An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives

USA

USA - The WHO Code and Breastfeeding: An International Comparative Overview

Page last updated: 03 May 2012

Facts and figures

  • As of July 2009 there were approximately 307,006,550 people in the USA.
  • The number of births was 4,247,694; the birth rate was approximately 14.0 per 1,000 population, with a fertility rate of 68.6 births per 1,000 women aged 15–44 years.
  • The mean age of women at first birth was 25 years. It should be noted that the population in the USA varies from state to state, as does the birth rate (Martin et al 2010).
Table 28 shows the key birth statistics in 2008 for various races in the USA (Martin et al 2010).

Table 28: Key birth statistics in 2008 for various races
Race of mother
All races White Black American Indian or Alaskan Native Asian or Pacific Islander
Births 4,247,694 3,274,163 670,809 49,537 253,185
Birth rate 14.0 13.4 16.6 14.5 16.8
Fertility rate 68.6 67.8 71.9 64.6 71.3


Breastfeeding rates and practices in the USA vary considerably between states, racial/ethnic groups, socioeconomic groups, and combinations of these factors and others. The data also vary from source to source due to differing methodologies and time points of measurement. The CDC Breastfeeding Report Card (Centers for Disease Control and Prevention 2011a) provides annual data on some breastfeeding-related indicators, but are limited in scope. Table 29 summarises the national data for various broad breastfeeding indicators.

Table 29: National data for various breastfeeding indicators in 2010 (Centers for Disease Control and Prevention 2011a)
Objective Data
Proportion of infants who are breastfed (%) Ever 74.6
At six months 44.3
At one year 23.8
Exclusively through three months 35.0
Exclusively through six months 14.8
Proportion of employers that have worksite lactation support programs (%) 25.0
Proportion of breastfed newborns who receive formula supplementation within the first two days of life (%) 24.5
Proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies (Baby Friendly Hospital Initiative accredited facilities) (%) 4.53
Number of La Leche League Leaders per 1,000 live births 0.99
Number of International Board Certified Lactation Consultants per 1,000 live births 2.67
Number of state health department full-time equivalent (staff) dedicated to breastfeeding 125.06
State childcare centre regulation supports lactation 6 regulations are optimal (Arizona, California, Delaware, Mississippi, North Carolina, and Vermont)


Table 30 shows the breastfeeding rates among infants aged between 19 to 35 months at the time of data collection, born in 2007 in the USA.

Table 30: Breastfeeding rates among infants born in 2007 (%) (Centers for Disease Control and Prevention 2007; U.S.Department of Health and Human Services 2011).
Socio-demographic factor Ever breastfed Breastfed at 6 months Breastfed at 12 months
Total for USA 75.0 43.0 22.4
Race ethnicity American Indian or Alaska Native 73.5 42.4 20.7
Asian or Pacific Islander 83.0 56.4 32.8
Hispanic or Latino 80.6 46.0 24.7
Non-Hispanic Black or African American 58.1 27.5 12.5
Non-Hispanic White 76.2 44.7 23.3
Receiving WIC Yes 67.5 33.7 17.5
No, but eligible 77.5 48.2 30.7
Ineligible 74.6 54.2 27.6
Maternal education Not a high school graduate 67.0 37.0 21.9
High school graduate 66.1 31.4 15.1
Some college 76.5 41.0 20.5
College graduate 88.3 59.9 31.1


Data from 2007 reported that there were different distributions of infants ever breastfeeding by state in the USA. It reported that the western states (including Alaska and Hawaii) had a higher breastfeeding occurrence than the eastern states, with some north-eastern states also having high breastfeeding occurrence (Centers for Disease Control and Prevention 2007; U.S.Department of Health and Human Services 2011).

A 2008 study attempted to analyse the variations in breastfeeding practices with state policies. The study aimed to determine the impact of socio-demographic and behavioural factors and state legislation on breastfeeding initiation (child ever fed breast milk) and duration (Kogan et al 2008). This study used data from a nationally representative study of children aged 6 to 71 months (n=33,121); calculated unadjusted and adjusted state estimates for breastfeeding initiation and duration; used logistic regression models to examine factors associated with never breastfeeding or breastfeeding less than 6 months; and conducted a multilevel analysis of state legislation’s role. They found that:

“there were wide state variations in breastfeeding initiation and duration. The western and northwestern states had the highest rates. Covariate adjustment accounted for 25% to 30% of the disparity. Multivariate analysis showed that the adjusted odds of not being breastfed were 2.5- to 5.15-times greater in southern states compared with Oregon (reference). Children in states without breastfeeding legislation had higher odds of not being breastfed” (Kogan et al 2008).

It was concluded that:

“Sociodemographic and maternal factors do not account for most breastfeeding rate variation. The association with breastfeeding legislation should be explored and may reflect cultural norms.”

A longitudinal study on women across the USA conducted by the US Food and Drug Administration (FDA) and Centre for Disease Control and Prevention (CDC) during 2005 to 2007 showed that on average, breastfeeding women in the study group had higher levels of education, were older, were more likely to be white, were more likely to have a middle-level income, and were more likely to be employed than the overall US female population. It noted that almost half of breastfed infants were supplemented with infant formula milk while still in the hospital after birth, with more than 40% eating solid foods within the first four months after birth (Fein et al 2008).

The ongoing CDC survey of Maternity Practices in Infant Nutrition and Care (mPINC) indicates that barriers to breastfeeding are widespread during labour, delivery, postpartum care and during hospital discharge planning. In 2007, hospitals on average scored 63 out of a possible 100 points on an overall measure of breastfeeding-related maternity care (Centers for Disease Control and Prevention 2011c).

The CDC’s National Centre for Health Statistics analysis of data up to 2006 from the National Health and Nutrition Examination Surveys showed that (McDowell et al 2008):
  • The percentage of infants who were ever breastfed increased from 60% among infants who were born in 1993 to 1994 to 77% among infants who were born in 2005 to 2006.
  • Breastfeeding rates increased significantly among non-Hispanic black women from 36% in 1993 to 1994 to 65% in 2005 to 2006.
  • Breastfeeding rates in the period 1999 to 2006 were significantly higher among those with higher income (74%) compared with those who had lower income (57%).
  • Breastfeeding rates among mothers 30 years and older were significantly higher than those of younger mothers.
  • There was no significant change in the rate of breastfeeding at six months of age for infants born between 1993 and 2004.
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Implementation of WHO Code

Until the late 1980s, infant formula was not marketed directly to consumers in the USA, with marketing focused on the relationship between health professional and parent in making decisions about infant feeding. However, over the past 20 years, there has been more direct-to-consumer marketing (Shealy et al 2005). This change has apparently made it more challenging for healthcare systems and health workers to comply with the WHO Code. The United States entered into a consensus agreement in 1994 endorsing the WHO Code and other World Health Assembly (WHA) resolutions up to that date. The USA also joined all other nations in consensus agreement in 1996 and 2001 on support for the Code and the resolutions being considered at each time (National Alliance for Breastfeeding Advocacy 2011).

