Breastfeeding in the military: Part I. Information and resources provided to service women

Military Medicine, Oct 2003 by Bell, Michael R, Ritchie, Elspeth Cameron

Increasing the incidence and duration of breastfeeding is a major goal in Healthy People 2010. Little is known about the progress that the Department of Defense (DoD) health care system, TRICARE, has made toward reaching that goal. This study is the first of a two-part series that reviews DoD/TRICARE support for breastfeeding and discusses policy issues related to breastfeeding. Methods used include searches of MEDLINE, DoD/TRICARE documents, legislative and policy websites, and the Internet. A survey of DoD hospitals was also conducted. Based on the search results and survey, TRICARE may not be meeting the goals of Healthy People 2010. There is minimal policy guidance regarding breastfeeding. Programs are in place at most hospitals, but the quality and content varies greatly. After mothers return to work, support is meager. DOD/TRICARE may need to establish written policy guidelines and devote additional resources to adequately support breastfeeding.

Introduction

Over 20 years of scientific research has established that human milk is the optimal source of nutrition for infants.1,2 In fact, breastfeeding provides such vast benefits to the infant, the mother, and society that it has been described by the American Academy of Pediatrics as "uniquely superior for infant feeding."2 Many other professional societies have also acknowledged breastfeeding as the ideal source of nutrition for infants.3-6 Benefits of breastfeeding are illustrated in Table I.

Recognizing these benefits, the U.S. Department of Health and Human Services made increasing the rate and duration of breastfeeding a major goal in Healthy People 2000 and Healthy People 2010. The published goal is to increase the incidence of breastfeeding to 75% in the early postpartum period and 50% at 6 months.26,27 Unfortunately, the proportion of infants who are breastfed continues to fall short of established goals.26,28

This problem may be more acute within the Department of Defense (DoD) because of the demographics of the active duty military force, mission requirements, and organizational barriers. For example, nationwide, the lowest rates of breastfeeding are found among lower income, minority mothers (particularly African Americans and Hispanics), and those with less than a college education.28 These populations are strongly represented in the active duty force. It is also well documented that full-time employment decreases both the initiation and duration of breastfeeding.29-31 This directly impacts active duty mothers, because by regulation, they must return to work 6 weeks after delivery. The effect is compounded by the fact that they are required to be worldwide deployable 4 months postpartum.32

Infant and maternal health issues such as breastfeeding have assumed greater importance for the military as the percentage of women on active duty has increased to approximately 15% of the total force.32 In this era of dual military couples and single-parent families, readiness can be impacted by an infant's illness because the infant may be sent home from daycare and a parent may then have to take time off of work. Additionally, in today's competitive labor market, quality of life issues such as support for breastfeeding may have an impact on recruiting and retention of qualified women. Finally, considering the limited resources available to TRICARE, increased attention is being placed on preventive measures that can improve health and decrease health care use. Given these factors, it could be argued that the military should have a policy regarding breastfeeding. This two-part series is intended to summarize the issues regarding breastfeeding policy and provide a starting point for discussion of the topic.

Methods

To determine what is known about the incidence, duration, and barriers to breastfeeding in the military, we searched Medline from 1970 to 2001 using the following MESH subject headings: "breastfeeding," "breastfeeding (statistics and numerical data)," "breastfeeding (psychology)," "military personnel," and "military medicine." To minimize the effect of publication bias, we also searched the holdings of the Defense Technical Information Center, which catalogs all research funded by the military. To determine whether there were any policies or materials produced by TRICARE regarding breastfeeding, we searched the Military Health System Web Site, which serves as a repository for all materials produced by TRICARE. We also reviewed the regulations, technical manuals, and field manuals from each service regarding pregnancy and reproductive/developmental hazards for sections mentioning breastfeeding. To ascertain the federal and state laws and policies that pertain to breastfeeding, we searched the Internet using the MSN search engine using the keywords "breastfeeding," "policy," and "law." We also searched the FIRSTGOV and the Library of Congress "THOMAS" web sites using the keyword "breastfeeding."

To examine the resources, information, and services provided at DoD hospitals, we conducted a survey of lactation support programs at military hospitals. Facilities were chosen from a list of all DoD hospitals that offer obstetric care so that at least two medical centers, two community hospitals, and one overseas hospital from each service were included. The sample included approximately one-third of DoD hospitals that provide obstetric care. Hospitals were called on the telephone and a standardized questionnaire was administered to a person at each facility who was identified as being knowledgeable about the lactation support programs at the hospital. Usually this person was a nurse who was in charge of the lactation support program at the facility. In addition to the standardized questionnaire, the respondent was given the opportunity to provide any other details about their hospital that they thought might be relevant.