Friday, June 13, 2008

RWJF asks for public comment as to how to achieve a Healthier America...

Public Comment
Presented at the Robert Wood Johnson Foundation Commission to Build a Healthier America
Raleigh, North Carolina Field Hearing
June 12, 2008

Good Afternoon. My name is Miriam Labbok. I am a Preventive Medicine Physician Epidemiologist, and a Professor of the Practice of Public Health at UNC School of Public Health, Department of Maternal and Child Health. Previously, I have served on the faculties of Johns Hopkins and Georgetown, and worked at USAID as a Medical Officer and served as a Senior Advisor at UNICEF headquarters. I have worked in more than 50 countries, and more than 20 states. I am pleased today to be working in North Carolina.

You may be wondering whether this international maternal and child health background is relevant to our discussion. Today, we live in a global community, and there is much that we might learn from the work of other countries. We are not that different from others in terms of our problems; while we have excellent medical centers, unfortunately, in some pockets, our infant mortality rates and inequities equal that of some developing countries.

North Carolina, with its 8 million some citizens, and 100 counties, is larger than many countries around the world and equally complex. And with its demographics, and with its “mountains, prairies, and ocean white with foam”, it also might be considered a microcosm – a laboratory - for the United States.

Since 1978, the world has accepted a definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. It also had been accepted as a fundamental human right.

Therefore, I am asking you to come with me on a paradigm (pair o’ dime) shift. In our discussions today, we have concentrated on pre-school children, those over 2 year old. However, the reality is that health and development are biologically inter-generational. May I propose that we shift this discussion from concentrating on fixing what is already broken, to attention to avoiding breakage in the first place? To do this, we must consider primary prevention and equity. We must shift ourselves into the reality that parents/mothers are the prime providers and educators, and that the period of minus 12 to plus 24 in the life every child is the time when the health, growth and development trajectories are set.

What should we do? One thing that is clear is that we must address readiness for pregnancy and the vital issue of breastfeeding. There is abundant research that confirms that breastfeeding impacts on at least 18 major health problems, including diabetes, obesity, breast cancer, respiratory disease hospitalizations (all of which carry major heavy health care costs, let alone the associated pain and suffering), and many others. Teenage mothers, who already are at risk, suffer more bone loss if they do not breastfeed their infants. LACK OF BREASTFEEDING is costing our nation billions of dollars and untold individual suffering and untimely deaths. We calculate that improved breastfeeding in North Carolina could prevent 100 infant deaths or more, about the same number as are currently lost to SIDS. Consider, what would we be willing to pay for a treatment that yielded all of these benefits?

LACK OF BREASTFEEDING IS A “SILENT CATASTROPHE” and it is going unnoted by those who are in a position to create needed changes.

First, let us consider: Who doesn’t breastfeed? The answer is, “Nearly everyone”. But breastfeeding is especially rare among the young, African American, low educated, and in the southeastern US. WIC and selected hospitals have begun to make changes to increase initiation, however, sustained and exclusive breastfeeding remain rare. If we only consider equity, here in North Carolina, infant mortality rates are more than twice as high in the African American population compared to whites, but the rate of continued and exclusive breastfeeding is about half that of whites.

Why don’t mothers breastfeed? There is “asymmetrical information” provided by the media, and by aggressive advertising of commercial infant formula to parents and to health professionals, alike. We have a health care workforce unskilled in breastfeeding support: there is no dedicated breastfeeding curriculum in our medical schools. There are also social pressures and work pressures on women. But the overriding issue is that, with all of these failures, our worst is that we undercut mothers’ self-efficacy, and breastfeeding success is, to a large degree, a “confidence game”.

What is needed? Here in North Carolina, our Blueprint for Action to Protect, promote and support breastfeeding has not as yet been implemented. It provides eight recommended actions. One that we are beginning to develop now is the call for a statewide breastfeeding-friendly maternity effort. This is timely, as the National Maternity Practices in Infant Nutrition and Care (mPINC) Survey findings were just published TODAY. They provided a clear message for North Carolina and for the country: we have a lot of work to do to create breastfeeding-friendly practices. In North Carolina, we score just below average for the nation (again – a microcosm…), and our breastfeeding initiation rates are also just below average. In practices associated with breastfeeding continuation and exclusivity (labor and delivery, immediate postpartum contact, post discharge support), we score below average. And, yes, in North Carolina, we lag behind the nation in breastfeeding continuation and exclusivity.

We need to ensure that our health care workers are trained in the skills necessary to support breastfeeding, that there is coverage of the population by availability of lactation consultants and other skilled workers, and that these skills are covered by insurance. We need the political will to regulate aggressive formula advertising and manipulation of the health system – we did it for cigarettes, we can do it again. We need social marketing and K-12 educational exposure to breastfeeding as normal and healthy; we need community and church commitment to our mothers and children. And we must gain workplace support, such at that reported here by Dan Gauthreux. Perhaps most of all, we must foster the role of that primary provider and primary educator, by insisting on paid maternity leave – a right guaranteed in virtually every other developed country in the world.

Can we do it? Yes. It would pay for itself. The reduced costs of health care when all of these diseases and causes of death are reduced would more than cover the costs of providing the needed changes, as well as paid maternity leave.

The bottom line is: do we care about our children, our future? If we do, we must act now to stem the impact of this SILENT CATASTROPHE, and act to enable all women to have accurate information upon which to base their decision to breastfeeding and to succeed with that decision.

Thank you for considering this shift, and supporting intervention for the period of minus 12 to plus 24 months.