Two major aspects of the challenge in complying with the full WHO Code in the USA involve reconciling seemingly opposing needs. The concepts and recommendations put forth in the WHO Code may seem to conflict with legislation about freedom of speech, including advertising (Shealy et al 2005). A further complication is the limited regulation of product label claims within the USA, although this is changing gradually.

The provisions of the WHO Code are not legally binding in the USA (U.S.Department of Health and Human Services 2011). Manufacturers are only voluntarily obligated to obey the WHO Code and other recommended advertising and health guidelines. According to NABA REAL:

“The United States entered into a consensus agreement in 1994 endorsing the Code and other WHA resolutions up to that date. The US also joined all other nations in consensus agreement in 1996 and 2001 on support for the Code and the resolutions being considered at each time. The Code is a voluntary agreement that has no legislation or mandates for companies to adhere to and no sanctions for violating” (National Alliance for Breastfeeding Advocacy 2011).

The FDA regulates and monitors infant formula nutritional composition and manufacturing activities in the USA. The FDA has specific nutrient requirements in infant formulas. Any new infant formula being marketed in the USA must register their infant formula with the FDA, notify the FDA of the manufacture of the new formula, and verify the formula as being compliant with the specific requirements of the Federal Food, Drug, and Cosmetic Act (FFDCA) (Food and Drug Administration 2006). The FDA does not advise or monitor marketing activities. It will however look at fundamental changes in the type of packaging used for infant formulas, as well as changes in nutritional content or ingredients of the formulas, where in that case labelling has to change to reflect the new composition of the formula (Food and Drug Administration 2006).

The FFDCA defines infant formula as "a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk" (FFDCA 201(z)). FDA regulations define infants as persons not more than 12 months old (Title 21, Code of Federal Regulations 21 CFR 105.3(e)) (Food and Drug Administration 2006).

The laws and regulations governing foods apply to infant formula. Additional statutory and regulatory requirements apply to infant formula. These additional requirements are found in section 412 of the FFDCA and FDA's implementing regulations in 21 CFR 106 and 107 (Food and Drug Administration 2011a; Food and Drug Administration 2011b). The Center for Food Safety and Applied Nutrition is responsible for regulation of infant formula. The Office of Nutritional Products, Labeling, and Dietary Supplements (ONPLDS) has program responsibility for infant formula. The Office of Food Additive Safety (OFAS) has program responsibility for food ingredients and packaging. ONPLDS evaluates whether the infant formula manufacturer has met the requirements under section 412 of the FFDCA. ONPLDS consults with OFAS regarding the safety of ingredients in infant formula and of packaging materials for infant formula. Under sections 201(s) and 409 of the FFDCA, OFAS evaluates the safety of substances intended for use in or in contact with infant formula (Food and Drug Administration 2006).

A 2006 report by the US Government Accountability Office (GAO) reviewing market research and studies conducted between 1980 to 2005 found that advertising of infant formula was widespread and increasing in the USA (U.S.Government Accountability Office 2006). The GAO reports that there has been some use of the federal Women, Infants, and Children (WIC) nutrition program branding in infant formula marketing, but this is forbidden by federal law; however, states do not seem to enforce this regulation in their WIC contracts. This misleads parents into thinking that certain infant formulas are endorsed by WIC when they are not.

National Alliance for Breastfeeding Advocacy (NABA) REAL is a non-profit organisation responsible for monitoring compliance with the WHO Code in the USA. NABA REAL trains others in monitoring compliance and maintains a help centre to assist people in reporting violations of the WHO Code. NABA publishes and distributes documentation of WHO Code violations in the USA (National Alliance for Breastfeeding Advocacy 2011; U.S.Department of Health and Human Services 2011). NABA REAL monitors the Code in the USA. They have conducted two monitoring projects with their respective reports titled, “Selling Out Mothers and Babies” and “Still Selling Out Mothers and Babies” (published in 2007). Violations of the Code are spotted and reported by NABA’s Code monitors. This is a volunteer group of breastfeeding advocates who have attended NABA’s Code training workshop and report periodically on violations in their area of the country.

In the USA, the Federal Trade Commission is the highest authority on advertising regulations and standards; however states and local political divisions can have their own laws on advertising. In December 2009, a federal court upheld a US$13.5 million jury verdict against manufacturer Mead Johnson & Co. for false and misleading advertising; the court permanently barred Mead Johnson from claiming that its Enfamil LIPIL infant formula would give babies better visual and brain development than ingredients in store-brand formula (BusinessWire 2009). In 2006, the GAO found that manufacturers of infant formula had violated the USDA Food and Nutrition Service rules by using the WIC logo and acronym in advertising formula (U.S.Government Accountability Office 2006).

A study published in 2006 “examined infant feeding advertisements in 87 issues of Parents magazine, a popular parenting magazine, from the years 1971 through 1999” using “content analysis results to predict subsequent changes in levels of breastfeeding among U.S. women (Ross Laboratories Mothers Survey). When the frequency of hand feeding advertisements increased, the percentage change in breastfeeding rates reported the next year generally tended to decrease”(Foss & Southwell 2006). "Hand feeding" advertisements included infant formula, cereal/solid food or hand feeding equipment. This study is one such study to examine the potential influence of popular media content on US breastfeeding patterns and public health trends and show that marketing in general, beyond having advertisements abide by the WHO Code, may change breastfeeding behaviour in the general population. It should be noted that Ross Laboratories is part of Abbott Laboratories, who manufacture infant formula.

An analysis of media from 1930 to 2007 in Parents magazine showed that:

“Of the 237 issues studied, 95 addressed breastfeeding, bottle-feeding, or both ... Thirty-five articles solely mentioned bottle-feeding and 29 only addressed breastfeeding. Additionally, 31 articles referred to both breast and bottle-feeding. Forty-six images of bottle or breastfeeding appeared in the issues studied: 23 of breastfeeding and 23 of bottle-feeding. The time period from the 1990s to 2008 contained the most articles and images”(Foss 2010).

There was a large increase in breastfeeding only articles from 2000 to 2007 compared to bottle-feeding or either type combined.

