6

Breastfeeding and the U.S. Health Care System

As indicated in the social ecological model presented in Chapter 3, the health care system plays a key role in breastfeeding support. Pérez-Escamilla et al. (2023) noted that major structural challenges across the globe affect breastfeeding care. This care is particularly fragmented in the United States, making it difficult for mothers to access skilled lactation support and resources.

Typically, infants receive health care services from a different set of providers than their mothers and on a different schedule (Anjur & Darmstadt, 2023); in other words, the breastfeeding dyad does not have a shared medical home.¹ Across categories of breastfeeding care and within various health care settings, lactation support services and resources can vary by provider education, training, licensure, and credentialing. While these professionals are not all part of the health care system, the care or services they provide may overlap (see Chapters 3 and 4 for examples of community and public health lactation support).

This chapter will focus on key opportunities to support breastfeeding within the health care system, emphasizing strategies that span clinical settings, provider types, and levels of care. As a central touchpoint for mothers and infants, the health care setting plays a critical role in shaping breastfeeding outcomes through early clinical encounters, postpartum follow-up, and continuity of care. The chapter first examines evidence-based interventions,

___________________

¹ The American Academy of Pediatrics (AAP; 2025) defines a medical home as “an approach to providing comprehensive and high-quality primary care” (para. 1). It extends beyond a physical setting and may include educational services, specialty care, and family support (AAP, 2025).

including the Baby-Friendly Hospital Initiative (BFHI), designed to improve breastfeeding outcomes. It then explores the role of quality improvement initiatives. An additional focus of this chapter is the importance of health care provider education and training. Minimal clinical preparation and inconsistency in lactation-related knowledge among clinicians remain persistent barriers to breastfeeding support.

Finally, the chapter highlights the value of systematic documentation and data capture of breastfeeding outcomes in clinical settings. Standardized approaches to recording breastfeeding status, support encounters, and lactation-related health indicators are essential for monitoring quality, identifying differences across populations, and informing continuous improvement efforts. Collectively, these opportunities underscore the need for an integrated, coordinated approach to breastfeeding support in health care settings—an approach that aligns policies, clinical best practices, and system-level infrastructure to better meet the needs of families.

Framing breastfeeding support and care in the health care setting through the public health model of primary, secondary, and tertiary prevention provides a helpful road map for understanding who delivers care, where care is delivered, and what kind of care is needed. This model also highlights the dynamic and evolving nature of breastfeeding support in the United States, which involves a wide range of health care and community providers working across diverse settings (see Box 6-1).

INTERVENTIONS FOR IMPROVING BREASTFEEDING OUTCOMES IN THE HEALTH CARE SETTING

The sections below explore interventions that demonstrate positive effects on or relationships to breastfeeding in the health care setting. These interventions may span the life course and breastfeeding journey, highlighting how the care provided to mothers—across preconception, the prenatal period, in the birth setting, immediately postpartum, and in the months that follow—influences breastfeeding outcomes (see also Chapter 2).

Through all aspects of care opportunities exist for strong, coordinated, and culturally appropriate communication between family, health care providers, community health workers, doulas, and lactation support providers. This communication enables everyone to work together to support the breastfeeding dyad. In addition, practice models such as team-based care can help coordinate care across settings and providers and ensure a continuum of care.²

___________________

² The American College of Obstetricians and Gynecologists (ACOG) recommends team-based care to fulfill all the requirements of well-woman visits, including obstetrician-gynecologists, physician assistants, nurse practitioners, and other health professionals (American College of Obstetricians and Gynecologists, 2018). The pediatric or family physician medical home can function with a team approach, from scheduling nursing and provider care to including providers with lactation expertise in the office (Bunik, 2021).

BFHI

As introduced in prior chapters (e.g., see Chapter 5), the BFHI aims to help mothers and their newborns receive timely and appropriate care before and during their stay in a health care setting that provides maternity and newborn services, and during the postpartum period (World Health Organization [WHO] & United Nations Children’s Fund [UNICEF], 2018).

BFHI was launched in 1990 and launched in 1991 by the WHO and UNICEF as a program for improving the structure and quality of breastfeeding care in birthing facilities. BFHI draws on the framework of the WHO/UNICEF Ten Steps to Successful Breastfeeding (Ten Steps; see Box 6-2), which was developed based on the growing body of evidence on key determinants of breastfeeding in health care settings (WHO, 2013).

The 2018 revision of the Ten Steps elaborated on their importance and included a number of important updates (WHO & UNICEF, 2018). The revision made a strong call for governmental support for scaling up its implementation of BFHI in national policy and interventions for improving breastfeeding. Additionally, the revision fully incorporated the 1981 World Health Assembly’s International Code of Marketing of Breast-Milk Substitutes (the Code) and subsequent resolutions, emphasized the importance of six months of exclusive breastfeeding, incorporated attention to the role of mother-friendly birthing practices, included preterm infants, and emphasized shared decision-making.

Systematic evaluation of the impact of the BFHI globally, including in the United States, has demonstrated substantial impact on breastfeeding outcomes: breastfeeding initiation, exclusive breastfeeding at the time of discharge, exclusive breastfeeding, and any breastfeeding duration (Pérez-Escamilla et al., 2016). A study by the U.S. Agency for Healthcare Research and Quality found that implementing the BFHI in the United States increased breastfeeding initiation and duration (Feltner et al., 2018). Importantly, evidence showed that the greater the number of BFHI steps implemented, the greater the improvement across breastfeeding outcomes. The evaluation also pointed out the importance of step 10 (linkage to community support) in maintaining these improvements. Subsequent evaluations strengthened the evidence base of these impacts (see Bookhart et al., 2023; Chan et al., 2025; Ducharme-Smith et al., 2022; Feldman-Winter et al., 2017a; Feltner et al., 2018; Merewood et al., 2019; Munn et al., 2018; Patterson et al., 2018).

