Breastfeeding promotion programs

There is strong evidence that breastfeeding promotion programs increase initiation, duration, and exclusivity of breastfeeding (Oliveira 2017, Cochrane-Balogun 2016, Patnode 2016, Haroon 2013, Cochrane-Renfrew 2012, Cochrane-Lewin 2010, Dyson 2010). Breastfeeding provides many health benefits to children, including fewer ear infections, lower respiratory tract infections, and gastrointestinal infections for infants (Stuebe 2009, Fisk 2011), and lower likelihood of childhood obesity, type 2 diabetes, and asthma (Giugliani 2015, Stuebe 2009, Harder 2005). Breastfeeding has also been shown to reduce rates of breast and ovarian cancer for mothers (AICR-CUP report 2017, Li 2014a, Stuebe 2009) and has been associated with lower rates of maternal hypertension, diabetes, and cardiovascular disease (Schwarz 2009).

Education interventions increase breastfeeding initiation rates (Dyson 2010), particularly among women with low incomes (Cochrane-Balogun 2016), and increase exclusive breastfeeding until babies are 6 months old (Oliveira 2017). Face-to-face support (Cochrane-Renfrew 2012) and tailored education (Cochrane-Renfrew 2012, Cochrane-Balogun 2016) increase the effectiveness of breastfeeding promotion programs. Combining pre- and post-natal interventions increases initiation and duration more than pre- or post-natal efforts alone (USPSTF-Chung 2008, USPSTF-Breastfeeding 2008).

Support from health professionals (Cochrane-Renfrew 2012, CDC-Breastfeeding 2013, USPSTF-Breastfeeding 2008), including International Board Certified Lactation Consultants (IBCLC) (Chetwynd 2019), lay health workers (Cochrane-Renfrew 2012, Cochrane-Lewin 2010, USPSTF-Chung 2008), and peers (Chapman 2010, Dyson 2010, CDC-Breastfeeding 2013, USPSTF-Breastfeeding 2008) have demonstrated positive effects, including increases in initiation, duration, and exclusivity of breastfeeding. For employed mothers, supportive work environments also increase the duration of breastfeeding (Dinour 2017). Tailored text-based interventions may also help increase breastfeeding duration (Henshaw 2024).

Components of the Baby Friendly Hospitals Initiative (BFHI), which includes 10 steps to support breastfeeding, have been shown to increase breastfeeding rates when implemented as a whole or individually (Wouk 2017, Perez-Escamilla 2016, Dyson 2010). Step 3 of BFHI, which combines breastfeeding education and interpersonal support, increases breastfeeding rates, especially when women’s partners or family are involved (Wouk 2017).

Breastfeeding promotion programs can help reduce obstacles for women of color and those who earn low incomes, such as little to no paid parental leave, lack of social and workplace support, and language and literacy barriers (Louis-Jacques 2017). Low breastfeeding rates are associated with many factors, including physical and mental health status, younger maternal age, less than high school education, racial or ethnic background, and income level; a lack of appropriate supportive resources can create barriers to initiating and continuing breastfeeding (Gomez-Pomar 2018). Breastfeeding rates are also disproportionately low among adolescent mothers. Interventions that focus on adolescent mothers, as well as their mothers and partners, may help promote breastfeeding initiation, duration, and exclusivity among adolescent mothers (Sipsma 2015).

Cost benefit analysis suggests that breastfeeding promotion programs are cost effective (Bartick 2010).

Breastfeeding promotion programs are a suggested strategy to decrease disparities in breastfeeding rates for individuals of color and those with low incomes (Louis-Jacques 2017, Anstey 2017). Available evidence suggests such programs can help reduce obstacles that make breastfeeding particularly challenging for women of color who earn low incomes (Louis-Jacques 2017,Anstey 2017). The Baby Friendly Hospital Initiative increases breastfeeding rates among mothers with lower education levels, which may reduce socio-economic disparities in breastfeeding rates (Hawkins 2015).

Experts suggest breastfeeding promotion programs incorporate multicultural awareness and cultural sensitivity training to best support the needs of mothers from different backgrounds and increase breastfeeding (Louis-Jacques 2017). It is important to understand the barriers preventing mothers, especially those with low incomes or from racial and ethnic minoritized populations, from meeting their breastfeeding goals. Lack of appropriate postpartum support in hospital settings for parents who are Black perpetuates existing disparities; for example, many health facilities that serve large Black populations offer infant formula instead of providing lactation support to new mothers. Additionally, women who are Black are also more likely to return to work earlier than 12 weeks (PBS-Santhanam 2019).