Table 31: Evaluation of the implementation of the WHO Code in the USA
Article of the WHO Code Implemented Partially implemented / Not implemented
Articles 2 & 3: Scope FDA regulations refer to compositional and labelling requirements for infant formula and infant foods intended for use by infants (up to 12 months old). The Federal Food, Drug, and Cosmetic Act (FFDCA) section Title 21, Code of Federal Regulations 21 CFR 105.3(e) defines what infant formula is. FDA regulations have a limited scope and apply only to infant formula and foods rather than the whole range products covered by the WHO Code (including all breast milk substitutes, bottle-fed complementary foods, baby teas, bottles and teats etc). The FDA regulations do not cover advertising or the provision of information.
Article 4: Information & Education No Federal regulations or codes for this article.
Article 5: General public & mothers No Federal regulations or codes for this article.
Article 6: Health care systems No Federal regulations or codes for this article.
Article 7: Health workers No Federal regulations or codes for these article.
Article 8: Persons employed by manufacturers and distributors No Federal regulations or codes for these article.
Article 9: Labelling Articles 9.1, 9.3 & 9.4: Any new infant formula being marketed in the USA must register their infant formula with the FDA, notify the FDA of the manufacture of the new formula, and verify the formula as being compliant with the specific requirements of the Federal Food, Drug, and Cosmetic Act (FFDCA).
The Centre for Food Safety and Applied Nutrition is responsible for regulation of infant formula. The Office of Nutritional Products, Labelling, and Dietary Supplements (ONPLDS) has responsibility for infant formula. The Office of Food Additive Safety (OFAS) has responsibility for food ingredients and packaging.
Articles 9.2: There doesn’t seem to be Federal regulations or codes for these aims. Does not include the requirements for a statement on the superiority of breastfeeding, restrictions of imagery or on terms such as ‘humanised’. However, labelling needs to conform to other federal and state laws pertaining to advertising and claims.
Article 10: Quality Article 10.1: USA has several Federal regulations & bodies that work together to administer standards for product quality.
10.2: USA is a member of the Codex Alimentarius.
Article 11: Implementation & Monitoring Article 11.4: The National Alliance for Breastfeeding Advocacy (NABA) REAL is a non-profit organization responsible for monitoring compliance with the WHO Code in the USA. There are no Federal bodies that are responsible for implementing or monitoring the WHO Code, except for aspects regarding food quality and labelling standards.


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Complementary policies

Government policies and initiatives

There are conflicts between federal and state legislations and laws in the USA. This is also the case for breastfeeding, where state laws may override federal initiatives in directing public behaviours. As of July 2007, 47 states had passed some type of legislation in support of the right to breastfeed, with most laws addressing some aspect of breastfeeding in public (Garner 2008). However these vary in their nature and scope. Other categories of state breastfeeding legislation include workplace issues, jury duty, family law, economic issues, and support services and education.

In terms of federal actions, according to the 2011 Surgeon General’s report, numerous government agencies have programmes on breastfeeding or programmes that affect breastfeeding indirectly. The USDA has the WIC programme. The Department of Health and Human Services has several breastfeeding initiatives with the Maternal and Child Health Bureau, the National Institutes of Health, CDC, DFA, AHRQ, OWH and the Indian Health Service (U.S.Department of Health and Human Services 2011). It is noted that no formal structure exists to coordinate federal breastfeeding initiatives to reduce overlap or to identify gaps in current programmes.

In 2000, the Office on Women’s Health, with other federal agencies, healthcare professional organisations, and the Office of the Surgeon General, published the HHS Blueprint for Action on Breastfeeding. This Blueprint for Action established a comprehensive breastfeeding policy for the USA. The Blueprint for Action introduced an action plan for breastfeeding based on education, training, awareness, support and research. It recognised that breastfeeding rates are influenced by various factors, and recommended actions to be taken in the healthcare system, workplaces, childcare facilities, public education and support services, and on marketing of breast milk substitutes (U.S.Department of Health and Human Services 2000).

The objectives of Healthy People 2020 for breastfeeding include:
  • increasing the proportion of infants who are breastfed to:
    • 81.9% for ever breastfed
    • 60.6% for breastfed at six months
    • 34.1% for breastfed at one year
  • increasing the proportion who are exclusively breastfed to:
    • 46.2% for through three months
    • 25.5% through six months
  • increasing the proportion of employers that have worksite lactation support programmes to 38%
  • reducing the proportion of breastfed newborns who receive formula supplementation within the first two days of life to 14.2%
  • increasing the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies is 8.1% (U.S.Department of Health and Human Services 2010).

U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) – Special Supplemental Nutrition Program for Women, Infants and Children (WIC) serves low-income and nutritionally at risk women and infants, including pregnant women (through pregnancy and up to six weeks after birth or after pregnancy ends), breastfeeding women (up to infant’s first birthday), non-breastfeeding postpartum women (up to six months after the birth of an infant or after pregnancy ends), infants (up to first birthday), and children up to their fifth birthday. In 1989, the US Congress began designating a specific portion of each state's WIC budget allocation to be used exclusively for the promotion and support of breastfeeding among its participants. It is very important to note that WIC now serves 53% of all infants born in the USA (U.S.Department of Agriculture, Food and NutritionService 2011).

The benefit WIC provides to women and children are: supplemental nutritious foods, nutrition education and counselling at WIC clinics, screening and referrals to other health, welfare and social services. WIC is a federal grant program for which Congress authorises a specific amount of funds each year for the program. WIC is administered at the federal level by FNS, and administered by 90 WIC state agencies, through approximately 47,000 authorised retailers, and operates through 1,900 local agencies in 10,000 clinic sites, in 50 state health departments, 34 Indian tribal organisations, the District of Columbia, and five territories (Northern Mariana, American Samoa, Guam, Puerto Rico and the Virgin Islands). WIC services are provided in various settings such as county health departments, hospitals, mobile clinics (vans), community centres, schools, public housing sites, migrant health centres and camps, and Indian Health Service facilities (U.S.Department of Agriculture, Food and NutritionService 2011).

The WIC program is governed by various Legislative Requirements contained in Section 17 of the Child Nutrition Act of 1966, as well as various regulations (U.S.Department of Agriculture 2011b; U.S.Department of Agriculture 2011c). Regulations have called for state agencies to ensure:
  1. a sustainable infrastructure for breastfeeding activities
  2. the prioritisation of breastfeeding mothers and children in the WIC certification process activities to support education in nutrition for breastfeeding mothers, including peer support
  3. allowances for using program funds to carry out activities that improve support for breastfeeding among WIC participants. WIC has begun a nationwide training program for all local agencies called “Using Loving Support to Grow and Glow in WIC: Breastfeeding Training for Local WIC Staff” to ensure that all WIC staff can promote and support breastfeeding (Every Mother Inc 2010).
Breastfeeding mothers on the WIC program are supported in various ways (U.S.Department of Agriculture, Food and Nutrition Service, 2011). These include:
  • provision of information through counselling and breastfeeding educational materials
  • receiving follow-up support through peer counsellors
  • eligibility to participate in WIC longer than non-breastfeeding mothers
  • receiving breast pumps, breast shells or nursing supplementers to help support the initiation and continuation of breastfeeding
  • mothers who exclusively breastfeed their infants receive an enhanced food package. This means offering a food package with higher monetary value, and incorporating larger amounts of fruits and vegetables in the packages.
In a 2002 study, it was found that infants from low income families, including those in the WIC programme, were less likely to be breastfed than children in middle and upper income families (Ryan et al 2002). A 2007 study of women in the WIC program showed that 36% of women thought breastfeeding would protect babies against diarrhoea (McCann et al 2007). Another study in 2007 notes that WIC has always faced the challenge of promoting breastfeeding while simultaneously providing infant formula to mothers who choose not to breastfeed (Jacknowitz et al 2007). These dual objectives raise the concern that WIC itself may influence a participant’s breastfeeding choice, as the high cost of infant formula provides a strong economic incentive to breastfeed however when WIC provides the formula at no cost, that incentive is removed. Researchers used an approach that controlled for some of the factors and other incentives that influence the complex decision to breastfeed, but the study results could not establish a causal link between WIC and breastfeeding. The 2007 study still found that WIC participation was associated with lower rates of exclusive breastfeeding. The researchers found that WIC mothers were more likely than eligible non-participants to adhere to AAP guidelines to delay introducing cow’s milk to their infants. However, the researchers also found that WIC participants were more likely to introduce solid foods before six months, with about one-quarter of WIC mothers introducing solid foods by four months (Jacknowitz et al 2007).

