The Milky Way Mothers:
Mom-to-Mom Support to Ensure Breastfeeding Success
Program Planning & Evaluation Spring 2015
Kristen Amrhine, Laura Allen, Jenifer Fahey & Lauren Gritzer
Goal
To improve infant and child
health in West Baltimore by
increasing the number of
women who successfully
breastfeed their infants.
American Academy of Pediatrics
(AAP) Breastfeeding
Recommendations
● Women should try to breastfeed their infants for the first 12
months of life.
● Women who don't have health problems should exclusively
breastfeed their infants for at least the first 6 months of life
(except for vitamin D supplements).
● After the first 6 months and until 1 year old, the mother
should continue breastfeeding while gradually introducing
solid foods.
Why Breastfeeding?
Public Health Relevance
● Nutritionally balanced meals- Perfect mix of vitamins, whey
and casein (proteins), and fat
● The colostrum made by breasts the first few days after
childbirth helps newborn’s digestive system grow and
function. Breast milk is also easier to digest than formula
● Protection against common childhood illnesses and infections
● Physical and emotional benefits of breastfeeding directly from
the mother's breast due to skin-to-skin contact
Why Breastfeeding?
Public Health Intervention Relevance
● Better survival during the first year of life, including lower risk
of Sudden Infant Death Syndrome
● Less chance of developing some allergic diseases
● Less chance of developing type 1 diabetes
● Shown connection between breastfeeding and better
cognitive development in children through school age
● Less likely to develop asthma
● Mothers who breastfeed have a decreased risk of breast and
ovarian cancers
Why Breastfeeding?
Public Health Intervention Relevance
Respiratory Tract Infections and Otitis Media
● Any breastfeeding compared with exclusive commercial infant
formula feeding will reduce the incidence of otitis media (OM)
by 23%.1
● Any breastfeeding is associated with a 64% reduction in the
incidence of nonspecific gastrointestinal tract infections. This
effect lasts for 2 months after cessation of breastfeeding.1,2,3,4
● One case of necrotizing enterocolitis could be prevented if 10
infants received an exclusive human milk diet, and 1 case of
NEC requiring surgery or resulting in death could be
prevented if 8 infants received an exclusive human milk diet.5
Breastfeeding National Rates
• While 75% of new mothers start out breastfeeding, only 13%
of them still exclusively breastfeed by the time their infants
are 6 months old.
• At the end of six months, breastfeeding rates fall to 43%,
and only 13% of babies are exclusively breastfed.
• Among African-American babies, the rates are significantly
lower, 58% start out breastfeeding, and 28% breastfeed at
six months, with 8% exclusively breastfed at six months.
Major Factors That Have Influenced
Breastfeeding Policy in the US
➢ 1984 U.S Surgeon General’s Workshop on
Breastfeeding & Human Lactation
➢ 1990 Innocenti Declaration, WHO and UNICEF
➢ 2000 Healthy People 2010
➢ 2000 HHS Blueprint for Action on Breastfeeding
➢ 2010 Healthy People 2020
➢ 2011 Surgeon General’s Call to Action to Support
Breastfeeding
● Goal: Improve the health and well-being of women,
infants, children, and families.
Objective: Increase the proportion of
infants who are breastfed
● Increase the proportion of infants who are ever
breastfed, target= 81.9%
● Increase the proportion of infants who are breastfed at 6
months, target= 60.6%
● Increase the proportion of infants who are breastfed at 1
year, target= 34.1%
● Increase the proportion of infants who are breastfed
exclusively through 3 months, target= 46.2%
● Increase the proportion of infants who are breastfed
exclusively through 6 months, target= 25.5%
Healthy People 2020 Goals
vs. Actual
Breastfeeding Rates by Country
Maryland Mothers who
Breastfed for at Least 10
Weeks, 2004-2007
Breastfeeding Rates of Children Born in 2007
US Average vs. Maryland vs. Baltimore City
n
Ever
Breastfeeding
Breastfeeding
at 6 months
Breastfeeding
at 12 months
US National
16629
75.0±1.2
43.0±1.3
22.4±1.1
MARYLAND
444
73.4±7.8
45.5±8.0
17.9±5.6
253
62.6±7.3
36.4±6.7
19.9±5.0
State & Breakdown
MD-Baltimore City
Provisional Geographic-specific Breastfeeding Rates among Children born in 2007
(Percent +/- half 95% Confidence Interval)
Why Are African American Women Not
Breastfeeding?