Implementing BFHI

The United States has been relatively successful in implementing the BFHI, with strong leadership from the U.S. Centers for Disease Control and Prevention (CDC; Hernández-Cordero et al., 2022). Importantly, implementing BFHI has been associated with substantial increase in breastfeeding initiation for Black mothers and mothers participating in WIC (Merewood et al., 2019). It has emerged as a promising intervention as part of larger effort to reduce differences in breastfeeding rates that persist by race, ethnicity, and socioeconomic status (Bookhart et al., 2024; Burnham et al., 2022; Jung et al., 2021; Merewood et al., 2019; Nobari et al., 2017; Patterson et al., 2018, 2021; Segura-Perez et al., 2021; Tucker et al., 2025).

Recent evidence has consistently reinforced the relationship between implementing Baby-Friendly maternity care practices and better breastfeeding outcomes. Bookhart et al. (2023) again demonstrated a dose–response relationship between the Baby-Friendly steps implemented and breastfeeding outcomes using a large dataset of over 2,000 U.S. hospitals from the 2018 Maternity Practices in Infant Nutrition and Care Survey.

That study showed particularly substantial impacts on exclusive breastfeeding for step 6 (limited infant formula supplementation), followed by prenatal breastfeeding information (step 3), responsive feeding (step 8), care right after birth (step 4), and rooming-in (step 2). This study, along with prior evidence, also pointed to variation in the implementation of the Ten Steps. Some of the most impactful steps, such as step 6 (do not supplement with infant formula unless medically indicated), were the least commonly implemented in this sample of U.S. hospitals (28%; Bookhart et al., 2023).

Baby-Friendly practices also have potential benefits for preterm infants (Richter et al., 2024). Implementing the recent neo-BFHI guidelines (Maastrup et al., 2022) can be another promising avenue for improving breastfeeding outcomes and addressing differences in rates among various populations. Davis et al. (2023), McLemore et al. (2018) and the National Academies of Sciences, Engineering, and Medicine (2024) have identified that these efforts could be integrated with broader initiatives that address racism in birth settings overall, especially in relation to the treatment of women who experience preterm birth, who are disproportionately Black women.

In the United States, about one-quarter of births occur in hospitals that have achieved Baby-Friendly designation (CDC, 2022). Barriers to scaling up the implementation of BFHI include primarily upfront cost and competing priorities (Arslanian et al., 2022). There are debates about the value of BFHI accreditation compared with only adopting the Ten Steps. Additionally, there is considerable variation in the implementation of the Ten Steps in practice. Recent examinations of the implementation of Baby-Friendly practices have noted substantial increases in overall uptake, with over half of hospitals implementing at least six of the ten steps in 2022 (Marks et al., 2024). However, these data also revealed a decline in the implementation of some steps, notably step 6 (avoiding infant formula supplementation).

Policy initiatives across the United States have focused primarily on incentivizing and scaling up BFHI or implementing the Ten Steps for greater coverage. California, for instance, enacted the Hospital Infant Feeding Act in 2011, which required hospitals to adopt the Ten Steps by January 2025. Other states (e.g., Alaska, Florida, and Illinois) encourage the adoption of Baby-Friendly practices but do not require the implementation of the Ten Steps (Alakaam, 2019). The Indian Health Service also committed to making its 13 birthing facilities Baby Friendly in 2011, a goal it achieved two years after the program was launched (CDC, 2021; see further discussion below). The program has been highly successful as reported by increasing breastfeeding exclusivity and duration (CDC, 2021). CDC’s recent funding initiative to accelerate the implementation of the Ten Steps in 100 hospitals to address racial variances in breastfeeding is an exemplar of initiatives that could be scaled up nationally with sufficient investment, as discussed further in this chapter.

While BFHI is the gold standard for maternity care practice to support breastfeeding, some states have implemented designation programs that follow the Ten Steps. For example, Ohio First Steps is a voluntary program led by the Ohio Department of Health (2023) and the Ohio Hospital Association; it recognizes facilities that have taken steps to protect, promote, and support breastfeeding.

It is important to note that the scale-up of BFHI is only one part of addressing the overall determinants of breastfeeding following a multisectoral person-centered approach (Pérez-Escamilla et al., 2023); hence it is necessary but not sufficient to eliminate differences in rates on its own. Importantly, universal adoption of the Ten Steps would make a substantial impact across breastfeeding indicators and associated health outcomes.

In a recent evaluation of the implementation of BFHI in the United States, Hernández-Cordero et al. (2022) found that numerous factors have played a role in the success of the adoption of the Ten Steps to date; these observations can inform future work aiming to improve uptake. First, CDC has played a leading role in supporting uptake of Baby-Friendly practices, with funding and technical assistance, as part of its efforts to improve breastfeeding outcomes (e.g., Best Fed Beginnings, Empower, and CHEER). Coordination between Baby-Friendly USA, the accrediting body of the BFHI, and CDC has enabled ongoing monitoring and comparative analysis of birth facility policies and practices. Hernández-Cordero et al. (2022) found that monitoring and disseminating updates via CDC likely encouraged the uptake and continuation of Baby-Friendly practices.

At the same time, Hernández-Cordero et al. (2022) also highlighted several challenges that need to be addressed to achieve scale-up of the program. A critical part of moving the needle on implementing BFHI is the high cost of accreditation. Thus, national investment and economic incentives for BFHI implementation are key tools for scaling up the adoption of BFHI. Other barriers to implementation remain repeated efforts to cast doubt on BFHI’s safety and efficacy (Hernández-Cordero et al., 2022). This could be addressed via investment in public health messaging and outreach that highlights the initiative’s effectiveness. Pervasive commercial milk formula marketing and distribution at hospitals remains another challenge, which could be addressed by implementing the Code in health care settings (see Chapter 5).

