BREASTFEEDING:
PROMOTION & LEGISLATION
Virginia C. Petrikonis
Introduction
Upon completion of this PowerPoint, the reader will be
able to:
 Understand the significance of breastfeeding and why
it is a political issue.
 Identify the history and evolution of U.S. breastfeeding
legislation and understand the need for current policies.
 Determine alternatives to legislation action that can
potentially influence change.
 Identify the role of healthcare providers in influencing
the future of breastfeeding policy.
Why Breastfeed?
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Breast-milk has every vitamin, mineral, and other nutrient
that a baby needs whereas formulas do not (Wiessinger,
West, & Pitman, 2010).
Breastfeeding decreases a baby’s risk of allergies, dental
problems, infections, intestinal upsets, respiratory problems
and SIDS (Wiessinger, West, & Pitman, 2010).
Breastfeeding mothers save money, lose weight more
readily, miss less work, and are less likely to suffer from
postpartum depression or get breast, uterine, or cervical
cancer (Breastfeeding, 2011).
Breastfeeding ensures the best possible health as well as the
best developmental and psychosocial outcomes for the infant
(Crase, 2005).
Breastfeeding & Society
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Recent research shows that if 90% of families breastfed
exclusively for 6 months, nearly 1,000 deaths among infants
could be prevented.
If 90% of families breastfed, it is estimated that the U.S.
would save $13 billion per year because medical care costs
are lower for breastfed infants.
Breastfeeding is better for the environment: less trash and
plastic waste than formula cans and bottle supplies.
Breastfeeding leads to a more productive workforce since
mothers miss less work to care for sick infants.
(Breastfeeding, 2011)
AAP & Breastfeeding
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The abundance of new data about the beneficial
effects of breastfeeding influenced the American
Academy of Pediatrics (AAP) to update its
guidelines, now recommending exclusive
breastfeeding for about 6 months, followed by
continued breastfeeding as complementary foods
are introduced, with continuation of breastfeeding
for 1 year or longer as mutually desired by mother
and infant (Rochman, 2012).
Barriers to Breastfeeding
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Health professionals lack training, education, and resources to provide appropriate
breastfeeding support.
Legislation and policies do not adequately support breastfeeding. The U.S. lacks
consistent legislation to support the socioeconomic need for paid maternity leave,
necessary for exclusive breastfeeding. This contrasts with Canada, European Union
countries, and many other countries worldwide where paid maternity leave is
required.
Worksites generally do not support the needs of lactating employees, nor are there
national laws to require worksite lactation support.
There is increasing aggressive advertising of human milk substitutes, including
widespread hospital distribution.
The cultural emphasis in the U.S. on the sexuality of the human breast has created
significant barriers to the cultural acceptance of breastfeeding.
Breastfeeding rates are lower among mothers who are young, not college
educated, or unmarried.
U.S. mothers at high risk for early weaning include first-time mothers, those with less
formal education, those who are non-White, and those who are ill postpartum.
(A Call to Action on Breastfeeding, 2007)
Breastfeeding:
A Public Health Issue
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Economic, cultural, and political pressures often
confound decisions about infant feeding (Crase, 2005).
The AAP has recalibrated the national dialogue on
breast-feeding, deeming it a “public health issue and
not only a lifestyle choice” (Rochman, 2012).
Breastfeeding is an important public health issue that
merits societal support from the hospital to the
workplace (Rochman, 2012).
Data indicate that the rate of initiation & duration of
breastfeeding in the U.S. is well below the Healthy
People 2010 goals (Crase, 2005).
International Treaties & Conventions
Supporting Breastfeeding
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In May 1981, the International Code of Marketing of
Breast-milk Substitutes and its resolutions was
overwhelmingly approved by the World Health
Assembly by a vote of 118:1. The lone vote against the
Code came from the U.S., which was concerned that the
Code could have a detrimental effect on U.S. business.
For more information:
http://bestforbabies.wordpress.com/2007/05/09/inte
rnational-treaties-and-conventions-supportingbreastfeeding/
(Cayetano, 2007)
Should Breastfeeding Be Protected
Under U.S. Law?
Yes!
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Breastfeeding mothers sometimes need to feed their
babies in public since a baby’s feeding needs
cannot be determined by a set schedule.
Indecent exposure and dress code laws need to be
adapted for breastfeeding mothers.
Breastfeeding mothers who work need to be
ensured reasonable breaks in order to express milk.
The CDC reports that formula marketing has a
disproportionately negative impact on U.S. mothers
already at high risk for early weaning.
