Category Archives: breastfeeding

A Tale of Two Cities with One Common Goal: To Improve Breastfeeding Support for Low Income Mothers in Marion County, IN

By Julie Patterson, PhD, MBA, RDN, LDN, Northern Illinois University; Lindsay Moore-Otsby, MD, HealthNet; Carrie Bonsack, DNP, CNM, HealthNet, and Kay Johnson, HealthNet 

Our story begins with an internal champion, a physician whose personal struggles with breastfeeding inspired the creation of a breastfeeding clinic at HealthNet. She engaged internal and external stakeholders to develop a breastfeeding model of care in collaboration with Northern Illinois University. This model aims to improve breastfeeding support and outcomes at HealthNet, and ultimately could serve as a model for other clinics to improve breastfeeding disparities. This project has succeeded in many ways, particularly in highlighting the need for multipronged, multidisciplinary breastfeeding support efforts not only within the clinic system itself, but also in collaboration with local support services.

Challenge Statement

Indiana ranked 43rd out of 50 states for Infant Mortality Rate (IMR) in 2018, according to the America’s Health Rankings report. Indiana’s IMR was 7.3 infant deaths per 1,000 live births compared to the national average of 5.9. Indiana State Department of Health data shows Marion County’s 2017 overall IMR was 7.5 and its African American IMR was 11.6. This can be visualized as representing 104 empty school buses per year, with most of those seats belonging to African American children. This data highlights health outcome disparities faced by HealthNet’s patient population.

Solution and Results

Breastfeeding reduces the risk of morbidity and mortality for mothers and infants, as shown in a meta-analysis published in The Lancet in 2016 by Victora et al. Centers for Disease Control and Prevention (CDC) data shows the lowest rates of breastfeeding are among African American, Hispanic, lower socio-economic status, single, and younger mothers. Developing an outpatient breastfeeding model is crucial to address maternal breastfeeding concerns during prenatal and early postnatal care. HealthNet is uniquely suited, as it cares for dyads during these key times, and therefore, could positively influence breastfeeding outcomes.

HealthNet is the largest of the Federally Qualified Health Centers in Indiana. It offers extensive healthcare services and community programs in their nine Marion County clinics. All mother-baby dyads deliver at a Baby-Friendly Hospital. The purpose of this project was to create a Breastfeeding Support Model (BSM) using a Policy, Systems and Environment (PSE) framework. Funding was granted by the National Association of County and City Health Officials and Northern Illinois University.

To begin, we conducted an organizational assessment and used a tool created by Bermejo et al. (2015) to measure healthcare professionals’ (HCP) and staff breastfeeding attitudes, beliefs, subjective norms, and behavioral intentions. Information collected during this formative period was utilized to prioritize project objectives within the PSE framework.

For the policy aim, we worked collaboratively with internal and external stakeholders to develop a breastfeeding support policy for employees, patients, and visitors. For the systems aim, a workgroup was created to revise the Electronic Health Record (EMR) to optimize breastfeeding care. Obstetric visit templates were created to measure mothers’ breastfeeding intentions, anticipated duration, perception of support, confidence, and concerns. Newborn templates were created to measure duration and intensity of breastfeeding. The templates were piloted at one center with plans to implement across the system. For the environmental aim, marketing created culturally diverse breastfeeding-friendly screen savers to display on computers in exam rooms. Marketing messages and images were reviewed and approved by the project team and have been translated in the three main languages spoken by HealthNet patients. We also worked collaboratively with the recipients of the CDC’s Racial and Ethnic Approaches to Community Health (REACH) grant at the health department to create a breastfeeding asset map to begin identifying a network of breastfeeding support services available in the county.

In the short term, a baseline assessment of breastfeeding attitudes, beliefs, social norms, and intentions was conducted. Forty medical providers, twenty-six support staff and twenty-one nurses responded. The majority reported positive attitudes and beliefs about breastfeeding, and most recognized their role in positively influencing mothers’ decision to breastfeed.

Opportunities were: (1) knowledge of a policy to support breastfeeding employees and breastfeeding mothers, (2) lack of patient facing breastfeeding images and messages, and (3) a need for breastfeeding training. Additionally, medical providers and nurses reported time limitations as a barrier to providing adequate breastfeeding support.