Public Health Intervention Relevance
●
Perceived lack of information about
benefits and management of
breastfeeding
●
●
●
Difficulties breastfeeding in public
●
Easy availability of formula
supplements at hospital
Fear of embarrassment
Lack of a support system for
continued breastfeeding
Why Are African American Women Not
Breastfeeding?
Public Health Intervention Relevance
●
●
●
Fear of difficulty or pain during breastfeeding
●
Poor maternal health at delivery
●
●
Cessation to return to work or school
Belief of not having enough milk
Time constraints
Infant breast rejection
Surgeon General’s Call to Action
Includes:
● Importance of Breastfeeding
● Rates of Breastfeeding
● Barriers to Breastfeeding in the US
● Breastfeeding from a Public Health Perspective
Call to Action Includes Steps for…
● Mothers and their families
● Communities
● Health Care
● Employment
● Research & Surveillance
● Public Health Infrastructure
BASELINE ASSESSMENT
Define
Population/
Community
Identify
Partners &
Stakeholders
Assess
Resources
Identify Gaps
in Services
Define
Population/
Community
Target Population
● Women who receive prenatal care at Maryland
Women’s Center at Penn Street and who deliver their
babies at UMMC.
● Approximately 800 women/year
Catchment Area Maryland
Women’s Center at Penn Street
Volume
61-350
patients
61-100
patients
21-60
patients
3-20
patients
1-2
patients
Data Source:
FPI
WEST
BALTIMORE
Community Demographics &
Health Statistics
● Median Household Income $27,158 (US $51,759)
● Race:
● Black or African American 76.2 %
● White 17.6%
● Life Expectancy at birth 65.0 years (US 78.4)
● Infant mortality 13.6/1000 (US 6.1/1000)
● Adjusted mortality 1573/10000 (US 740/10000)
Patient Demographics
Primarily African-American
● African American
● Caucasian
● Hispanic
● Asian
● Native American
● Other
Primarily on Public Insurance
● Medicaid
● Private Insured
● Uninsured
● Other
85%
11%
2%
1%
<1%
<1%
93%
3%
1%
3%
30%
……breastfeeding initiation
~6%
……breastfeeding continuation to
6 months
Identify
Partners &
Stakeholders
Partners & Stakeholders
● University of Maryland Medical
Center
● Breastfeeding Committee
● Hospital Executive Office
● University of Maryland
Department of Obstetrics &
Gynecology and Department
of Pediatrics
● Baltimore City Health
Department
● DHMH
● WIC
● Women of reproductive age
and their families
Assess
Resources
Resources
● University of Maryland Medical Center
● Breastfeeding Committee
● 1.1 FTE lactation consultants
● WIC*
● Nursing staff
● Space
● Penn Street
● Nurses
● Nurse-midwives
● Space
● West Baltimore
● WIC
● Mothers who have breastfed
Identify
Gaps in
Services
“Well, I found that number one, there wasn’t
support in the African-American community to
breastfeed. Support – as far as support
groups, information about breastfeeding,
breastfeeding classes, people saying that ‘hey,
you should breastfeed your baby’, there wasn’t
even a dialogue about breastfeeding.”
-Kathi Barber
Baltimore City Mom
Founder of the African American Breastfeeding Alliance
Program hypotheses:
● If babies are breastfed until they are at least 6 months
of age, then they are more likely to be healthier and
less likely to die in their first year of life than if they are
not breastfed.
● If women have increased access to breastfeeding
support during the first few weeks home with a
newborn, then they will be more likely to continue
breastfeeding.
Program hypotheses:
● If women have an opportunity to interact with other
women from their community who have successfully
breastfed, then they will have an increased sense that
they too will also be able to successfully breastfeed.
● If women have access to support individuals with whom
they identify, then they will be more likely to seek
advice or help when they are having difficulties
breastfeeding or considering breastfeeding
discontinuation.
Program hypotheses:
● If women seek advice from women who are knowledgeable about
breastfeeding and who have successfully breastfed themselves,
then they will be more likely to follow accurate advice rather than
advice that may be inaccurate and counterproductive to
breastfeeding success.
Intervention
To establish a peer-led antenatal educational
program and a peer-support system for new,
breastfeeding mothers who receive their
prenatal care at the University of Maryland
Women’s Center at Penn Street.