(A Call to Action on Breastfeeding, 2007)
The Constitutional Right To Breastfeed
Dike v. Orange County School Board, 650 F.2d 783 (5th
Cir., 1981)
 A teacher wanted to nurse her baby on her lunch break,
but the school claimed that insurance provisions
prohibited teachers from bringing their children onto
school property & also prohibited teachers from
leaving the school grounds during the day. The trial
court ruled that the mother had no right to breastfeed.
In Dike, the appeals court reversed the case, stating that
breastfeeding is a protected constitutional right.
(Baldwin, 1999)
History of U.S. Breastfeeding
Legislation
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HR 2490, with a breastfeeding amendment, was signed
into law on September 29, 1999. It stipulated that no
government funds may be used to enforce any
prohibition on women breastfeeding their children in
federal buildings or on federal property.
U.S. Public Law 106-58, Sec. 647 was enacted in 1999.
It states that "a woman may breastfeed her child at
any location in a federal building or on federal
property, if the woman and her child are otherwise
authorized to be present at the location.”
Breastfeeding in public is now legal in all 50 states &
DC.
(Breastfeeding Laws, 2011)
State Breastfeeding Laws
45 states have laws that specifically allow women to
breastfeed in any public or private location.
 28 states exempt breastfeeding from public indecency laws.
 24 states have laws related to breastfeeding in the
workplace.
 12 states exempt breastfeeding mothers from jury duty.
 5 states have implemented or encouraged the development
of a breastfeeding awareness education campaign.
For more information on specific state breastfeeding laws:
http://www.ncsl.org/issues-research/health/breastfeedingstate-laws.aspx
(Breastfeeding Laws, 2011)
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(Existing Legislation, 2011)
(Existing Legislation, 2011)
ACA & Breastfeeding
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Section 4207 of the Patient Protection and
Affordable Care Act (ACA) amended the Fair
Labor Standards Act (FLSA). The amendment
requires employers to provide reasonable break
time and a private, non-bathroom place for nursing
mothers to express breast-milk during the workday,
for one year after the child’s birth. The new
requirements became effective when the ACA was
signed into law on March 23, 2010.
(Existing Legislation, 2011)
Recent Legislation:
HR 2758
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HR 2758: Breastfeeding Promotion Act of 2011
Breastfeeding Promotion Act of 2011 amends the Civil
Rights Act of 1964 to include lactation as protected conduct.
It amends the Fair Labor Standards Act of 1938 to extend
the requirement that certain employers provide reasonable
break time for an employee to express breast-milk for her
nursing child to bona fide executive, administrative, or
professional capacity employees or outside salesmen who
are exempt from federal labor laws that limit the number of
hours in a workweek.
The bill is currently in the House Subcommittee on Health,
Employment, Labor, and Pensions.
(HR 2758, 2011)
How Healthcare
Affects Breastfeeding
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Health professionals have inadequate training, education,
and resources to provide appropriate breastfeeding
support.
Maternity & birthing practices that are not medically
indicated interfere with the establishment of breastfeeding.
Infant formula marketing, particularly hospital discharge
packs, discourages breastfeeding.
The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) is
a package of 10 evidenced-based steps shown to increase
sustained breastfeeding rates, but it has been achieved by
fewer than 3% of maternity hospitals and birth centers in
the United States.
(A Call to Action on Breastfeeding, 2007)
Breastfeeding Report Card:
2011 is its 5th year. It provides perspectives on state and national trends in
breastfeeding data.
Percent of births at Baby-Friendly facilities in 2011, by state
(Breastfeeding Report Card-United States, 2011)
Stakeholders
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American Academy of Pediatrics (AAP)
American Public Health Association (APHA)
Centers for Disease Control & Prevention (CDC)
La Leche League International (LLLI)
International Baby Food Action Network
International Code of Marketing of Breast-milk Substitutes
National Initiative for Children’s Healthcare Quality (NICHQ)
National Prevention, Health Promotion, and Public Health Council
National Women’s Health Information Center
United Nations Children’s Fund (UNICEF)
United States Breastfeeding Committee (USBC)
U.S. Department of Health & Human Services
U.S. Surgeon General
World Health Organization (WHO)
Stakeholders:
Supporting Breastfeeding
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The WHO & grassroots non-governmental organizations
such as IBFAN have played a large role in encouraging
governmental departments to promote breastfeeding &
the development of national breastfeeding strategies.
There continues to be an ongoing struggle between
corporations promoting artificial substitutes and
grassroots organizations & WHO who promote
breastfeeding.