The intermediate outcome was the creation of a collaboration among members of HealthNet, Northern Illinois University, Marion County Health Department, the Indiana Department of Public Health, and the Indiana Milk Bank. We also plan to expand upon the breastfeeding asset map to better understand the impact of the breastfeeding support services offered. Additionally, creative solutions will be identified to meet breastfeeding training needs of our medical assistants, nurses, and medical providers. The challenge continues to be the time and funding needed to provide breastfeeding training while ensuring schedules are managed to maximize patient care availability. Long-term outcomes include utilizing EMR data to improve breastfeeding support and outcomes.

HealthNet and its community have many breastfeeding support resources in place. A main challenge is creating a cohesive breastfeeding support system from these somewhat fragmented efforts. Further investigation must focus on how to best integrate those services into an overarching model of care. Research must also explore the barriers and facilitators for mothers’ participation in these programs.

HCP and support personnel need proper clinical training to better integrate professional breastfeeding support into patient care. Creative solutions and buy-in from leadership are necessary to deliver adequate, cost-effective training without taking staff away from needed clinical duties.

The literature shows breastfeeding’s health benefits. Further study must explore how to support breastfeeding in the face of countless obstacles. Many patients face financial burdens and return to work or school within weeks of delivery, often with minimal workplace and caregiver lactation support. Assisting mothers with practical prenatal and postpartum guidance is critical and must utilize health literate communication strategies.

Federally Qualified Health Centers have specific processes for policy and procedural approval. Leadership buy-in is predicated on an understanding of the organizational structure and dynamics of competing priorities. This must be considered when planning a BSM with realistic project timelines and objectives.

For more information, please contact Julie Patterson at or Lindsay Moore-Otsby, MD or      

Increasing Breastfeeding Support at Erie Family Health Centers

By Misty Romero, BA, RN, IBCLC and Hrishikesh T. Shetty, Institutional Giving Manager, Erie Family Health Centers 

Through NACCHO’s Building a Breastfeeding Support Model for Community Health Centers’ eight-month project, Erie Family Health Centers, a community health center network comprising 13 sites, was able to standardize and improve breastfeeding support throughout the organization and make services more accessible to patients. To reflect Erie’s mission and evidence-based medical practice, we updated our organization-wide breastfeeding and employee pumping policies and procedures to align with state and federal standards. We reconvened our internal workgroup; The Erie Breastfeeding Committee (EBC) and increased Erie’s organizational capacity by training our lactation specialists as trainers, who then trained more staff. Finally, we improved our clinic environment to be supportive of breastfeeding.

Problem Statement

Mothers with lower rates of breastfeeding tend to be young, low-income, African American and Hispanic, unmarried, less educated, overweight or obese before pregnancy, and more likely to report their pregnancy was unintended (Ahluwalia IB, Morrow B, and Hsia J. Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring

System. Pediatrics 2005; 116:1407–1412). At the same time, while breastfeeding is beneficial to almost all mothers and infants, the benefits may be significantly greater for minority women who are disproportionately affected by adverse health outcomes (Mirsa D, editor., ed. The Women’s Health Data Book: A Profile of Women’s Health in the United States, 3rd ed. Washington, DC: Jacobs Institute of Women’s Health and The Henry J. Kaiser Family Foundation, 2001).

At Erie, 73% of patients are Latino, 12% are African American, 63% have Medicaid, 29% are uninsured, and 94% are at or below 200% federal poverty level (FPL). Lack of education, language barriers, and access to resources have a negative impact on breastfeeding rates among Erie patients. The community surrounding Erie’s West Town Health Center is home to approximately 21,500 residents, with 46% of the people coming from minority populations including Hispanic (23.7%), Black (18.8%) and Asian (3.7%) ( Given the high volume of underserved families being served at Erie, we have enormous potential to improve breastfeeding outcomes among low-income, minority Chicagoans.

