cooperating to address barriers that interfere with the initiation and con- tinuation of breastfeeding. Tennessee's Breastfeeding Promotion Task Force was organized to develop a statewide breastfeeding education and promotion campaign. It is composed of representatives from the nursing, nutrition, and maternal and child health divisions of the State Department of Public Health. A technical advisory committee has been organized and includes two private-practice obstetricians, the chairman of the Perinatal Advisory Committee of the state chapter of the American Academy of Pediatrics, two university nursing professors, and a hospital nurse and lac- tation counselor. A policy letter stressing the importance of providing serv- ices that support breastfeeding has been issued to all local health depart- ments in the state. A workshop, entitled "Promoting Breastfeeding in Massachusetts: Research Issues, Policy Implications and Practical Strategies," was held to set the groundwork for a statewide campaign. Organized by the Massachusetts Breastfeeding Promotion Task Force, the workshop was cosponsored by the Massachusetts Department of Public Health, Boston University School of Public Health, Boston Area Health Education Center, Department of Health and Hospitals, and the Erna Yaffe Foundation. Numerous state, professional, and voluntary organizations were involved. Conference proceedings will be available in December 1985. Cities and counties in various geographic areas were also active in pro- moting breastfeeding. For example, the La Crosse, WI Breastfeeding Task 11 Force, organized in 1982, has continued its efforts to work with local hospitals, clinics, social services, and Women, Infants, and Children pro- grams to increase the incidence and duration of brgastfeeding. The Las Vegas, NV Perinatal Coalition is working to involve the La Leche League in staff training and to modify hospital policies which have discouraged breastfeeding. The Montgomery County, MD Breastfeeding Coalition has developed "Guidelines for Enlisting Support of Local Health Care Pro- viders and Health Professional Training Programs." Four committees have been established: Patient Education, Professional Eduction for Physicians, Community Outreach, and Literature. The Steering Committee to Promote Breastfeeding in New York City continues to implement specific strategies to promote breastfeeding. The work of six task groups is well underway, and reports of some of their activities are discussed in other sections of this report. In addition to all of these state and local coalition activities, Healthy Mothers, Healthy Babies state coalitions in Arizona, California, Maryland, and Montana reported a focus on the promotion of breastfeeding. Education Systems Limited efforts to integrate breastfeeding information into existing secondary school curricula and educational programs and systems are being reported. The New York State Health Department reported loaning films on breastfeeding free of charge to schools for family life education courses. In Arizona, La Leche League members are invited to speak in some schools. Primary care projects such as North Jefferson Health Systems, Inc., Clayton, NY provide films, informational materials, and staff to lecture on breastfeeding in schools. In addition, prenatal and parenting classes conducted by a wide variety of health agencies include information on breastfeeding. Such agencies in- clude Clinica Sierra Vista (Lamont, CA), Northern Oswego County Health Services, Inc. (Pulaski, NY), San Juan Department of Health and the Con- cilia De Salud Integral De Loiza, Inc. (PR), and the Anchorage Health Department (AK). Coordination/Sharing of Educational Materials Educational materials on breastfeeding developed by such organiza- tions as La Leche League, International Childbirth Education Association, the American Academy of Pediatrics, and The American Dietetic Associa- tion are utilized nationwide. In addition, information and materials available from industries such as Ross Laboratories, Mead Johnson, Wyeth Laboratories, and Gerber are also used and adapted as necessary. Many local health departments report that they utilize materials from their respec- tive state health agencies. Data Collection It appears that more effort is being made to collect baseline data useful in monitoring changes in attitudes and behavior related to breastfeeding. States utilizing the automated data system of the Women, Infants, and Children program to monitor the incidence of breastfeeding are Alabama, Arizona, Colorado, Connecticut, Iowa, Kentucky, Maine, Montana, 12 Nebraska, New Jersey, North Carolina, Rhode Island, Tennessee, and Wisconsin. Over 300 maternal and child health agencies and primary care programs in the Department of Health and Human Services Region VI have surveyed knowledge, attitudes, and practices among their clients. Maine, California, and Oregon report use of their state-wide newborn screening program data base to determine incidence of breastfeeding. In Maine, for example, a recently initiated Newborn Breastfeeding Surveillance Program provides information on breastfeeding rates in Maine hospitals and about feeding practices of at least 90 percent of the newborns in the state. The Ross Laboratories National Mothers Survey is conducted on an annual basis to track infant feeding practices in the United States. The data from the 1984 survey are scheduled to be published in the December 1985 issue of Pediatrics. Surveys to assess practices and policies were also conducted by Alaska's State Department of Health and Social Services; Arizona's State Depart- ment of Health; St. Louis, Missouri's County and City Women, Infants, and Children Advisory Council; and Tennessee's State Department of Public Health. The surveys obtained information from mothers, birth cer- tificates, hospitals, health programs, and other data sources. 