Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Seven: Objectives 17-19
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Seven: Objectives 17-19
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
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Image used with permission; Marissa Funkhouser’s Mom’s Group, Summer 2012.
What can Hospitals do?
Partner with Baby-Friendly hospitals to learn how to improve maternity care.
Use CDC's Maternity Practices in Infant Nutrition and Care (mPINC) survey data to prioritize changes to improve maternity
care practices.
Stop distributing formula samples and give-aways to breastfeeding mothers.
Work with community organizations, doctors, and nurses to create networks that provide at-home or clinic-based
breastfeeding support for every newborn.
Become Baby-Friendly.
What can doctors and nurses do?
Help write hospital policies that help every mother be able to breastfeed.
Learn how to counsel mothers on breastfeeding during prenatal visits, and support breastfeeding in the hospital and at each
pediatric doctor's visit until breastfeeding stops.
Include lactation consultants and other breastfeeding experts on patient care teams.
Coordinate lactation care between the hospital and outpatient clinic.
Further Professional Support: What do IBCLCs do?
IBCLCs are health professionals who specialize in the clinical management of breastfeeding. IBCLCs work in many health care
settings, such as hospitals, birth centers, physicians' offices, public health clinics, and their own offices. A strong statewide
group of professional breastfeeding experts (IBCLCs) is needed to assist the mother-infant pair, create and administer
lactation programs, and educate other health professionals about breastfeeding. Availability is measured by the ratio of
IBCLCs to the number of live births.
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•All interactions contain positive messages about breastfeeding
•Assumption that a woman will BF
•No question of ? BF or ? Bottle
•Not just a matter of choice
When women are asked either/or questions by a professional, there is an assumption that this must
be an equal choice.
We have choices about all sorts of things. We want women to make the best choice.
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When Mom Says: Baby wants to eat “all the time”:
Nurse can say:
• What a smart baby you have!
• This is just what I would expect of a smart, healthy baby.
• You’re going to have the best milk supply in town.
• These early feeds are really just putting in your order. – Melanie
Ashworth
• I wish every baby around here was as good a breastfeeder as
yours.
When Mom Says: “I don’t have any milk”:
All of these responses/quotes are from Molly
Pessl, 2011.
What can you say?
“You can do this!”
“Breastfeeding can be challenging in the
beginning, but it will get easier”
“Don’t quit easily. It is so important for you and
your baby!”
Section Seven: Objectives 17-19
Nurse can say:
• I know you feel as if you don’t have any milk.
• I can show you that you have milk.
• You have the perfect milk for your baby.
• You have just the right amount of milk.
• We’re learning that it isn’t good for babies to get too much milk in
the beginning.
• The small amount of early milk helps your baby learn to suck,
swallow and breathe at the same time.
When Mom Says: “Just Give Him/Her Formula”:
Nurse can say:
• I can give your baby some formula, but before we do that, let’s
look at some other options.
• Can you tell me why you want to give your baby cow milk?
• The thing that has me concerned about giving your baby cow milk
is…….
• Sometimes cow milk upsets the baby’s stomach
• Some babies are allergic to cow milk/soy milk
• For some babies, just one bottle of cow’s milk can upset the
baby’s stomach.
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Image used with permission from Marissa Funkhouser; Baby Addyson and Daddy, Summer 2012.
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Image taken by Jennifer DeJong; Brad and Carolyn, Spring 2008.
The Golden Start Team at Otter Tail County Public Health provides professional services to families with
breastfeeding questions and challenges during pregnancy and at any time during the breastfeeding
experience.
We promote and support a commitment to mother's milk for your baby for the first four weeks.
Mother's milk IS the Golden Start.
Responses from Molly Pessl, 2011:
When Mom Says: “I’m so tired”:
The Nurse Can Say:
I can imagine how tired you are.
This can be overwhelming in the beginning.
Your baby needs to suck for comfort, he needs you.
We may miss his early feeding cues….
(Molly Pessl, 2012)
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What Can Be Done
We must help hospitals support mothers to breastfeed.
Federal government can:
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Education of mothers, families, employers, communities ---- changing policy, enforcing policy,
listening and creating systems change.
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Public Health Interventions
Applications for Public Health Nursing Practice
March 2001
Minnesota Department of Health
Division of CommunityHealth Services
Public Health Nursing Section
Public health nurses (PHNs) work in schools, homes, clinics, jails, shelters, out of mobile vans and dog sleds.