Hernández-Cordero et al. (2022) stated that monitoring efforts need to be strengthened in order to reduce variation in implementation and achieve greater fidelity, especially for implementing step 10. A recent scoping review also emphasized the importance of building out step 10 for the Baby-Friendly Community Initiative (BFCI), with strong collaborations among all involved parties, including community-based organizations, as well as health professional education to improve sustained exclusive breastfeeding and support the BFHI on a global scale (Walsh et al., 2023).

The CDC-funded CHAMPS National program, which enrolls 100 hospitals to achieve BFHI designation, is an example of investment that addresses both cost and the need for technical expertise; the program also strongly centers community partners in implementation. This effort could serve as the basis for even larger-scale efforts with proportionately larger investment. Such investments would have high impact and a very high return, producing substantial savings.

The BFHI has been implemented globally for over 25 years and only more recently in the United States, with a presumed focus on the healthy breastfeeding dyad. Suggested revisions of the BFHI recommendations have been made to address the needs of preterm infants. In 2020, WHO (2020) released guidelines on breastfeeding for small, sick, and preterm infants.

Indian Health Service Baby-Friendly Initiative

In 2011, the Indian Health Service (IHS) coordinated an initiative seeking for all federally administered IHS obstetric facilities to earn the Baby-Friendly designation based on the implementation of the Ten Steps and the Code, as attested by an on-site evaluation from Baby-Friendly USA (Karol et al., 2016).

To achieve this goal, the IHS took an empowering, community-engaged, equitable approach, guided by systems thinking. Specifically, IHS hospitals across the country formed task forces, created a network of practitioners to develop and share successful breastfeeding promotion strategies, updated policies, and improved medical record templates. Senior staff from IHS headquarters visited facilities to address on-site barriers, provide training and technical assistance, and conduct mock Baby-Friendly assessments. Strategies and solutions were shared systemwide via webinars and conference calls. Quality improvement methods, technical assistance, and site visits assisted with the implementation process. Between 2011 and December 2014, 100% of the IHS federally administered hospitals gained Baby-Friendly designation, indicating that the IHS BFHI was highly successful (Karol et al., 2016). Furthermore, the rate of breastfeeding at age six months increased from 37.3% of American Indian and Alaska Native babies born in 2011 to 55.0% of babies born in 2015 (CDC, 2024). During the same period, the rate of exclusive breastfeeding through age six months increased from 15.6% to 19.6% (CDC, 2024).

The process evaluation found that although some individual health care providers were resistant to implementing the Ten Steps, enthusiasm from community members overcame this resistance. The BFHI approach was found to be strongly consistent with Native American culture. For example, separating mothers and babies immediately after birth can often undermine traditional birthing practices. Ten Steps policies such as skin-to-skin

care and rooming-in, however, are very consistent with cultural birth and childcare practices. Hence, centering the initiative around the experiences of local communities was critical to its success.

Conclusion 6-1: The Baby-Friendly Hospital Initiative (BFHI) is a well-established, evidence-based program designed to improve breastfeeding outcomes by aligning maternity and newborn care practices with the Ten Steps to Successful Breastfeeding. Since its inception, the BFHI has demonstrated consistent and substantial benefits for breastfeeding initiation, exclusivity, and duration across a variety of health care settings. In the United States, implementation of the Ten Steps, whether through formal Baby-Friendly designation or through stepwise policy adoption, has been associated with improved outcomes and reductions in breastfeeding variances, especially when community engagement and culturally responsive practices are centered.

Recommendation 6-1: The U.S. Centers for Medicare & Medicaid Services and The Joint Commission, in collaboration with other hospital accrediting bodies, hospital associations, and state health regulators, should ensure that every maternity care facility in the United States implements the United Nations Children’s Fund/World Health Organization’s Baby-Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding as the standard of care.

Currently, the Baby-Friendly designation is voluntary for hospitals and birthing centers, meaning facilities can choose whether to pursue certification. Many hospitals and birthing centers opt out because of cost, resource constraints, or logistical challenges in implementing all the required steps (Arslanian et al., 2022; Hernández-Cordero et al., 2022). The certification process involves a multiyear and multiphase accreditation system, including self-assessment, external evaluation, and ongoing compliance reviews, which can be demanding for health care facilities with limited budgets, staffing shortages, or competing priorities. Some states have addressed these challenges by offering financial incentives—via Medicaid, insurance providers, and philanthropic organizations—for hospitals that achieve Baby-Friendly status (e.g., Burnham et al., 2022; Merewood et al., 2019). These incentives recognize the role that Baby-Friendly hospitals play in reducing health care costs, improving maternity care practices, and promoting better infant and maternal health outcomes.

For hospitals in which implementing the Ten Steps is perceived as challenging or difficult, additional resources, including technical support and investments need to be provided. Funding for implementing the Ten Steps needs to be allocated for hospitals serving communities with large differences in breastfeeding outcomes across populations to support them in

pursuing Baby-Friendly status. For example, public–private partnerships of insurers could support this work and provide funding to make this possible.

The U.S. Centers for Medicare & Medicaid Services (CMS) and The Joint Commission have the authority to set standards, establish compliance with these standards, and enforce regulations in hospitals or birth settings. Medicaid funds a significant portion of U.S. maternity care (i.e., approximately 41% of births; see Chapter 7). And The Joint Commission currently accredits nearly 80% of U.S. hospitals; it also sets the quality and safety standards hospitals must meet to maintain accreditation. Box 6-3 presents actions that CMS and the Joint Commission could take to support the implementation of the Ten Steps in hospitals and birth settings.

Staffing Ratios

In tandem with the adoption of evidence-based maternity care practices, adequate staffing is needed so that all breastfeeding dyads receive a standard of care for breastfeeding support (Arslanian et al., 2022). For example, the BFHI stipulates that these staff members are trained and competent in providing breastfeeding care. In addition, delivery hospitals need to staff dedicated lactation consultants. Similarly, the U.S. Lactation Consultants Association recommends that one provider with the International Board Certified Lactation Consultant^® (IBCLC) designation be available for every 783 breastfeeding dyads and varying staffing models based on the size and level of care of the neonatal intensive care unit (Lober et al., 2021). These examples span various settings, which will be discussed throughout the chapter.

