How Arizona is helping new moms meet breastfeeding goals

Moms at the breastfeeding support group at Cardon Children's Medical Center listen to advice and instruction about feeding schedules and issues surrounding breastfeeding.

In Michaela Zach’s imagination, breastfeeding her newborn son for the first time would be no less than glorious. “I felt like the heavens were going to open and the angels would sing and it would be this wonderful thing.”
But that wasn’t how it went at all.

Getting her baby to “latch” correctly took patience and time; that threw her a learning curve she hadn’t expected. “It was a few weeks of ‘I hate this, why am I doing this?’” says Zach. “But I was committed. Once he got it—and I got it—it became second nature.”

The entire birth experience changed her life. She ultimately became a certified lactation educator as well as a Lamaze childbirth educator and certified labor doula, practicing with Southwest Perinatal Education Services.

Whether or not a new mother and her baby “get it” depends on a few factors. One key predictor of long-term success for breastfeeding is what happens in those precious hours after birth, says Anne Whitmire, IBCLC, RLC, who is breastfeeding coordinator for the Arizona Department of Health Services. “Breastfeeding has a short window. If moms don’t take advantage of that while their milk is available…if they go to formula too soon, they lose out.”

Meeting personal breastfeeding goals hinges on a number of factors, according to the Centers for Disease Control and Prevention. For many women, there are barriers along the way. Though 75 percent of U.S. babies start out breastfeeding, the CDC says only 13 percent are exclusively breastfed at the end of six months. The rates are particularly low among African-American infants.

Catherine Warren, RN, IBCLC, a lactation consultant for Paradise Valley Hospital, says those first days can be daunting. Breastfeeding knowledge isn’t always passed from mother to daughter as it was in past generations; some new mothers may never have seen anyone breastfeed. “They worry about starving their babies,” says Warren. “Without education, they don’t have the confidence.”

Whitmire, who has worked as a lactation consultant for six years and in public health for 20 years, examined evidence-based predictors of what works best when helping new mothers meet their breastfeeding goals. She and her team then built a set of policy guidelines for hospitals and birthing centers to make sure that new moms had all the support they needed to be successful.

“What drew me in,” she says, “was the number of women who mourned losing their breastfeeding experience.”

The result was Arizona Baby Steps to Breastfeeding Success, a roadmap for hospitals and birthing centers. Funded in part by the CDC, the voluntary program was offered to hospitals in Arizona and implemented early in the summer of 2010.

“We found the evidence, we did the training, we helped with policies and provided resources to get this done efficiently,” says Whitmire, who did the grant writing for the project.

Baby Steps is based on the Baby-Friendly Hospital criteria established by UNICEF and the World Health Organization. The “Baby-Friendly” credential requires a hospital to meet additional goals over and above what the Baby Steps program requires.

There are more than 125 Baby-Friendly Hospital sites throughout the United States, but none yet in Arizona. Whitmire hopes that hospitals and birthing centers around the state that embrace the Baby Steps requirements will continue to work toward becoming Baby-Friendly facilities.

Meeting the Baby Steps requirements takes a commitment of resources from hospitals, says Whitmire. It’s not easy. Training must be provided for all staff members who work with moms and babies to make sure everyone is on the same page. Breastfeeding must be initiated within one hour of birth, no pacifiers or other artificial nipples can be used and “rooming in” for moms and babies is highly encouraged so moms will begin to notice an infant’s hunger cues early in the relationship.

Because Baby Steps requirements change the way formula is to be used—only when medically necessary—many hospitals that buy in to the program have shifted their relationships with the baby formula industry, ending a long-time practice of distributing industry-sponsored free formula in the traditional new-parent discharge bags. “It is more about using formula as a medicine,” says Whitmire, “rather than a marketing tool.”

The Baby Steps program creates an opportunity for nurses to have conversations with new mothers about the many evidence-based benefits of breastfeeding so they will be able to make an informed choice about how to feed their babies.

“I love interacting at the bedside, especially for new moms,” says Debi Hill, RNC, IBCLC, RLC, a lactation consultant for Banner Ironwood Medical Center in the San Tan Valley, which is participating in the program. “They are so hungry to learn what is best for their baby.”

Whitmire says no one is pushing breastfeeding on anyone; the best feeding decision is what works for a woman and her family. But the evidence is clear—breastfeeding offers many health benefits when compared to alternatives.

“It’s not like formula is to breast milk as Coke is to Pepsi,” she says. Experts agree that breastfeeding protects against illnesses like diarrhea, ear infections and pneumonia. Breastfed babies are less likely to become obese, develop asthma or die of sudden infant death syndrome (SIDS). The list goes on. In fact, breastfeeding as a long-term benefit continues to be studied and likely provides benefits yet to be discovered.

Women stand to gain health benefits, too. Research shows a decreased risk of breast and ovarian cancers among mothers who breastfeed.

“The gold standard is breast milk for babies,” says Hill. “They’ve nourished their baby for nine months, it just makes sense that they would continue to nourish their babies with their bodies. It is not to stop when the baby is born. We’re not saying that formula is horrible, but babies are hardwired to breastfeed. When they come out, they are expecting a breast. That is in their makeup.”

And there’s a public health advantage. A recent study estimated that the United States would save $13 billion per year in health care and other costs if 90 percent of U.S. babies were exclusively breastfed for six months. Because of new evidence that shows these kinds of advantages to society, Surgeon General Regina Benjamin announced a “Call to Action to Support Breastfeeding.” That report identifies ways that families, communities, employers and health care professionals can improve breastfeeding rates and increase support for breastfeeding.

As of December 2011, 25 Arizona hospitals have agreed to participate in the Baby Steps program, which has far exceeded Whitmire’s expectations. “We presented this idea to the hospitals, but the hospitals have really taken off with it. We are astounded every day at how they have taken it above and beyond.”

The experience that Michaela Zach had with her firstborn, now a freshman in college, inspired her to support new mothers in her role as an educator, no matter what their choice might be. “However you choose to feed your baby can be a challenge,” she says. “But a woman should be educated and that information should come from reliable sources.”

Baby-Friendly requirements

To achieve the Baby-Friendly Designation, facilities must register with Baby-Friendly USA, complete the all of the requirements and ultimately demonstrate during an on-site assessment that they have correctly integrated all of the “Ten Steps To Successful Breastfeeding” [as outlined by UNICEF/WHO] into their practice for healthy newborns.

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice “rooming in”—allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

Source: Baby Friendly USA, Inc. (


Lactation consultants are certified by The International Board of Lactation Consultant Examiners (IBLCE). Other certifications (such as CBC, CLE and CLC) are not regulated by any governing body.

Registered Lactation Consultant (RLC) is the official “title” of a consultant who has passed the IBCLE exam.

International Board Certified Lactation Consultant (IBCLC) is a health care professional who specializes in the clinical management of breastfeeding. IBCLCs are certified by the International Board of Lactation Consultant Examiners, Inc. IBCLCs work in a wide variety of health care settings, including hospitals, pediatric offices, public health clinics and private practice. They can assess clinical conditions such as mastitis, thrush or nipple inversion.

RNC is a registered nurse who is certified in a particular area.

CLE is a certified lactation educator who can teach and consult on breastfeeding/lactation issues but does not diagnose a physical condition.

Doula: From the Greek, meaning “a woman who serves.” According to DONA International (, a doula is a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.


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