In 2009, the WIC food packages underwent the most substantial revision since the program began in 1974. While the previous package provided infant cereal at four months of age, the revised WIC package does not include solid foods until the infant is six months old. The new packages are supposed to promote breastfeeding by providing a greater amount and variety of food in the WIC package for women who exclusively breastfeed. In addition, the new food package no longer includes formula for fully breastfed infants, and it provides a reduced amount of formula for partially breastfed infants (Tiehen 2010).

A 2004 study estimated the effect of WIC participation in 1999 to 2000 on breastfeeding initiation and duration and child care. This used a sample of 2,136 unmarried, low-income, urban mothers from the Fragile Families and Child Wellbeing Study. It was reported that “WIC participation was associated with small increases in the probabilities of initiating breastfeeding and having had at least 4 well-child visits since birth-behaviors that
benefit infants beyond the newborn period-but not with breastfeeding duration” (Chatterji & Brooks-Gunn 2004).

About half of all infants born in the USA participate in the WIC program (Oliveira & Frazao 2010). Although WIC encourages breastfeeding, mothers can get vouchers redeemable for infant formula at authorised retail stores. A recent study estimated WIC's share of the infant formula market and determined that 57% to 68% of all infant formula sold in the USA in 2004-06 was purchased through WIC (Oliveira & Frazao 2010). In terms of economics, in fiscal year 2008, rebate savings totalled US$2 billion for state WIC agencies. In exchange for the rebate, the manufacturer's brand is the exclusive WIC-approved formula for the state (Oliveira & Frazao 2010).

The USDA has a social marketing campaign to encourage and support breastfeeding within the WIC program called “Loving Support Makes Breastfeeding Work” (U.S.Department of Agriculture, Food and Nutrition Service, 2011), which includes the following programs and resources: “Using Loving Support™ to Grow and Glow in WIC (Breastfeeding Competency Training”, “Breastfeeding a Magical Bond of Love (WIC Hispanic Breastfeeding and Promotion Project)”, “Partnering with WIC for Breastfeeding Success”, "Using Loving Support to Build a Breastfeeding Friendly Community™”, and "Using Loving Support to Implement Best Practices in Peer Counselling™”. A 1997 evaluation of the campaign in Iowa showed an increase in the initiation of breastfeeding from 57.8% to 65.1% after one year of implementation, with breastfeeding at six months postpartum increasing from 20.4% to 32.2% after one year of the program (Social Marketing Institute 1997). However, this is an evaluation of one state, and was done over 10 years ago, so various circumstances may have changed.

The Patient Protection and Affordable Care Act of 2010, H.R. 3590, 111th Cong., 2nd Sess. (2010) includes provisions to expand home visitation programs for pregnant women and children from birth through to kindergarten entry (Senate and House of Representatives of the United States of America in Congress 2010). However, it is unclear whether or how quickly this Act can facilitate improved follow-up breastfeeding care for low-income families, and how the implementation of it will be evaluated. In 2010, the Act included a provision requiring employers to provide workplace accommodations that enable employees who are breastfeeding to express their milk. Section 4207 of the Affordable Care Act amends the Fair Labor Standards Act of 1938 by requiring employers to provide reasonable, though unpaid, break time for a mother to express milk and a place, other than a restroom, that is private and clean where she can express her milk (Senate and House of Representatives of the United States of America in Congress 2010).

Choose My Plate is a revamp of the food pyramid, where the recommended daily intake (RDI) of foods has been updated and now shown as a plate graphic instead of a pyramid graphic in the USA. Choose My Plate has a subsection on daily food plans for pregnancy and breastfeeding (U.S.Department of Agriculture 2011a). It also encourages women to breastfeed and provides resources for women wanting to find out more about
nutrition during breastfeeding.

The Office of Women’s Health in the Department of Health and Human Services operates a National Breastfeeding Helpline (Office on Women’s Health 2011). It is staffed by trained breastfeeding peer counsellors to help answer common breastfeeding questions, and help mothers decide if they need to see a doctor or lactation consultant.

On 11 June 2009, the Breastfeeding Promotion Act was introduced in both houses of Congress, to provide a unified national policy to keep mothers, their children, and their communities healthy. The Breastfeeding Promotion Act of 2009 (H.R. 2819, S. 1244) includes five provisions (Representative Carolyn B.Maloney (NY) & Senator Jeff Merkley (OR) 2011; United States Breastfeeding Committee 2011a):
  • Amends the Civil Rights Act of 1964 to protect breastfeeding women from being fired or discriminated against in the workplace.
  • Provides tax incentives for businesses that establish private lactation areas in the workplace, or provide breastfeeding equipment or consultation services to their employees.
  • Provides for a performance standard to ensure breast pumps are safe and effective.
  • Allows breastfeeding equipment and consultation services to be tax deductible for families (amends Internal Revenue Code definition of "medical care").
  • Protects the privacy of breastfeeding mothers by ensuring they have break time and a private place to pump in the workplace (applies to employers with 50 or more employees; see text of legislation for details).
However, this Bill is still being considered and has not yet become law (United States Breastfeeding Committee 2011a).

Implementation of the Baby Friendly Hospital Initiative (BFHI)

As of 28July 2011 there were 114 BFHI-accredited hospitals and birthing centre in the USA (Baby Friendly Hospital Inititiative USA 2011). The percentage of births at BFHI-accredited facilities in 2011 in various states in the USA is less than 20% for all but two states. Only Alaska and Nebraska have more than 20% of births in BFHI-accredited facilities (Baby Friendly Hospital Inititiative USA 2011; Centers for Disease Control and Prevention 2011a). However, even this number is still vague and could be lower or higher. According to the American Hospitals Association website, there were 5,795 registered hospitals in 2010. It is assumed that not all registered hospitals may have a maternity ward. This means that the BFHI rate is approximately 2% at the lowest estimation.