13 HEALTH CARE SYSTEM Recommendation: Strengthen the support for breastfeeding in the health care system Practices of the health care team and policies of health care institutions do not always reflect concern for lactation and the promotion of breast- feeding. In fact, frequently they negate support for it. This recommenda- tion deals with the need for breastfeeding promotion in ambulatory health care settings as well as hospitals. The need for education for all members of the health care team about the process and the advantages of lactation in human reproduction and infant health was emphasized. Adoption of in- stitutional policies supportive of lactation and breastfeeding and removal of disincentives to breastfeeding were recommended. Many supportive actions are also reported under Professional Education and Support Services. Five different strategies appeared frequently to be used to strengthen the health care system's support of breastfeeding. These include: develop- ment and promulgation of institutional policies, standards, and protocols; modification or enactment of laws and regulations; implementation of model or demonstration programs; education of staff and clients; and development of task forces, guides, and materials. Examples of each of these strategies follow. Policies/Standards/Protocols Federal, state, and local agencies report the development, adoption, and dissemination of policies, standards, and protocols designed to increase support for breastfeeding in the health care system. Some examples are given below: o The United States Department of Agriculture revised "Efforts To Pro- mote Breastfeeding in the Supplemental Food Programs," a fact sheet which describes federal requirements, publications, and guidance available from the United States Department of Agriculture, cooperative efforts, and other useful information. o The Division of Maternal and Child Health/Department of Health and Human Services included breastfeeding promotion as a priority area for competitive grant applications for Fiscal Year 1985 funding under the Maternal and Child Health Improvement Projects category of Special Projects of Regional and National Significance. o In New Mexico, nutrition recommendations for lactating women and in- fant feeding were included in a state nutrition manual. Breastfeeding: A Problem Solving Manual was also developed by the nutrition staff of the state health agency for use by nurses, nutritionists, and other health pro- fessionals. 14 8 The Women, Infants, and Children and the Commodity Supplemental Foods Program State Plans and Policies continue to emphasize breastfeeding as a priority among program goals. Connecticut, Min- nesota, and Wisconsin Women, Infants, and Children programs require each local agency to include measures to promote breastfeeding in its an- nual plan. o A policy and procedure manual on breastfeeding for babies requiring newborn intensive care and other special care was developed at the University of Kansas Medical Center. Policy changes have been instituted to support breastfeeding of preterm and sick infants. o Six Steps to Breast Feeding Promotion: A Handbook for Health Care Professionals in Maternal and Infant Care Facilities was developed by the Prenatal and Postpartum Ambulatory Care Task Group of the Steering Committee to Promote Breastfeeding in New York City. o The Suggested Guidelines and Standards for Maternal and Perinatal Nutrition Care, which includes breastfeeding, continues to be pro- mulgated by the Michigan Health Department in cooperation with the Michigan State Medical Society and the Michigan Dietetic Association. o "A Model Breastfeeding Policy for Full-Term Normal Newborn Infants" was developed by the San Diego Lactation Program (CA), and a similar policy is in preparation by the Greater Southeast Community Hospital (DC). o A "Breastfeeding Promotion Policy," issued by the Tennessee Depart- ment of Health and Environment, is posted in every health department clinic statewide. A Breastfeeding Promotion Handbook to assist local health departments with planning and implementing such efforts is being completed. o The Arkansas Public Health Association adopted the American Public Health Association resolution on Breastfeeding Encouragement. 