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Breast-Feeding Promotion Interventions: Good Public Health and Economic Sense Karen Bonuck, PhD Peter S. Arno, PhD Margaret M. Memmott, MPH Kathy Freeman, DrPH Marji Gold, MD Diane Mckee, MD

The health benefits of breast - feeding are well documented, as are the positive effects of breast - feeding promotion interventions. There is a clear dose – response relationship between breast - feeding and infant health in the first year of life, and beyond. Further, nearly all breast - feeding promotion interventions improve — at least minimally — breast - feeding initiation and duration rates. However, the extent to which the costs of such interventions might be offset by the potential health care cost savings during the infant’s first year of life has not been examined. From a health policy perspective, such an economic analysis is indicated. Journal of Perinatology ( 2002 ) 22, 78 – 81 DOI: 10.1038/sj/jp/7210620

INTRODUCTION The overwhelming health benefits of breast-feeding, including longterm effects, are well documented.1 The American Academy of Pediatrics2 now recommends exclusive breast-feeding for 6 months, and continuation of partial breast-feeding up to at least 1 year. Breast-fed children are healthier than those who are not, resulting in lower health care utilization and costs. Since the early 1970s, research has evolved from describing factors that affect breastfeeding behavior to investigating the impact of various interventions upon it. However, the economic benefits of breastfeeding promotion interventions have not been evaluated, despite their potential potency and cost savings. We argue that if effective, supportive interventions are provided to mothers, their breastfeeding initiation and duration rates will increase, resulting in lower health care costs. Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, New York, USA. This work was supported by a grant from the Robert Wood Johnson Foundation. Address correspondence and reprint requests to Karen Bonuck, PhD, 111 East 210th Street, Bronx, NY 10467, USA.

HEALTHIER BABIES Breast-feeding’s protective effects have been documented against a range of illnesses. Particularly in the first year of life, the preponderance of data suggests that breast-feeding’s protective effects are greatest for: otitis media,3 – 6 respiratory infections,6 – 9 and gastrointestinal (GI) illnesses.10,11 Accordingly, these may be termed ‘‘breast-feeding–sensitive morbidities.’’ These three illnesses, in turn, are the most common reasons for illness visits among young children. Otitis media is the most frequent diagnosis in physician office practices among children nationally.12 Lower respiratory infections and GI illness affect approximately one third13 and one half of infants,14 respectively, and are associated with increased health care utilization.15 The above data citing breast-feeding’s health benefits compared with formula feeding are limited by a caveat to all breast-feeding studies. They are, necessarily, drawn from observational studies; ethics preclude a randomized control trial (RCT) of breast-feeding. Therefore, confounding factors associated with breast-feeding (both observed and unobserved) may not be adequately controlled in such studies. Despite these health benefits, the US still remains far below the Healthy People 2010 goal of 50% of women breast-feeding at 6 months, with only 29% doing so currently.16,17 Furthermore, initiation rates overrepresent the actual amount of breast-feeding in the early post-partum period because women who breast-fed only are included. Demographically, breast-feeding is positively correlated with older maternal age, higher income, and education, and Latinas and white women versus African–Americans.18 – 21 For instance, women with household incomes below US$10,000 had initiation and 6-month duration rates of 42% and 12%, respectively. African– American women had initiation and duration rates of 45% and 19%, respectively, compared to white mothers whose initiation and duration rates were 64% and 31%.17

BREAST-FEEDING PROMOTION RESEARCH Numerous interventions to increase breast-feeding initiation and duration have been studied; nearly all show some positive impact. The most effective interventions include in-person, individualized lactation support spanning the pre- and post-natal periods. Lactation consultant (LC) support throughout these periods (including hospital stays) doubled the breast-feeding initiation rate Journal of Perinatology 2002; 22:78 – 81 # 2002 Nature Publishing Group All rights reserved. 0743-8346/02 $25

