Breastfeeding Priorities: Safe Sleep, Bias, Gender Equitable Norms, and Paid Leave 

Q&A with Internationally and Nationally Recognized Breastfeeding Expert, Lori Feldman Winter, MD, MPH

August 5, 2019

In 2010, the U.S. made breastfeeding a national health improvement priority by identifying eight key breastfeeding objectives in the Healthy People 2020 goals, a ten-year agenda for promoting national health. And while we’ve made significant improvements as a nation (surpassing five of the eight breastfeeding objectives), there is still considerable progress needed to help more mothers reach their breastfeeding goals.  

Feldman-Winter serves as a faculty expert on the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network (NAPPSS-IIN), funded by the Health Resources and Services Administration Maternal and Child Health Bureau. NAPPSS-IIN seeks to make infant safe sleep and breastfeeding the national norm by aligning stakeholders to test safety bundles in multiple care settings to improve the likelihood that infant caregivers and families receive consistent, evidence-based instruction about safe sleep and breastfeeding. Along with NAPPSS-IIN, Feldman-Winter is the Physician Lead for the Communities and Hospitals Advancing Maternity Practices (CHAMPS) project, under the Center for Health Equity, Education and Research (CHEER) of Boston Medical Center, and the Chair of the American Academy of Pediatrics (AA) Section on Breastfeeding, and member of the AAP Task Force on SIDS. She is the Professor of Pediatrics at Cooper Medical School of Rowan University and Pediatrics/Adolescent Medicine specialist at Cooper University Health. 

This need and national commitment have sparked numerous NICHQ-led breastfeeding initiatives that have touched hundreds of thousands of infants across the country. Now, in honor of National Breastfeeding Month, we’ve taken time with NICHQ Faculty Expert, Lori Feldman-Winter, MD, MPH, an internationally and nationally recognized expert on breastfeeding nutrition, education and policy, to recognize successes and learn about opportunities for improvement. Her frank description of bias and her passion for promoting gender-equitable social norms have inspired us to continue pursuing sustainable improvements. 

NICHQ: Since 2010, what are the biggest breastfeeding improvement successes you’ve seen? What suggestions do you have for harnessing and scaling those successes?

Lori Feldman-Winter: For one, the NICHQ-led Best Fed Beginnings Initiative, where we worked with 89 hospitals across the country to improve maternity care practices to better support breastfeeding. This was really a major landscape change for the United States. By implementing evidence-based practices that support breastfeeding, hospitals give mothers the tools to meet their breastfeeding goals right from the beginning and set them up for success once they go home. Now, nearly all of the Best Fed Beginnings hospitals have achieved the World Health Organization/UNICEF Baby-Friendly designation, which recognizes their success in supporting breastfeeding. This significantly increased the number of hospitals that have achieved Baby-Friendly designation, far exceeding the Healthy People 2020 goal, with over a million U.S. babies being born in Baby-Friendly hospitals every year.

The other major shift has been supporting breastfeeding through a collective impact model centered on equity. In 2011, the U.S. Surgeon General gave a call to action to support breastfeeding that looked beyond hospitals to what employers, community leaders, families and policy makers can do, and situated recommendations in the context of equity. The U.S. Breastfeeding Committee (USBC) took on the bulk of this work, transforming their approach to better represent and support diverse communities and reflect and realize the effects of implicit bias. This shift has sparked palpable change across the country, with many organizations emerging to better support under-represented populations and communities of color. We’ve seen this with our work on NAPPSS-IIN because so many experts from the USBC and other national organizations are members of the NAPPSS-IIN National Coalition, serving as advisors and helping us ensure an equitable approach that activates community champions.

Let’s talk about the connection between breastfeeding and sleep-related infant deaths. What does the latest research tell us?

There have been a lot of studies about this and the meta-analysis led by Dr. Thompson, which combines data from several studies, effectively enumerates the amount of protection that breastfeeding offers in preventing infant mortality, particularly regarding Sudden Infant Death Syndrome (SIDS). We can break this down a couple ways:

First, any breastfeeding, compared to no breastfeeding at all, can protect against death from SIDS, and this protection increases the longer you breastfeed, which means its dose-responsive and that is significant. If you can breastfeed for six months, you actually decrease the risk of SIDS by 60 percent, and that is really dramatic.

Second, the longer you exclusively breastfeed, the better—and that’s the AAP recommendation. We don’t have data for exclusive breastfeeding at six months, but we know there’s a 54 percent risk reduction at four to six months, so the risk reduction at six months may be even greater than the 60 percent reduction we see for any breastfeeding. 