0 The Georgia Division of Public Health, Office of Nutrition developed a position paper on breastfeeding. Guidelines are also being prepared and will be distributed statewide as part of a practice manual. o Quality assurance standards for lactation were developed by the Maternal and Child Health Division, Indiana Department of Health, and made available for use in all local health services. Laws/Regulations This particular strategy has not been used extensively, but several states have undertaken activities related to either changing existing laws and regulations, or developing new ones in order to influence the health care system to facilitate breastfeeding. Some of these activities are given below: o In New York State, breastfeeding regulations were issued as an amend- ment to the New York Hospital Code (see Support Services). o In Massachusetts, there is a proposed amendment to the patients' bill of rights to inform prenatal and maternity patients about the health benefits and techniques of breastfeeding and lactation. The bill (S2269) is in the Senate Steering and Policy Committee. o In the Pacific Basin, a model bilI supporting the promotion of breastfeed- ing and adaptable to each jurisdiction is being prepared for inclusion in a breastfeeding packet, This effort is part of the focus on breastfeeding, a priority of the Pacific Basin Maternal and Child Health Resource Center IS at the University of Guam. This center is supported by Division of Mater- nal and Child Health funds. Model/Demonstration Programs Many agencies implemented a variety of model or demonstration pro- grams which provide continuous support, professional consultation, client counseling, and education. Descriptions of a number of these programs are mentioned below: o "The Lactation Project" at Oregon Health Sciences University Hospital serves women who deliver their babies there as well as those referred by private physicians. The project includes a lactation clinic, inservice train- ing of staff, consultation to staff and private physicians, telephone followup of clinic clients, and prenatal education which includes breastfeeding. o "The Model Breastfeeding Program" of Tacoma-Pierce County Health Department is supported by the Washington State Office of Maternal and Child Health. Details of this project are discussed under Support Services. o The project "Overcoming Constraints to Breastfeeding in Lower Socio- economic Urban Groups" has been continued by the Population Council (NY). Focusing on factors over which hospital staff could exert some control, a Nursing Department Lactation Committee was developed in the hospital. Functions of the Committee relate to staff and patient education, reporting techniques, and development of more consistent, quality nursing care throughout the period of pregnancy, lactation, and infancy. An interdisciplinary group meets on an ad hoc basis to examine impediments to breastfeeding as they relate to medical and nursing issues. Plans include employment of a part-time lactation counselor, a telephone hotline for nursing mothers, and training of a multidiscipline staff. o The three-year "SPRANS Breastfeeding Project" at Albert Einstein Col- lege of Medicine (NY) is described under Professional Education. In ad- dition to activities cited elsewhere, a curriculum outline, "Art and Science of Breastfeeding," and a form for prenatal pediatric interviews have been developed. o A joint breastfeeding promotion project of the Washington State Office of Maternal and Child Health Services and the Seattle-King County Department of Public Health is developing a system to promote breastfeeding that can be replicated statewide. Supported as a Title V Maternal and Child Health Improvement Project, the goals of the project are: to establish a model for increasing the incidence and duration of breastfeeding among low-income and minority women that incorporates support for breastfeeding into the existing health care delivery system; to provide breastfeeding education to public health professionals throughout Washington; and to develop breastfeeding education materials for statewide use. A model of service will be developed, im- plemented, and evaluated at two sites that currently have very low rates of breastfeeding. A manual to assist others in the development of similar projects will also be written. o A breastfeeding promotion project conducted by Renewable Technologies, Inc., in Butte, MT aims to develop breastfeeding counsel- 16 ing and support in the existing private maternal and infant care system where virtually all such care is provided in Montana. Health care profes- sionals (nurse, nurse-midwife, dietitian) will function as breastfeeding subspecialists who will become self-supporting independent practitioners in the existing private system. The cost of providing breastfeeding sup- port services by a breastfeeding subspecialist and the potential for any reimbursement for payment of these services will be determined. o The pilot project "Maternal and Child Health Module" has been initiated at Shady Grove Adventist Hospital (MD). The focus includes change in hospital policies, staff education, and a strengthening of referral and followup. o The "Breastfeeding Promotion Program" at Yeatman, Union-Sarah Medical Health Centers, St. Louis, MO, involves promotion, education, counseling, and support activities. An ad hoc task force was organized to explore the feasibility of such a program and assist in its implementation. A prenatal counseling protocol was established. A series of letters to the client's family, including grandparents and fathers, was developed and many other actions implemented. o A project related to promotion of breastfeeding in the hospital setting was conducted by the Division of Child and Family Health, Department of Health and Welfare, Canada. Another project involved the develop- ment of a counseling guide, Feeding