Racial and ethnic disparities in breastfeeding initiation and duration exist in the United States, varying across states. As of 2019, the overall prevalence of breastfeeding initiation was about 80%; Asian Americans had the highest rate at 90%, while mother infant dyads who were Black had the lowest rate at 74% in 26 states, including Washington, D.C.; in 13 states, the lowest rate was among those who were American Indian or Alaska Native (CDC MMWR-Chiang 2021).

Experts such as the American Academy of Pediatrics and the World Health Organization recommend exclusive breastfeeding for six months to ensure infant health and survival (AAP-Newborn and infant breastfeeding, WHO-Breastfeeding), but only about 25% of U.S. families meet that goal (CDC-Breastfeeding). Families that are Black, Hispanic, or multiracial are less likely to breastfeed for six months compared to the national rate (1000 Days-Lozano).

In the past, those who could not or did not want to breastfeed largely turned to wet nurses. In cases where no one was available to nurse an infant, animal milk mixed with other prepared foods was used as a substitute, which was less nutritious and could be contaminated by bacteria. Today, technological advances like infant formula and bottles provide a safe breast milk alternative (Thulier 2009).

The reasons parents do not breastfeed, or do not breastfeed exclusively vary, from individual barriers such as a belief that their milk supply is insufficient (Gomez-Pomar 2018) to systemic barriers presented by needing to return to work (PBS-Santhanam 2019). Parents who are Black face additional obstacles to breastfeeding, including racial bias and discrimination in maternity care, as well as lack of breastfeeding support and role models from family and friends caused by the ongoing marketing of infant formula targeting Black families (1000 Days-Lozano). To address these disparities, states and public health professionals have implemented various programs, including hospital, community, employer, and early care and education supports (CDC-Breastfeeding report card) while considering culturally tailored approaches when designing and implementing programs (1000 Days-Lozano, Cochrane-Renfrew 2012).

Lack of parental leave in the United States creates many challenges for new parents, including insufficient time to establish a breastfeeding relationship and maintaining breastmilk supply (Van 2023, 1000 Days-Lozano). The Family and Medical Leave Act (FMLA) provides unpaid, job protected leave (US DOL-FMLA), but almost half of workers in the U.S. do not qualify for FMLA, particularly workers of color, and many cannot afford to take unpaid time even when it’s needed (NPWF-FMLA). Most employers in the U.S. do not provide paid parental leave, forcing many parents to return to work after the birth or adoption of a child far earlier than intended (Nandi 2019, NPWF-FMLA, 1000 Days-Lozano). Unpaid leave does not appear to provide the same potential health and economic benefits as paid leave, and evidence from FMLA suggests unpaid maternity leave may actually increase disparities, as its benefits are concentrated among those who can afford to take it (Nandi 2019).

• How does your community support breastfeeding? What efforts have been made to be inclusive of all breastfeeding parents?
• What resources are available to breastfeeding individuals and their support networks, such as up-to-date educational resources and information on how to access breast feeding supports like breast pumps?
• What efforts are made to ensure employers provide supportive work environments for all breastfeeding parents, such as sufficient time to pump in private spaces that are not bathrooms?

The Affordable Care Act (ACA) include provisions to encourage breastfeeding such as requiring insurance coverage of supplies and support and requiring employers to provide unpaid time and private space for nursing mothers to pump breast milk at work (AMCHP-Breastfeeding 2012).

As of 2025, all 50 states, Washington, D.C., Puerto Rico, and the Virgin Islands have laws that allow women to breastfeed in any public or private location; 30 states, Washington, D.C., Puerto Rico, and the Virgin Islands have workplace breastfeeding legislation; 4 states and Puerto Rico have implemented or encouraged development of a breastfeeding awareness education campaign. Additionally, 22 states and Puerto Rico exempt breastfeeding mothers from jury duty or allow for a postponement (NCSL-Breastfeeding).

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides breastfeeding promotion and support programs. All WIC staff are trained to provide support to new mothers and their infants; many WIC clinics offer peer counseling to mentor, coach, and support breastfeeding individuals (USDA-WIC breastfeeding support).

In 2021, more than 1 in 4 live births occurred at Baby Friendly facilities (CDC-Breastfeeding report card). Many breastfeeding promotion programs have started incorporating inclusive language, like chestfeeding, to celebrate all lactating parents (Inclusivity in chestfeeding).

