Breastfeeding promotion refers to coordinated activities and policies to promote health among women, newborns and infants through breastfeeding.
The World Health Organization (WHO) recommends infants should be exclusively breastfed
for the first six months of life to achieve optimal health and
development, followed by complementary foods while continuing
breastfeeding for up to two years or beyond. However, currently fewer than 40% of infants under six months of age are exclusively breastfed worldwide.
Public health awareness events such as World Breastfeeding Week, as well as training of health professionals and planning, aim to increase this number.
Significance of breastfeeding promotion in the United States
Breastfeeding promotion is a movement that came about in the
twentieth century in response to high rates of bottle-feeding among
mothers, and in recognition of the many health benefits to both mothers
and children that breastfeeding offers. While infant formula had been
introduced in developed countries in the 1920s as a healthy way to feed
one's children, the emergence of research on health benefits of
breastfeeding precipitated the beginning of the breastfeeding promotion
movement in the United States. In the 1950s, La Leche League meetings began. The United States began incorporating benefits specific to breastfeeding promotion into its Women, Infants, and Children
program in 1972. In 1989, WIC state agencies began being required to
spend funds targeted at breastfeeding support and promotion, including
the provision of education materials in different languages and the
purchase of breast pumps and other supplies. In 1998, WIC state agencies were authorized to use funds earmarked for food to purchase breast pumps.
Each year, the Centers for Disease Control and Prevention release
a Breastfeeding Report Card, detailing breastfeeding rates and
promotion programs nationally and in all fifty states. In 2013, 76.5% of
US women had ever breastfed their children; 16.4% exclusively breastfed
up to six months of age. The Healthy People 2020 target for exclusive
breastfeeding at six months is 25.5%.
The proportion of infants who were breastfed exclusively or
non-exclusively at six months was 35% in 2000 and increased to 49% by
2010.
Promotion techniques
Effective
support techniques for breastfeeding include support given by people
with specialized training during and after pregnancy, regular scheduled
visits, and support that is directed towards specific groups of people. Support has been shown to be effective when offered by both professional or peers, or a combination. Providing face-to-face support has been shown to be more likely to be successful for women who are breastfeeding exclusively.
Prenatal care
The discussion of breastfeeding during early prenatal care
can positively effect a woman's likelihood to breastfeed her child.
During regular checkups, a woman's physician, midwife or other
healthcare provider can initiate a conversation about the benefits of
breastfeeding, which can influence a woman to breastfeed her child for a
longer period of time than she might have otherwise. In addition, the involvement of lactation consultants in the prenatal visits of low-income women increases the likelihood that they will breastfeed.
Peer support and counseling
Peer
support techniques can be used before, during, and after pregnancy to
encourage exclusive breastfeeding, particularly among groups with low
breastfeeding rates. Breastfeeding peer counselors, who are ideally
women who have breastfed who can provide information, support, and
troubleshooting to mothers, have had a positive effect on the
breastfeeding rate in American Indian populations.
Peer counseling has also been effective at increasing breastfeeding
initiation rates and breastfeeding rates up to three months after birth
in Hispanic populations in the United States. In addition, peer
counseling can be effective in encouraging not only exclusive
breastfeeding, but also breastfeeding rates in combination with formula,
or "any breastfeeding".
Peer counseling has had a strong effect on breastfeeding initiation and duration in developing countries such as Bangladesh and in areas where home births are more prevalent than hospital births. When combined with nutrition support, particularly the WIC
program in the United States, the presence of peer counselors can have a
significant effect on incidence of breastfeeding among low-income
women.
Support during and immediately after childbirth can also help
women initiate and continue breastfeeding while working through common
concerns related to breastfeeding. This support can be non-medical, as doula
care is. Culturally sensitive care (for example, care from a peer of a
similar ethnic background) may be most effective at encouraging
high-risk women to breastfeed.
Lactation consultants
Lactation consultants
are health care professionals whose primary goal is to promote
breastfeeding and assist mothers with breastfeeding on an individualized
or group basis. They work in a variety of health care settings,
including hospitals, private doctor's offices, and public health
clinics. Lactation consultants are board-certified by the International Board of Lactation Consultant Examiners.
The majority of lactation consultants hold a certification in another
healthcare profession, often as a nurse, midwife, dietician or
physician. However, there is no specific post-secondary education
required to become a lactation consultant.