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Breast - Feeding Promotion Interventions: Good Public Health and Economic Sense

in one (unblinded) RCT, and led to significantly longer duration of breast-feeding at 2 months post-partum.22 Women who received a mean of seven home support contacts were significantly more likely to be breast-feeding at 2 months in another RCT.23 Similarly, a pre-natal class combined with individual meetings and support within 3 days of birth doubled the initiation rate and tripled the breast-feeding rate at 3 to 6 weeks post-discharge in the intervention versus (historical) control group.24 Pre-natal classes that offered incentives for partners to attend resulted in a two- to three-fold increase in breast-feeding rates in a RCT.25 However, large class formats alone (versus individualized teaching) had limited effectiveness, as did videos or peer counseling alone, after adjusting for maternal intention to breast-feed among WIC participants in a non-randomized study.26 WIC participation, combined with advice to breast-feed, increased initiation but not duration of breast-feeding in one study,27 whereas in another, pre-natal WIC participation did not influence initiation.28 Hospital-centered interventions have been somewhat less effective. An in-hospital lactation session only had limited impact on duration among a sample of women who planned to breastfeed in this RCT.29 Telephone follow-ups of women intending to breast-feed, who were seen as in-patients by a lactation nurse, found no gains in breast-feeding duration and no decrease in formula introduction in another RCT.30 In contrast, when postpartum home and phone contact were added to a hospital-based intervention to women who intended to breast-feed, 100% of Intervention group women were breast-feeding at 4 weeks, compared to 68% in the controls.31 Overall, continuity of care and individualized support appear to be most successful. The decision to initiate breast-feeding is generally made early, often before 24 weeks, whereas extending the duration of breast-feeding requires post-partum management.22 The first few days and weeks after hospital discharge are critical to breast-feeding success.32 Individualized phone and home visit contact are wellsuited to supporting women during this period. Interpretation of research in this area requires consideration of several factors. One is that initiation is a necessary but insufficient condition for imparting benefits, given breast-feeding’s dose– response effects. Another factor is that statistically significant differences cited — even in RCTs — are difficult to interpret. This is because power analyses to determine the adequacy of the sample for either initiation or duration effects are absent from most studies. Finally, non-RCTs cannot control for biases associated with the decision to initiate or maintain breast-feeding, i.e., selection effects. HEALTH POLICY IMPLICATION OF BREAST-FEEDING PROMOTION INTERVENTIONS The value of primary prevention efforts, such as breast-feeding support and education, may be difficult for health care providers and insurers to appreciate. Lactation support is precisely the type of Journal of Perinatology 2002; 22:78 – 81

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preventive activity that managed care plans might cover and promote if the economic costs and benefits were known. Directing resources toward first-time breast-feeding mothers who might breast-feed a subsequent child would decrease the perceived expense.33 Most private plans and public health programs do not provide or reimburse for breast-feeding follow-up visits, or pre-natal breastfeeding education per se.34,1 Although reimbursement for breastfeeding education and support could be substantiated under current outpatient provider codes, most women will not make a specific visit to a provider in the early post-partum period for this purpose. Furthermore, by the time babies are seen post-partum (3 to 7 days after birth), many women who experienced breast-feeding difficulties have given up. LIMITED DATA ON THE ECONOMIC BENEFITS OF BREAST-FEEDING Evidence suggests a significant return on investment with breastfeeding promotion, although no such published studies exist.35 Data on cost savings associated with breast-feeding itself are described below. As noted earlier, these studies are also subject to selection bias, which may not be adequately controlled. Potential public cost savings based upon estimates of reduced illness associated with breast-feeding among Hmong women are based upon simulated model data in one ethnic group.36 Another HMO-based study found that medical costs of bottle-fed infants were US$200 higher than those of breast-fed infants in the first year of life.37 If the Healthy People 2010 objective for 50% of women to breast-feed for 6 months were met, WIC could save US$6.5 million/ month, according to a comparison of exclusively breast- versus bottle-fed infants.38 It costs WIC half as much to support a breastfeeding mother, compared with a formula-feeding mother, according to one estimate.39 Excess costs in the first year of life were examined for the three most prominent ‘‘breast-feeding sensitive’’ morbidities: otitis media, GI, and respiratory illnesses. Researchers identified 2033 excess office visits, 212 excess days of hospitalization, and 609 excess prescriptions for these illnesses per 1000 never breast-fed infants compared with 1000 infants exclusively breast-fed for 3 months. The never breast-fed infants’ additional use of health care services cost US$331 to US$475 per infant.40 They conclude that ‘‘health care plans will likely realize substantial savings, as well as provide improved care, by supporting and promoting exclusive breast-feeding.’’ Whereas the above study reports breast-feeding cost savings, it did not examine the economic benefits a breast-feeding intervention might yield. Also, it included women who were more pre-disposed to breast-feeding — white middle class women — and thus might 1 Work conducted for the Weiler Hospital Breast - feeding Committee of MMC found that of the plans surveyed, four do not cover the service, while one will authorize it for teen mothers or after a complicated delivery. A large Medicaid managed care plan in the area decides on a case - by - case basis. The medical center’s IPA does not cover these services.