CDC DNPAO-Data - Centers for Disease Control and Prevention (CDC), Division of Nutrition Physical Activity and Obesity (DNPAO). Nutrition, physical activity and obesity: Data, trends and maps online tool.

CDC-Breastfeeding - Centers for Disease Control and Prevention (CDC). Breastfeeding.

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Inclusivity in chestfeeding - Drexel University College of Medicine. Women’s health education program (WHEP) blog. Inclusivity in chestfeeding. Retrieved April 21, 2025.

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USDA-WIC breastfeeding support - U.S. Department of Agriculture (n.d.). U.S. Department of Agriculture WIC breastfeeding support. Learn together. Grow together. Retrieved April 17, 2025.

* Journal subscription may be required for access.

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AAP-Newborn and infant breastfeeding - American Academy of Pediatrics. (n.d.). Newborn and infant breastfeeding. Retrieved April 16, 2025.

AICR-CUP report 2017 - World Cancer Research Fund/American Institute for Cancer Research (AICR). Diet, nutrition, physical activity and breast cancer. Continuous Update Project (CUP). 2017.

Anstey 2017 - Anstey EH, Shoemaker ML, Barrera CM, et al. Breastfeeding and breast cancer risk reduction: Implications for black mothers. American Journal of Preventive Medicine. 2017;53(3 Suppl 1):S40-S46.

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CDC MMWR-Chiang 2021 - Chiang, K. V., Li, R., Anstey, E. H., & Perrine, C. G. (2021). Racial and ethnic disparities in breastfeeding initiation - United States, 2019. Morbidity and Mortality Weekly Report, 70(21), 769–774.

CDC-Breastfeeding - Centers for Disease Control and Prevention (CDC). Breastfeeding.

CDC-Breastfeeding 2013 - Centers for Disease Control and Prevention (CDC). The CDC guide to strategies to support breastfeeding mothers and babies. Atlanta: U.S. Department of Health and Human Services (U.S. DHHS); 2013.

CDC-Breastfeeding report card - Centers for Disease Control and Prevention (CDC). (2025). Breastfeeding Report Card. Retrieved April 23, 2025.

Chapman 2010 - Chapman DJ, Morel K, Anderson AK, Damio G, Perez-Escamilla R. Breastfeeding peer counseling: From efficacy through scale-up. Journal of Human Lactation. 2010;26(3):314-26.

Chetwynd 2019* - Chetwynd, E. M., Wasser, H. M., & Poole, C. (2019). Breastfeeding support interventions by international board-certified lactation consultants: A systemic review and meta-analysis. Journal of Human Lactation, 35(3), 424–440.

Cochrane-Balogun 2016 - Balogun OO, O’Sullivan EJ, McFadden A, et al. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews. 2016;(11):CD001688.

Cochrane-Lewin 2010* - Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews. 2010;(3):CD004015.

Cochrane-Renfrew 2012 - Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews. 2012;(5):CD001141.

Dinour 2017* - Dinour LM, Szaro JM. Employer-based programs to support breastfeeding among working mothers: A systematic review. Breastfeeding Medicine. 2017;12(3):131-141.

Dyson 2010 - Dyson L, Renfrew MJ, McFadden A, et al. Policy and public health recommendations to promote the initiation and duration of breast-feeding in developed country settings. Public Health Nutrition. 2010;13(1):137-44.

Fisk 2011 - Fisk CM, Crozier SR, Inskip HM, et al. Breastfeeding and reported morbidity during infancy: Findings from the Southampton Women’s Survey. Maternal & Child Nutrition. 2011;7(1):61-70.

Giugliani 2015 - Giugliani ERJ, Horta BL, Loret de Mola C, Lisboa BO, Victora CG. Effect of breastfeeding promotion interventions on child growth: A systematic review and meta-analysis. Acta Paediatrica. 2015;104(467):20-29.

Gomez-Pomar 2018* - Gomez-Pomar, E., & Blubaugh, R. (2018). The Baby Friendly hospital initiative and the ten steps for successful breastfeeding. A critical review of the literature. Journal of Perinatology, 38(6), 623–632.

Harder 2005 - Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: A meta-analysis. American Journal of Epidemiology. 2005;162(5):397-403.