Babies in the Eighties, for health professionals. Staff/Client Education A diverse group of health care agencies took positive steps to improve the knowledge and skills of staff and clients involved in the health care system. Activities directly related to this recommendation are also discussed under Professional Education, Public Education, and Support Services, and some are mentioned in the paragraphs that follow: o The first step in a multifaceted program for Alabama's health depart- ment personnel is in-service training on aspects of breastfeeding promo- tion. Five of the ten health districts are focusing on increasing the in- cidence of breastfeeding. o Significant numbers of community health centers have stepped up their efforts to provide individual counseling and patient education, and to use prenatal and childbirth preparation classes effectively for education regarding breastfeeding. Among such health centers were the Oak Orchard Health Center and Coney Island Community Health Center (NY), East Orange Family Health Center (NJ), Clinica Adelante, Inc. (AZ), and Neponset Health Center (MA). o Nurses in the area of Cleveland Metropolitan General and Highland View Hospitals (OH) received training on the promotion of breastfeeding of high risk infants from the neonatal nutritionist. o The Hudson Headwaters Health Network, Warrensburg, NY, provides a free pediatric visit for couples before their baby is born. During this visit the pediatrician stresses the importance of breastfeeding. Information about breastfeeding is also presented during the Lamaze classes spon- sored by the Network. 17 Task Forces/Guides/Materials A variety of organizations and agencies, both individually and in groups, have formed committees and have developed guides and other materials to improve the support for breastfeeding throughout the health care system. A brief summary of these guides and other materials is given below: o A breastfeeding task force is being established by the Cincinnati Depart- ment of Health and University Hospital (OH). This collaborative effort is expected to result in an increase in the incidence and duration of breastfeeding in health service facilities. o The chart, "Hospital Practices Which Influence Breastfeeding Ini- tiation," included in the Report of the Surgeon General's Workshop on Breastfeeding and Human Lactation, has been widely used by hospitals as a guide to assess hospital practices and identify areas in need of im- provement . o A handbook, Six Steps to Breartfeeding Promotion, has been prepared for health care professionals in maternal and infant care facilities by the New York City Steering Committee to Promote Breastfeeding. The com- mittee's Facility Task Group is planning a workshop to develop strategies for decreasing institutional barriers to breastfeeding. o Numerous hospitals have prepared or adopted breastfeeding guidelines, policies, and education materials to improve in-hospital ,and out-patient services related to breastfeeding. These include Brigham and Women's Hospital, Boston, MA, New Orleans Charity Hospital (LA), and many others. o St. Luke%Roosevelt Hospital Center Breastfeeding Committee (NY), composed of representatives from the departments of Pediatrics, Obstetrics, Nursing, Food Service and Nutrition, Pharmacy, and Social Services continues its work. After three years of coordinated effort, its Breastfeeding Manual is ready to be published. Geared toward educating all hospital staff, it is a direct "hands on" reference and teaching tool in Spanish and English. It will be formally introduced to the staff at a breastfeeding conference. SUPPORT SERVICES Recommendation: Develop a broad range of support services in the community This recommendation focuses on the need for women to have access to the followup support necessary to cope with questions and problems related to lactation and breastfeeding, both during hospitalization and following discharge from the hospital. Such support should: 1) emphasize the strengths of the family; 2) respect the variations found within different cultural, ethnic, and economic groups as well as life styles; 3) offer a con- tinuum of care for the mother and baby throughout the reproductive cycle and infancy; and 4) effectively use community resources. Seven general approaches seem to be used to develop and ensure the availability of a range of community support services. These include maintenance of telephone calling systems, development of peer support groups, use of peer breastfeeding counselors and professional lactation specialists, provision of nurse followup and referral, sponsorship of breastfeeding clinics and classes, removal of institutional barriers and im- provement of institutional practices, and the operation of human milk banks. Many of the activities reported under Professional Education, Public Education, and World of Work address the need for followup support. Ad- ditional examples of activities targeted on the development of community support services follow. Telephone Calling Systems One method of providing local support for breastfeeding mothers is telephone followup by staff or volunteers. A few examples are given below: o The Nutrition Project, Inc. (WI) developed a new publication, Starting a Telephone Support System for Breastfeeding Mothers. This guide pro- vides step-by-step advice