A recent study by DelliFraine found that a non-statistically significant difference in labour-and-delivery costs for the baby-friendly sites (US$2,205 per delivery), compared with the non-baby friendly matched pair ($2,170) (DelliFraine et al 2011). Another study by DiGirolamo found that:

“Only 8.1% of the mothers experienced all 6 “Baby-Friendly” practices. The practices most consistently associated with breastfeeding beyond 6 weeks were initiation within 1 hour of birth, giving only breast milk, and not using pacifiers. Bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding termination. Compared with the mothers who experienced all 6 “Baby-Friendly” practices, mothers who experienced none were ~13 times more likely to stop breastfeeding early. Additional practices decreased the risk for early termination” (DiGirolamo et al 2008).

A national survey done from 2001 to 2003 of baby-friendly hospitals stated that “Baby-Friendly designated hospitals in the USA have elevated rates of breastfeeding initiation and exclusivity. Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates” (Merewood et al 2005).

Other complementary policies

In the USA, there are three states with no law protecting the right to nurse in public. The other states either have a law protecting nursing in public but without an enforcement provision; have a law protecting nursing in public with an enforcement provision; or only have a law excluding breastfeeding from some criminal charges (Mothering magazine Inc 2010). For example, Texas has two laws in place supporting breastfeeding (State Government of Texas 1995; WIC Nutrition Program,Texas Department of State Health Services 2009). These are:
  • “Section 165.002 Legislative Finding” which states “The legislature finds that breastfeeding a baby is an important and basic act of nurture that must be encouraged in the interests of maternal and child health and family values. In compliance with the breastfeeding promotion program established under the federal Child Nutrition Act of 1966 (42 U.S.C. Section 1771 et seq.), the legislature recognizes breastfeeding as the best method of infant nutrition”
  • “Section 165.002 Right to Breastfeed” which states “A mother is entitled to breastfeed her baby in any location in which the mother is authorized to be”.
The Texas Department of Health maintains a National Breastfeeding MediaWatch Campaign to monitor both positive and negative media mentions of breastfeeding and formula. Volunteers look for positive images of breastfeeding and acknowledge media outlets or other groups for any positive messages conveyed to the public. MediaWatch aims to increase the number of positive references to breastfeeding in media and thus shape societal views in favour of breastfeeding (Shealy et al 2005). Although this is a state initiative, it spans the national media, so it may be relevant for this review in terms of initiatives with national reach.

National guidelines on out-of-home child care from the National Resource Center for Health and Safety in Child Care and Early Education provide information about how childcare providers should support breastfeeding mothers and families (American Academy of Pediatrics et al 2002). The new guidelines recommend that those who provide childcare should encourage, make arrangements for, and support breastfeeding families, such as by providing a space for a mother to breastfeed or express milk for her child. The guidelines include information about preparing, storing and handling expressed human milk, as well as the importance of feeding all children on cue rather than on a schedule. A 2009 evaluation of the implementation of these guidelines reported that these guidelines were not implemented in all states, and that small services are not covered by the guidelines (Benjamin et al 2009). It is also noted that some states such as Colorado (InfaNET Nutrition for Child Care Providers 2009) and Wisconsin (Wisconsin Department of Health and Family Services 2011; Wisconsin Department of Health and Family Services & Wisconsin Breastfeeding Coalition 2009) have their own guidelines and training materials for breastfed infants in childcare centres.

On 4 August 2007, the Transportation Safety Administration (TSA) instituted a new policy for transporting pumped breast milk in airplane carry-on luggage. Breast milk may now be carried in any quantity and in no special container, as long as it is declared for inspection at the airport security checkpoint. Breast milk, which the TSA now classifies as a “medical necessity,” will be treated by TSA agents as a liquid medication. Under this classification, breast milk must be presented for visual inspection and may be X-rayed (Mothering magazine Inc 2010).

“Babies Were Born to Be Breastfed” was the campaign tag line of the U.S. National Breastfeeding Awareness Campaign launched by the U.S. Department of Health and Human Services’ Office on Women’s Health and the Advertising Council. The campaign was to help promote the HHS Blueprint for Action on Breastfeeding (U.S.Department of Health and Human Services 2000). The campaign targeted first-time parents through television, radio, out-of-home, internet, and print advertising that highlighted the health consequences of not breastfeeding (Shealy et al 2005). The goal of the campaign was to increase initiation and exclusive breastfeeding rates at six months, with the public encouraged to call the National Women’s Health Information Center Breastfeeding Warmline at 1-800-994-WOMAN or visit their website at http://www.4woman.gov for breastfeeding information. Eighteen community demonstration projects provided breastfeeding services, community coalition building and outreach to local media.

The overall goal of the campaign was to increase the proportion of mothers who breastfeed their babies in the early postpartum period to 75% and those within six months postpartum to 50% by the year 2010 (US Department of Health and Human Services' Office on Women's Health 2011). The campaign aimed to empower women to commit to breastfeeding and to highlight new research that shows that babies who are exclusively breastfed for six months are less likely to develop ear infections, diarrhoea, respiratory illnesses, and may be less likely to develop childhood obesity. Besides trying to raise initiation rates, the campaign stressed the importance of exclusive breastfeeding for six months. The campaign was launched in June 2004 and ended in April 2006 (US Department of Health and Human Services' Office on Women's Health 2011).

The Office of Women’s Health and the Advertising Council implemented the campaign, and although the educational awareness campaign has ended, continued promotion efforts are underway with a communications contractor. This includes a World Breastfeeding week media event, print media coverage and radio interviews. The campaign was being marketed in partnership with strategically selected organisations and was done through public service announcements for television, radio, newspapers, magazines, mass transit shelters, billboards and the internet.

Sixteen community-based demonstration projects (CDPs) throughout the USA worked in coordination with the U.S. Department of Health and Human Services' Office on Women's Health and the Advertising Council (US Department of Health and Human Services' Office on Women's Health 2011). According to the Office of Women’s Health, “the CDPs attempted to build self-efficacy by working to educate women about the benefits of breastfeeding, empower them to choose to breastfeed, and create awareness that breastfeeding is normal, desirable, and achievable”. They also stated that:

“These CDPs ensured that breastfeeding mothers had access to comprehensive, up-to-date and culturally tailored lactation services provided by trained physicians, nurses, lactation consultants and nutritionists/dieticians; developed breastfeeding education for women, their partners and other significant family members during the prenatal and postnatal periods; established family and community programs that enable breastfeeding continuation when women return to work in all possible settings; developed social support and information resources for breastfeeding women such as hotlines, peer counselling, and mother-to-mother support groups; and encouraged fathers and other family members to be actively involved throughout the breastfeeding experience” (US Department of Health and Human Services' Office on Women's Health 2011).

The United States Breastfeeding Committee (USBC) provides a forum for NGOs and representatives from the federal government to collaborate on joint initiatives supporting breastfeeding. It was formed in 1995 and has as its aims to protect, promote, and support breastfeeding in the USA. In 2001, the USBC released a strategic plan to increase breastfeeding called “Breastfeeding in the United States: A National Agenda” (United States Breastfeeding Committee 2001). The USBC has also facilitated the meeting of important players in the breastfeeding movement in the USA. In 2006 there was the first National Conference of State Breastfeeding Coalitions, and these meetings have been conducted every two years since.