In low-income contexts, interventions by breastfeeding
consultants can be effective in promoting breastfeeding among high-risk
populations. In one study, while exclusive breastfeeding rates were low
in both control and intervention groups, black and Latina low-income
women who had prenatal and postnatal support from a lactation consultant
were more likely to breastfeed at 20 weeks than women who had not
accessed this support.
In general, lactation consultants give a greater proportion of positive
feedback to mothers regarding breastfeeding than either physicians or
nurses do; the amount of positive advice that a first-time mother
receives regarding breastfeeding from any health care provider can
influence her likelihood to continue breastfeeding for a longer period
of time.
Social marketing and media
Social
marketing has been shown to influence women's decision to breastfeed
their children. One study found that in years when Parents magazine ran
formula advertisements at a higher frequency, the proportion of women
who breastfed often decreased in the following year. Conversely, women who are exposed to marketing that promotes breastfeeding are likely to breastfeed at higher rates.
The growth of the Internet's influence has also influenced
women's choices in infant feeding. The Internet has served as both a
vector for formula advertisement and a means by which women can connect
with other mothers to gain support and share experiences from
breastfeeding. In addition, social media is a category of advertising that did not exist when the International Code of Marketing of Breast-milk Substitutes
was published; thus, while some advertising practices undertaken by
formula companies on the Internet violated the Code, they did so in ways
that could not have been anticipated.
One social medium used to promote breastfeeding is video. These
videos are often independently filmed and produced by lactation
consultants who seek a new way to reach clients. While the efficacy of
these videos has not been formally studied, they are a relatively new
medium of conveying messages about breastfeeding to women.
Cultural and social factors
Ethnicity and breastfeeding promotion
Breastfeeding
initiation and duration varies significantly by race and ethnicity. The
National Immunization Survey in the United States found that while
73.4% of all women in the United States initiated breastfeeding upon the
birth of their child, only 54.4% of black, non-Hispanic women and 69.8%
of American Indian and Alaska Native women did. White non-Hispanic
women initiated breastfeeding 74.3% of the time and Hispanic women had
an initiation rate of 80.4%.
However, one study found that in a low-income environment,
foreign-born black women had a similar breastfeeding rate to Hispanic
women; both of these rates were higher than that of non-Hispanic white
women. In addition, native-born black women had a somewhat higher rate
of breastfeeding than white women.
Immigrant status in the United States is a predictor for breastfeeding adherence. In particular, the Hispanic paradox
plays a role in the high breastfeeding rates observed among
Hispanic/Latina women in the United States. Breastfeeding initiation
rates among this population are higher for less acculturated immigrants;
Hispanic women who have been in the United States for longer are less
likely to breastfeed.
This disparity does not depend on age, income level, or education
level; more acculturated Hispanics are likely to cite the same reasons
for bottle-feeding as native-born white women do. In many cases, the
connection that Hispanic women feel to their culture and its values can
strongly influence their decision regarding breastfeeding.
Access to prenatal care, socioeconomic status, cultural
influence, and postpartum breastfeeding support all influence the
differing rates of breastfeeding in different ethnic groups. In the
United States, black women are more likely than white women to report
that they "prefer bottle-feeding" to breastfeeding, and they are also
more likely to be low-income and unmarried and to have lower levels of
education. The decision to bottle-feed rather than breastfeed is of
similar importance to low birth weight in predicting infant mortality,
particularly in regards to the black-white infant mortality gap. Thus,
breastfeeding promotion initiatives focused on black women should
emphasize education and encourage black women to prefer breastfeeding to
bottle-feeding.
Experts attribute high mortality rates and under nutrition
amongst infants to the decreasing number of woman who breastfeed. This
delay in breastfeeding initiation increases the risk of neonatal
mortality. Experts suggest breastfeeding within the first day of birth
until the infant is 6-months old. Promotion of breastfeeding during
this period could potentially reduce the mortality rates by 16% if
infant was breast fed since day one and 22% if the infant was breastfed
within the first hour.
Rates of breastfeeding initiation vary with ethnicity and socioeconomic
situations. Studies suggest that college educated women over their 30
are more likely to initiate breastfeeding in comparison to other women
who have different levels of educational attainment.
Ethnicity, age, education, employment, marital status, and location are
reported factors of delayed breastfeeding and infant under nutrition.