about how to establish a "buddy" support system directed to low-income breastfeeding mothers. o Several community health centers also provide for telephone contact. For example the Charles Drew Health Center, Inc. in Omaha, NE provides for a telephone call to the mother one to three days after hospital discharge and a home visit within the first week. For ongoing peer sup- port, referrals are made to the local La Leche League. In Lamont, CA, Clinica Sierra Vista provides for a telephone followup call to breastfeeding mothers the first two days after discharge from the hospital. Call are made by a nutrition aide. 19 o The Milwaukee, WI Task Force on Breastfeeding maintains a telephone "buddy" support system using 40 trained volunteers to answer questions and assist with problems. Peer Support Groups One of the most widely available sources of support for breastfeeding mothers in local communities is peer support groups. Some exampIes of peer support groups and their activities are given below: o La Leche League continues to be a major resource for peer support in a large number of communities in every state. Health care providers in both the private and public sectors report working closely with League groups to make referral arrangements that facilitate necessary support during lactation. The Zanesville Muskingum Prenatal Clinic in Zanesville, OH and the Valley Health Center in Yuma, AZ are examples of such joint ef- forts. o Public health agencies and community health programs are increasing their efforts to establish support groups. In Georgia, for example, district health departments are promoting the development of such groups. A volunteer support system has been established in Eau Claire, WI, and it works closely with local hospitals, clinics, social service agencies, and Women, Infants, and Children programs. The Appalachian Ohio Rural Health Initiative Program sponsors group sessions on breastfeeding for women in the third trimester of pregnancy. The Catawba Public Health District (SC) continues its monthly Nursing Mothers Support Group meetings, provides information through telephone contacts by volunteers, and recommends books and other material on breastfeeding to be carried by bookstores and specialty shops. A breastfeeding mothers support group in Sussex County, DE focuses on prenatal patients and hospital obstetric patients. In Hamilton County, OH the Women, In- fants, and Children program makes a small library of breastfeeding references available for client use. The Deposit Health Center in Deposit, NY utilizes the United Heath Services outreach worker for. home followup to assist and provide support for breastfeeding mothers. o In the southeast Queens area of New York City, Cornell University Co- operative Extension's Expanded Food and Nutrition Education Program, in conjuction with the National Black Women's Health Project, is establishing breastfeeding support groups. Many of these groups are composed of volunteers recruited from the Education Program's homemakers. They include both English and Spanish language groups. It is expected that hospital maternity staff and Women, Infants, and Children program staff will refer clients to the support groups. o Metro Nursing Mothers was initiated in St. Paul, MN to provide profes- sional support and problem solving to both professional persons and breastfeeding families. This non-profit organization holds weekly clinics in a church. Breastfeeding Counselors The availability of professional and peer breastfeeding counselors is in- creasing as a source of support for mothers. Mentioned below are some of these counseling services: 20 o The Adams County, OH Women, Infants, and Children program uses private funding to support a part-time lay breastfeeding counselor to pro- vide education and followup services. She is available for home and hospital visits which are followed up by phone and mail contacts. A similar program in a large Arizona hospital employs La Leche League leaders as paid breastfeeding counselors six days a week to provide educa- tion and counseling. o The North Central Bronx Hospital has a "Doula" project funded by the New York State Department of Health. The "Doula" works with new breastfeeding mothers individually, participates in postpartum rounds and classes, provides telephone followup, and helps families obtain other needed services. o Two county health departments in Maryland are involved in a pilot pro- gram for peer counselors. Protocols for the program were developed by a graduate student from Johns Hopkins University School of Public Health. o The Riverside County, CA Women, Infants, and Children pro- gram staff developed a Lactation Counselor Manual. Materials from the National Child Nutrition Project (PA) also include a Counselor's Guide to Breastfeeding. o Through a grant to the Rhode Island Women's Health Collective, the Rhode Island State Department of Health has supported a part-time per- son to train peer counselors who promote breastfeeding in the Hispanic population. Not all efforts to develop peer counseling programs have been suc- cessful. For example, the Waianae Coast Comprehensive Health Center in Hawaii explored the possibility of using Women, Infants, and Children pro- gram participants who were currently nursing or had previously breastfed their babies for six months or more as