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Table 1 Well and Sick Child Visits of 82 Infants, 0 to 14 Months* Total number, sample

Mean / infant

SD

842 1042 251 60 345 177

10.26 12.71 3.06 0.73 4.26 2.16

4.29 5.50 2.32 1.30 3.57 2.70

Total visits Total diagnoses All sick diagnoses 6 months BFy - sensitive diagnoses 6 months All sick diagnoses at 7 months BFy - sensitive diagnoses at 7 months

For the purposes of this analysis, they included the following codes based from the International Classification of Diseases, Ninth Revision, Clinical Modification ICD - 9 - CM: 382.9 unspecified otitis media; 493.9 unspecified asthma; 490.00 unspecified bronchitis; 486.0 unspecified pneumonia; 465.9 unspecified acute respiratory infection; 079.0 viral / chlamydia infection; 079.99 unspecified viral / chlamydia infection; 787.91 symptoms with digestive system; 789.00 abdominal pain / colic. *Patterns of well and sick baby visits for children born between July and October 1998, who had both a newborn and a 12 - to 14 - month visit at Montefiore’s Family Health Center. yBF, breast - feeding – sensitive diagnoses include those associated with: otitis media, GI, and respiratory illnesses.

show fewer gains after an intervention than a sample of lowerincome, inner-city women. DATA NEEDED TO INFORM HEALTH POLICY Ultimately, well-designed studies could determine whether intervention costs are offset by decreased health care expenditures overall, and in relation to breast-feeding–sensitive morbidities, specifically. This financial concept — ‘‘cost offset’’ — is immediately more meaningful to health care payers than traditional cost effectiveness analysis because it demonstrates how this intervention compares to usual care, which does not provide or reimburse for it. Public savings from reduced formula and health costs are also likely.38 To determine the proportion of illnesses that might be reduced in the first 12 months of life by breast-feeding, we analyzed visit and diagnosis data in our population (see Table 1). We identified three ‘‘breast-feeding–sensitive morbidities’’ based upon their published protective effects: otitis media, respiratory, and GI infections for analysis. Two family physicians (D. M. and M. G.) selected specific outpatient billing and encounter diagnostic codes to comport with these illnesses. We identified 82 consecutive infants in continuous care at one of our medical center’s family health centers. Continuous care was identified as having both a newborn visit and a 12-month check-up (up to 14 months) at the center. Breast-feeding–sensitive morbidities accounted for 40% of sick diagnoses, and 23% of all diagnoses during the first 12 months. Breast-feeding–sensitive morbidities tripled in the second 6 months of life, compared with the first 6 months, which may be explained by decreasing maternal antibodies and illustrates the importance of breast milk.41 CONCLUSION Health promotion activities that result in healthier children and reduced health care costs are good public health policy. Few preventive health activities have the potential to yield as many shortand long-term benefits for children as breast-feeding promotion. 80

Yet, neither the U.S. government nor commercial insurers have been impelled to fund or promote lactation services based upon published findings that breast-fed children are healthier and have lower infant health care costs. Well-designed studies that examine the economics of intervention should be supported. Such studies will need to consider selection effects associated with initiating or maintaining breast-feeding. Data on a variety of interventions in different health care setting and populations would be a significant contribution.

Acknowledgment The authors thank Neil Leibowitz, JD, for his editorial assistance.

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