Solutions and Results

To address these rates, Erie created a system-wide and comprehensive breastfeeding support structure that impacts breastfeeding awareness and adherence among patients and staff, and can serve as a critical resource in the community. The following activities helped us achieve an improved breastfeeding program for our patients and staff:

  • As a community health center network made up of 13 sites, each location had adopted its own set of breastfeeding practices and standards for staff and patients that were not uniform. With support from NACCHO, we were able to establish a standardized clinical breastfeeding policy and procedure for all Erie staff and patients.
  • Provided two of Erie’s International Board Certified Lactation Consultants (IBCLCs) with specialized training to enable them to provide enhanced breastfeeding education to the patient facing staff at all sites. Erie currently has two IBCLCs within our network, certified to provide lactation consultation. However, the two IBCLCs encounter challenges in serving the growing breastfeeding patients at Erie while having to meet the demands of all other aspects of their jobs. In response, Erie trained two staff members through the Institute for the Advancement of Breastfeeding and Lactation Education (IABLE) to become Erie’s Breastfeeding Champions. Post-training, our IBCLCs now provide regular breastfeeding support and education classes at their home sites to other Erie staff. So far, 10 staff members have attended the 16-hour Outpatient Breastfeeding Champion course.
  • Increased the number of sites within our network with the capacity to provide “on the spot” lactation assistance to patients and ongoing breastfeeding education classes. Erie currently provides lactation support at four sites and holds free prenatal breastfeeding education classes at five of our health centers.
  • Improved the clinic’s environment to make our space more actively welcoming and supportive of breastfeeding. We displayed the International Breastfeeding symbol at the entrance of all Erie clinics. In addition, in August, during World Breastfeeding Week, we reached over 17,000 people across all our social media platforms with electronic breastfeeding resource materials. A one-minute breastfeeding informational video delivered in Spanish by Dr. Caitlin Lassus, our Family Medicine provider, was a huge success and received over five hours of total play time, reaching over 3,000 online viewers.

Lessons Learned

Re-establishing a dedicated Breastfeeding Committee (EBC) was beneficial to inform activities at the beginning of our grant period. It was critical to have a collaboration of staff at all clinical and administrative levels to deliver a successful breastfeeding program. Buy-in from the nurse, case managers, doctors, women’s health promoters, medical assistants, lactation consultants, social workers, and Erie leadership was crucial in improving patient engagement and staff awareness of Erie’s breastfeeding services.

A challenge in delivering the program was the time needed by staff to deliver breastfeeding education and support services to patients; This was greater than what we had projected at the beginning of the program. Clients’ language and culture barriers increase the direct service time needed by clinic staff to provide breastfeeding education and support. However, throughout the grant period, we were able to meet client breastfeeding needs, maintain positive organizational attitudes towards breastfeeding, and sustain buy-in from key members of our leadership. Erie continues to support and promote a positive breastfeeding culture across the organization, and we are confident that we will continue these achievements in the future.

For more information, contact Misty Romero at or Hrishikesh T. Shetty at .  

Leveraging Partnerships and Strengthening Connections to Support Breastfeeding Families

By Erica Peterson, MD, MPH, Internal Medicine and Pediatrics, Bluestem Health; Tami Frank, Partnership for Healthy Lincoln; and Karina Vargas, CLC, Bluestem Health

While the need to better support breastfeeding families in safety net clinics is well recognized, internal resources are often limited. Likewise, many community-based initiatives have difficulty engaging high- risk families who would benefit most from their efforts and supports. With funding from NACCHO’s initiative “Building a Breastfeeding Support Model for Community Health Centers”, the goal of the project’s cost-effective approach was to strengthen and leverage community partnerships, enhance internal systems, and provide ongoing training to all staff.


Bluestem Health is a multidisciplinary Federally Qualified Health Center (FQHC) located in Lincoln, Nebraska that provides adult primary care, pediatrics, prenatal care, dental care, and integrated behavioral health services to a predominantly low-income and diverse population. While our county boasts high rates of breastfeeding initiation rates (83.3%), these rates drop off significantly by two months (46.6%). Many Bluestem patients face barriers in accessing services, including lack of transportation, underinsurance, and language and cultural barriers. This makes the development of an effective integrated approach to promote and support breastfeeding at Bluestem even more critical. Lincoln had several established community resources at the start of this grant—including Partnership for a Healthy Lincoln, supported by a the Centers for Disease Control and Prevention’s REACH grant; the Lincoln Community Breastfeeding Initiative, a coalition of community partners focused on breastfeeding support; the Community Breastfeeding Educators, which trained community outreach resources; and MilkWorks, a local community breastfeeding center. However, Bluestem Health had not been integrally involved in coordinating efforts with these potential partners and had not yet developed an internal process outlining their approach to breastfeeding for clients and employees. Bluestem also had not systematized distribution of breastfeeding handouts, maternal depression screenings, and referral processes. Many staff members and providers had never been specifically educated about basic breastfeeding knowledge.