counselors. While 18 women agreed to become involved, attendance at followup training meetings was poor, and the project was dropped. Nurse Followup/Referral One example of nurse followup is the program of the Family Care Center of Carondelet in St. Louis, MO. It provides for prenatal and postpartum home visits for each client by the Maternal Health Nurse to discuss breastfeeding and other aspects of care. Referrals are made to La Leche League for continuing support. As noted earlier, the Charles Drew Health Center in Omaha, NE also provides for home visits and referrals to La Leche League. In Florida, the North Central Maternal and Infant Care- Women, Infants, and Children project continues to offer home visits to newly breastfeeding women within the first weeks after hospital discharge. Settlement Health and Medical Services, Inc. in New York City provides a hospital visit by a nurse-midwife and a home visit, within 48 hours after hospital discharge, by a pediatric nurse practitioner to ensure that breastfeeding is proceeding well. Clinics/Classes The Tacoma-Pierce County Health Department (WA) operates a Model Breastfeeding Program supported by the State's Office of Maternal and Child Health. Breastfeeding clinics are held twice weekly, and chsses 21 are scheduled monthly to promote breastfeeding, particularly among low- income women. A pediatric nurse practitioner is responsible for the pro- gram. In addition to the clinics and classes that provide an opportunity to address common concerns of breastfeeding mothers and assist them in locating community resources, she is available for telephone consultation and in-service education for health professionals. She also assists other local health departments through on-site consultation in developing similar pro- grams. In Wyoming, ongoing breastfeeding classes sponsored by county public health agencies are in progress in 22 of the 23 counties. Special classes are also conducted for new breastfeeding mothers through clinics serving clients of the Women, Infants, and Children program. La Leche League has developed a new format of breastfeeding classes to be available for mothers who prefer this to the traditional ongoing meetings. Institutional Practices Two examples of efforts to remove hospital barriers to breastfeeding are the National Child Nutrition Project (PA) program and the breastfeed- ing legislation enacted in New York State. Detailed descriptions of these ef- forts are given below: o Through a grant from the Ford Foundation, the NationalChild Nutrition Project has focused on removing hospital barriers to breastfeeding and strengthening the prenatal and postpartum breastfeeding support net- work in hospitals where low-income women deliver their babies. The Project's policies and procedures, materials, and research findings have been compiled into the Breastfeeding Promotion Guidebook which is available in English and Spanish. The guidebook served as the framework for three conferences in Chicago, Dallas/Fort Worth, and Baltimore. Teams of three to five persons representing hospital and ambulatory health services were invited to the conferences. One objective was to stimulate these teams to work together in developing a coordinated breastfeeding promotion effort for women during pregnancy and throughout the lactation period. o The State of New York has recently passed breastfeeding regulations to amend the New York Hospital Code. Under the 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 designate at least one person who is thoroughly trained in breastfeeding physiology and management to be responsible for presentation of an effective breastfeeding instruction program. Hospitals will be required to carry out policies and procedures such as: prohibiting the use of standing orders for antilactation drugs; assisting the infant to breastfeed immediately following delivery, unless contraindicated; pro- viding for the infant to be fed on demand; restricting supplemental feedings to those indicated by a medical condition of infant or mother; and restricting distribution of discharge packs of infant formula to an in- dividual order by the attending physician or the specific request of the mother. 22 Human Milk Banks Human milk banks appear to be increasing in number. Besides serving as a source of human milk, many of the banks instruct mothers about im- proved techniques for expression and storage of milk. For example, the Hawaii Mother's Milk Bank provides training to health professionals. The Mother's Milk Bank of San Jose (CA) has developed a manual for use by facilities desiring to set up human milk banks. The Community Human Milk Bank, Georgetown University Hospital (DC) issues a periodic Donor Newsletter to promote communication among donors and provide new in- formation from staff. 23 WORLD OF WORK Recommendation: Initiate a national breastfeeding promor: directed to women in the world of work The focus of this recommendation is the importance of facili:;ul~~,l , ,,, employed woman's opportunity to breastfeed. An increasing n'-in\tI,,, women are involved in school, job training, professional educa:i,\t\, "I employment, and these mothers frequently receive negative rnessa$i'x "(\I[ .I\, "`II breastfeeding. Moreover, institutional policies and practices I I\ , 1,. workplace, and the lack of appropriate support systems, often a