They work with communities, the individuals and families that compose communities, and the systems that impact the health
of those communities. Regardless of where PHNs work or whom they work with, all public health nurses use a core set of
interventions to accomplish their goals.
This framework, known as the “intervention model,” defines the scope of public health nursing practice by type of intervention
and level of practice (systems, community, individual/family), rather than by the more traditional “site” of service, that is,
home visiting nurse, school nurse, occupational health nurse, clinic nurse, etc. The intervention model describes the scope of
practice by what is similar across settings and describes the work of
public health nursing at the community and systems practice levels as well as the conventional individual/family l evel. These
interventions are not exclusive to public health nursing as they are also used by other public health disciplines. The public
health intervention model does represent public health nursing as a specialty practice of nursing. (See The Cornerstones of
Public Health Nursing, Appendix A)
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Public health nursing may be practiced by one public health nurse or by a group of public health
nurses working collaboratively. In both instances, public health nurses are directly engaged in the
inter-disciplinary activities of the core public health functions of assessment, assurance and policy
development. Interventions or strategies may be targeted to multiple levels depending on where
the most effective outcomes are possible. They include strategies aimed at entire population
groups, families, or individuals. In any setting, the role of public health nurses focuses on the
prevention of illness, injury or disability, the promotion of health, and maintenance of the health of
populations.
As of January 20, 2011, the U. S. Surgeon General, Regina Benjamin, released a Call to Action for
breastfeeding, by encouraging the entire nation to support the removal of barriers to
breastfeeding. “The Surgeon General’s Call to Action to Support Breastfeeding” is the first of its
kind and identifies 20 concrete action steps and implementation strategies to support mothers in
reaching their personal breastfeeding goals. True to the social-ecological framework, Benjamin
addressed six major sectors of society, including, providing support and education for a variety of
persons in a assortment of settings.
According to the USBC, actions, in the form of education and increased emotional and physical
support, shall be directed to:
From the article: Nurse-Supported Breastfeeding Promotion:
A Framework for Economic Evaluation (Frick, Milligan, White,
Serwint, & Pugh, August 2005).
From the American Public Health Association website:
http://www.apha.org/membergroups/sections/aphasection
s/phn/about/phnroles.htm
The Role of Public Health Nurses
Public health nurses integrate community involvement and
knowledge about the entire population with personal,
clinical understandings of the health and illness experiences
of individuals and families within the population. They
translate and articulate the health and illness experiences of
diverse, often vulnerable individuals and families in the
population to health planners and policy makers, and assist
members of the community to voice their problems and
aspirations. Public health nurses are knowledgeable about
multiple strategies for intervention, from those applicable to
the entire population, to those for the family, and the
individual. Public health nurses translate knowledge from the
health and social sciences to individuals and population
groups through targeted interventions, programs, and
advocacy.
Section Seven: Objectives 17-19
Mothers and their families: Benjamin (2011) emphasizes the need to educate and inform on the
importance of breastfeeding, and provide the ongoing support mothers need to continue.
Communities: Benjamin (2011) calls upon the entire community to support breastfeeding mothers,
including the provision of peer-counseling support, promotion of breastfeeding through
community-based organizations and traditional and new media venues, and the removal of
commercial barriers to breastfeeding.
Health Care: Benjamin (2011) urges the health care system to adopt evidence-based care system
to adopt evidence-based practices as outlined in the Baby-Friendly Hospital Initiative, provide
health professional education and training, ensure access to skilled, professional lactation care
services, and increase availability of banked donor milk.
Employment: Benjamin (2011) calls for paid maternity leave and worksite and child care
accommodations that support women when they return to work.
Research and Surveillance: Benjamin (2011) emphasizes the need for additional research,
especially regarding the most effective ways to address disparities and measure the economic
impact of breastfeeding, and calls for a national monitoring system.
Public Health Infrastructure: Benjamin (2011) calls for enhanced national leadership, including
creation of a federal interagency work group, and increasing the capacity of the United States
Breastfeeding Committee and affiliated state coalitions.
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A Breastfeeding Program for WIC Staff
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Ideas for Pre-Class Work:
Option 1: Each team designates two leaders who will interview a business in their community
Option 2: Another team might ask at their university/college/school/institution about infant-mother-friendly
practices. Is there a lactation room at your school? Tour the room. If possible, take pictures for the team to
share in class.