We first conducted surveys and focus groups and collected information about the resources in the community within Bluestem, and identified gaps in services. Then, we set our organizational process outlining our breastfeeding goals as an organization for both employees and clients. The employee process was designed in collaboration with Workwell, a local organization that assists employers in providing workplace lactation support. All pregnant employees now meet with our pediatric nurse and complete a Return to Work plan outlining plans for breastfeeding. We developed our own process for clients and outlined an internal workflow. As part of this procedure, handouts were designed or identified to be given out at specific prenatal visits and at the well-check visits in the first year of life. These handouts include a community resource guide developed in conjunction with our community partners, listing comprehensive updated information about available Certified Lactation Counselors (CLCs) and available breastfeeding support resources. A system was also established to refer prenatal and postpartum families to one of our interpreters, who are trained as community breastfeeding educators (CBC) by Milkworks.

We now attend the scheduled LCBI meetings and participate in a city-wide effort to improve screening for maternal depression. In collaboration with Partnership for Healthy Lincoln, we worked with pediatric and obstetrician (OB) offices across town to standardize maternal postpartum depression screening at the two-week well check. We helped to develop a process for positive screens to be communicated back to OB offices and referred to mental health resources. This is also a critical period where new mothers may need breastfeeding assistance and can now be immediately referred to lactation support. In addition, because transportation was a barrier for many of our clients, we tested some walk-in breastfeeding support and pump clinics at one of our locations. In partnership with Milkworks, we trained our entire staff on the benefits and history of breastfeeding and provided additional in-depth training for our healthcare providers on assisting clients with common breastfeeding problems.


While we recognize the need and opportunity to continue to grow our breastfeeding support efforts, we have already seen several positive outcomes from our initial activities over the past nine months of the grant period. We increased organizational capacity by increasing breastfeeding knowledge, with 68% of the staff reported learning something new at our general training, and we saw a 10% increase in those who believe that breastfeeding is the best source of nutrition for most infants. Likewise, our providers demonstrated a significant increase in clinical knowledge. For example, before the training, only 57% could correctly identify likely drugs responsible for low milk supply. After the training, this number rose to 91%. We have numerous stories of less quantifiable improvements since implementing our workflow and educational interventions. For example, one teen mom presented for her infant’s newborn visit complaining of breast pain. In the past, women with concerns about breastfeeding met with inconsistent, variable support and had difficulty connecting with Milkworks due to the barriers outlined above. Now with these organizational changes, this mom was educated about support services available. She was immediately referred to our CBE/CLC, who assisted with latching. Our CBE/CLC worked directly through our newly strengthened connections at Milkworks to facilitate access to a breast pump and appropriate pump flanges. The mom was also effectively referred and connected to a teen breastfeeding group.

Lessons Learned

Leveraging community resources, strengthening partnerships, and organizing systems through an internal continuity of care lens is a potentially cost-effective approach to enhancing supports for breastfeeding families in a relatively short period of time. While we could never have developed all the materials using our internal resources alone, we worked with our partners to develop a scaffold that best integrates our systems with resources in the community. Our path was filled with smaller lessons as well. An organizational “policy” proved to be cumbersome, so a breastfeeding support process served to set our compass in terms of breastfeeding goals. This resulted in our ability to find a process that best met our needs in a more expedient way. Initially, we met some internal resistance when discussing new breastfeeding supports, highlighting the need for a common process and education of all staff. While there is still significant opportunity for further improvements, these activities were achievable in a relatively short period of time and made a sustainable, real impact for our clinic and our patients.