Low- income mothers are specifically at risk for under nutrition and
high mortality rates amongst their infants because they replace breast
milk with formula.
They do so because they lack a supportive environment, embarrassment of
nursing, or the need to return to school or work. About 16.5% of
low-income mothers breastfed for the recommended time. Studies suggest
that scarce financial and social resources are consistent with the high
mortality rates amongst the infants of low-income mothers.
An example of neonatal and infant mortality that is directly
correlated with delayed initiation of breastfeeding is seen is
sub-Saharan, Africa. Mortality rates are highest in this region of the
world and have had the slowest progress to achieving reductions to the
overall child mortality. Even if low-income mothers exclusively breast
fed their infants for the 6 month – 1-year period, their infant is still
at risk because most women commonly delay first day initiation of
breast-feeding.
Most women aren’t aware that absence in breast milk put their infant
at risk for serious health problems in the future. The Centers for
Disease Control and Prevention (CDC) implements programs that promote
and support breastfeeding and the benefits for infants and children.
They compile many types of data so states can monitor progress and to
educate expecting parents on the subject . But for other countries these
programs aren’t so common.
Socioeconomic influence
Socioeconomic status
of mothers likely has a larger influence on breastfeeding adherence
than race or ethnicity, as many women who are members of groups with low
breastfeeding rates also have a low socioeconomic status. Among women
born in the United States, women who are wealthier are more likely to
breastfeed.
In addition, employment can influence the decision to breastfeed. When
either parent was unemployed or held a lower-status occupation (such as
labor or sales), their children were more likely to never have been
breastfed.
In addition, women with public insurance or with no health insurance
are more likely to never have breastfed their children, as are women who
receive WIC.
The time commitment of exclusive breastfeeding is also an
economic constraint. The time required per week to breastfeed rather
than bottle-feed or feed solids to children can be a significant burden
for women without other childcare or who need to spend this time doing
paid work.
However, some evidence suggests that the long-term benefits of
exclusive breastfeeding outweigh the short-term costs. In the United
States, workplace policy surrounding breastfeeding and parental leave
often does not reflect these benefits. In addition, women are often
unable to risk the loss of their jobs or loss of income due to
breastfeeding adherence, so bottle-feeding is the best solution for the
short-term.
Supporting breastfeeding among adolescent mothers
In recent times adolescent mothers have become a target population for breastfeeding education. In industrialized regions of the world including Canada, the United Kingdom, Australia, and the United States,
single, young mothers, under age 20, are less likely to initiate
breastfeeding and more likely to have lower rates of breastfeeding
duration.
Studies have found that social barriers to continuing breastfeeding
are insufficiently recognized and addressed by healthcare professionals.
Studies suggest that one of the greatest barriers to improving
breastfeeding rates among adolescent mothers are the expectations made
by health care providers who assume young mother are too immature to
breastfeed successfully. Therefore, these young mothers receive even
less education and support than adult mothers even though they need it
most.
Participants of the various studies reported that medical staff
directed them towards the hospital's vast supply of formula milk instead
of receiving lactation consultations even when they wished to
breastfeed.
Adolescent mothers have particular needs due to levels of
education, employment, exposure (or lack thereof) to breastfeeding,
self-esteem, support from others, and of cognitive and psychological immaturity. These factors contribute to a young mother's likelihood to experience distress during their breastfeeding experiences and may even lead first time adolescent mothers to have different
concerns and anxieties regarding breastfeeding from those of adult first
time mothers.
Studies suggest that even when young mothers are informed about
the health benefits of breastfeeding other social norms take precedence.
The potential of social embarrassment can be present in the minds of
expecting adolescent mothers and may be a major factor that influences
their choice of feeding method.
Adolescent mothers have also described conflicts between their wish to
resume activities outside of the home in the post-natal period and the
baby's need to be fed. Public breastfeeding was seen as risking social
disapproval, thus, discouraged breastfeeding. Some of the adolescent
participants of some studies described how their fears become a reality
when they were asked to stop breastfeeding in public areas.
The breastfeeding promotion and support of adolescent mothers
must take into account the context of the individual and their cultural
norms. Few teenagers can withstand the cultural pressure which
categorizes bottle feeding as a norm. Therefore, new teenage mothers
need more concerted prenatal anticipatory guidance, specialized
lactation education and an increase of face-to-face postpartum support.
