Children & COVID – Part 1: Making sense of rates and vaccination and Part 3:…
By Amanda M. McDougald Scott, MS, Institute for Child Success
Ashley Crary Lidow, MPH, WREN
Terri Negron, RN, MN, FNP, Prisma Health and
BZ (Melanie) Giese, BSN, RN, SC DHHS South Carolina Birth Outcomes Initiative
This blog is part of ICS’s series utilizing information from our South Carolina Early Childhood Databook, which highlights 80+ indicators of child and family well-being in South Carolina compared to North Carolina, Georgia, and the national average. More resources from this publication can be accessed here.
Breastfeeding is Important
Given the well-documented fact that the health and psychological benefits to mothers and babies multiply the longer breastfeeding continues, it is notable that the number of South Carolina mothers breastfeeding declines over time in the first year of an infant’s life. The American Academy of Pediatrics, World Health Organization, and Institute of Medicine all recommend exclusive (non-formula supplemented) breastfeeding to six months of age and continued breastfeeding to 1 year of age or longer if mutually desired by both the mother and infant 1.
Why is it so important? Breastfeeding for any length of time has been shown to improve both physical and psychological factors for infant and maternal health 1-5. The graphic below highlights research-documented benefits for babies of various lengths of breastfeeding as well as for mothers:
* Research has identified these impacts for children exclusively breastfed for this period – that is, with no formula supplementation.
Studies with special populations of infants, such as preterm infants, have demonstrated that breastfeeding is essential to the development of preterm infants’ immune systems, and is recommended as the optimal food, except for in cases in which the mother cannot breastfeed; in those cases, human donor milk is recommended, as ICS has written before 6. Psychological improvements include mutual benefits to the mother and infant due to skin-to-skin time, which has been shown to improve maternal-infant bonding 5.
South Carolina Breastfeeding by the Numbers
The number of South Carolina mothers breastfeeding declines over time in the first year of an infant’s life. In 2017, 76% of South Carolina mothers reported ever breastfeeding their infants, which was significantly lower than both of our neighboring peer states (Georgia 84%, North Carolina 85%) and the national average of 83%3. The breastfeeding rate dropped to 45% non-exclusively at six months – that is, breastfeeding combined with another milk – which has an even greater margin of difference when compared to peer states and the national average. North Carolina has the highest rate, 59%, of non-exclusive breast feeding at six months than the national average at 58%, and lastly but still significantly above South Carolina, Georgia at 56%3. Fewer than 25% of South Carolina mothers continue to breastfeed exclusively for six months which is on par with the national average of 25%; in our comparison, only North Carolina is above the 25% mark at 27%. These statistics discuss all mothers and do not get into the notable demographic differences that are well-documented7.
What type of support is available for mothers who want to breastfeed?
Lactation consultants are seen as an increasingly important resource in promoting breastfeeding and have been shown to improve breastfeeding initiation and intensity 8. Two common types of lactation consultants are Certified Lactation Counselors (CLC) and International Board-Certified Lactation Consultants (IBCLC). Both are qualified professionals whose intervention can improve breastfeeding rates and consistency.
Availability of lactation consultants may vary depending upon where you live. In South Carolina, there are 3.87 CLCs and 3.32 IBCLCs per 1,000 live births. Nationally, the averages are 4.57 and 3.79 respectively. Georgia and North Carolina each favor either CLCs or IBCLCs more than the other. Georgia has 5.97 CLCs and 2.77 IBCLCs per 1,000 live births while North Carolina has 1.19 CLCs and 5.38 IBCLCs 3.
Additionally, Prisma has adopted the QTIP (Quality through Technology & Innovation in Pediatrics) program, which works to improve healthcare for all children in South Carolina. One of the 2019 objectives is to create a baby friendly practice that encourages and documents breastfeeding during the infants first four weeks of life. As of 2018, 41.7% of South Carolina babies were born in baby-friendly facilities, which are designated as such due to the support they provide for lactating mothers and their babies. As the US Preventative Services Task Force recommends breastfeeding support which begins during pregnancy and continues into the child’s life, ensuring access to support services is essential to timely intervention.
Baby-friendly work environments are currently defined by the Centers for Disease Control Guide to Breastfeeding Interventions 9 as:
including several types of employee benefits and services, including writing corporate policies to support breastfeeding women; teaching employees about breastfeeding; providing designated space for breastfeeding or expressing milk; allowing flexible scheduling to support milk expression during work; giving mothers options for returning to work, such as teleworking, part-time work, and extended maternity leave; providing on-site or near-site child care; providing high-quality breast pumps; and offering professional lactation management services and support (p.7).
Baby-friendly work environments have been shown to increase breastfeeding rates 10, 11, and support working mothers in the workforce. The lactation room should be comfortable, clean, and include important components such as electrical outlets 12, 13. Co-workers and supervisors should also display positive attitudes towards lactating mothers 12.
So, breastfeeding is important. What are the barriers?