QUALITY IMPROVEMENT INITIATIVES AND MEASURES

Quality improvement involves an iterative method of changes that include processes, structure, outcomes, and balancing measures. An example of a process change that can impact breastfeeding rates is a hospital transitioning from a traditional nursery setting to rooming-in, in alignment with step 7 of the Ten Steps. A structural change could be adding details to electronic health records (EHRs) such as skin-to-skin contact in the delivery room and exclusive and overall breastfeeding. Another example of a structural change is educating health care professionals and verifying their competencies in providing breastfeeding care. Outcome measures often include exclusive and overall breastfeeding at specific time points but may also include receiving any human milk (e.g., expressed mother’s milk, donor milk). Finally, balancing measures often include time and costs related to the changes being made but could also include adverse or sentinel events. Quality improvement projects may begin as early as undergraduate education; they are required in most residency programs and for maintenance of certification in many specialties, including pediatrics.

One challenge in quality improvement is that some outcome measures, including breastfeeding rates, are difficult to measure beyond the newborn period. While the federal government tracks national breastfeeding rates using the National Immunization System, the Pregnancy Risk Assessment Monitoring System survey, and the Infant Feeding Survey, there is no consistent method at the local practice level for tracking breastfeeding continuation rates for exclusive and/or overall breastfeeding.

Large national quality improvement collaboratives following the framework of “the Breakthrough Series” (Institute for Healthcare Improvement, 2003) have been very successful in increasing breastfeeding initiation, duration, and exclusivity, and even in reducing racial differences in breastfeeding rates (Arbour et al., 2019; Burnham et al., 2022; Feldman-Winter et al.,

2017a; Merewood et al., 2019). These initiatives, funded by both the federal government and private foundations, have brought together experts in quality improvement methodology, content leaders, physician and other clinical leaders, as well as effective trainers to engage the health care system to undergo a series of transformational changes in the landscape of breastfeeding protection, promotion, and support. These systemic changes aim to eliminate bias in care and overcome variances in breastfeeding outcomes.

Among the many lessons learned in these collaboratives, two of the most important aspects of change include leadership buy-in (Feldman-Winter & Ustianov, 2016) and community involvement (Burnham et al., 2022). Changes that not only engage community partners but are created and led by community champions have the best potential for overcoming hesitancy and mistrust. Once community partners are provided the opportunity to lead changes within the health system, the “funded outsiders” can transfer oversight to the community (Julian et al., 2020). Together with establishing and maintaining connections, continuing to track both process and outcome measures enables such projects to be sustainable.

Continued funding for quality improvement collaboratives is needed and warranted, given their success. At the time of this writing, CDC is funding another large national collaborative, CHAMPS National, building on the model of bridging the health system with the community and enrolling 100 new hospitals with the goals of implementing the Ten Steps and reducing racial variances in breastfeeding initiation. Also, the World Health Organization (WHO; 2025) and United Nations Children’s Fund (UNICEF) have recently published a new monitoring manual for the BFHI, including the internal monitoring system to ensure the quality of implementation of the Ten Steps.

Lactation support among clinicians has been associated with improved knowledge, confidence, and attitudes about breastfeeding for their own patients (Dixit et al., 2015). In contrast, Dixit et al. (2015) reported that inadequate support may undermine breastfeeding and leave clinicians in training with feelings of guilt and remorse. As such, clinical training may be an important time frame for opportunities to enhance breastfeeding support and create a culture of clinician support for breastfeeding. For example, the AAP, along with the American Academy of Family Physicians and ACOG, established a quality improvement collaborative for pediatric, family medicine, and obstetrics and gynecology residency training programs to implement a standardized policy for breastfeeding support (Lanigan et al., 2023).

INTEGRATING BREASTFEEDING SUPPORT IN PRIMARY CARE

Step Ten from the BFHI Ten Steps calls for ensuring the continuum of breastfeeding care once the dyad leaves the maternity facility. In addition to connection to community resources for breastfeeding support, scheduling

the first newborn visit with a provider is key. The AAP (n.d.b) recommends that the first hospital follow-up visit for infants occur on days 3–5 after birth, or within 48 hours of discharge from the hospital, and that this visit utilize hospital information such as newborn weight trajectories, bilirubin level, and feeding patterns to determine what should be included in the ambulatory assessment (Hoyt-Austin et al., 2022). Meek et al. (2022) noted that feedings need to be observed by a trained health care professional at least once every 8–12 hours during the early postpartum period, including at least once in the 8 hours before discharge. Following discharge, dyads with risk factors (see Box 6-4) need to be seen by the pediatric care provider within 24–48 hours. All other dyads need to be seen within 48–72 hours. Usually, these visits are with the infant’s primary care provider (e.g., pediatrician, family physician, family nurse practitioner, primary care pediatric nurse practitioners) and can include the help of specialized lactation support providers if available in the outpatient setting.

Key practices can support exclusive breastfeeding in the first week of life (Feldman-Winter et al., 2020). Opportunities include utilizing the formerly known “Breastfeeding Checklist for Health Supervision” developed by the AAP and creating an electronic version tied to the EHR. This resource would prompt providers to ask relevant questions that would help ascertain breastfeeding concerns and identify the need for additional support (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 2022, pp. 157–164).

Similar recommendations are described in the Academy of Breastfeeding Medicine’s (ABM’s) protocol Breastfeeding-Friendly Physician’s Office—Optimizing Care for Infants and Children (Vanguri et al., 2021). Breastfeeding support and tools can be embedded even within busy primary care practices and can involve an interdisciplinary support team that includes nursing staff, community partnership with lactation support providers, and staff education (Kawan et al., 2023).