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Workplace

Parental leave arrangements

New parents in the USA may access leave through the Family Medical Leave Act (FMLA) of 1993. FMLA leave consists of 12 weeks of unpaid leave that must be taken continuously and on a full-time basis. Unlike parental leave in the other countries discussed here, FMLA leave covers both new parents and employees who are either ill or caring for ill family members. Thus, unlike their counterparts abroad, US workers who take leave upon the birth of a child forfeit the ability to take leave later in the same year if the need for medical care arises. In addition, 13 states offer either partially-paid disability leave for new mothers or greater FMLA protections (Ray 2008). Therefore, among 173 countries the USA is one of only four without a national policy requiring paid maternity leave (Heymann et al 2010). In 2009, approximately 14% of US employers offered paid maternity leave beyond short-term disability benefits (Society for Human Resource Management 2009). The Family and Medical Leave Act of 1993 provides for up to 12 weeks of unpaid, job-protected maternity leave (U.S.Department of Labour 1993); however unpaid leave is not feasible for many low-income families. This could be interpreted as a barrier to better breastfeeding practices.

As of March 2010, five states had laws that ensure some level of paid maternity leave. These are California, Hawaii, New Jersey, New York, and Rhode Island (National Conference of State Legislatures 2009). In addition to this, Minnesota and New Mexico have at-home infant care programs that fund low-income parents to stay home with their infants (Progressive States Network 2011).

Female workforce participation

According to the U.S. Department of Labor for the year 2010, of the 123 million women aged 16 years and over in the USA, 72 million, or 58.6% were labour force participants (working or looking for work). Women comprise 47% of the labour force. Approximately 66 million women were employed in the USA, with 73% of employed women worked in full-time jobs, while 27% worked on a part-time basis. The largest percentage of employed women, 40.6%, worked in management, professional and related occupations; 32.0% worked in sales and office occupations; 21.3% in service occupations; 5.2% in production, transportation and material moving occupations; and 0.9% in natural resources, construction, and maintenance occupations. The largest percentage of employed Asian (46.1%), white (40.6%), and black (33.8%) women worked in management, professional and related occupations. Hispanic women showed their strongest attachment to service occupations at 33.2% (U.S.Department of Labour 2011).

Arrangements for breastfeeding in the workplace

In 2010, the Patient Protection and Affordable Care Act of 2010 included a provision requiring employers to provide workplace accommodations that enable employees who are breastfeeding to express their milk. Section 4207 of the Affordable Care Act amends the Fair Labor Standards Act of 1938 by requiring employers to provide reasonable, though unpaid, break time for a mother to express milk and a place, other than a restroom, that is private and clean where she can express her milk (Senate and House of Representatives of the United States of America in Congress 2010).

“The Business Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits” resource kit was developed by the Health Resources and Services Administration. The kit includes resources for business and human resource managers and employees. Program components outlined in the kit include flexible breaks and work schedules, a sanitary and private place to express milk, education for pregnant and lactating women, and support from supervisors and co-workers (Health Resources and Services Administration 2008).

Most states in the USA have either no workplace breast pumping law or no law requiring employers to allow on-site pumping. Five states have laws concerning workplace pumping but that does not require employers to allow on-site pumping (Mothering magazine Inc 2010).

The Nutrition, Physical Activity, and Obesity Program is a cooperative agreement between the CDC’s Division of Nutrition, Physical Activity and Obesity (DNPAO) and 25 state health departments as of June 2010. The program goal is to prevent and control obesity and other chronic diseases through healthy eating and physical activity. One of the aims of the program is to “increase breastfeeding initiation, duration, and exclusivity” (Centers for Disease Control and Prevention 2011b). The program states that:

“Support for breastfeeding in the workplace includes several types of employee benefits and services including writing corporate policies to support breastfeeding women; teaching employees about breastfeeding; providing designated private 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 onsite or near-site child care; providing high-quality breast pumps and refrigerated storage; and offering or referring professional lactation management services and support” (Centers for Disease Control and Prevention 2011b).

The DNPAO provide a few examples from various states that have implemented various workplace initiatives to support breastfeeding.

A review of 20 studies in the USA between 1995 and 2006 summarised that:

“When working mothers possess certain personal characteristics and develop a strategic plan, breastfeeding is promoted. When social support is available and when support groups are utilized, lactation is also facilitated. Part-time work, lack of long mother-infant separations, supportive work environments and facilities, and child care options facilitate breastfeeding” (Johnston & Esposito 2007).

The USA has not ratified ILO Convention No. 183 (International Labour Standards Department 2011).

Childcare arrangements for babies under one year of age

According to a 2008 UNICEF Innocenti Research Centre report, the USA has subsidised and regulated childcare services for at least 25% of children under three; at least 50% of staff in accredited early education services tertiary educated with relevant qualification; and a minimum staff-to-children ratio of 1:15 in preschool education. In general, more than 50% of under-ones are in some form of childcare – three-quarters of them from the age of four months or earlier and for an average of 28 hours per week. However, there is no federal control as early childhood services are the responsibility of individual states. In the USA data suggest that the cost of childcare is around US$5,000 per child per year for half-day school-year programmes, and can rise to about US$9,000 per year for full-day school-year programmes (UNICEF 2008).

An estimated 67% of mothers who had their first child in 2001/03 worked during their pregnancy, mostly on a full-time basis (Johnson 2008). In 2009, 50.1% of all mothers with children younger than 12 months were employed, and 69% of those employed worked full-time (35 or more hours per week) (U.S.Bureau of Labour Statistics 2011).

In 2001, 26% of nine-month-old infants were regularly cared for by relatives; 15% were cared for by a nonrelative in either their own or another family’s home; and 9% were in centre-based care. By percentage, more black than white infants were in centre-based care (U.S.Child Care Bureau 2003). A review of studies from the 2011 report by the Surgeon General states that among employed mothers, there is a lower initiation rate for breastfeeding and shorter duration of breastfeeding, but rates are higher in women who have longer maternity leave, who work part-time, and have breastfeeding support programs in their workplace (U.S.Department of Health and Human Services 2011).

In 2009, 15 states required that employers support breastfeeding employees when they return to work (Centers for Disease Control and Prevention 2011a). A 2009 employee benefits survey found that 25% of employers have on-site lactation rooms, with smaller businesses least likely to have these rooms ((Society for Human Resource Management 2009).

The Child Care and Development Fund helps low-income families obtain childcare so they can work or attend training or education. Among infants served by this program, 49% were in centre-based care (Flanagan & West 2004).


Culture

La Leche League (www.llli.org) is a major advocate for breastfeeding. There are also various racial / ethnic support groups such as the African-American Breastfeeding Alliance, the Black Mothers’ Breastfeeding Association (www.blackmothersbreastfeeding.org), and Mocha Moms (www.mochamoms.org). All 50 states have breastfeeding coalitions, and there are many local, tribal, and territorial coalitions as well (United States Breastfeeding Committee 2011b), with most of these being small and unfunded.