Option 3: Another team might address baby-friendly practices at a local hospital or clinic. How many steps are
the hospitals following? Are they attempting to achieve Baby-Friendly designation? Do they have a steering
committee?
Option 4: Another team might address lactation policies at a local childcare setting
Option 5: Another team might interview a local restaurant about their policies regarding
breastfeeding/pumping of their employees if any, and/or breastfeeding of clientele at their restaurant
Option 6: Another team might identify whether or not their local shopping center or mall has a lactation space
for mothers
Option 7: Another team might identify whether or not their local parish/faith communities have lactation
space for mothers
Option 8: Another team might go to a LLL Meeting in their town and report back to the class what they
observed
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McKinley and Hyde (2004) discussed this dilemma in their research
comparing a personal attitudes model (i.e., infant feeding choices are based
on individual mind-sets) and a structural factors model (i.e., feeding choices
are produced by the structural contexts of women’s lives as much as
personal attitudes), stating:
Breastfeeding has been neglected in feminist analyses, probably because
breastfeeding poses significant dilemmas for feminists (Blum, 1993; Galtry,
1997; Laws, 2000). One dilemma derives from the issue of whether women
and men should be treated equally (this is, identically) or differently (Blum,
1993; Galtry, 1997) although one might argue that equal treatment should
include treatment according to one’s needs. Reproductive behaviors, such
as pregnancy, childbirth, and breastfeeding all pose a challenge to the
concept of equal treatment espoused by U.S. feminists. (pp. 388-389)
Stay-at-home mom versus mom who works in blue
collar/white collar.
Who in this picture is more likely to be breastfeeding
and why?
Tell me a story about these women.
______________________
Employment, School, and Childcare Setting
(Exosystem)
Returning to work is one of the greatest barriers to
breastfeeding (Auerbach & Guss, 1984; Fein & Roe,
1998; Gielen et al., 1991; Roe et al., 1999; Ryan &
Martinez, 1989; Visness & Kennedy, 1997). Often,
Western cultures associate the act of breastfeeding
with the home environment (Schewel, 1997). For some
people, breastfeeding or expressing milk outside this
private domain threatens traditional views of women’s
roles. Some fear that the gender-specific behavior of
breastfeeding will contradict the equality framework in
the American workplace (Schewel, 1997).
Section Seven: Objectives 17-19
Working women are aware that breastfeeding provides numerous health
benefits to their children (Ball & Wright, 1999; Beaudry, Dufour, & Marcoux,
1995; Dewey, Heinig, & Nommsen-Rivers, 1995; Duffy, Faden, Wasielewski,
Wolf, & Krystofik, 1997), and many women want to continue to provide breast
milk while being employed. Because of real or perceived threats in their
exosystem, many women anticipate an unsupportive workplace following
their return from maternity leave and terminate breastfeeding while
preparing mentally and physically for their return to work (Mills, 2009).
For women who continue to breastfeed, managing milk expression during
work may prove cumbersome in finding time and physical space. While
many states and countries around the world have passed laws to ensure
protection for nursing mothers who choose to express breast milk at work,
many others have not. As a result, many women either quit breastfeeding or
attempt to secretly modify their places of work in order to make them more
conducive to the expression of milk without the assistance of mandated
accommodation (Mills, 2009).
The percentage of women in the U.S. workforce has increased from 29% in
1975 to 65% in 2000 (Galtry, 2003); it is estimated that 25% of all women in the
U.S. with a child younger than one year will be concurrently breastfeeding
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and employed for at least one month (Zinn, 2000). Although the U.S. enacted legislation in 1993 with the passage of
the Family and Medical Leave Act (FMLA) that provides up to 12 weeks of unpaid leave for both men and women, the
U.S. has been relatively sluggish in developing policies to support parents. In comparison, families in Ireland receive 18
weeks of leave at 70% of pay and families in Sweden receive up to 480 days of leave at 90% pay (Galtry, 2003). Their
high breastfeeding rates reflect their policies.
The decrease in the breastfeeding rate before the 1970s is often attributed to the difficulty of combining breastfeeding
with maternal employment (Hirschman & Butler, 1981).