In a review of breastfeeding in the first week, Feldman-Winter et al. (2020) outlined evidence-based practices for infant care providers. The authors highlight a structured framework for breastfeeding assessment across inpatient, discharge, and outpatient settings. During hospitalization, trained professionals are advised to observe feedings every 8–12 hours and again within eight hours before discharge, with attention to latch, milk transfer, maternal comfort, infant output, and jaundice. At discharge, timely followup is emphasized: within 24–48 hours for high-risk dyads (such as late preterm infants, those with excessive weight loss, or maternal pain) and within 48–72 hours for all other breastfed infants. Outpatient assessments focus on maternal issues like nipple trauma, engorgement, or mastitis, and infant concerns such as weight loss of 7% or more at 5–6 days, which warrants close monitoring. Other potential best practices include underscore documenting weight loss with validated tools like NEWT, leveraging tele-lactation and breastfeeding clinics to improve access, and addressing persistent latch or transfer challenges with targeted support.

Pediatric primary care providers can be well positioned to support the breastfeeding dyad (Ware & Piovanetti, 2020). However, most may not receive the necessary training or education to support breastfeeding effectively (Brzezinski et al., 2018; Esselmont et al., 2018). If lactation support is not embedded within the practice, pediatric primary care providers could have a local referral process to lactation experts for their breastfeeding families. The pediatric appointment can involve the following:

1. Identify the breastfeeding differential diagnosis³ after history and physical evaluation of mother and baby, including a feeding assessment.
2. Create an infant feeding plan to ensure adequate nutrition while protecting maternal milk production in the context of prioritizing maternal mental health.
3. Refer for additional breastfeeding help if not available within the primary care provider’s office, along with close follow up with the primary care provider.

In addition, Meek et al. (2017) identified opportunities for pediatric and other health care offices to employ breastfeeding-friendly features (see Box 6-5).

When lactation challenges occur or when a mother relies on pumping to sustain her milk supply, it is important not only to address the physical aspects of breastfeeding but also to consider the mother’s emotional

___________________

³ A differential diagnosis may include a wide range of disorders associated with persistent breast and nipple pain, such as latch issues, pump trauma, or infection (American College of Obstetricians and Gynecologists, 2021).

well-being and the adequacy of her support systems. Close follow-up care should prioritize maternal mental health, recognizing that ongoing efforts to breastfeed, while often encouraged, may in some circumstances place undue strain on mothers and contribute to distress or diminished well-being if adequate support is lacking (Tucker & O’Malley, 2022). When supplementation is medically indicated, it is important for the pediatric primary care provider to recommend the appropriate amount of mother’s own milk, donor human milk, or infant formula for the clinical situation to avoid overfeeding and to have a plan to decrease supplementation as soon as clinically prudent (Feldman-Winter et al., 2020).

PROVIDER EDUCATION AND TRAINING

Breastfeeding has been unevenly incorporated into training across health care disciplines. This section focuses on the education and training of the lactation support workforce that is found in the health care setting and those who interface with it (i.e., are provided payment for services by insurance companies or other mechanisms).

Physician Education and Training

Investing in breastfeeding education and training is essential to provide competent breastfeeding care and uphold the principles of primary preventive breastfeeding services. Evidence dating back to 1995 (Arslanian et al., 2022; Freed et al., 1995) shows that physicians report not receiving adequate education and training in breastfeeding, and not enough has changed within the physician workforce (Meek et al., 2020). The AAP conducts periodic surveys to determine the status of pediatrician knowledge, practice patterns, and confidence in providing breastfeeding care (Meek et al., 2020). The most recent analysis indicates that pediatricians’ knowledge about breastfeeding has become better aligned with recommendations for breastfeeding; however, more pediatricians than in the past had negative attitudes about the likelihood of breastfeeding success, including mothers reaching their own goals (Feldman-Winter et al., 2017b).

A recent landscape analysis of breastfeeding-related physician education in the United States revealed that medical education about lactation in a variety of specialties is not included universally (Meek et al., 2020). Numerous activities and programs have been developed to close the gap in breastfeeding knowledge, attitudes, and confidence among physicians, yet they are not a required part of training programs. Residency training curriculum can result in better outcomes for breastfeeding women (Feldman-Winter et al., 2010). Nevertheless, there are no quality metrics to determine whether breastfeeding care is delivered at all, let alone in an evidence-based and culturally congruent manner.

The ABM has a comprehensive course, What Every Physician Needs to Know About Breastfeeding, designed to provide a basic level of education suitable for physicians of all specialties. The course is accessible currently for physicians and other providers from around the world who attend the ABM annual conferences, and microlearning modules have been made available free for all.⁴ The AAP (n.d.a) has updated its online curriculum to address learners at all professional levels; it includes cultural examples of care and is designed to reach a younger audience of learners with short videos and a variety of adult learning tools.

Ideally, education and training among health care professionals begins early in the educational process and becomes integrated into the basic sciences component of the curriculum followed by clinical curriculum for doctors, nurses, and all other health professionals that provide care for breastfeeding dyads. In the U.S. Medical Licensing Examination, breastfeeding is delineated in the outline of topics for all three steps of the exam, yet there is wide variability in how medical school curriculum prepares students

___________________

⁴ https://www.bfmed.org/need-to-know-videos

to develop the knowledge, skills, and attitudes necessary to pass board examination questions related to breastfeeding topics.

Education, training, and now competencies are integrated into step 2 of the Ten Steps to Successful Breastfeeding. The new requirements, including implementation of the Code, involve demonstrating competencies for staff caring for mother–infant dyads in the hospital setting. As this new program requirement is just being implemented, it is too soon to determine if this improves safety and quality of care.