According to the US Surgeon General’s 2011 call to supporting breastfeeding, several cultural barriers were identified. These includes mothers’ lack of knowledge about breastfeeding, social norms against breastfeeding, poor family and social support, embarrassment, lactation problems, employment and childcare arrangements that discourage breastfeeding, and barriers related to health services (U.S.Department of Health and Human Services 2011).

In a 2002 study, it was found that infants from low-income families, including those in the WIC programme, were less likely to be breastfed than children in middle and upper income families (Ryan et al 2002). However, other factors apart from income and race / ethnicity are also cited as influencing breastfeeding rates, including educational status (higher educated women are more likely to breastfeed); geographical disparities southeastern states are less likely to breastfeed; rural women are less likely to breastfeed); negative media stories about breastfeeding; hospital policies and practices; recommendations by WIC counsellors; marketing of infant formula; policies on work and parental leave; legislation; social and cultural norms; and advice from family and friends (U.S.Department of Health and Human Services 2011).

There are beliefs in the USA that bigger babies are healthier and thus supplemental formula feeding and earlier introduction of solid foods is common. There is also a misconception that infants might benefit from being fed both breast milk and other food sources to get “extra” nutrients (e.g. infant formula), so both are given (U.S.Department of Health and Human Services 2011).

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Health system and health worker training

The US healthcare system is a complex patchwork of players. In general, the USA consists of many separate legal entities that manage healthcare. Healthcare facilities are mostly owned and managed by the private sector with federal, state, county, and city governments owning certain facilities. There are also non-profit hospitals and for-profit hospitals in operation. Health insurance is now primarily provided by the Government in the public sector, with most being provided by programs such as Medicare, Medicaid, TRICARE, the Children's Health Insurance Program, and the Veterans Health Administration. Most citizens receive their health insurance through their employers. With the new “Obamacare” healthcare reform package being implemented, changes will apparently see improvements in the way healthcare is provided in the USA.

Every two years, the CDC administers a national survey of maternity care practices related to breastfeeding, known as the Maternity Practices in Infant Nutrition and Care (mPINC) Survey to all maternity care facilities in the USA. In 2007, the first national survey was done, and this survey established a baseline measure of these practices and documented the extent to which practices vary by state. The mPINC Survey is a key element of CDC’s coordinated activities addressing maternity care practices and policies as they relate to breastfeeding outcomes (CDC Division of Nutrition,Physical Activity,and Obesity 2011).

The US Surgeon General released a “Call to Action to Support Breastfeeding” in 2011 in support of breastfeeding and to increase awareness of the importance of breastfeeding (U.S.Department of Health and Human Services 2011). This is a report that summarises the current status of programmes and initiatives in the USA to encourage breastfeeding and outlines actions to encourage breastfeeding in the future.

The CDC Division of Nutrition, Physical Activity, and Obesity (DNPAO) suggests that supportive hospital practices include (CDC Division of Nutrition,Physical Activity,and Obesity 2011):
  • skin-to-skin contact
  • teaching about breastfeeding
  • early and frequent breastfeeding
  • exclusive breastfeeding
  • rooming-in
  • active follow-up after discharge.
DNPAO collaborates with state governments to provide initiatives to support better maternity care practices that occur during the intrapartum hospital stay. The DNPAO states that “Some maternity care practices with the potential to influence breastfeeding include developing a written policy on breastfeeding, providing all staff with education and training, encouraging early breastfeeding initiation, supporting cue-based feeding, restricting supplements and pacifiers for breastfed infants, and providing post-discharge follow-up” (Centers for Disease Control and Prevention 2011b). Various states have a variety of initiatives and policies to support mothers and infants during their hospital stay, which can be found on the DNPAO website.

Breastfeeding has been endorsed by various health and medical organisations and associations, including:
  • American Academy of Pediatrics (AAP) (2011)
  • American Academy of Family Physicians (AAFP) (2007)
  • American College of Obstetricians and Gynecologists (2007)
  • American College of Nurse–Midwives (2004)
  • American Dietetic Association (James et al 2009),
  • American Public Health Association (2007).
These organisations recommend that most infants be breastfed for at least 12 months, and recommend that for about the first six months, infants be exclusively breastfed, meaning they should not be given any foods or liquids other than breast milk, not even water.

The AAP has an “American Academy of Pediatrics Breastfeeding Initiatives” website and “Safe and Healthy Beginnings: A Resource Toolkit for Hospitals and Physicians' Offices” that provides resources and a framework for continuity of care for the infant from childbirth and beyond, and includes various tools for clinicians, including:
  • Clinical Care Path for Breastfeeding
  • Sample Hospital Breastfeeding Policy for Newborns
  • Infant Breastfeeding Assessment Tool (IBFAT)
  • LATCH: A Breastfeeding Charting System and Documentation Tool
  • Mother-Baby Assessment Tool
  • A Clinician’s Guide: Suggested Questions to Assess Breastfeeding in Primary Care Practice
  • Breastfeeding Assessment Checklist for Mothers in Primary Care Practice (English and Spanish versions included)
  • Assessing Your Local Breastfeeding Resources (English and Spanish versions included).
The USBC has a guidance document called “Core Competencies in Breastfeeding Care and Services for All Health Professionals. Revised edition” published in 2010 that lists the core competencies that healthcare staff should have when providing breastfeeding care and services (United States Breastfeeding Committee 2001).

The AAFP explicitly discourages formula use for healthy infants in its policies stating that:

“The AAFP encourages that hospital staff respect the decision of the mother who chooses to breastfeed exclusively by not offering formula, water or pacifiers to an infant unless there is a specific physician order. The AAFP discourages distribution of formula or coupons for free or discounted formula in hospital discharge or physician office packets given to mothers who choose to breastfeed exclusively” (American Academy of Family Physicians 2007).

International Board of Certified Lactation Consultants (IBCLC) are healthcare professionals who specialise in the clinical management of breastfeeding, and carry certification by the International Board of Lactation Consultant Examiners (IBLCE). IBCLE is like other US certification boards for healthcare professionals and is under the direction of the US National Commission for Certifying Agencies. IBCLCs work in inpatient, ambulatory and community care settings. There are studies that show having IBLCE as staff improves breastfeeding rates; however their presence varies widely from facility to facility in the USA (U.S.Department of Health and Human Services 2011).

Most state health departments have no staff to support breastfeeding activities, except for the WIC program. This lack of infrastructure makes it difficult to carry out any breastfeeding programs at the state level (U.S.Department of Health and Human Services 2011).