Breastfeeding legislation aims to increase the incidence
and duration of breastfeeding by helping to change
the public opinion about breastfeeding.
(Existing Legislation, 2011)
Stakeholders: Resources
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Resources include mothers and families, communities, healthcare,
employers, research & surveillance, & public health infrastructure.
(Breastfeeding: Promotion & Support, 2011)
The National Breastfeeding Policy Conference in 1998 was a major
resource for stakeholders. The conference helped identify policies &
strategies to move the U.S. forward towards setting a national policy
agenda to promote breastfeeding.
 The conference brought together new members to a partnership
of stakeholders to support breastfeeding. The mandate from the
conference was transferred to the USBC.
 The federal government, through the Maternal & Child Health
Bureau, Health Resources and Services Administration, asked the
USBC to provide a strategic plan to protect, promote, & support
breastfeeding in the U.S.
(National Breastfeeding Policy Conference, 2008)
Role of Policymakers
& Stakeholders
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Support small nonprofit organizations that promote
breastfeeding in African-American communities.
Support compliance with the International Code of
Marketing of Breast-milk Substitutes.
Increase funding of high-quality research on
breastfeeding.
Support better tracking of breastfeeding rates as
well as factors that affect breastfeeding.
(Fact Sheet, 2011)
Current Policies & Initiatives:
NICHQ: Best Fed Beginnings
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The CDC supports NICHQ in leading Best Fed
Beginnings, an effort to help U.S. hospitals make
quality improvements to maternity care to better
support mothers and babies to be able to
breastfeed.
This project addresses the need to improve hospital
practices to support breastfeeding & help hospitals
move toward Baby-Friendly status.
(Existing Legislation, 2011)
Current Policies & Initiatives:
National Prevention Strategy
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The National Prevention Strategy is a comprehensive plan that
will help increase the number of Americans who are healthy at
every stage of life.
The National Prevention Strategy was released on June 16,
2011, by the National Prevention, Health Promotion, & Public
Health Council.
The strategy identifies seven Priorities: Tobacco Free Living,
Preventing Drug Abuse and Excessive Alcohol Use, Healthy Eating,
Active Living, Injury and Violence Free Living, Reproductive and
Sexual Health, & Mental and Emotional Well-Being.
Breastfeeding is included under Healthy Eating & specifically
calls to "Support policies and programs that promote
breastfeeding.”
(Existing Legislation, 2011)
Current Policies & Initiatives:
Surgeon General’s Call to Action to Support Breastfeeding
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The Surgeon General’s Call to Action to Support
Breastfeeding outlines steps that can be taken to
remove some of the obstacles faced by women who
want to breastfeed their babies.
Identification of 20 key actions to improve support
for breastfeeding.
Calls for a commitment to ensure that breastfeeding
support is consistently available for every mom and
baby.
Visit www.surgeongeneral.gov for more information.
(Fact Sheet, 2011)
Current Policies & Initiatives:
Let’s Move! Campaign
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Let’s Move! is a comprehensive initiative launched
by First Lady Michelle Obama. It is dedicated to
solving the problem of childhood obesity.
Under its 5 pillars is pillar #1: Creating a healthy
start for children.
4 recommendations under the 1st pillar outline the
support of breastfeeding by healthcare providers,
health departments, community-based
organizations, insurance companies, & early
childhood settings.
(Existing Legislation, 2011)
Current Policies & Initiatives:
Healthy People 2020
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Healthy People provides research-based, 10-year national
objectives for improving the health of all Americans. It is
managed by the U.S. Department of Health and Human
Services.
Healthy People 2020 objectives on breastfeeding are under
the Maternal, Infant, and Child Health Topic Area, under the
section on "Infant Care.”
Seeks to increase the proportion of infants who breastfeed,
increase worksite lactation support programs, increase
lactation support in hospitals, and reduce infant
supplementation in breastfed newborns.
Goals include: 82% ever breastfed, 61% at 6 months, and
34% at one year.
(Existing Legislation, 2011)
Current Policies & Initiatives:
CDC Guide To Breastfeeding Interventions
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CDC Guide To Breastfeeding Interventions provides
state & local communities information to choose the
breastfeeding intervention strategy that best meets
their needs.
Support for breastfeeding is needed in many different
arenas, including worksites, medical systems, and family
settings.
The Guide builds upon the research that demonstrates
effective interventions as well as the expertise of the
nation's leading scientists and experts in breastfeeding
management and interventions.