Logic Model: Milky Way Mothers
Resources
Activities
Outputs
Funds
Training of Peer
Counselors
Trained Peer
Counselors
Increased percentage
of women who initiate
breastfeeding
Space
Design and
Development of
Breastfeeding Class
Breastfeeding Class
Presentation
Women know what to
expect in first few
weeks of
breastfeeding
Training Curriculum
Weekly Support
Group Sessions
Pregnant mother
participation in
breastfeeding classes
Women are able to
seek and receive help
when they have
breastfeeding
difficulties
Health Educator(s)
Weekly One-to-One
Counseling Sessions
Breastfeeding mom
participation in support
groups and counseling
sessions
Women have a
supportive network of
breastfeeding women
from their community
Lactation Consultant
Referrals to Lactation
Consultant
Lactating mothers with
problems seen by
lactation consultant
Decrease in women
who discontinue
breastfeeding in first
6-10 weeks
postpartum
Educational Materials
Outcomes
Impact
Mothers and infants
are healthier
Increase in
percentage of women
who are breastfeeding
at 6 months
postpartum
Evaluation: Process, outcome and impact measures
Behavioral Change Theories
Guiding Intervention
● Social support general concepts:
● Always intend to be helpful
● Is consciously provided
● Provided within the context of caring, trust, and respect to the
receiver
● The receiver has the right to make his/her own decisions and
choices
● Social Support & Health- Strong Evidence of:
● Lower all-cause mortality
● Better health behaviors
● Positive mental health
Program Planning Model
● Advocating and Planning for a Behavioral
Health Peer Support Program by Peer
Behavioral Health Work Greater National Peer
Support Collaborative Learning Network
Peer Support to Enhance
Breastfeeding Duration
The Evidence Base
Breastfeeding Support:
Cochrane Review
Overview:
● 52 studies from 21 countries (56,451 mother-infant
pairs)
● All forms of extra support analyzed together showed an
increase in duration of ‘any breastfeeding’ (includes
partial and exclusive breastfeeding)
● RR for stopping any breastfeeding before six months
0.91, 95% confidence interval (CI) 0.88 to 0.96)
● All forms of extra support together also had a positive
effect on duration of exclusive breastfeeding
● RR at six months 0.86, 95% CI 0.82 to 0.91; RR at four
to six weeks 0.74, 95% CI 0.61 to 0.89.
Breastfeeding Support:
Cochrane Review
Conclusions:
● All women should be offered support to breastfeed their
babies to increase the duration and exclusivity of
breastfeeding.
● Support may be offered either by professional or lay/peer
supporters, or a combination of both.
● Strategies that rely mainly on face-to-face support are
more likely to succeed
● Support should be tailored to the needs of the setting and
the population group.
Breastfeeding Support:
A Systematic Review of Literature
● 110 RTCs or quasi-experimental studies that compared
breastfeeding education or support interventions
compared to routine care
● 90% increase in exclusive breastfeeding at 1-5 months
● 18% reduction in “no breastfeeding” at 1-5 months
● Combined individual and group counseling superior to
individual or group counseling alone
Peer Support of Breastfeeding:
Review of the Literature
● Peer support has been shown to increase
breastfeeding duration
● Black women who attended peer support groups were
twice as likely to initiate breastfeeding as women who
did not (Mickens et al., 2009)
● Women who have access to peer support may feel
more self-confident in breastfeeding
“I think too, and not to make it a racial thing, but
sometimes you need to see someone that looks like
you and lives the same life and has the same
challenges…I mean it helps to see somebody like
you, to set the example.”
Breastfeeding mom, discussing the need for peer support
(Lewallen & Street, 2010)
Lactation Consultant = Resource and Referral
Program Coordinator/Health Educator = Oversees Program
Peer Counselors = Paid volunteers recruited from same
population as enrollees
Enrollees = New moms who need ongoing breastfeeding support
Antenatal
Classes
Peer
Support
Meetings
Milky
Way
Mothers
Referral
to
Services
One-onOne
Peer
Support
Program Workers’ Roles
Lactation Consultant
● Supports the Program Coordinator/Health Educator, acts as a
resource for the Peer Counselors, and handles all referrals
Program Coordinator/Health Educator
● Responsible for program promotion, registering new moms in
program, curriculum development, collecting
continuation/drop-out data at 2, 4, 6, 8, & 10 week intervals,
administering and evaluating a pre-test/post-test to enrollees
regarding breastfeeding knowledge and skills, teaching two
breastfeeding classes per month to enrollees, and performing
6-month and 1-year follow-up regarding breastfeeding
continuation/duration and infant health
Program Workers’ Roles
Cont.
Peer Counselors
● Each peer counselor will complete the 20-hr Loving
Support WIC peer counseling program
● Upon successful completion of training, each peer
counselor will have a caseload of 5 newly breastfeeding
moms who need ongoing support
● Peer counselors will be
expected to spend
approximately one hour
per week per enrollee,
providing a total of 5
hours per week of
counseling services
*Salary range for a Program Coordinator/Health Educator is $41,724.00 ─
$74,873.00. Salary provided for one year due to ongoing follow-up of enrollees, data
collection, and program evaluation at 6 months and 1 year.