For more information, contact Karina Vargas at

Streamlining Breastfeeding Support and Education in a Federally Qualified Health Center in New York City

By Lindsay DuBois, MPH, CLC, Associate Director; and Melissa Olson, RD, Nutritionist, Community Healthcare Network 

In New York City, we have witnessed staggering inequities in maternal health outcomes, which is largely driven by racial discrimination.[1] This inequity extends to breastfeeding rates. Through NACCHO’s Building a Breastfeeding Support Model for Community Health Center grant, Community Healthcare Network (CHN) implemented a project to improve organizational policies and practices to help increase breastfeeding rates within our low-income, African American community. This eight-month (February to September–2019) breastfeeding initiative was a multipronged approach to address the core tenets of breastfeeding: promotion, protection, and support within our network of health centers. Continue reading

NACCHO Exchange Summer 2018: Breastfeeding

The summer 2018 issue of NACCHO Exchange showcases the ways in which local health departments are implementing policy, systems, and environment changes to increase breastfeeding rates in their communities. Below is an excerpt from the issue.

By Emily Bernard, IBCLC, NACCHO Consultant; Harumi Reis-Reilly, MS, LDN, CHES, IBCLC, Lead Program Analyst, Breastfeeding Project, NACCHO; and Nikia Fuller-Sankofa, MPH, MPA, Director, Breastfeeding Project, NACCHO

Breastfeeding in the Community: Using Policy, Systems, and Environmental Change Strategies to Facilitate Continuity of Care

Leading health agencies in the United States recognize breastfeeding as a public health priority, including the American Academy of Pediatrics, the American Public Health Association, the Centers for Disease Control and Prevention (CDC), and the U.S. Department of Health and Human Services. Suboptimal breastfeeding has significant public health implications. Because human milk contains unreplaceable immunomodulation properties and live substances including antibodies, hormones, and enzymes that are not found in breast milk substitutes, infants who are not breastfed do not receive the same protection against illnesses.1 Not breastfeeding also increases the mother’s risk of several diseases, including breast cancer, ovarian cancer, cardiovascular diseases, and type 2 diabetes. Infants who are not breastfed have higher rates of diarrhea, necrotizing enterocolitis, otitis media, sudden infant death syndrome, obesity, and childhood leukemia.2 Annually, suboptimal breastfeeding contributes to 3,340 excess deaths, with medical costs totaling $3 billion and the costs of premature death totaling $14.2 billion.3 Continue reading

Dakota County Public Health Builds on Breastfeeding Program to Create Rapid Referral System

By Harumi Reis-Reilly, MS, LDN, CHES, IBCLC, Lead Program Analyst, NACCHO, and Katie Galloway, MBA, RD, LD, IBCLC, Dakota County WIC Program

Dakota County Public Health Department (DCPHD) in Minnesota, a 2017 NACCHO Model Practice awardee, built upon their comprehensive breastfeeding program and implemented a rapid referral system to expand access to critical lactation care to low-income families. Through the Reducing Breastfeeding Disparities through Peer and Professional Support grant, DCPHD increased participation by 68% in prenatal breastfeeding classes and more than doubled their rapid-response lactation visits. Continue reading

Leveraging Existing Resources to Achieve Breastfeeding Equity

By Emily Bernard, IBCLC, NACCHO Consultant; Barb Hawkins Palmer, KCHD, Executive Director of Healthy Kent; Bonita Agee, Strong Beginnings, Education Coordinator; Teresa Branson, KCHD, Deputy Administrative Health Officer; and Chelsey Saari, KCHD, Project Director for Population Health & Accreditation Coordinator


Recognizing there was significant racial inequity in breastfeeding among African American mothers, the Kent County Health Department (KCHD), in Grand Rapids, Michigan, deemed the disparity unacceptable and convened a group of stakeholders to discuss this issue and ways to address it. Only 53% of African American mothers initiated breastfeeding, compared to 79% for white clients. Although there is a WIC program operated by KCHD and various additional maternal and infant health support services in the community, stakeholders determined that mothers would benefit more from receiving one-on-one breastfeeding-specific care. Using the well-documented success of peer mentor models, and with funds from NACCHO, KCHD formed a committee who worked in collaboration with the Healthy Kent Breastfeeding Coalition and the EMPower Hospital (Mercy Health Saint Mary’s), to create the Mothers Helping Mothers Breastfeed project, peer mentor home visiting program, in an effort to close the breastfeeding continuity of care gap for African American women. Continue reading