In addition to the above-mentioned breastfeeding training opportunities through ABM and AAP, various other opportunities for breastfeeding education are available. Physicians not only have a duty to provide breastfeeding support as optimal nutrition and immune protection for mothers and their infants, but they also have a role to play in eliminating breastfeeding variances and promoting health equity. Furthermore, in-service training is needed for practicing physicians to ensure clinical competencies are up to date and to minimize misinformation. Research can elucidate best practices for disseminating evidence-based breastfeeding care, adopting new treatments into practice, and coordinating care with other health care professionals interfacing with the family. For example, McCormack et al. (2013) summarized how multicomponent approaches can address, reach, and motivate clinician changes in behavior. In addition, there are important opportunities to engage fathers and partners throughout the life course and lactation journey.

Physicians may become fellows of the ABM (n.d.) and join the Section on Breastfeeding of the AAP (n.d.c) to become more involved in breastfeeding and lactation medicine issues. As of 2023, breastfeeding medicine as a specialty was recognized by the North American Board of Breastfeeding and Lactation Medicine (NABBLM) and a board-certifying examination was established. Some physicians in the United States and Canada have passed the board examination and are credentialed as NABBLM certification (NABBLM-C). In future years, this board will seek recognition by the American Board of Medical Specialties. Physicians with NABBLM-C practice breastfeeding medicine in both inpatient and ambulatory settings

Certified Nurse Midwife Education and Training

Certified nurse midwives in the United States are advanced practice registered nurses who complete a master’s or doctoral degree in nurse midwifery from an accredited program. They must pass the certification exam administered by the American Midwifery Certification Board and obtain a state license to practice. Accredited midwifery programs are overseen by the Accreditation Commission for Midwifery Education, which includes competencies related to lactation in its standards for curriculum and clinical training.

Breastfeeding and lactation are core components of midwifery education, reflecting the midwife’s role in prenatal, intrapartum, and postpartum care. Curricula typically include physiology of lactation, maternal anatomy and hormonal regulation, assessment, and troubleshooting common breastfeeding problems. While the specific number of hours devoted to breastfeeding varies by program, midwifery students are expected to demonstrate competence in providing evidence-based breastfeeding support before graduation. Many midwives pursue continuing education in lactation, and some go on to become IBCLCs. This dual credential strengthens their ability to address complex lactation issues and lead initiatives in perinatal health.

Nurse Education and Training

Nurses in all health care settings, including hospitals, public health clinics and programs, and community organizations, play a vital role in protecting, promoting, and supporting breastfeeding dyads through evidence-based lactation care (WHO & UNICEF, 2021). However, many nurses may receive minimal education on human milk and lactation during their academic training. Spatz and Pugh (2007) highlighted the integration of breastfeeding education into baccalaureate nursing curricula, emphasizing the importance of equipping nurses with foundational knowledge on lactation care. For example, the University of Pennsylvania’s undergraduate course on human milk and lactation includes 28 hours of didactic instruction and 14 hours of clinical experience, serving as a potential model for incorporating lactation education into nursing programs. Comparatively, typical didactic instruction on lactation is usually 1–5 hours embedded in maternal, obstetric, or gynecological coursework. In addition, clinical experience may vary.

Nurses who do not receive sufficient lactation education during their initial training can supplement their education with on-the-job learning, consistent with step 2 of the Ten Steps (Arslanian et al., 2022). Spatz (2005) documented a staff program aimed at promoting breastfeeding support in a children’s hospital, demonstrating improved outcomes for vulnerable infants. The Breastfeeding Resource Nurse (BRN) Model comprises ten steps aimed at improving human milk and breastfeeding outcomes, particularly for vulnerable infants (Spatz, 2018). These steps range from informed decision-making and milk supply establishment to discharge preparation and follow-up, with an additional emphasis on specialized nurse education and empowerment to effectively implement the model across health care settings (Spatz, 2018). The BRN Model has been instrumental in advancing lactation care in clinical settings. Marhefka et al. (2021) evaluated this model across a statewide initiative, finding it effective in enhancing breastfeeding support and outcomes. Spatz (2018) expanded on the BRN Model through the Spatz

10-Step Model, which emphasizes comprehensive lactation education and support at the point of care. Froh et al. (2015) explored the experiences of BRNs, underscoring their critical role in improving breastfeeding practices and advocating for systemic changes to optimize care delivery.

Integrating lactation education into nursing curricula and ongoing professional development is crucial for empowering nurses to support breastfeeding dyads effectively. Nurses’ roles extend beyond clinical settings to public health and community environments, where they serve as trusted advocates for maternal–child health. By enhancing their knowledge and skills in lactation care, nurses can significantly improve breastfeeding outcomes and likely contribute to long-term health benefits for mothers and infants.

Access to Other Lactation Support Providers: Lactation Consultants, Doulas, and Registered Dietitians

Though not universally available to all mothers, involving lactation consultants, doulas, and other lactation support providers can also positively affect breastfeeding initiation and duration, particularly in low-income and Black and Hispanic communities (Bonuck et al., 2014; Hartman et al., 2012; Louis-Jacques et al., 2021; Reno, 2018). The support of breastfeeding peer counselors, doulas, and community health workers during the prenatal period in particular has been shown to be effective in improving breastfeeding outcomes in community-based settings (Khatib et al., 2023; Louis-Jacques et al., 2021; Reno, 2018; Sobczak et al., 2023). In addition, support during labor from a doula can also improve the chances of a vaginal birth, shorten labor, and improve a mother’s experience of labor (Acquaye & Spatz, 2021; Bohren et al., 2017; Louis-Jacques et al., 2021), factors that are associated with better breastfeeding outcomes. The impact of peer counselors and community health workers⁵ on breastfeeding outcomes is discussed in detail in Chapter 3.

