Breastfeeding is recognized as the best infant feeding source.1 The overwhelming health risks of not breastfeeding make low breastfeeding rates a public health concern. The American Academy of Pediatrics recommends that mothers exclusively breastfeed their babies for 6 months and continue for at least 12 months, with age-appropriate additional feeding.2

Research consistently shows that babies who are not breastfed are at an increased risk for conditions such as gastroenteritis, lower respiratory tract infections, otitis media, necrotizing enterocolitis, sudden infant death syndrome, obesity, diabetes, and childhood leukemia.2 Not breastfeeding also increases the mother's risk for several diseases. Women who do not breastfeed are at higher risk for breast cancer, ovarian cancer, cardiovascular diseases, and type 2 diabetes. Furthermore, women who breastfeed experience a more rapid return to prepregnancy weight and a decreased risk of postpartum bleeding.2 Medical contraindications to breastfeeding are rare. Breastfeeding offers numerous economic benefits to the overall population. A cost analysis published in Pediatrics in 2010 concluded that if 90% of families breastfed exclusively for 6 months, the United States would save $13 billion in direct and indirect health care costs per year and prevent an estimated 911 excess deaths.3

The benefits of breastfeeding are widely accepted; however, not all infants start or continue to breastfeed for the first 6 months of their lives. According to the Centers for Disease Control and Prevention (CDC), nationally 80% of newborn infants initiate breastfeeding, with 51% breastfeeding for 6 months and 29% breastfeeding for 12 months. Only 22% of infants are exclusively breastfed for the first 6 months of their lives.4

Although breastfeeding has increased across all racial and ethnic groups, racial and ethnic disparities in breastfeeding initiation and duration rates persist. Breastfeeding rates among blacks have consistently fallen short of the goals identified as national public health priorities in Healthy People 2020. In 2012, the rate of black infants ever breastfed was 66.4%, compared with 83% for whites and 82.4% for Hispanic infants. Only 35.3% of black babies were breastfed at 6 months, compared with 55.8% of white babies and 51.4% of Hispanic babies. At 12 months, only 16.9% of black babies were still breastfed, compared with 32.8% of white babies and 27.9% of Hispanic babies.4

Local Health Departments Play Essential Roles in Breastfeeding Promotion

The Surgeon General's Call to Action to Support Breastfeeding, recommends the use of organizations based in communities to promote and provide support for breastfeeding.5 Local health departments are uniquely positioned to lead efforts in coordinating community-level breastfeeding services. Health department staff should be knowledgeable about the health risks of not breastfeeding, the economic benefits of breastfeeding to society, and how to support the mother-baby dyad.

In 2014, the National Association of County & City Health Officials (NACCHO), through a cooperative agreement with the CDC's Division of Nutrition, Physical Activity and Obesity, implemented the Reducing Breastfeeding Disparities through Peer and Professional Support project. NACCHO funded a total of 63 organizations, including 27 LHDs, to implement evidence-based and innovative breastfeeding support practices and services in local communities.

Collectively, grantees provided a diversity of peer or professional-led lactation support services in group or individual sessions to prenatal and postpartum women. Project activities can be classified into two main categories: building organizational capacity to better serve breastfeeding mothers and establishing community partnerships to improve safety nets to support breastfeeding. Specifically, grantees built organizational capacity by training their staff and community partners at multiple skill and service levels on breastfeeding promotion, support and management. Organizations implemented systems to bolster infrastructure by establishing lactation rooms and developing breastfeeding support policies and procedures. Some projects addressed structural barriers that mothers face to access services by providing transportation vouchers, meals, and childcare.

Dutchess County Department of Health, in New York, enhanced breastfeeding services by opening a walk-in breastfeeding education and support center. To establish the center, the LHD staff wrote policies and procedures, created staff competencies, developed class content, ordered supplies, and established an advisory board. This enabled them to provide multilevel professional services primarily focused on supporting women with breastfeeding challenges. As a result of NACCHO funding, four of the department's staff members from diverse backgrounds received training and the certified lactation counselor (CLC) certification. Now, all home-visiting services are provided by public health nurses who are CLCs.

The Dakota County Department of Health, in Minnesota, focused on access to care and institutional-level change by developing a toolkit comprising evidence-based practices and policies to help LHDs achieve Breastfeeding-Friendly Health Department status. The program recognizes health departments for their efforts in supporting nursing mothers.

Most breastfeeding classes in Dakota County are fee-per-service education sessions, which limit access by low-income and culturally diverse women. The department achieved institutional change by increasing staff breastfeeding capability and implementing an effective rapid-response referral system among partners to provide no-cost breastfeeding information, support services, and continuous follow-up. Internally, the department identified the key components of its approach to reaching low-income and culturally diverse families.

Florida Department of Health-Broward County (DOH-Broward) partnered with a local hospital to support the Baby-Friendly Hospital Initiative, which recognizes hospitals for providing the optimal level of care for infant feeding and mother-baby bonding, to close the continuity of care gap following postpartum discharge. The department developed a memorandum of agreement with the hospital to incorporate peer breastfeeding support into the maternity care setting. Two community agencies promoted the Breastfeeding Peer Counselor program during prenatal programs. Paraprofessional counselors provided ongoing breastfeeding support to mothers during their hospital stays and after discharge through home visits. DOH-Broward fostered collaboration with community stakeholders by leading the Broward Breastfeeding Coalition, which meets monthly to collaborate and strategize ways to increase breastfeeding rates in the community.

Recommendations for LHDs and Public Health Providers to Improve Community-Based Breastfeeding Support

NACCHO recommends that LHDs and public health providers do the following to improve community-based breastfeeding support:

* Model community and workplace breastfeeding support by including breastfeeding-friendly practices in the health department, such as implementing an organizational breastfeeding support policy and providing breastfeeding training to all staff members.

* Partner with local breastfeeding experts, advocates, and maternal and child practitioners to develop (1) a local breastfeeding committee or coalition to support breastfeeding duration and exclusivity; and (2) a community resources guide.

* Coordinate with state, other LHDs, and local providers to implement community-based programs that support increasing breastfeeding duration and exclusivity.

* Develop and implement internal breastfeeding support policies and procedures to become a Breastfeeding-Friendly Health Department.

* Work with community-based clinics, federally qualified health centers, and local provider offices to help them implement breastfeeding-friendly practices in their facilities.

* Provide mentoring opportunities for individuals working toward becoming International Board Certified Lactation Consultants (IBCLCs) or CLCs and breastfeeding peer counselors wanting to improve their skills.

* Provide training and continuing education opportunities for lactation consultants, lactation counselors/educators, and peer counselors.

* Collaborate with hospitals and community breastfeeding support sites (eg, Women, Infants, and Children Supplemental Nutrition Program [WIC] clinics, community support groups, home-visiting programs) to improve continuity of care by creating an effective referral system for women to access breastfeeding resources during the prenatal period and upon discharge from the hospital.

* Share program examples, lessons learned, and practice-based strategies via webinars and published manuscripts.

* Promote breastfeeding-friendly practices in local businesses, childcare settings, and local government by providing technical assistance to organizations wishing to create a lactation program for their employees.

* Coordinate breastfeeding support efforts between local breastfeeding professionals such as WIC peer counselors, IBCLCs, and CLCs in the community.

* Expand existing breastfeeding support programs and health clinics in the community to leverage resources and increase support.

* Change public health messaging to focus on the risk of not breastfeeding or alternative feeding instead of only stating the benefits of breastfeeding.

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