(Existing Legislation, 2011)
Group Theory & Breastfeeding Policy
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The interaction among groups is central to the development
of breastfeeding policies (Cox, 2010).
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An ongoing struggle exists between corporations promoting
artificial substitutes and grassroots organizations & WHO who
promote breastfeeding (Existing Legislation, 2011).
Breastfeeding public policy results from an equilibrium
reached in the group struggle (Cox, 2010).
Policy moves in the direction desired by the groups gaining
influence and away from desires of groups losing influence
(Cox, 2010).
 WHO & grassroots organizations have gained influence, yet
issues remain regarding the Baby-Friendly Hospital Initiative due
to marketing of formulas and concerns about U.S. business
(Existing Legislation, 2011).
Group Theory & Breastfeeding Policy
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The political system has managed group conflict by
arranging compromises & balancing interests as well
as enacting compromises in the form of public policy
(Cox, 2010).
 Mothers may breastfeed in public in all 50 states.
 Development of indecent exposure & dress code laws
have been adapted for breastfeeding mothers in many
states.
 Breastfeeding mothers who work must be provided with
reasonable breaks in order to express milk.
(Existing Legislation, 2011)
Development:
The Future of Breastfeeding Policy
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In order to effectively make changes in breastfeeding
laws and public policy, powerful group involvement and
increased public awareness are needed.
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As more research has come out and public awareness has
increased, groups such as AAP & WHO have gotten
involved to make U.S. breastfeeding rates a matter of
public health rather than lifestyle choice (Rochman, 2012).
Currently, fewer than 12% of U.S. babies are
exclusively breastfed for 6 months, despite
recommendation from UNICEF and WHO.
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A multi-faceted, multi-disciplinary approach to infant
feeding is needed in order to significantly increase
breastfeeding rates.
(Breastfeeding: A Vision for the Future, 2011)
Alternatives to Policy
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Create widespread knowledge of the importance of
breastfeeding and the risks of not breastfeeding.
Educate mothers and families so they can make
informed choices about feeding children.
Allow & encourage women to begin and continue
breastfeeding for as long as they wish.
Educate healthcare providers on evidence-based
birth practices and breastfeeding care.
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Encourage more hospitals to become Baby-Friendly.
(Breastfeeding: A Vision for the Future, 2011)
Policy Recommendations:
Breastfeeding: A Vision for the Future
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USBC created the Vision that sets 9 specific objectives that
must be met in order to fully address the barriers to
breastfeeding:
1. Meet and exceed the Healthy People objectives to increase the
proportion of mothers who breastfeed.
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Important to implement, but difficult to monitor.
2. Implement maternity care practices that foster normal birth and
breastfeeding in every facility that cares for childbearing women.
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May be difficult to get providers to adhere to these practices.
3. Ensure that healthcare providers provide evidence-based, culturally
competent birth and breastfeeding care.
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Effective way to ensure breastfeeding needs of new mothers are met.
4. Create and foster work environments that support breastfeeding
mothers.
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Difficult to quantify but is appropriate and effective.
(Breastfeeding: A Vision for the Future, 2011)
Policy Recommendations:
Breastfeeding: A Vision for the Future
5. Ensure that all federal, state, and local laws relating to child welfare
and family law recognize the importance of breastfeeding and support its
practice.
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Ensures equity throughout the U.S. and is an efficient means of awareness.
6. Implement curricula that teach students of all ages that breastfeeding is
the normal and preferred method of feeding infants and young children.
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Will promote responsiveness and effectively decrease stigma.
7. Reduce the barriers to breastfeeding imposed by the marketing of
human milk substitutes.
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Will be difficult to implement due to U.S. economic climate.
8. Protect a woman’s right to breastfeed in public.
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Effective and appropriate means of increasing the incidence of breastfeeding.
9. Encourage greater social support for breastfeeding as a vital public
health strategy.
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Appropriate in order to increase responsiveness and increase the incidence &
duration of breastfeeding.
(Breastfeeding: A Vision for the Future, 2011)
How Health Professionals Can Help
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Lobbying: give examples from patients in your practice or
individuals you know and how the legislation would impact them.
Support legislation & programs to help women to succeed with
breastfeeding.
Include lactation consultants on patient care teams.
Help write hospital policies that help every mother be able to
breastfeed.
Patient education can promote breastfeeding & help legislation
succeed.
Support compliance with the International Code of Marketing of
Breast-milk Substitutes.
Increase funding of high-quality research on breastfeeding.
Support better tracking of breastfeeding rates as well as factors
that affect breastfeeding.