Following discharge from the hospital, lactation problems can occur, which result in problem-oriented visits to a physician’s office or a lactation support professional. Effective management by the physician, advanced practice professional, or lactation support provider is necessary to protect breastfeeding, especially exclusive breastfeeding. There is currently no universal structure to support payment of lactation care for problem-oriented visits if they are not provided by a physician or advanced practice professional. While some insurance companies reimburse a certain number of

___________________

⁵ Community health workers, or community navigators, are trusted members of the community and serve as liaisons to health and social services. They also provide outreach, education, informal counseling, social support, and advocacy (American Public Health Association, 2024). For those working with new mothers, it is important to have basic breastfeeding knowledge and to be aware of local breastfeeding resources. Additional breastfeeding training is also helpful (Furman & Dickinson, 2013).

visits for lactation consultants, this is not widely implemented, and only certain states have Medicaid payment for lactation consultants (see below sections for detailed discussion on Medicaid and payment for services).

Lactation Consultants

IBCLCs provide skilled lactation support, expert breastfeeding and lactation care, and promote policies and practices that support breastfeeding (International Board of Lactation Consultant Commission, 2017). In addition to pathways for health care professionals to become IBCLCs, more nontraditional pathways enable community members to attain the certification (see Box 6-6). The IBCLC designation requires rigorous training with many hours of supervised care for lactating families, along with didactic learning and a certification exam. Many IBCLCs work in hospital settings, but others work in the community in outpatient settings, in private practice, or in association with a hospital-based outpatient system. As of March 2025, there were 20,540 IBCLCs in the United States; most were based in California (2,913), Texas (1,496), and New York (1,091; International Board of Lactation Consultant Examiners, 2025).

Doulas

A doula is a trained professional who provides continuous support, including physical, emotional, and informational support before, during, and after childbirth. The presence of continuous support such as that of doulas is one of the most effective ways to improve labor and delivery outcomes (Caughey et al., 2014). Doulas have been noted to improve not only birth outcomes, but also the initiation and continuation of breastfeeding, including for those in low-income populations (Sobczak et al., 2023). The first doula certification program was developed by Doulas of North America in 1982 by perinatal child health experts; the organization now serves countries across the globe. As lay professionals, doulas do not require a license, but more than 80 organizations across the United States currently provide doula certifications (Ramey-Collier et al., 2023), and breastfeeding education is included in their training. More states are now taking steps to add doula care into Medicaid coverage (Mondestin, 2024). Community-based doulas are a strategy for improving birth outcomes and parent–child bonding and for addressing health equity by supporting women who may not trust the health care system (Prenatal-to-3 Policy Impact Center, 2024).

Registered Dietitians

Dietitians’ expertise in nutrition highlights their importance in breastfeeding support as the first food. A registered dietitian has earned a graduate degree from an accredited dietetics program. The supervised practice requirement is 1,000 hours of real-world experience followed by passing a national exam to become a credentialed registered dietitian and meeting all state requirements for licensure (Academy of Nutrition and Dietetics [AND], n.d.) It is the position of the AND that registered dieticians should continue efforts to shift the norm of infant feeding toward human milk feeding (Lessen & Kavanagh, 2015; Theurich & McCool, 2016). Despite calls for the incorporation of lactation education and training into dietetics curricula, no specific learning outcomes are mandated (AND, 2021). Some registered dieticians attain the IBCLC certification; in 2022, 660 (<1%) registered dieticians self-reported that they were also IBCLCs (Hilliard, 2023).

USBC Core Competencies

As described above, breastfeeding has been incorporated unevenly into training across health care disciplines. Adding to the unevenness of health care preparedness for breastfeeding support, some providers lack personal experience with breastfeeding, which can present challenges when

treating others. This is a unique consideration for health care—for example, it would be unacceptable for an oncologist to rely on personal experience to treat cancer. However, a 2004 national survey of pediatricians found that only 63% of those without personal experience felt confident managing breastfeeding problems, compared with 89% of those with personal experience (Feldman-Winter et al., 2008). With 84% of U.S. women initiating breastfeeding (see Chapter 1), it is imperative that all health care disciplines become proficient in breastfeeding support.

To address these gaps, the U.S. Breastfeeding Committee (USBC, 2010) developed a set of core competencies for all health professionals that include knowledge, skills, and attitudes, as well as additional skills for health team members with primary or secondary care responsibilities for childbearing women, infants, and young children. Furthermore, the USBC (2010) recommends that all health professionals incorporate these core competencies in their work to provide effective and comprehensive services to mothers, children, and families.

USBC (2010) calls for all health care team members to recognize breastfeeding as the optimal feeding for infants and young children, to understand the basic anatomy and physiology of the breast, and to know when and how to refer to appropriate lactation specialists. USBC (2010) states that those who work with infants and childbearing women should be able to share strategies for common breastfeeding challenges, and those who provide hands-on care should be able to assess the lactating breast, recognize normal and abnormal feeding patterns, and develop a breastfeeding care plan. Additionally, USBC (2010) recommends that health professional organizations include relevant breastfeeding-related knowledge and skills in the core training competencies for their disciplines.

Conclusion 6-2: The current lactation support workforce in the health care setting consists of a wide range of providers (e.g., nurses and nurse practitioners, midwives, physicians, advanced practice professionals, International Board Certified Lactation Consultants^®, registered dietitians, peer counselors, doulas). Their education and training with respect to breastfeeding care and training differ widely.

Recommendation 6-2: Accrediting boards and regulatory bodies for health professionals, federal and state agencies, public health organizations, and philanthropic organizations should increase investment in the training and availability of lactation support providers.

1. Accrediting and regulatory bodies for health professionals and state boards of nursing should include a minimum set of competencies in human lactation and breastfeeding into their licensing, certification, and accreditation requirements.

1. 2. Federal agencies, such as the U.S. Health Resources and Services Administration and U.S. Department of Agriculture, in collaboration with state, tribal, and local governments, should work together to provide support for the training and certification of health professionals or lactation support providers to provide breastfeeding support services (e.g., through the breastfeeding peer counseling program offered by the Special Supplemental Nutrition Program for Women, Infants, and Children).
   3. Public health organizations and philanthropic organizations should work together to fund initiatives to increase the number of lactation support providers to ensure that their communities’ lactation needs are met.