Breastfeeding discrimination in the workplace and in American society is a barrier; at work, this type of discrimination can result in various kinds of economic loss, including job loss. Women are also frequently subject to humiliating or harassing behavior by co-workers or supervisors at work, particularly when they are not given appropriate privacy or accommodations to express milk 13.
There are federal laws designed to ensure that women who would like to continue to breastfeed when they return to work are able to do so, but the current language leaves many women without respite when it comes to realizing this protection 13. Excluded workers often include professions in which women are not usually given a break, such as teaching, nursing, shift work, farm work, and others 13, 14. The laws are also frequently unenforceable13.
How can policy help?
Workplace lactation laws have been shown to be effective in increasing breastfeeding rates. Twenty-nine states already have laws related to breastfeeding in the workplace that range from limited coverage to laws that give accommodation rights to every employee in the state.15 One study found that the gains observed in states with lactation laws suggested that such laws may help disparities in breast feeding.10
Great news for South Carolinians is that our state is currently one of the most supportive states in the United States for women who want to continue breastfeeding when they return to work 16. The South Carolina Pregnancy Accommodations Act that passed in May 2018 allowed South Carolina to become a leader in the realm of workplace policies that support breastfeeding women. The law gives explicit rights to reasonable accommodations for a pregnancy related condition including lactation. The act covers employees whose workplaces have 15 or more employees.
Only 11 states have received the top distinction for most protective lactation laws granted by the Center for WorkLife Law, and South Carolina is now poised to be a true leader if H.3200 passes. The Lactation Support Act, H.3200, will build off of the success of the Pregnancy Accommodations Act by ensuring all workers have the explicit right to break time to express their breastmilk.
This bi-partisan bill amends existing lactation law to provide adequate definitions to ensure that employees are provided reasonable unpaid or paid break times to express milk. Furthermore, employees are to be provided areas for private lactation, and shall not be discriminated against for choosing to express milk in the workplace. This bill has support from a number of entities in the state, including the Women’s Rights and Empowerment Network (WREN) who is leading the campaign, along with the Palmetto Family Alliance, South Carolina Catholic Conference, Southern Baptist Convention, March of Dimes, Birth Outcomes Taskforce- Spartanburg County, and women from across the state. It has already passed the South Carolina House of Representatives by a vote of 93-0 and is waiting to be heard by the South Carolina Senate.
To follow the bill’s progress, please bookmark this WREN web page.
The choice of how to feed an infant is one of the most personal a family can make, and families should work with their health care professionals to determine what works best. However, many families currently make decisions to end breastfeeding based on cultural and/or societal barriers. We are proud to see South Carolina work to remove these deterrents, helping to ensure families can choose what is best for them.
1.National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development. What are the recommendations for breastfeeding? 2017 [cited 2019 March 28]; Available from: https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/recommendations
2.Breastfeeding and the use of human milk. Pediatrics. 2012; 129:e827-41.
3.CDC National Immunization Survey (NIS). Breastfeeding Report Card. 2018.
4.National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development. What are the benefits of breastfeeding? 2018 [cited 2019 March 28]; Available from: https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/benefits.
5.Feldman-Winter L, Goldsmith JP. Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns. Pediatrics. 2016; 138.
6.Underwood MA. Human milk for the premature infant. Pediatric clinics of North America. 2013; 60:189-207.
7.U. S. Preventive Services Task Force. Primary Care Interventions to Support Breastfeeding: US Preventive Services Task Force Recommendation StatementUSPSTF Recommendation: Interventions to Support BreastfeedingUSPSTF Recommendation: Interventions to Support Breastfeeding. JAMA. 2016; 316:1688-93.
8.Witt AM, Smith S, Mason MJ, Flocke SA. Integrating routine lactation consultant support into a pediatric practice. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine. 2012; 7:38-42.
9.Control CfD. The CDC Guide to Breastfeeding Interventions.
10.Hawkins SS, Stern AD, Gillman MW. Do state breastfeeding laws in the USA promote breast feeding? Journal of epidemiology and community health. 2013; 67:250-6.
11.Smith-Gagen J, Hollen R, Tashiro S, Cook DM, Yang W. The association of state law to breastfeeding practices in the US. Maternal and child health journal. 2014; 18:2034-43.
12.Tsai S-Y. Impact of a breastfeeding-friendly workplace on an employed mother’s intention to continue breastfeeding after returning to work. Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine. 2013; 8:210-6.
13.Morris L, Lee J, Williams JC. Exposed: Discrimination Against Breastfeeding Workers: Center for Worklife Law, University of California, Hastings College of the Law,2018.
14.Lauer EA, Armenti K, Henning M, Sirois L. Identifying Barriers and Supports to Breastfeeding in the Workplace Experienced by Mothers in the New Hampshire Special Supplemental Nutrition Program for Women, Infants, and Children Utilizing the Total Worker Health Framework. International journal of environmental research and public health. 2019; 16:529.
15.National Conference of State Legislatures. Breastfeeding State Laws. 2019 [updated April 4, 2019; cited 2019 April 12]; Available from: http://www.ncsl.org/research/health/breastfeeding-state-laws.aspx.
16.Center for WorkLife Law. State Workplace Lactation Laws2018.