Background
Many women struggle to obtain their breastfeeding goals. Women typically experience these struggles in the early postpartum period when routine checkups with their pediatric provider are most frequent. Studies show that women are more likely to stop breastfeeding in the first month, when they experience such problems as sore nipples, inadequate milk production, and infant difficulties with breastfeeding (Ahluwalia et al., 2005). Many of these problems could easily be addressed during routine pediatric visits. There should be a “zero zone of separation” between breastfeeding support staff and the breastfeeding dyad, with easily accessed and readily available lactation services at all times. A lactation consultant in or near the pediatric office can help women overcome these difficulties and thereby increase duration of breastfeeding (Ahluwalia et al., 2005).
Recommendations
Healthcare follow-up for mothers and babies should include “well breastfeeding care.” This term is borrowed from what we call regular newborn follow up appointments: well baby care. The concept is similar in design: have routine breastfeeding check-ups at regular intervals, as is done for well baby care. This model is also followed in prenatal care: women have routine check-ups at regular intervals to prevent problems, provide education, assure wellbeing and diagnose any abnormalities, rather than only seeking care when some pregnancy-related catastrophe occurs. It is much easier, cheaper, and healthier to prevent problems than to fix them.
Ideally, lactation care for all women should begin during the first trimester of pregnancy (Gutowski, Hoover, & Kautz, 2009). Women who receive prenatal education, postpartum visits, and telephone contacts with a lactation consultant, are more likely to breastfeed through week 20 and at a higher breastfeeding intensity (Ahluwalia et al., 2005). After delivery, instead of the current “crisis intervention” model of lactation intervention, breastfeeding support would be provided continuously. The lactation consultant would work with the mother to eliminate barriers to breastfeeding, provide education, prevent problems, and enhance the mother’s confidence. Lactation care would then continue until the time of weaning (Gutowski et al., 2009).
Breastfeeding is foundational to health; it affects the lifelong health of the individual, physically, emotionally, and mentally, both for babies and mothers. It should therefore be foundational in healthcare and covered by healthcare premiums. Health care dollars are spent on treating diseases and conditions that could have been effectively prevented by breastfeeding. In order to appropriately address this preventative health care gap and the excessive costs that result, consumers, health care providers, insurers and employers need to be able to identify and access qualified lactation consultants to provide services and protect quality of care (Gutowski, Walker, & Chetwynd, 2010). Building lactation care into office visits would take care of the billing aspect by making it part of the billing for the office visit.
One example that shows breastfeeding impacting long-term health is its role in preventing obesity. One of every 3 adults is obese, and almost 1 in 5 children. This problem is costing the health care system an estimated $117 billion annually (Gutowski et al., 2010). Obesity is a condition that is very difficult to correct; health detriments have already set in by the time the person has become overweight. Breastfeeding has been showed to reduce obesity (Ip, Chung, Raman, Chew, Magula, DeVine, Trikalinos, & Lau 2007; Gillman, Rifas-Shiman, Camargo, et al. 2001; World Health Organization 2006; Dietz, 2001). Helping women successfully breastfeed will help reduce obesity and its associated morbidities and costs.
Such routine lactation care is very cost-effective as well as cost saving. Breastfeeding reduces healthcare costs and is a wise healthcare investment. Breastfeeding is good for managed care: $1.3 billion more is spent by insurers, including Medicaid, to cover sick-child office visits and prescriptions to treat the three most common illnesses—respiratory infections, otitis media (ear infections), and diarrhea—in the first year of life for formula-fed infants versus breastfed infants. One study showed that increased access to lactation consultants resulted in greater continuation of breastfeeding and a $149-per-delivery reduction in cost for planned hospital care, planned follow-up visits, and unplanned care costs (Lieu et al., 1998).
Integral to this model of care is the expanded view of the lactation consultant as a healthcare professional and a member of the healthcare team. The LC is part of a collaborative team, with knowledge and skill to contribute as a viable, trusted, and valuable resource to healthcare in disease prevention, health maintenance, and as a consultant in her field of expertise.
In this model, lactation care would become a regular part of an individual’s healthcare.
Barriers
Barriers to this model of readily available lactation consultant contact include space, time, and money. Lactation care should be local and easily accessible. “A family with breastfeeding issues needs access to lactation support locally and quickly with minimal effort” (Gutowski et al., 2010). Patients should have access to lactation support any time they have needs on an ongoing basis. People pay high premiums for their health insurance; lactation support should be provided as a covered benefit or at a copay just as any aspect of healthcare. In this regard, breastfeeding is a major contributor to health, and saves healthcare dollars.
