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APHA Endorses the Surgeon General’s Call to Action to Support Breastfeeding

Policy Date: 11/1/2011
Policy Number: 201115

Low rates of breastfeeding duration and exclusivity in the United States are related to a variety of factors beyond the direct control of mothers. The US surgeon general, Dr Regina Benjamin, launched a Call to Action to Support Breastfeeding[1] on January 20, 2011, that identifies 20 Action Steps that families, communities, employers, and health care professionals must take to improve a mother’s chances of successfully breastfeeding. By endorsing the Surgeon General’s Call to Action to Support Breastfeeding, the American Public Health Association (APHA) affirms its support for those actions, all of which contribute positively to the landscape of breastfeeding support.
Breastfeeding is recommended for at least the first year of a child’s life, and exclusively for the first 6 months.[2–5] The weight of evidence shows that breastfeeding is important for both maternal and child health outcomes in industrialized countries, including the United States.[6] Longer lifetime durations of breastfeeding are associated with decreased risks of maternal breast cancer,[6,7] ovarian cancer,[6,8] type 2 diabetes,[6,9,10] and cardiovascular disease.[11] In addition, longer durations of breastfeeding are associated with decreased risk of many common childhood infections [6] and sudden infant death syndrome,[6,12] as well as chronic conditions in offspring such as obesity,[6] type 1 diabetes,[6] and leukemia.[6]
Dr David Meyers, director of the Center for Primary Care at the Agency for Healthcare Research and Quality, summarized the current status on the value of breastfeeding, stating, “The evidence suggests that the debate over the relative value of breastfeeding compared with artificial means of feeding is over, as the data are unequivocal in favor of breastfeeding. The challenge must now be to establish appropriate systems and resources to support women and families who are interested in breastfeeding.”[13(p1308)]

The gap between current US breastfeeding rates and medical recommendations is believed to result in an estimated annual economic cost of $13 billion and an estimated 911 annual excess deaths among infants and children.[14] The costs include direct and indirect costs as well as the cost of premature death.

Despite the known risks of early weaning, US breastfeeding durations fall well short of the recommendations of health professional organizations[2–5] and the goals of Healthy People 2010 and, now, Healthy People 2020.[15] Seventy-five percent of babies initiate breastfeeding but only 13% are still exclusively breastfed at 6 months, with a disproportionately lower rate among African American women and lower rates in certain geographic regions of the United States.[16]

The sharpest drop-off in breastfeeding (20%) comes in the first month.[4] Research shows that evidence-based maternity practices are associated with longer breastfeeding durations in the first months,[17–19] and that peer counseling plays an important role in increasing breastfeeding duration, especially in low-income populations.[20–22] However, less than 4% of all US births occur in hospitals that employ evidence-based maternity care practices around breastfeeding, as certified by the Baby-Friendly Hospital Initiative.[23] Furthermore, the average US hospital scored only 63 out of a possible 100 points on the government survey of evidence-based maternity practices in infant feeding and care,[24] and this average even included those few hospitals designated as “baby-friendly.” In addition, there is a lack of consistent, mandated training and competencies on breastfeeding for health professionals that care for women and children. Appropriate training courses exist for nurses, for example, but hospitals often believe that paying for time and education as too costly a burden.[25]

Some important progress has been made with the 2010 passage of the Patient Prevention and Affordable Care Act. Section 4207 of that law requires employers to provide reasonable break time and a private, nonbathroom place for nursing mothers to express breast milk during the workday for 1 year after the child’s birth. However, this law does not include all working mothers and only addresses the expression of milk while at work, not other important issues such as paid parental leave and allowing mothers direct access to their infants while they are at work.
The surgeon general’s report notes that unacceptable disparities in breastfeeding have persisted by race/ethnicity, socioeconomic characteristics, and geography.[1] For example, breastfeeding rates for Black infants are about 50% lower than those for White infants at birth, age 6 months and age 12 months, even when the family’s income or education level is controlled for. Women with less than a high school education are less likely breastfeed than women who have earned a college degree. Children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which uses lower income to determine eligibility, are less likely to breastfeed than children in middle- and upper-income families. The southeastern United States consistently has the lowest breastfeeding initiation rates.