To succeed with the task at hand, inpatient nursing care need to be
tailor to the unique needs of this population. Positive perception of
inpatient postpartum nursing care has been found to be an important
influence in a young mother's success with breastfeeding. In a study
conducted in the United States, young mothers reported positive
postpartum experiences, especially in respect to breastfeeding
initiation and mother-infant bonding, when their nursing care was
targeted for adolescent mothers. The mothers reported that they felt
better cared for and more motivated to initiate and sustain
breastfeeding when nurses were friendly, patient, respectful and
understanding of their individual needs. Maternal self-confidence is a
contributing factor that influences positive breastfeeding outcomes
especially among adolescent mothers. Empowerment, compassion,
understanding and patience are key when caring for young moms.
Support outside of clinical settings is also important. Changes
to policies have been introduced in the California (U.S.) legislature
that identify schools as key institution of support for adolescent
mothers. In 2015, State Assembly Member Cristina Garcia from Los
Angeles, introduced an amendment which required an employer to provide
break time to accommodate employees to express breast milk for the
employee's infant child, breast-feed an infant child or address other
needs related to breast-feeding. This amendment also requires public
schools to provide similar accommodations to lactating students. These
accommodations include but are not limited to access to a private or
secure room, other than a restroom, permission to bring into a school
campus any equipment used to express breast milk, access to a power
source for said equipment, and access to store expressed breast milk.
The bill does not mandate the construction of new space to make these
accommodations possible. The policy hopes to validate young mothers’ wishes to continue breastfeeding their infant children without shame.
On a global scale, recommendations have been made to educate
school age children using curriculum that promotes healthy nutrition
which includes breastfeeding. The World Health Organization's Global
Strategy for Infant and Young Child Feeding recommend education
authorities help form positive attitudes through the promotion of
evidence-based science regarding the benefits of breastfeeding and other
nutrition programs.
Worldwide efforts
La Leche League
La Leche League International was founded in 1956 after breastfeeding rates in the United States dropped to about 20%.
Today, La Leche League has groups in all 50 states and many countries
worldwide. Its goals include promoting understanding of breastfeeding as
a part of child development and providing support and education for breastfeeding mothers. La Leche League utilizes peer support groups in breastfeeding promotion in addition to supporting World Breastfeeding Week
and other breastfeeding promotion initiatives. All La Leche League
support group leaders have been specially trained and accredited in
breastfeeding support.
La Leche League also operates an online help form, online discussion
forums, and podcasts to enable remote access to breastfeeding support
resources.
Baby Friendly Hospital Initiative
The Baby Friendly Hospital Initiative (BFHI) is an initiative of the World Health Organization and UNICEF
that seeks to encourage initiation of breastfeeding among mothers who
give birth to their children in hospitals. Facilities that achieve its
"Ten Steps to Successful Breastfeeding" and implement the International
code of Marketing Breast-milk Substitutes can be recognized as a
Baby-Friendly facility by the BFHI.
In the United States, accreditation by the BFHI allows facilities to
approach the Healthy People 2020 breastfeeding initiation goals.
Worldwide, facilities that fulfill the requirements of the BFHI have
been able to greatly increase their breastfeeding initiation rates among
patients.
The guidelines of the BFHI have also been effective in increasing
breastfeeding initiation rates among populations that typically have
lower incidences of breastfeeding, such as black women. In one study,
the rate of infants exclusively breastfeeding more than quintupled over a
four-year period upon the implementation of the BFHI.
World Breastfeeding Week
World Breastfeeding Week is an international initiative of the World Alliance for Breastfeeding Action that seeks to promote exclusive breastfeeding.
Since 1992, it has been held each year from August 1 through August 7.
In 2013, the theme of World Breastfeeding Week was "Breastfeeding
Support: Close to Mothers"; past themes include early initiation of
breastfeeding, the role of communication in breastfeeding, and
breastfeeding policy.
World Breastfeeding Week provides informational materials about
breastfeeding to healthcare providers and breastfeeding specialists via
download or purchase. In addition, groups or individuals worldwide are
able to "pledge" that they will undergo promotion activities related to
World Breastfeeding Week in order to show their support for the
initiative.