Breast milk donated to the banks associated with the Human Milk Banking Association of North America (HMBANA) generally go to help other infants who are sick or fragile (e.g. preterm infants), or to infants whose mothers cannot provide them with enough or any breast milk. HMBANA and milk banks can be seen as facilities that encourage breastfeeding in the face of natural circumstances that may prevent normal breastfeeding. On 6 December 2010, the U.S. Food and Drug Administration’s Office of Pediatric Therapeutics convened a meeting of national experts, including directors of two HMBANA milk banks, to discuss the safety, ethics and regulatory implications of donor human milk. The FDA Pediatric Advisory Committee endorsed donor human milk banking and deemed informal sharing of human milk to be unsafe. HMBANA also support the concepts laid out by the Baby-Friendly Initiative and the WHO Code (Human Milk Banking Association of North America 2011a; Human Milk Banking Association of North America 2011b).


Summary

The USA has limited regulations to support the WHO Code on infant formula, with only some groups monitoring marketing of infant formula. Various federal and state policies and initiatives help to implement and support some of the other WHO Code articles to varying degrees, as do other national and state healthcare organisations. The FDA regulates and monitors infant formula nutritional composition, labelling and manufacturing activities in the USA. The US Government Accountability Office (GAO) has reviewed market research and studies conducted between 1980 and 2005 and found that advertising of infant formula was widespread and increasing in the USA; however it is unclear whether it monitors marketing regularly. The National Alliance for Breastfeeding Advocacy (NABA) REAL is a non-profit organisation responsible for monitoring compliance with the WHO Code in the USA. The Federal Trade Commission is the highest authority on advertising regulations and standards; however states and local political divisions can have their own laws on advertising. There also does not seem to be any national industry code that adheres to the WHO Code.

In terms of complementary policies, the USA has many federal initiatives, but there are also confounding state policies that may override federal policies. This review did not investigate in detail all individual state policies. However, as of July 2007, 47 states had passed some type of legislation in support of the right to breastfeed, with most laws addressing some aspect of breastfeeding in public. These vary in their nature and scope. Other categories of state breastfeeding legislation include workplace issues, jury duty, family law, economic issues, and support services and education. In the USA, there are three states with no law protecting the right to breastfeed in public. The other states either have a law protecting nursing in public but without an enforcement provision; have a law protecting nursing in public with an enforcement provision; or only have a law excluding breastfeeding from some criminal charges. It is noted that no formal structure exists to coordinate federal and state breastfeeding initiatives to reduce overlap or to identify gaps in current programs.

The WIC program is a major influence on nutrition and feeding behaviours in the USA. A portion of each state's WIC budget is allocated for the promotion and support of breastfeeding. WIC now serves 53% of all infants born in the USA. It has been found that infants from low-income families, including those in the WIC programme, were less likely to be breastfed than children in middle and upper income families, and the WIC program has always faced the challenge of promoting breastfeeding, while simultaneously providing infant formula to mothers who choose not to breastfeed.

In terms of other federal initiatives, the USA’s national Healthy People 2010 initiative that calls for 75% of mothers to initiate breastfeeding; for 50% of mothers to continue breastfeeding for six months; and 25% to continue breastfeeding for one year. The new “Choose My Plate” initiative, which replaces the food pyramid, has a subsection on daily food plans for pregnancy and breastfeeding, which encourages women to breastfeed and provides resources for women wanting to find out more about nutrition during breastfeeding. The Office of Women’s Health in the Department of Health and Human Services operates a National Breastfeeding Helpline, and there are also national guidelines on out-of-home childcare and breastfeeding from the National Resource Centre for Health and Safety in Child Care and Early Education.

In 2009, in terms of workplace support, 15 states required that employers support breastfeeding employees when they return to work, and an employee benefits survey found that 25% of employers have on-site lactation rooms, with smaller businesses least likely to have these rooms. New parents in the USA may access leave through the Family Medical Leave Act (FMLA) of 1993. FMLA leave consists of 12 weeks of unpaid leave that must be taken continuously and on a full-time basis. As of March 2010, five states had laws that ensure some level of paid maternity leave, and two extra states had at-home infant care programmes that fund low-income parents to stay home with their infants. In addition to this, the USA has the Child Care and Development Fund that helps low-income families obtain childcare so they can work or attend training or education.

The Health Resources and Services Administration (HRSA) developed “The Business Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits” resource kit to promote breastfeeding in the workplace. The Patient Protection and Affordable Care Act of 2010 includes a provision requiring employers to provide workplace accommodations that enable employees who are breastfeeding to express their milk. However, most states in the USA have either no workplace breast pumping law or no law requiring employers to allow on-site pumping. The Nutrition, Physical Activity, and Obesity Program (NPAO) is a cooperative agreement between the CDC’s Division of Nutrition, Physical Activity and Obesity (DNPAO) and 25 state health departments, with one of the aims of the program being to “increase breastfeeding initiation, duration, and exclusivity”. The USA has not ratified ILO Convention No 183 that supports breastfeeding in the workplace.

The USA has various organisations that contribute to increasing social awareness of breastfeeding. The US Breastfeeding Committee provides a forum for NGOs and representatives from the federal government to collaborate on joint initiatives supporting breastfeeding. The La Leche League is a major advocate for breastfeeding, and all 50 states have breastfeeding coalitions, as well as many local, tribal, territorial coalitions, and racial / ethnic support groups. “Babies Were Born to Be Breastfed” was the campaign tag line of the U.S. National Breastfeeding Awareness Campaign launched by the U.S. Department of Health and Human Services’ Office on Women’s Health and the Advertising Council, and although the educational awareness campaign has ended, continued promotion efforts are underway. In relation to social and public enablement of breastfeeding, on 4 August 2007, the TSA instituted a new policy for transporting pumped breast milk in airplane carry-on luggage.

There are also many cultural barriers to breastfeeding in the USA. There is the belief that bigger babies are healthier and thus supplemental formula feeding and earlier introduction of solid foods is common. There is also a misconception that infants might benefit from being fed both breast milk and other food sources to get “extra” nutrients (e.g. infant formula), so both are given. According to the US Surgeon General’s 2011 call to supporting breastfeeding, cultural barriers include a mothers’ lack of knowledge about breastfeeding, social norms against breastfeeding, poor family and social support, embarrassment, lactation problems, employment and childcare arrangements that discourage breastfeeding, and barriers related to health services.

For the healthcare system, every two years, the CDC administers a national survey of maternity care practices related to breastfeeding, known as the “Maternity Practices in Infant Nutrition and Care (mPINC) Survey” to all maternity care facilities in the USA. This helps to identify breastfeeding trends. Breastfeeding has been endorsed by various health and medical organisations and associations, including the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists, American College of Nurse–Midwives, American Dietetic Association and the American Public Health Association. The USA also has the Baby-Friendly Hospital Initiative for hospitals to support and encourage breastfeeding. As of 28 July 2011, there were 114 BFHI-accredited hospitals and birthing centres in the USA. The percentage of births at BFHI-accredited facilities in 2011 in various states in the USA is less than 20% for all but two states. Only Alaska and Nebraska have more than 20% of births in BFHI-accredited facilities.
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