The disparities in breastfeeding rates among population groups is well recognized. Data show that women who are poor, single, black, and poorly educated are less likely to breastfeed. In an effort to address these disparities, Melissa Bartick, M.D. and her colleagues from the Massachusetts Breastfeeding Coalition (MBC) have written what Dr. Bartick describes as a “proposal for proposal.”

The next step is to submit the one-page document to the National Association of State Medicaid Directors, asking that consideration be given to providing insurance incentives to hospitals to promote breastfeeding. Other state breastfeeding coalitions and advocacy groups are encouraged to follow Massachusetts’ lead, targeting Medicaid as well as private insurance companies. The best part is that there is no need to reinvent the wheel, because MBC has been kind enough to share their proposal (see below).

Kudos to Dr. Bartick and her colleagues!

Massachusetts Breastfeeding Coalition Proposal for Proposal

Background:

• The Surgeon General and the CDC recognize significant disparities in breastfeeding rates with lower income populations and African-American women breastfeeding at lower rates.

• Breastfeeding rates after hospital discharge fall well short of Healthy People 2010 Goals.^{1, 2}

• Fewer than 3%³ of US hospitals are certified as Baby-Friendly, meaning they comply with a package of ten evidence-based practices outlined by WHO/UNICEF to promote breastfeeding (The Baby-Friendly Hospital Initiative).⁴

• Hospitals which adhere to the Baby-Friendly ten steps have been shown to have greater duration of breastfeeding and higher rates of exclusive breastfeeding.^5-9 The CDC has shown that most hospitals fall well short of optimal breastfeeding practices.¹⁰

• All major medical authorities recommend babies get no other food or drink than human milk for the first 6 months of life, with continued breastfeeding for at least the first 1-2 years of life.^11-16

• California has publicly reported “any” and “exclusive” breastfeeding rates for all hospitals, emphasizing the gap between the two rates, which has encouraged many hospitals to adopt evidence-based practices for newborn and breastfeeding care.

• The National Quality Forum is proposing measuring exclusive breastfeeding in the hospital as one of 15 quality metrics for perinatal care.

• Withholding 0.5% of a DRG for failure to meet specific breastfeeding objectives resulted in significant increases in breastfeeding in Northern Italy¹⁷ (no such program has ever been implemented in the US).

Public Health and Financial Impact:

• Increasing breastfeeding rates in the US will save money¹⁸ and lives.¹⁹

• Evidence-based best hospital practices have result in marked increases in exclusive breastfeeding in the hospital, even in Medicaid populations.

• Hospital rates of exclusive breastfeeding correspond with a hospital’s implementation of evidence-based best practices and thus likely predict longer breastfeeding duration.

• Exclusive breastfeeding for 3 months reduces health care costs for infants in the first year of life by up to $475, compared to non-breastfed infants.²⁰

• Early cessation of breastfeeding increases the risk of many costly or chronic diseases in offspring: obesity, diabetes (types 1 and 2), SIDS, and leukemia.²¹

• Early cessation of breastfeeding increases the risk of maternal breast cancer, ovarian cancer, and type 2 diabetes.²¹

Performance Incentive Proposal

• Urge all states to publicly report their hospitals’ rates of breastfeeding initiation and the rates of supplementation for breastfed babies, and use this metric as a leading pediatric/maternal quality indicator. Any/exclusive breastfeeding can be measured at one point in time at 24 to 96 hours of life, such as during routine genetic screening.

• Provide a monetary bonus for hospitals who maintain a supplementation rate of less than 15%, or who decrease their supplementation rates by at least 15 percentage points per year.

• Consider providing a monetary bonus for hospitals that have achieved designation as a Baby-Friendly Hospital™ after the objective evaluation of Baby-Friendly USA.

• Consider providing a monetary bonus for office providers who are compliant with the International Code of Marketing of Breast-milk Substitutes²² and publicly report them.

References:

1. Shealy K, Li R, Benton-Davis S, Grummer-Strawn L. The CDC Guide to Breastfeeding Interventions. Atlanta: US Department of Health and Human Services, Center for Disease Control and Prevention; 2005.

2. US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: US Department of Health and Human Services, Office on Women’s Health; 2000.

3. US Baby-friendly hospitals and birth centers as of February 2008. 2008.

4. World Health Organization, UNICEF. Baby-friendly hospital initiative (Revised, updated and expanded for integrated care). In; 2006.

5. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase breastfeeding duration: results from a population-based study. Birth 2007;34(3):202-11.

6. DiGirolamo A, Grummer-Strawn L, Fein S. Maternity care practices: Implications for breastfeeding. Birth 2001;28(2):94-100.

7. World Health Organization, Division of Child Health and Development. Evidence for the ten steps to successful breastfeeding (revised). Geneva: WHO; 1998.

8. Duyan Camurdan A, Ozkan S, Yuksel D, Pasli F, Sahin F, Beyazova U. The effect of the baby-friendly hospital initiative on long-term breast feeding. Int J Clin Pract 2007;61(8):1251-5.

9. Caldeira AP, Goncalves E. Assessment of the impact of implementing the Baby-Friendly Hospital Initiative. J Pediatr (Rio J) 2007;83(2):127-32.

10. Centers for Disease Control and Prevention. Breastfeeding-related maternity practices at hospitals and birth centers — United States, 2007. MMWR 2008;57(23):621-25.

11. American Academy of Family Physicians. Breastfeeding (Position Paper). In; 2001.

12. American College of Nurse Midwives. Position Statement: Breastfeeding. Silver Spring, MD: American College of Nurse Midwives; 2004 Feb.

13. American College of Obstetricians and Gynecologists. Breastfeeding. Washington, DC; 2003 July.

14. American Public Health Association. American Public Health Association Policy No. 200714: A call to action on breastfeeding: a fundamental public health issue. 2007.

15. European Commission. Protection, promotion and support of breastfeeding in Europe: a blueprint for action. Dublin Castle, Ireland; 2006 June 18.

16. WHO/UNICEF. WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Geneva: WHO; 2003.

17. Cattaneo A, Borgnolo G, Simon G. Breastfeeding by objectives. Eur J Public Health 2001;11(4):397-401.

18. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506.

19. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004;113(5):e435-9.

20. Ball T, Wright A. Health care costs of formula-feeding in the first year of life. Pediatrics 1999;103(4 Pt 2):870-6.

21. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. In: Evidence Report/Technology Assessment Number 153: Agency for Healthcare Research and Quality; April 2007.

22. World Health Organization. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 1981.