WHO and UNICEF Initiatives
In
addition to overseeing the Baby-Friendly Hospital Initiative, the WHO
and UNICEF have promoted breastfeeding on an international level. In
1990, the Innocenti Declaration On the Protection, Promotion, and
Support of Breastfeeding was published after a joint meeting of WHO and
UNICEF policymakers. The Innocenti Declaration set forth goals of
exclusive breastfeeding up to 4–6 months, helping women be confident in
their ability to breastfeed, and national policies regarding
breastfeeding to be determined by individual countries, among other
benchmarks.
In addition, UNICEF has published "Ten Steps to Successful
Breastfeeding" which has been implemented in the Baby-Friendly Hospital
Initiative.
The WHO and UNICEF also undertake independent research and
reviews of recent research on breastfeeding in order to inform their
future recommendations.
UNICEF, alongside its recommendations for nutrition for children and
adults, advocates exclusive breastfeeding up to six months of age and
complementary feeding up to two years of age for young children. With
these guidelines in mind, UNICEF believes that with optimal
breastfeeding practices, up to 1.4 million deaths of children under 5 in
the developing world can be prevented.
Trends in exclusive breastfeeding(EBF) among infants from birth to 5months of four different regions of the world. *Excluding China.
Exclusive Breastfeeding (EBF)
WHO infant
feeding recommendation states infants should be breastfed exclusively
for the first six months of life to achieve optimal growth, development
and health. Exclusive breastfeeding (EBF) refers to the practice of feeding an infant on breastmilk alone for the first six months of life without supplementing of other food or even water. According to WHO and UNICEF,
mothers should initiate the breastfeeding within the first hour after
birth. Thereafter, exclusive breastfeeding should be continued for at
least the first six months of life before addition of supplementary
feeding. Exclusively breastfed infants can only take oral rehydration solution, vitamins and minerals, and prescribed medications. Scientific studies carried out by WHO and UNICEF have shown that both the mother and the child benefit from breastfeeding. Breastfeeding
is a cost effective intervention that reduces the infant mortality and
morbidity by lowering the risk of sickness from acute and chronic
infections. Prevalence of EBF increased in almost all regions in the developing world, from 1995 to 2010. The biggest improvement can be seen in the West and Central Africa where the prevalence of EBF is more than doubled from 12% in 1995 to 28% in 2010. Southern and Eastern Africa also shows improvements with an increase from 35% in 1995 to 47% in 2010.
However, according to the UNICEF, there are no satisfactory changes in
the EBF rates for the first six months since 1990. In order to provide
breastfeeding support, WHO and UNICEF have developed two feeding
programs, i.e.the 40-hour breastfeeding counseling, and the five-day
infant and young child feeding counselling.[65][66] Furthermore, Yılmaz, Elif et al.,in
their clinical investigation report states, despite all the
recommendations of the WHO, the rates of breastfeeding initiation and
duration are still far from expectations worldwide.
International Code of Marketing of Breast-Milk Substitutes
The International Code of Marketing of Breast-milk Substitutes was adopted in May 1981 by the Health Assembly of WHO and UNICEF.
It sets forth standards for health care systems, health care workers,
and formula distributors regarding the promotion of formula in
comparison to breastfeeding. It also delineates the responsibilities of
formula manufacturers to monitor the safety of breast-milk substitutes
and governments to monitor the implementation of policies that promote
breastfeeding.
Although the Code has been successful in some settings, it has faced
some opposition and non-compliance from the pharmaceutical industry. This has caused hospitals in different regions of the world to face unsolicited advertising
from breast-milk substitute manufacturers, which inhibits their ability
to make unbiased, evidence-based recommendations to patients.
Breastfeeding promotion projects by region
Africa
Uganda
In Uganda, campaigns to promote breastfeeding have been conducted in the mass media, including public service announcements
via radio, television, posters, newspapers and magazines, leading to
improved knowledge of the benefits of breastfeeding for infants and
mothers among individuals and communities.
Asia
Bangladesh
In
Bangladesh, prelacteal feeding is a common custom; this is the practice
of feeding other foods to infants before breast milk during the first
three days of life. A study found that in a region of rural Bangladesh,
89.3% of infants were fed prelacteally, and only 18.8% of these infants
were exclusively breastfed between three days and three months
postpartum. 70.6% of infants who were not fed prelacteally were
exclusively breastfed up to three months.
Peer counseling and support programs have been shown to have a positive
effect on exclusive breastfeeding rates in rural Bangladesh.