Haroon 2013 - Haroon S, Das JK, Salam RA, Imdad A, Bhutta ZA. Breastfeeding promotion interventions and breastfeeding practices: A systematic review. BMC Public Health. 2013;13(Suppl 3):S20.

Hawkins 2015 - Hawkins SS, Stern AD, Baum CF, Gillman MW. Evaluating the impact of the Baby-Friendly Hospital Initiative on breast-feeding rates: A multi-state analysis. Public Health Nutrition. 2015;18(2):189-197.

Henshaw 2024 - Henshaw, E., Cooper, M., Wood, T., Krishna, S., Lockhart, M., & Doan, S. (2024). A randomized controlled trial of the happy, healthy, loved personalized text-message program for new parent couples: Impact on breastfeeding self-efficacy and mood. BMC Pregnancy and Childbirth, 24(1), 506.

Inclusivity in chestfeeding - Drexel University College of Medicine. Women’s health education program (WHEP) blog. Inclusivity in chestfeeding. Retrieved April 21, 2025.

Li 2014a - Li DP, Du C, Zhang ZM, et al. Breastfeeding and ovarian cancer risk: A systematic review and meta-analysis of 40 epidemiological studies. Asian Pacific Journal of Cancer Prevention. 2014;15(12):4829-4837.

Louis-Jacques 2017* - Louis-Jacques A, Deubel TF, Taylor M, Stuebe AM. Racial and ethnic disparities in U.S. breastfeeding and implications for maternal and child health outcomes. Seminars in Perinatology. 2017;41(5):299-307.

Nandi 2019* - Nandi A, Jahagirdar D, Dimitris MC, et al. The impact of parental and medical leave policies on socioeconomic and health outcomes in OECD countries: A systematic review of the empirical literature. Milbank Quarterly. 2018;96(3):434-471.

NCSL-Breastfeeding - National Conference of State Legislatures (NCSL). Breastfeeding laws.

NPWF-FMLA - National Partnership for Women and Families. (2025). Key facts: The family and medical leave act. Retrieved April 16, 2025.

Oliveira 2017* - Oliveira IBB, Leal LP, Coriolano-Marinus MW de L, et al. Meta-analysis of the effectiveness of educational interventions for breastfeeding promotion directed to the woman and her social network. Journal of Advanced Nursing. 2017;73(2):323-335.

Patnode 2016* - Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary care interventions to support breastfeeding: Updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;316(16):1694-1705.

PBS-Santhanam 2019 - Santhanam L. (2019). Racial disparities persist for breastfeeding moms. Here’s why. Public Broadcasting Service.

Perez-Escamilla 2016 - Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: A systematic review. Maternal & Child Nutrition. 2016;12(3):402-417.

Schwarz 2009 - Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics & Gynecology. 2009;113(5):974-982.

Sipsma 2015* - Sipsma HL, Jones KL, Cole-Lewis H. Breastfeeding among adolescent mothers: A systematic review of interventions from high-income countries. Journal of Human Lactation. 2015;31(2):221-229.

Stuebe 2009 - Stuebe A. The risks of not breastfeeding for mothers and infants. Reviews in Obstetrics & Gynecology. 2009;2(4):222-231.

Thulier 2009* - Thulier, D. (2009). Breastfeeding in America: A History of Influencing Factors. Journal of Human Lactation, 25(1), 85–94.

US DOL-FMLA - U.S. Department of Labor (U.S. DOL). Family and Medical Leave Act (FMLA).

USDA-WIC breastfeeding support - U.S. Department of Agriculture (n.d.). U.S. Department of Agriculture WIC breastfeeding support. Learn together. Grow together. Retrieved April 17, 2025.

USPSTF-Breastfeeding 2008 - U.S. Preventive Services Task Force (USPSTF). Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 2008;149(8):560-4.

USPSTF-Chung 2008* - Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: An evidence review for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2008;149(8):565-82.

Van 2023* - Van, T., Varadi, D., Adams, A. C., & Feldman-Winter, L. (2023). Promotion, protection, and support of breastfeeding as a human right: A narrative review. Breastfeeding Medicine, 18(8), 561–570.

WHO-Breastfeeding - World Health Organization. (n.d.). Breastfeeding. Retrieved April 16, 2025.

Wouk 2017* - Wouk K, Tully KP, Labbok MH. Systematic review of evidence for Baby-Friendly Hospital Initiative Step 3: Prenatal breastfeeding education. Journal of Human Lactation. 2017;33(1):50-82.