*Hospital will cover costs of meeting space and utilities.
Cost-Analysis of Breastfeeding
vs. Formula-Feeding
● If 90% of mothers would breastfeed their infants
exclusively for 6 months, health care costs in the U.S.
would be reduced by $13 billion dollars per year.
● Studies have found reductions in costs for the following
pediatric diseases:
● necrotizing enterocolitis, otitis media, gastroenteritis,
hospitalization for lower respiratory tract infections, atopic
dermatitis, SIOS, childhood asthma, childhood leukemia,
type 1 diabetes, and childhood obesity.
(Spencer et al., 2013)
Cost of Formula
Formula Cost Calculator available at KellyMom.com
Measurable Health
Indicators
Process, Outcome, and Impact of the Milky Way Moms
Program
Outcome Objective
● To increase the number of
new moms who continue to
breastfeed beyond 6-10
weeks post-partum
● Measure: Compare
breastfeeding duration of
moms who attended
prenatal lactation classes
only vs. moms who
attended peer-supported
lactation group and receive
one-on-one peer support
Process/Performance
Objectives
● Baseline number of new moms who have initiated
breastfeeding in the hospital and enrolled in program
compared to number who are still in program and
breastfeeding at 2 weeks; 4 weeks, 6 weeks; 8 weeks;
and 10 weeks;
● Number of program/support classes attended by
breastfeeding moms;
● Number of encounters with peer support at each twoweek evaluation interval.
Outcome
Objectives/Indicators
● Percentage of infants 0-10 weeks who are exclusively
breastfed;
● Percentage of women who completed program
successfully and continue to breastfeed post-10 weeks
compared to percentage of women who took prenatal
lactation classes only who continue to breastfeed post10 weeks (nonequivalent comparison group);
● Percentage of children at 6 months and 1 year postpeer support program still breastfeeding.
Impact
Objectives/Indicators
● Number of sick-child visits to pediatrician in first
year of life
● Number of hospital visits in first year of life
● Number of babies with: asthma, recurrent URI,
recurrent ear-infections in group that
participated in program compared to nonprogram participants
References
American Academy of Pediatrics (AAP). (2012, February 27). Breastfeeding and the use of human milk. Pediatrics, 129, e827–e841.
Retrieved April 27, 2012, from http://pediatrics.aappublications.org/content/129/3/e827.full.pdf+html
Anderson, J. W., Johnstone, B.M., & Remley, D. T. (1999). Breast-feeding and cognitive development: A meta-analysis. American Journal of
Clinical Nutrition, 7, 525-535.
Duijts L, Jaddoe VW, Hofman A, Moll HA. Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy.
Pediatrics. 2010;126(1). Available at: www.pediatrics.org/cgi/content/full/126/1/e18
Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and Quality’s evidence report on
breastfeeding in developed countries. Breastfeed Med. 2009;4(suppl 1):S17–S30
Ip S, Chung M, Raman G, et al; Tufts-New England Medical Center Evidence-based Practice Center. Breastfeeding and maternal and infant
health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007;153(153):1–186
Kramer, M. S., Aboud, F., Mironova, E., Vanilovich, I., Platt, R. W., Matush, L., et al. (2008). Breastfeeding and child cognitive development:
New evidence from a large randomized trial. Archives of General Psychiatry, 65, 578-584.
http://newsone.com/2430024/black-women-and-breastfeeding/
http://www.acog.org/Patients/FAQs/Breastfeeding-Your-Baby
http://www.cdc.gov/breastfeeding/data/NIS_data/2007/state_any.htm
https://www.youtube.com/watch?v=SZ3QO-7h4YA
References
Quigley, M. A., Hockley, C., Carson, C., Kelly, Y., Renfrew, M. J., & Sacker, M. (2012). Breastfeeding is associated with improved child
cognitive development: A population-based cohort study. Journal of Pediatrics,160(1), 25–32. PMID: 21839469
Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom
Millennium Cohort Study. Pediatrics. 2007;119(4). Available at: www.pediatrics.org/cgi/content/full/119/4/e837
Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis
than a diet of human milk and bovine milk-based products. J Pediatr. 2010;156(4):562–567, e1
www.surgeongeneral.gov
Yamakawa, M., Yorifuji, T., Inoue, S., Kato, T., & Doi, H. (2013). Breastfeeding and obesity among schoolchildren: A nationwide
longitudinal survey in Japan. JAMA Pediatrics, 167(10), 919–925. PMID: 23939787