The reality is that we don’t know the mechanism of protection, and it is likely to be multifactorial. The evidence is overwhelming that beyond putting baby to sleep on back, breastfeeding is the biggest thing we can do to reduce SIDS and SUID.

There’s been a lot of progress with increasing breastfeeding rates, but there are persistent racial and ethnic disparities. What can we do to close the breastfeeding gap?

First, we need to keep elevating and empowering community champions. As health care professionals, we have the knowledge-base, understand the evidence and know the policies. But we may not be the best ones to do the work of community champions; we aren’t the best messengers because we don’t necessarily have the community’s trust, and we don’t necessarily share the community’s culture. Instead, we need to partner with community coalitions and allies—trusted individuals who share their community’s values and can talk with families in an environment where they feel safe, respected and heard. By building these partnerships, we can impart success stories and help families hear clear and consistent messages in their communities that complement what they hear in the hospital. We see this in NAPPSS-IIN, where our Wisdom Council and Communities of Practice help to assure that we are hearing the community’s voice. And when we launch NAPPSS-IIN’s third cohort, we’ll deepen the work in the communities, which is essential to achieving our aim.

We also need to do more to bring down systemic barriers to breastfeeding, and health care in general. We [the medical community] carry implicit bias and we practice differently depending on the populations we serve. Until this is widely recognized, disparities in care and in outcomes will persist.

That’s why it is so important to collect data broken down and stratified by race and ethnicity; it will help us illustrate differences in care so health facilities and practitioners can engage in improvement efforts that reduce, if not eliminate, those disparities. Together, we can change how we deliver care, checking our biases at the door and promoting equitable outcomes.

The 2019 World Breastfeeding Week theme is “Empowering Parents, Enabling Breastfeeding,” which acknowledges the need to be inclusive of all types of parents and caregivers. How can we do this? How do we promote gender-equitable social norms to better support breastfeeding?

This is again about taking an equity lens to breastfeeding and breaking down barriers. We need to consider all caregivers, including fathers, as well as those who identify as gender neutral and those within the LGBTQI+ community. We need to ask, ‘how do we better support breastfeeding among gender nonconforming individuals and nontraditional partners?’ so we don’t alienate anyone when it comes to breastfeeding. It starts with being more inclusive and acknowledging that the benefits of breastfeeding aren’t all tied to the concept of the “breast” itself. Breastfeeding is a complex compilation of systems including biological benefits from skin-to-skin touching and nurturing; nutrients from human milk that can be breast- or bottle-fed; and benefits that come directly from the flora on a lactating/nursing breast.

All of this to say that there are multiple ways to look at breastfeeding, talk about breastfeeding and understand its benefits. A chest that may not be able to produce milk can still nurture babies through the benefits of skin-to-skin contact. People who don’t produce breastmilk can still provide human milk through donor milk and bottle feeding. Transgender men and gender nonconforming parents and caregivers may still breastfeed safely if they choose to, and may prefer the term chestfeeding over breastfeeding because it respects their identity. All kinds of arrangements can be made to truly provide an equitable support system. As clinicians and scientists, we need to keep an open mind as we look at breastfeeding and explore how to optimize the health and well-being of all babies and families.

What work needs to happen at the policy-level to support breastfeeding?

If we are really serious about improving the health of the nation, and if we believe that health depends on increased breastfeeding, we have to get serious around discussions about paid parental leave. Parents need to feel supported—culturally, socially and economically supported—to stay home and establish and sustain breastfeeding.

Women should feel empowered to meet their breastfeeding goals and their personal and workforce goals. This requires longer paid leave that equips women to establish breastfeeding, and workplace policies that allow for continuation, including lactation rooms for pumping and onsite childcare so women can breastfeed directly. We should pursue opportunities to incentivize breastfeeding, whether through the Affordable Care Act or modifying tax structures, so that moms are afforded the time, space and money to breastfeed to meet their personal goals.   

One of the barriers to policy change is that, as a nation, we don’t equate the work of breastfeeding in any financial way. And as a result, financial gain can become a tradeoff for breastfeeding. We have a lot to learn from countries that calculate the work of breastfeeding into their gross national product. We’re a working nation; it’s a defining part of our culture, which means recognizing the work of breastfeeding is critical to pursuing national policy change.

We’ll be celebrating breastfeeding awareness all through August. Join us in celebrating; access a breastfeeding social media toolkit here.