Primary Care Interventions to Promote Breastfeeding

Fact Sheet and Resources

In the US, an estimated 75% of mothers initiate breastfeeding; however, by 6 months only 15% breastfeed exclusively.

Evidence indicates that interventions to promote and support breastfeeding increase the rates of initiation, duration, and exclusivity of breastfeeding.

U.S. Preventive Services Task Force (USPSTF) Grade: B
USPSTF Recommendation:
Interventions during pregnancy and after birth to promote and support breastfeeding.¹

Consider multiple strategies: 1) Formal breastfeeding education for mothers and families 2) Direct support of mothers during breastfeeding 3) Training of primary care staff about breastfeeding and techniques for breastfeeding support 4) Peer support. Among these, strategies that included contacting women before and after delivery were more effective compared to the strategies involved in only one of the periods.²

Breastfeeding - Provider Fact Sheet    PDF version - 332.17 KB

• Why is this important?
• How frequently is this preventive service being provided?
• What are the best interventions identified in the literature?
• What barriers exist for providers?
• What are some ideas to address these barriers?
• What does the Affordable Care Act cover?
• What does Medicaid cover?
• References

For More Information

• Provider Implementation Tools
• Other Resources

Why is this important?

Breastfeeding has been shown to be one of the most effective preventive measures mothers can take to protect their children's health.³

Breastfeeding can help lower a mother's risk of type 2 diabetes, breast cancer, ovarian cancer and postpartum depression.⁴

In the United States, an estimated 79% of infants initiate breastfeeding; however, by 6 months just 19% breastfeed exclusively.⁵

Rates are significantly lower for African–American infants.⁶

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How frequently is this preventive service being provided?

Assessments of the various components of lactation services are not currently available in the literature.⁷

In 1991, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) established the Baby–Friendly Hospital Initiative (BFHI), which supports and recognizes hospitals and birthing centers that offer an optimal level of care for infant feeding by following the BFHI's Ten Steps to Successful Breastfeeding. Multiple studies have demonstrated improved breastfeeding outcomes when hospitals adopt these steps.⁸

A relationship has been found between the number of BFHI steps in place at a hospital and a mother's breastfeeding success. One study found that mothers who stayed in hospitals that did not follow any of the steps were eight times as likely to stop breastfeeding before their infants were 6 weeks old as mothers who stayed at hospitals that followed six of the steps.⁹

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What are the best interventions identified in the literature?

A systematic review and meta–analysis of 38 randomized, control trials investigated the effectiveness of primary care–initiated interventions to improve breastfeeding initiation or duration among health mothers with healthy, term infants. The evidence review found these interventions significantly increased exclusive breastfeeding in both short term (1–3 months) and long–term (6–8 months). The interventions determined to meet the eligibility criteria included:

• Direct assistance, support, and education to mothers and families about breastfeeding, from a variety of providers (peer counselors, nurses, lactation consultants, midwives, physicians) across a variety of settings (hospital, home, clinic, community) and in various levels of formality or structure;
• Structured training to health professionals on how to effectively assist and educate mothers and families and other aspects of breastfeeding support.

The evidence review also found that interventions with pre– and postnatal components were more effective than those with only pre– or postnatal elements, and that including peer support or peer counseling in the interventions improves short–term breastfeeding rates.¹⁰

Added benefits may result from efforts that are integrated into systems of care. System–level interventions can incorporate clinician and team member training and policy development, and through senior leadership support and institutionalization, these initiatives may be more likely to be sustained over time.

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What barriers exist for providers?

• Lack of experience and training on breastfeeding support as an integral component of the provision of primary care contributes to providers' hesitation to initiate discussions with patients about breastfeeding.
• Unsure how to go about gaining adequate reimbursement for these services.
• Lack of awareness that breastfeeding equipment and supplies, such as breast pumps are covered by the Affordable Care Act (ACA), as is breastfeeding counseling, including direct assistance, support, and education to mothers.

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What are some ideas to address these barriers?

• Include questions about breastfeeding on intake forms.
• Train providers on breastfeeding, including criteria for follow–up and referral, problem–solving, and ways to effectively discuss breastfeeding without taking over the patient encounter.
• Identify reliable local breastfeeding experts to whom patients can be referred and those from whom providers can learn new strategies and gain support and expertise.
• Provide a workflow process for billing and reimbursement methods.

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What does the Affordable Care Act cover?

All Marketplace plans and many other plans must cover Breastfeeding comprehensive support and counseling for pregnant and nursing women without charging a copayment or coinsurance. This is true even if the patient has not met their yearly deductible. This applies only when these services are delivered by a network provider.¹¹

Pregnant and postpartum women now have access to comprehensive lactation support and counseling from trained providers, as well as to breastfeeding equipment.¹²

The Centers for Medicare and Medicaid Services (CMS) also provides information about the Coverage of Preventive Services.

HealthCare.gov provides lists of preventive care benefits for all adults and those specific to women.

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What does Medicaid cover?

Each state has its own plan for Medicaid coverage. To find out more about Medicaid and CHIP eligibility and coverage in your state, please visit Medicaid.gov.

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For more information

Provider Implementation Tools

Centers for Disease Control and Prevention (CDC) Breastfeeding Promotion & Support from Health Care providers and settings includes The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies and other helpful resources.

How Doctors Can Help: Surgeon General's Call to Action to Support Breastfeeding [PDF] provides actions doctors can take to support mothers in breastfeeding; with support mothers are more likely to be able to breastfeed their babies.

Academy of Breastfeeding Medicine (ABM) is a worldwide organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation.

• ABM Clinical Protocol #14 – Breastfeeding–Friendly Physician's Office: Optimizing Care for Infants and Children
• ABM Clinical Protocol number #19 – Breastfeeding promotion in the prenatal setting

American Academy of Pediatrics Breastfeeding Residency Curriculum aims to help residents develop confidence and skills in breastfeeding care.

U.S. Breastfeeding Committee provides a listing of organizations that provide breastfeeding education and training for health care professionals.

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Other Resources

The CDC Breastfeeding website provides a variety of information including recommendations, data and statistics, research, promotion & support, policies, and other resources and publications.

The Baby–Friendly Hospital Initiative (BFHI) is a global initiative of the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). It is implemented in the United States by Baby–Friendly USA, Inc. (BFUSA). As of August 2014, 194 maternity facilities in the U.S. have been designated Baby–Friendly, having completed the assessment and award process set forth by WHO and UNICEF and requiring systemic and active engagement throughout all levels of facility care in supporting mothers to start and continue breastfeeding.

U.S. Breastfeeding Committee (USBC) is an independent nonprofit organization which brings together a coalition of more than 70 organizations that work collaboratively to protect, promote, and support breastfeeding. The health care section of their website provides information on Training for Heath Care Professionals, Professional Lactation Services, Hospital/Maternity Center Practices, and other education materials.

Ten Steps to Successful Breastfeeding WHO/UNICEF describes recommendations for maternity care facilities according to the document: Protecting, Promoting, and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF statement published by the World Health Organization.

Office on Women's Health Breastfeeding website provides information for consumers including tips and suggestions to help successfully breastfeed.

U.S. Department of Agriculture (USDA) Health & Nutrition Information for Pregnant & Breastfeeding Women is an interactive and informational website for consumers.

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