Indeed, numerous studies have found a negative relationship between maternal employment and breastfeeding
duration (Barber-Madden, Petschek, & Pakter, 1987; Gabriel, 1986; James, 2004; Lindberg, 1997; Raju, 2006; Roe et al.,
1999; Wright, 1998). Results from these studies concluded that women who were employed are not as likely to
breastfeed as are unemployed women, primarily because of time constraints and job requirements (Bryant, 1982;
Hirschman & Butler, 1981; Roe et al., 1999; Ryan, 1989).
Although studies support that employment no longer decreases lactation initiation, research suggests that
employment significantly decreases the duration of breastfeeding, especially at three and six months postpartum
(Kimbro, 2006; USDHHS, 2000; Wright, 2001). For instance, Ortiz (2004) found that women in the U.S. who reported
awkwardness about expressing breast milk at work weaned their infants an average of 10 weeks sooner than those
who felt at ease (Roe et al., 1999).
Similarly, Arlotti, Cottrell, Lee, and Curtin (1998), in their descriptive, longitudinal study comparing infant feeding
practices of women who received peer support during the first three months postpartum with women who did not,
found that a mother’s career plans had the greatest effect on the duration of breastfeeding. In this study, women who
intended to return to work, attend school, or both, breastfed 6 to 9 weeks less than mothers who intended to stay
home.
Duberstein and Hermalin (1994) completed a dissertation that examined breastfeeding and maternal employment in
the U.S. from 1968 to 1986 and found that most postpartum women stopped breastfeeding before they entered
employment. Women were most likely to quit breastfeeding in the month prior to their return to work. Duberstein and
Hermalin (1994) found part-time employment to be a method of balancing the demands of breastfeeding and
employment for many women, with part-time employees showing a higher incidence and longer duration of
breastfeeding than women employed full time.
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Utilizing data from the Sri Lankan demographic and Health Survey, Zaki (1998) wrote a doctoral dissertation researching
the mechanisms through which maternal employment affected child development and survival in Sri Lanka. Zaki
(1998) found that maternal employment negatively affected the health status of children in large households and that
non-breastfeeding status contributed negatively to the nutritional status of the children.
Lastly, J. M. Smith’s (1986) dissertation examined the impact of socioeconomic status and other factors, including
employment and counseling available to mothers, on the breastfeeding behavior of urban Tunisian women. It is
common for those women to initiate and continue to breastfeed for longer durations than in the U.S. According to J.
M. Smith (1986), 95% of Tunisian women breastfeed after delivery, and 70% continue to at least 6 months’ duration.
Among Tunisian women in this study, work appeared to have little effect on breastfeeding duration, secondary to the
widespread rights of maternity leave and breastfeeding breaks. Unlike many mothers in the U.S., Tunisian women often
continue to breastfeed after they return to work, with non-working women weaning at intervals similar to those of
working women.
According to former U.S. Surgeon General Satcher (2001):
We need to address the breastfeeding challenges for mothers who return to the workplace. . . . We should establish
family and community programs that enable breastfeeding continuation when women return to work, and facilitate
on-site breastfeeding or breast milk expression. Employers should offer flexible work hours, job sharing, adequate
breaks, and education for personnel about why their breastfeeding co-workers need support. The workplace can also
provide private “Mothers’ Rooms” for expressing milk in a secure and relaxing environment, and refrigerators for
storage of breast milk. (p. 72)
According to Bar-Yam (1997) and Cohen, Mrtek, and Mrtek (1995), as cited in the CDC Guidelines by Shealy et al.
(2005), several studies indicated that support for lactation at work profits individuals and families, as well as their
employers, via improved productivity and staff loyalty; enhanced public image of the employer; and decreased
absenteeism, healthcare costs, and employee turnover.
In a study of resident physicians in postgraduate study, Miller (1996) researched how employment affected the
breastfeeding practices of physicians in training. Questionnaires (n = 1500) were mailed to females in the 1990
graduating class of American-based medical schools (45% return rate), in which 60 female students had delivered a
child during their residency. Of the 60, 48 (80%) of the residents initiated breastfeeding, and continued for the duration
of their maternity leave.