Accrediting or regulatory bodies for health professionals, including state licensing boards for nursing, need to explore including a minimum set of competencies in human lactation and breastfeeding into their licensing, certification, and accreditation requirements. This could ensure that individuals providing breastfeeding support in health care settings would have a shared, minimum level of training and education.

In addition, a significant portion of the lactation support workforce is employed in community-based or public health settings, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (see Chapter 4). Thus, federal and state investment in education and training initiatives for registered dietitians, nutritionists or nutrition assistants, IBCLCs, and breastfeeding peer counselors is critical to ensure that community-level needs are met for primary breastfeeding care. In addition, investment in these initiatives could also support data collection on workforce capacity and compensation to ensure that lactation support providers from historically underserved communities are compensated for their work appropriately.

To safeguard the delivery of an optimal standard of care, consistency and alignment across workforce training and education are needed. This would facilitate continuity of care across the life course for the breastfeeding dyad. Additional efforts to collect data on the demographics of the workforce, its geographic location, and the populations it serves will aid in evaluating the impact of this recommendation.

DOCUMENTATION OF BREASTFEEDING OUTCOMES

It is said, “If it was not documented it was not done.” Almost everything that takes place in the delivery of health care services is documented in the medical record. The medical record contains all protected health information, which is kept private except by covered entities (i.e., treating health care professionals). The medical record was recorded mainly by

handwritten paper charts until the Affordable Care Act, which contained penalties for not converting to EHRs. The EHR provides an opportunity to exchange health information between health care professionals and potentially lactation support providers; it is also tied to coding and billing of health-related services (see next section).

Opportunities to improve breastfeeding monitoring and evaluation in the ambulatory setting can complement the public health surveillance efforts described in Chapter 3. However, additional monitoring is needed to address differences in breastfeeding outcomes among various populations, to understand breastfeeding continuation rates throughout the postpartum period, and to support to health care programs and initiatives designed to support breastfeeding.

HEDIS Measures

A Healthcare Effectiveness Data Information Set (HEDIS) is a widely used tool for measuring health care performance used by over 90% of U.S. health plans, covering more than 190 million enrollees. The dataset is determined by the National Committee for Quality Assurance (NCQA), which has representatives from primary and preventive care. NCQA identified breastfeeding as a priority in 2014, and it implemented measures for exclusive breastfeeding and exclusive breastfeeding (considering mother’s feeding plan); the Perinatal Care Core Measures 05 and 05a (PC-05 and PC-05a) (Feldman-Winter et al., 2013). This reporting system, adopted and monitored by The Joint Commission, previously required that hospitals monitor and report exclusive breastfeeding rates, as well as exclusive breastfeeding rates including mother’s feeding plan, on an annual basis, which provided additional data on breastfeeding and led to improvements in hospital-based quality improvement initiatives (USBC, 2013; Feldman-Winter et al., 2013). The Joint Commission no longer requires these measures, however, as it has transitioned to incentive-based programs (i.e., the outcomes are no longer required to be reported to the NCQA on an annual basis). Most hospitals continue to track them voluntarily, which provides a window into the impact of maternity care practices in the inpatient setting on breastfeeding outcomes. But the measures are no longer tied to accreditation and associated quality standards.

Similar processes would presumably occur if an ambulatory HEDIS measure was established and aligned with the Healthy People goals, such as the 2030 goal for six months of exclusive breastfeeding for 42.4% of infants. There could also be goals regarding reduction or elimination of variances. This measure would prompt EHR vendors to created automated fields that capture infant feeding at each visit and permit a more universal data capture to determine baseline and post–improvement project outcomes.

Another benefit to a universal breastfeeding HEDIS measure for the ambulatory setting would be to identify “lactation care deserts,” as indicated by low breastfeeding rates. Currently, the only county-level breastfeeding data available are initiation rates from the birth certificate. With duration data, federal resources such as grants and Title V funding could be appropriated to these areas to fill gaps in care and enhance the workforce with culturally congruent care providers.

Measures could also be adopted for prenatal care regarding anticipatory guidance for breastfeeding and lactation. And, to identify lactation care deserts and support targeted workforce development, the Health Resources and Services Administration’s National Center for Health Workforce Analysis could include data on lactation support providers in its Area Health Resources Files.

Finally, national datasets monitor breastfeeding and the use of human milk for sick and vulnerable infants; for example, the Vermont Oxford Network provides coordinated programs of research, education, and quality improvement projects. And national collaborative data collection projects for well newborns include the Better Outcomes through Research on Newborns Network, which collects national data to identify issues such as neonatal weight loss, hyperbilirubinemia, and other potential adverse outcomes of poor breastfeeding care. However, a more robust preventive strategy can be imagined and implemented.

Conclusion 6-3: The creation of a Healthcare Effectiveness Data Information Set performance measure for breastfeeding would require electronic health records to create automated fields to better capture infant feeding practices across time (i.e., in the birth setting and during postpartum and pediatric care). Practices at baseline and after implementing improvement projects would be recorded to assess how well health plans and health care providers protect, support, and promote breastfeeding. In addition, measures that are aligned with the care and support of sick or vulnerable infants can be established, to better track breastfeeding outcomes and future investment in inpatient settings.

Recommendation 6-3: The U.S. Centers for Medicare & Medicaid Services should develop and implement a Healthcare Effectiveness Data Information Set performance measure of breastfeeding.

Overall, a HEDIS measure would provide a standardized approach to evaluating and comparing the performance of different health plans (e.g., by identifying breastfeeding trends) so that health care networks can make actionable and informed decisions on potential quality improvement initiatives needed to improve breastfeeding rates.

REFERENCES

This page intentionally left blank.