Initiation of “MAA- Mother’s Absolute Affection” a nationwide programme to promote breastfeeding in New Delhi, India.
India
The Government of India initiated the nation-wide breastfeeding programme: MAA- Mother’s Absolute Affection,
in August 2016. Initiation of breastfeeding within the first hour of
birth and exclusive breastfeeding for at least six months are the two
main goals of the MAA programme.
Early Initiation of Breastfeeding in some of the Asian countries. Source: 2018 Global Breastfeeding Scorecard
Sri Lanka
IYCF: Infant and Young Child Feeding practice play a critical role in growth and development of children in south Asian countries including Sri Lanka to promote breastfeeding, complementary feeding, food supplementation and food safety. A well-trained public health midwife, affiliated to IYCF care, is the frontline healthcare worker who delivers maternal and child health services during home visits, as well as within clinic settings.A
policy analysis project (2017) shows, that Sri Lanka has adopted
training materials from WHO/UNICEF breastfeeding training manual giving
strong focus on breastfeeding and on counseling.
Australia
Australia
implemented its first national breastfeeding policy in 2010, aimed at
protecting, promoting, supporting and monitoring breastfeeding through
each level of government and in non-government organization.
Europe
Russia
In
Russia, the Association of Natural Feeding Consultants (AKEV) promotes
breastfeeding. AKEV provides mother-to-mother support, educates
breastfeeding consultants as well as participates in public outreach
about breastfeeding importance. AKEV is a regional group of the International Baby Food Action Network in Russia.
North America
Canada
In Canada, the provinces of Quebec and New Brunswick have mandated the implementation of the Baby Friendly Hospital Initiative,
known as the Baby-Friendly Initiative (BFI) in Canada, which is
designed to support best practices in hospitals and communities to
ensure informed feeding decisions and enable families to sustain
breastfeeding. Other provinces and territories are implementing
strategies around the BFI at regional and local levels. The Canadian
adaptation of the Baby-Friendly Hospital Initiative is designed to
promote breastfeeding through a variety of facilities and settings;
thus, the word "Hospital" is omitted from its title.
Cuba
The Cuban
constitution contains a provision that allows one hour per day to
breastfeed for women who return to their jobs after giving birth.
Cuba also operates regional maternity homes for women who are
undergoing high-risk pregnancies; after giving birth, 80% of women in
these facilities will breastfeed.
United States
In
the United States, breastfeeding promotion often relates to activities
required to be carried out by state and local agencies using federal funds
provided for nutrition education and administrative services under the Special Supplemental Nutrition Program for Women, Infants and Children
(WIC program). States are required to use a portion of funds they
receive to promote breastfeeding by postpartum mothers participating in
the program.
Controversies
Breastfeeding and HIV
It has been argued that, in hindsight, the campaign for the universal
promotion of breastfeeding prior to the acknowledgement of HIV contraction via mother-to-child transmission (MTCT) fails to consider affected mothers in developing countries
who have limited or no access to procedures that would minify the
chance of spreading the virus to their young ones. Initiatives for a
decreased percentage of infants contracting HIV include administering Antiretroviral therapy
(ART) to their mothers and providing milk formula in hand with proper
water sterilization techniques to prevent disease from contamination.
The majority of opposition comes from local and global policy makers who
argue about the non-feasibility of these projects. However others argue
that there is limited say of the women directly affected, resulting in
further segregation of women in developing nations from preventive aid
and health care systems.
Infant formula marketing in hospitals
In
many hospitals, women who are being discharged after giving birth are
given discharge packs branded by a formula company that include formula
samples. Many breastfeeding experts argue that these commercial
discharge packs decrease the likelihood that a woman will breastfeed
and, if she does breastfeed, the length of time she will do so. Studies
have found that marketing of infant formula in hospitals makes it
likelier that a woman will breastfeed for a shorter amount of time due
to the perceived convenience of bottle-feeding.
Formula companies often offer these discharge packs, as well as a
general supply of formula, to hospitals at no cost, which can place some
facilities at an economic disadvantage if they choose to give up these
benefits. However, not accepting free formula is one of the criteria that determine whether a facility can be certified as Baby-Friendly;
thus, the economic burden of giving up access to formula for free can
be a significant barrier for disadvantaged facilities that wish to
achieve Baby-Friendly status.