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In this study, the mean duration was 7 weeks. Returning to residency, half (n = 24) of those who had initiated
breastfeeding discontinued, and at 6 months, 15% (9 of the 60) had quit. The most common reason (80%) for lactation
termination was reported as work schedule. Of the 24 who continued breastfeeding upon returning to work, 83%
pumped during their shift; 79% reported insufficient time to pump; and 42% reported no appropriate place at work to
express milk. According to this group, only 54% of those who continued to breastfeed and/or express milk felt
supported by their attending physician for their efforts to breastfeed, and 67% felt colleagues were supportive (Miller,
1996).
According to Libbus and Bullock (2002), only 30% of employers in the U.S. provide a private place to express milk, and
only 25% believe that there is value in promoting breastfeeding in the workplace. Even in hospital and childcare
settings, where one would imagine the physical environment to be conducive to breastfeeding, research suggests
otherwise (Dodgson, Chee, & Yap, 2004; McPhillips et al., 2007). According to Satcher (2001):
With a large number of infants enrolled in childcare, it is important that childcare facilities be supportive of
breastfeeding. Childcare centers should make accommodations for mothers who wish to come in and breastfeed, or
be supportive of mothers who want their children to be fed expressed milk. (p. 73)
Satcher (2001) concluded, “Above all, we must send a message that breastfeeding is normal, desirable, achievable,
and a natural part of community life” (p. 73).
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Lecture:
Childcare Centers
Child care providers play an important role in supporting employed, breastfeeding mothers. As an indicator of
support for breastfeeding mothers, child care regulations first appeared on The Breastfeeding Report Card in
2010. This year (2011), state child care regulations related to breastfeeding have been classified to reflect the
range of support in states based on the National Resource Center for Health and Safety in Child Care and
Early Education best care standards. States that received optimal scores were those whose regulations fully
comply with national standards regarding breastfeeding, including making arrangements for a mother to be
able to feed her child on-site.
Support in Child Care Settings
In the U.S., nearly two thirds of infants are routinely cared for by someone other than a parent. About half of
these infants attend child care centers; the other half spend time in a variety of home-based settings including
licensed family child care homes or the home of a family member, friend, or neighbor. Thus, child care facilities
– both family child care homes and child care centers – play an important role in promoting breastfeeding
among mothers whose infants are cared for in these facilities. State scores were obtained by using the
average appropriate fluids rating (1A1) as determined by the National Resource Center for Health and Safety
in Child Care and Early Education. Cut-off points (1- inappropriate; 2- not optimal; 3- less optimal; 4- optimal)
were set. States whose regulations are less than optimal can improve breastfeeding support at child care
facilities by meeting best-practice standards as set by the 3rd edition of Caring for Our Children.
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Students can visit www.eagertolearn.org (note: org not “com”)
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Community or Neighborhood (Exosystem)
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McCann et al. (2007) voiced concern, saying, “It is disturbing that the national HealthStyles surveys of the
general population indicate that support for breastfeeding may be declining” (p. 113). To illustrate, Shealy et
al. (2005) documented that public agreement with the statement “Infant formula is as good as breast milk”
increased significantly from 14.3% in 1999 to 25.7% in 2003 and increased further to 28.3% in 2005. This
perception was universal in all three ethnic groups analyzed; yet, the increase was greatest for Blacks (16.7% in
1999 to 30.0% in 2003), intermediate for Whites (13.4% to 25.1%), and lowest for Hispanics (19.5% to 27.1%; Li et
al., 2007).
A similar study by Tarrant and Dodgson (2007) explored the relationship among university students’ infant
feeding knowledge, attitudes, exposure to breastfeeding, and future infant feeding intentions of male and
female Chinese university students in Hong Kong. Participants were young (94.4% were less than 25 years old),
undergraduate students (92.2%) who were unmarried (99.2%) and without children (100%). Results indicated
that 63% of the 403 total participants wanted their future children to be breastfed, with those intending to
breastfeed scoring higher on knowledge of breastfeeding (71.1%) and reporting that they had been breastfed
or that they knew of someone who had breastfed. The authors concluded that future infant campaigns should
be directed at the societal level to change negative attitudes more than increasing educational efforts
specifically aimed at childbearing couples who have likely already made their decision.
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The authors concluded that these findings highlight a knowledge deficit that may contribute
to premature cessation of breastfeeding among Canadian women. Further education was
advised.
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Go around the room and have each student summarize their paper very briefly. What is your Take-Home for
the Day?
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