In January 2011, U.S. Surgeon General Regina M. Benjamin released the landmark document The Surgeon General's Call to Action to Support Breastfeeding. Prepared by three agencies of the U.S. Department of Health and Human Services (USDHHS; Centers for Disease Control and Prevention [CDC], the Office on Women's Health [OWH], and the Office of the Surgeon General), this document summarizes the background literature around the importance of breastfeeding, rates of breastfeeding, barriers to breastfeeding in the United States, and breastfeeding from the public health perspective. It details the call to action with 20 specific actions in the categories of mothers and their families, communities, health care, employment, research and surveillance, and public health infrastructure (Table 1). The full document is freely available as a download at http://surgeongeneral.gov/topics/breastfeeding/calltoactiontosupportbreastfeeding.pdf
|Mothers and their families||1. Give mothers the support they need to breastfeed their babies.|
|2. Develop programs to educate fathers and grandmothers about breastfeeding.|
|Communities||3. Strengthen programs that provide mother-to-mother support and peer counseling.|
|4. Use community-based organizations to promote and support breastfeeding.|
|5. Create a national campaign to promote breastfeeding.|
|6. Ensure that the marketing of infant formula is conducted in a way that minimizes its negative impacts on exclusive breastfeeding.|
|Health care||7. Ensure that maternity care practices throughout the United States are fully supportive of breastfeeding.|
|8. Develop systems to guarantee continuity of skilled support for lactation between hospitals and health care settings in the community.|
|9. Provide education and training in breastfeeding for all health professionals who care for women and children.|
|10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.|
|11. Ensure access to services provided by International Board Certified Lactation Consultants.|
|12. Identify and address obstacles to greater availability of safe banked donor milk for fragile infants.|
|Employment||13. Work toward establishing paid maternity leave for all employed mothers.|
|14. Ensure that employers establish and maintain comprehensive, high-quality lactation support programs for their employees.|
|15. Expand the use of programs in the workplace that allow lactating mothers to have direct access to their babies.|
|16. Ensure that all child care providers accommodate the needs of breastfeeding mothers and their infants.|
|Research and surveillance||17. Increase funding of high-quality research on breastfeeding.|
|18. Strengthen existing capacity and develop future capacity for conducting research on breastfeeding.|
|19. Develop a national monitoring system to improve the tracking of breastfeeding rates as well as the policies and environmental factors that affect breastfeeding.|
|Public health infrastructure||20. Improve national leadership on the promotion and support of breastfeeding.|
A national emphasis on the support of breastfeeding by the U.S. surgeon generals began in 1984 when the first Surgeon General's Workshop on Breastfeeding was convened by then Surgeon General C. Everett Koop (USDHHS, 1984). This workshop resulted in recommendations in six areas (the world of work, public education, professional education, health care system, support services, and research) with progress toward implementing the recommendations tracked in public reports in 1985 (USDHHS, 1985) and 1991 (Spisak & Gross, 1991). In 1991, the United States also supported the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding adopted by the United Nations Children's Fund (UNICEF) and World Health Organization (WHO) (1990). In response to the charge in 1999 by Surgeon General David Satcher to reduce racial and ethnic disparities in breastfeeding, the OWH published the HHS Blueprint for Action on Breastfeeding in 2000. Declaring breastfeeding to be a key public health issue in the United States, this document has been widely used in public health and other venues in the subsequent years.
The overall goal of The Surgeon General's Call to Action to Support Breastfeeding (2011) was to outline specific steps that individuals, organizations, and government must take to advance a society-wide approach to support mothers and babies who are breastfeeding. Although the Healthy People 2010 goal of 75% of new mothers initiating breastfeeding was met in the past decade, the 2010 goals of 40% of mothers breastfeeding exclusively for 3 months and 17% for 6 months were not met. Breastfeeding rates are lowest among women who reside in the southeastern states, are non-Hispanic Blacks, have lower levels of education, and participate in the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Clearly, additional targeted actions are needed to achieve our nation's breastfeeding goals and to create a society in which breastfeeding is the social norm so that babies and women are afforded the significant health benefits that breastfeeding provides.
Unfortunately, the United States is characterized by significant barriers to the success of breastfeeding for women and their infants. Specifically, significant barriers to successful breastfeeding remain in health care such as failure to put the baby to breast immediately after birth; supplementing full-term, healthy newborns with formula; providing gift packs containing formula to breastfeeding mothers; separating mothers and their babies during the postpartum stay, etc. Although these are not new issues, the tragedy is that despite knowledge about the negative effects of these practices on the success of breastfeeding initiation and continuation, these practices continue in many U.S. hospitals. One challenge in the Surgeon General's Call to Action is for U.S. hospitals to implement the 10 steps of the WHO and UNICEF's Baby-Friendly Hospital Initiative (http://babyfriendlyusa.org/). Widespread adoption of these principles and hospital's designation as Baby-Friendly will make significant progress toward removing health care related barriers to breastfeeding in hospitals.
An unfortunate omission in the document is any mention of the critical roles of nurses in the support of breastfeeding, particularly during the hospitalization surrounding childbirth, but also in the outpatient and community settings. Under the leadership of Chairperson Diane L. Spatz, PhD, RN-BC, FAAN, the Expert Panel on Breastfeeding of the American Academy of Nursing (AAN) organized a group of nurses to participate in writing a letter to the CDC to highlight the omission of nurses and nursing from the Call to Action. The CDC has acknowledged the enormity of this omission and is working on next steps to correct it in consultation with national nurse breastfeeding experts and leaders.
Removing long-standing barriers to breastfeeding in the United States is critical given the importance of breastfeeding to the health and well-being of mothers and children. Each of the 20 actions listed in Table 1 is further delineated in specific implementation strategies that merit nursing's attention and response, particularly those pertinent to health care. Nurses are the primary architects of the care that new mothers and their infants receive and, as such, hold considerable power to see that the health care strategies are implemented and that all health care professionals are held to the principles required to actively support breastfeeding mothers and their infants.