(Fact Sheet, 2011)
Implications of Supporting
Breastfeeding
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As the largest healthcare profession in the United States,
totaling 3.1 million professionals, nurses play a critical role
in breastfeeding education and support & should be the first
level of intervention for breastfeeding mothers and their
babies.
Health professionals need to support patients’ intentions to
breastfeed as well as health system changes to improve
patient satisfaction and breastfeeding outcomes.
Support of breastfeeding legislation will help remove
obstacles to breastfeeding and help increase breastfeeding
rates in the U.S.
(Spatz, 2011)
Summary
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WHO & AAP recommend that infants be exclusively
breastfed for the first six months of life (Spatz, 2011).
According to U.S. Surgeon General Dr. Regina M. Benjamin,
the lack of breastfeeding in the United States is a public
health crisis (Spatz, 2011).
APHA reports that hospital-based practices are key to the
success of breastfeeding, and the education of healthcare
workers can increase the success of breastfeeding (A Call to
Action on Breastfeeding, 2007).
Breastfeeding legislation aims to increase the incidence and
duration of breastfeeding by helping to change the public
opinion about breastfeeding (Existing Legislation, 2011).
Resources
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A Call to Action on Breastfeeding: A Fundamental Public Health Issue (2007,
November). American Public Health Association. Retrieved from
http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360.
Baldwin, J.D. (1999) A look at enacting breastfeeding legislation. Retrieved from
http://www.llli.org/law/lawenact.html#BREASTFEEDING%20LEGISLATION:%20A
N%20OVERVIEW.
Breastfeeding (2011, September). Womenshealth.gov. Retrieved from
http://www.womenshealth.gov/breastfeeding/why-breastfeeding-is-important/.
Breastfeeding: A Vision for the Future (2011). United States Breastfeeding
Committee. Retrieved from
http://www.usbreastfeeding.org/LegislationPolicy/BreastfeedingAdvocacyHQ/Br
eastfeedingAVisionfortheFuture/tabid/214/Default.aspx.
Breastfeeding Laws (2011, May). National Conference of State Legislators.
Retrieved from http://www.ncsl.org/issues-research/health/breastfeeding-statelaws.aspx.
Breastfeeding: Promotion and Support (2011, August). Centers for Disease
Control & Prevention. Retrieved
fromhttp://www.cdc.gov/breastfeeding/promotion/index.htm.
Resources
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Breastfeeding Report Card-United States (2011). Centers for Disease
Control and Prevention. Retrieved from
http://www.cdc.gov/breastfeeding/data/reportcard.htm.
Cayetano, P. (2007, May). International treaties and conventions supporting
breastfeeding. Retrieved from
http://bestforbabies.wordpress.com/2007/05/09/international-treatiesand-conventions-supporting-breastfeeding/.
Crase, B. (2005). AAP policy statement: breastfeeding and the use of
human milk. Pediatrics 115 (2), 496-506.
Cox, K.B. (2010). Models for Policy Analysis Part 1. (Unpublished
dissertation). University of Virginia, Charlottesville, VA.
Existing Legislation (2011). United States Breastfeeding Committee.
Retrieved from
http://www.usbreastfeeding.org/LegislationPolicy/ExistingLegislation/tabi
d/233/Default.aspx.
Fact Sheet (2011, January). Office of the Surgeon General. Retrieved from
http://www.surgeongeneral.gov/topics/breastfeeding/factsheet.html.
Resources
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HR 2758: Breastfeeding Promotion Act of 2011(2011). GovTrack.us. Retrieved
from http://www.govtrack.us/congress/bill.xpd?bill=h112-2758.
National Breastfeeding Policy Conference (2008). United States Breastfeeding
Committee. Retrieved from
http://www.usbreastfeeding.org/LegislationPolicy/FederalPoliciesInitiatives/N
ationalBreastfeedingPolicyConference/tabid/122/Default.aspx.
Rochman, B. (2012). Why pediatricians say breastfeeding is about public
health, not just lifestyle. Retrieved from
http://healthland.time.com/2012/02/29/why-pediatricians-say-breastfeeding-is-about-public-health-not-just-lifestyle/.
Spatz, D. (2011, June). Call to Breastfeeding Action – Policy and Practice for
Nurses. Retrieved from http://www.newswise.com/articles/call-tobreastfeeding-action-policy-and-practice-for-nurses.
Wiesenger, D., West, D., & Pitman, T. (2010). The womanly art of
breastfeeding. New York: Ballantine Books.