Effective national public health policy for the promotion and support of breastfeeding requires action from a wide variety of public and private stakeholders. Improved national public health policy will increase rates of exclusive breastfeeding and will improve breastfeeding duration by making the healthier choice, the easier choice. The surgeon general calls for building an infrastructure that supports breastfeeding (Action Step 20), including the formation of a federal Interagency Work Group on breastfeeding, to coordinate and strategize efforts to improve the nation’s breastfeeding rates. Such an infrastructure can create the appropriate support and incentives to make changes in the health care system, workplace, and society that make it easier for women to breastfeed longer and more fully.

The surgeon general’s report calls for 19 other Action Steps spread among the following sectors: mothers and their families, communities, health care, employment, research, and surveillance. These address the key barriers to breastfeeding identified in the report: lack of knowledge, lactation problems, poor family and social support, social norms, embarrassment, employment and child care, and health services.

For mothers and their families, the report calls for giving mothers the support they need to breastfeed (Action Step 1) and developing a program to educate fathers and grandmothers about breastfeeding (Action Step 2). There are 4 Action Steps for communities: strengthen programs that provide mother-to-mother support and peer counseling (Action Step 3), use community-based organizations to promote and support breastfeeding (Action Step 4), create a national campaign to promote breastfeeding (Action Step 5), and ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding (Action Step 6). For health care, the actions steps are as follows: ensure that maternity care practices throughout the United States are fully supportive of breastfeeding (Action Step 7); develop systems to guarantee continuity of skilled support for lactation between hospital and health care settings in the community (Action Step 8); provide education and training in breastfeeding for all health professionals who care for women and children (Action Step 9); include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians (Action Step 10); ensure access to services provided by International Board Certified Lactation Consultants (Action Step 11); and identify and address obstacles to greater availability of safe banked donor milk for fragile infants (Action Step 12).

In the employment sector, the surgeon general calls for working toward paid maternity leave for all employed mothers (Action Step 13), and ensuring that employers establish and maintain comprehensive high-quality lactation support programs for their employees (Action Step 14). It also calls for expanding the use of workplace programs that allow lactating mothers to have direct access to their babies (Action Step 15), and ensuring that all child care providers accommodate the needs of breastfeeding mothers and infants (Action Step 16). In terms of research and surveillance, the report calls for increased funding of high-quality research on breastfeeding (Action Step 17), and strengthening existing capacity and developing future capacity for conducting breastfeeding research (Action Step 18). Notably, the report also calls for the development of a national monitoring system to improve the tracking of breastfeeding rates as well as policies and environmental factors that affect breastfeeding (Action Step 19).
APHA has a history of activities that have contributed to the promotion of breastfeeding through research and advocacy.[26–28] The most recent comprehensive policy statement on breastfeeding, from 2007, called for exclusive breastfeeding to be identified as a leading health indicator for the nation, denounced aggressive marketing of human milk substitutes, supported paid maternity leave, and supported legislation and programs that allow women to succeed with breastfeeding in the United states, including worksite lactation protection. It also called for incorporating all components of the Baby-Friendly Hospital Initiative into the accreditation requirements of all facilities that provide maternity services. In this policy, APHA has also recognized the potential health risks that might arise from the contamination of human milk with toxins or viruses, and has called for the ratification of the Stockholm Convention on Persistent Organic Pollutants to minimize exposure of environmental contaminants to pregnant and lactating women.

Prior to the 2007 policy, APHA advocated for the reduction of the inappropriate marketing and use of breast milk substitutes,[29] including support for the Nestlé boycott.[30] APHA also supported the government’s Blueprint for Action on Breastfeeding (issued in 2000),[31] which highlights the need for worksite protection and promotion of the Baby-Friendly Hospital Initiative.
APHA appreciates the consistent work done by the Office of the Surgeon General from 1984 to the present. All the stakeholders in the area of maternal and child health have been involved in evaluating current knowledge and in developing a national approach to the promotion and protection of breastfeeding. The 20 Action Steps called for by the surgeon general are in line with prior APHA policy on breastfeeding.[26]

Therefore, APHA strongly endorses the Surgeon General’s Call to Action to Support Breastfeeding. APHA will continue to call for support in legislation and programs that enable women to succeed with breastfeeding in the United States.

APHA Recommendations:
1. In line with previous APHA policy,[26] APHA calls for Congress to appropriate adequate funding to implement the Call to Action to Support Breastfeeding, and for the Department of Health and Human Services to set aside funds that specifically allow for the implementation of the Call to Action.
2. APHA calls on legislators, policymakers, communities, and health care institutions to act to implement all 20 Action Steps recommended by the surgeon general in the Call to Action.


1. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2011.
2. WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Geneva, Switzerland: World Health Organization, United Nations Children's Fund; 2003.
3. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496–506.
4. American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women, Committee on Obstetric Practice. Breastfeeding: maternal and infant aspects. ACOG Clin Rev. 2007;12(1 suppl):1S–16S.
5. American Academy of Family Physicians. Family physicians supporting breastfeeding (position paper). Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed January 20, 2009.
6. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Evidence Report/Technology Assessment No. 153.
7. Stuebe AM, Willett WC, Xue F, Michels KB. Lactation and incidence of premenopausal breast cancer: a longitudinal study. Arch Intern Med. 2009;169(15):1364–1371.
8. Danforth KN, Tworoger SS, Hecht JL, Rosner BA, Colditz GA, Hankinson SE. Breastfeeding and risk of ovarian cancer in two prospective cohorts. Cancer Causes Control. 2007;18(5):517–523.
9. Liu B, Jorm L, Banks E. Parity, breastfeeding and the subsequent risk of maternal type 2 diabetes. Diabetes Care. 2010;33(6):1239–1241.
10. Schwarz EB, Brown JS, Creasman JM, et al. Lactation and maternal risk of type 2 diabetes: a population-based study. Am J Med. 2010;123(9):863.e1–e6.
11. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974–982.
12. Vennemann MM, Bajanowski T, Brinkmann B, et al. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics. 2009;123(3):e406–e410.
13. Godfrey JR, Meyers D. Toward optimal health: the maternal benefits of breastfeeding. J Womens Health (Larchmt). 2009;18(9):1307–1310.
14. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048–e1056.
15. Healthy People 2020: Improving the Health of Americans. Washington, DC: US Dept of Health and Human Services; 2010.
16. Breastfeeding Among US Children Born 1999–2007. CDC National Immunization Survey. Atlanta, GA: Centers for Disease Control and Prevention; 2010.
17. DiGirolamo A, Grummer-Strawn L, Fein S. Maternity care practices: implications for breastfeeding. Birth. 2001;28(2):94–100.
18. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122(suppl 2):S43–S49.
19. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase breastfeeding duration: results from a population-based study. Birth. 2007;34(3):202–211.
20. Chapman DJ, Damio G, Perez-Escamilla R. Differential response to breastfeeding peer counseling within a low-income, predominantly Latina population. J Hum Lact. 2004;20(4):389–396.
21. Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the US Preventive Services Task Force. Ann Intern Med. 2008;149(8):565–582.
22. Merewood A, Chamberlain LB, Cook JT, Philipp BL, Malone K, Bauchner H. The effect of peer counselors on breastfeeding rates in the neonatal intensive care unit: results of a randomized controlled trial. Arch Pediatr Adolesc Med. 2006;160(7):681–685.
23. Breastfeeding Report Card—United States, 2010. In. Atlanta, GA: Centers for Disease Control and Prevention; 2010.
24. DiGirolamo A, Manninen D, Cohen J, et al. Breastfeeding-related maternity practices at hospitals and birth centers—United States, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(23):621–625.
25. Bartick M, Edwards RA, Walker M, Jenkins L. The Massachusetts Baby-Friendly Collaborative: lessons learned from an innovation to foster implementation of best practices. J Hum Lact. 2010;26(4):405–411.
26. American Public Health Association. APHA Policy Statement 200714: A Call to Action on Breastfeeding: A Fundamental Public Health Issue. 2007. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360. Accessed January 1, 2007.
27. American Public Health Association. APHA Policy Statement 7403: Breast Feeding. 1974. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=745. (Archived: available only to APHA members.) Accessed January 1, 2007.
28. American Public Health Association. APHA Policy Statement 8226: Breastfeeding. 1982. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1030. (Archived: available only to APHA members.) Accessed January 1, 2007.
29. American Public Health Association. APHA Policy Statement 7922: Infant Feeding Advertising. 1979. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=944. Accessed January 1, 2007.
30. American Public Health Association. APHA Policy Statement 8126: Nestle Boycott. 1981. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=998. Accessed January 1, 2007.
31. American Public Health Association. APHA Policy Statement 200114: APHA Supports the Health and Human Services Blueprint for Action on Breastfeeding. 2001. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=253. Accessed January 1, 2007.