Outline for Implementation
1. Have a lactation consultant in the OB office for prenatal education for all prenatal patients, and anticipatory guidance for those with history of problems or health conditions which predict possible problems. Lactation care would start with a first trimester assessment/education visit. Research indicates that 50%-75% of new mothers make a decision about the method of choice for feeding their baby in the first trimester (Lukac, Riley, & Humphrey, 2006). Next, there would be a third trimester visit to discuss more specific aspects of breastfeeding, the impact of birthing practices, and recommendations for the early postpartum period. It is recommended that more efforts be concentrated on women in the final days of pregnancy to answer questions and reduce anxiety about breastfeeding issues (Wagner, Chantry, Dewey, & Nommsen-Rivers, 2013).
2. Have the lactation consultant in the pediatric office to see the breastfeeding dyad along with well newborn checks. These “well breastfeeding checkups” could prevent many problems for mother and baby and cut down on problem-oriented visits. The importance of a lactation consult at the newborn visit is demonstrated in studies showing that contact with a health care provider during early breastfeeding can significantly increase breastfeeding duration for that infant and may encourage breastfeeding for subsequent births (Lukac et al., 2006). The LC answers questions and addresses issues or concerns. Mothers are given assistance with latching and positioning, and educated about milk production. This is especially important over the first two weeks of the infant’s life. Breastfeeding concerns during this time period were shown by one study to be significantly associated with increased risk of stopping breastfeeding (Wagner et al., 2013). The pediatric provider would do the well-child exam and then the LC would see the couplet to check on breastfeeding during all regular appointments.
3. The lactation consultant would be available for problem oriented appointments in either the OB clinic or the pediatric clinic. These appointments would be scheduled by the providers or the patients who call in to the clinics with breastfeeding difficulties.
4. The lactation consultant would have an email contact as well as her own dedicated phone line with message capacity. This could be called the “Lactation Line.” These would be used for phone calls and emails from patients and providers with questions and problems. The lactation consultant can answer calls from patients with questions stored in the voicemail, receive urgent calls when on shift, and take calls for making appointments. She can also take calls from providers with questions. The LC would use this line/email to answer questions and make appointments.
5. The lactation consultant will conduct a weekly Mothers’ Support Group. Support groups have been demonstrated to increase breastfeeding rates and provide necessary peer support as well as a venue for professional guidance with questions and problems (Dennis, 2002).
6. The lactation consultant would have open time slots available for urgent LC visits on a drop-in basis. Drop in time could be used for urgent problems that cannot wait for a scheduled visit; this time would accommodate immediate needs and perceived immediate needs.
7. All office staff and all healthcare providers would be trained in the basics of breastfeeding. This would allow consistent information to be given to the breastfeeding mother from all sources within the office setting. Providers should be on the same page about breastfeeding. Info from healthcare providers makes a huge impact upon the patient. Inconsistent information is damaging and confusing to the patient. Evidence-based practice and education should be the standard. This requires all healthcare providers to be educated and up to date. Require all healthcare providers in contact with pregnant women, mothers, and babies to take a basic breastfeeding course. This could be an approved on line course, or a live class or webinar.
Each site that provides pediatric and obstetrical care would have a CLC-trained professional in the office setting. This trained professional would answer basic breastfeeding management questions from staff and patients to help diminish the load upon the lactation consultant and deal with issues that do not need to be referred to the IBCLC. Breastfeeding is an essential component to health and as such an essential aspect of healthcare. This would be a huge boost to the provider’s practice and a tremendous asset to the clinic. If problems outside of normal are encountered, the CLC trained provider would refer/schedule a problem oriented visit with the LC.
8. Baby-Friendly guidelines would be observed in the office setting. This health initiative from WHO/UNICEF basically promotes evidence-based practice in maternal/infant care. Observation of the Baby Friendly Ten Steps to Successful Breastfeeding greatly enhances breastfeeding. Data from around the world clearly indicates the positive impact of implementation of the Ten Steps on breastfeeding initiation, duration, exclusivity, and related child health outcomes.
9. The local hospital birthing center would contact the LC when discharging a patient with breastfeeding issues in order to provide information and schedule a follow-up problem-oriented appointment. If the patient was discharged with a written infant feeding plan, a copy would be faxed to the LC as a reference tool. This would allow the LC to evaluate the effectiveness of the feeding plan and adjust it according to the infant’s current needs. Birthing center staff would also fax a copy of the delivery record. This would allow assessment of infant weight changes and possible effects of delivery interventions, medications, and type of delivery on the infant’s feeding behavior.
Summary
Breastfeeding is essential to health maintenance, and should be a regular part of prenatal, well baby, and postpartum checkups. Lactation care should be readily available, local, and covered by the insurance copay. The lactation consultant is an essential member of the healthcare team. A lactation consultant in outpatient OB and pediatric clinics would be a valuable asset to the health and education of the family, from the prenatal period and continuing through weaning. Costs would be recaptured in the billing process for the provider visit. This model for outpatient lactation care is a win-win scenario for patients, staff, providers, and the long-term health and well-being of our society.
References
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