BREASTFEEDING MEDICINE

Volume 15, Number 6, 2020

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2019.0263

Landscape Analysis of Breastfeeding-Related

Physician Education in the United States

Joan Younger Meek,1 Jennifer M. Nelson,2,3 Lauren E. Hanley,4,5 Ngozi Onyema-Melton,6 and Julie K. Wood7
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Abstract

Background: Breastfeeding is the preferred form of infant nutrition supporting optimal health of mothers and
children. Research shows that medical training is deficient in preparing physicians to develop the knowledge
base, clinical management skills, and attitudes to provide optimal support for breastfeeding families. We
developed this project to assess the current gaps in breastfeeding education during medical training for phy-
sicians and to inform the plan to address those gaps.
Materials and Methods: We conducted key informant interviews with nine professionals representing medical
education, physician professional membership organizations, and ancillary stakeholders with an interest in
improving physician education and training with respect to breastfeeding. Using those results, we developed
and conducted a survey of physicians to identify training in breastfeeding received during medical school,
residency/fellowship, and continuing medical education; confidence in managing breastfeeding; and attitudes
about breastfeeding training. A total of 816 respondents completed the survey from the American Academy
of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Academy of
Family Physicians.
Results: Gaps exist in the training of physicians in terms of knowledge base, and clinical skills in breastfeeding
support as highlighted through detailed key informant interviews and physician surveys. Physicians surveyed in
the disciplines of pediatrics, obstetrics and gynecology, and family medicine indicated a desire to have more
breastfeeding education integrated into their training, especially addressing clinical evaluation and management
of breastfeeding problems.
Conclusion: The landscape analysis demonstrates that medical education in breastfeeding remains inadequate
despite previous efforts to address the gaps and that physicians desire more training in breastfeeding, especially
clinical skills training, to improve provider confidence and competence. The analysis provides the foundation
for further efforts to develop a comprehensive plan to enhance physician education in breastfeeding.

Keywords: breastfeeding, medical education, training, support

Introduction and supported by the Centers for Disease Control and Pre-
vention (CDC).5 In addition, women who breastfeed have

B reastfeeding is recommended as the optimal source

of infant nutrition by the American Academy of Pedia-
trics (AAP),1 the American College of Obstetricians and
reduced risk of several chronic diseases, including breast
and ovarian cancers, hypertension, and type 2 diabetes
mellitus.6 Thus, breastfeeding is important to public health,
Gynecologists (ACOG),2 the American Academy of Family both in the United States and globally, requiring efforts at all
Physicians (AAFP),3 and the World Health Organization4 societal levels.7

1
Department of Clinical Sciences, Florida State University College of Medicine, Orlando, Florida, USA.
2
Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
3
Commissioned Corps of the United States Public Health Service, Washington, District of Columbia, USA.
4
Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA.
5
Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA.
6
Maternal & Child Health Initiatives, Department of Primary Care and Subspecialty Pediatrics, American Academy of Pediatrics,
Itasca, Illinois, USA.
7
Health of the Public, Science and Interprofessional Activities, American Academy of Family Physicians, Leawood, Kansas, USA.

1
 2 MEEK ET AL.

With funding support from the CDC, the AAP initiated the formant interviews. The goal of the survey was to assess
Physician Engagement and Training focused on Breastfeed- breastfeeding-related physician education and training re-
ing project, which aims to (1) increase availability and ac- ceived during undergraduate, graduate, and postgraduate/
cessibility of medical provider education and training related CME. The AAP Institutional Review Board reviewed and
to breastfeeding, (2) provide recommendations on training determined that IRB approval was not required. The survey
and educational needs to build capacity of medical practi- was pilot tested with PAC members.
tioners to optimize breastfeeding practices, (3) provide rec- The web-based survey was distributed to select members
ommendations on strategies to engage medical practitioners of AAP, ACOG, and AAFP during a 2-week period in April
to improve the continuity of breastfeeding-related care from 2017. The AAP distributed the survey through its 500-
the prenatal period through infancy, and (4) support the safe member Section on Breastfeeding listserv. Two thousand
implementation of evidence-based breastfeeding practices. ACOG fellows were selected at random to receive the
To achieve these goals, the AAP convened medical pro- survey (typical response rate of 5%). The AAFP distributed
fessional organizations and key stakeholders to develop con- the survey to two large commissions and some member
sensus and align efforts to address gaps in breastfeeding- interest groups with *300 recipients. In addition, AAFP
related training for physicians. First steps included conducting distributed the survey to a family physician online com-
a landscape analysis of undergraduate and graduate medical munity with *2,000 physicians.
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education with respect to breastfeeding education and devel- Participant demographics included primary area of prac-
oping an action plan to address gaps in breastfeeding-related tice, years in practice, and geographic location of practice.
education and training. The key elements of a landscape Respondents were asked their level of interest in different
analysis include defining the stakeholders, the scope or targets lactation topics and whether they believed that breastfeeding
of the analysis, and the methods and parameters to study. care was a priority in their specialty. In addition, information
was obtained regarding the breastfeeding training received in
Materials and Methods medical school, residency/fellowship, after formal medical
education, and whether they perceived their training as being
The AAP Physician Engagement and Training focused on adequate (Appendix Table A1). For questions where re-
Breastfeeding Project Advisory Committee (PAC) consists of spondents could ‘‘check all that apply,’’ it could not be de-
breastfeeding subject matter experts and key stakeholders termined if an unchecked response option was ‘‘no’’ or
from the Academy of Breastfeeding Medicine (ABM), AAFP, ‘‘missing.’’ Therefore, if all response options in a given
AAP, ACOG, American College of Osteopathic Pediatricians question were missing (range: 0–150), it was assumed the
(ACOP), Association of Women’s Health, Obstetric and question was skipped and the respondent was excluded from
Neonatal Nurses (AWHONN), CDC, National Hispanic the denominator for analysis of that question; otherwise, for
Medical Association (NHMA), National Medical Association responses with at least one option selected, a blank response
(NMA), Reaching Our Sisters Everywhere (ROSE), and for any given response option was considered ‘‘no.’’
United States Breastfeeding Committee (USBC). The PAC Regarding whether breastfeeding was perceived as a priority
organizations, in collaboration with Altarum Institute (Al- within the specialty, response options were categorized as
tarum), designed a landscape analysis to assess the current follows: Agree (‘‘Strongly agree,’’ ‘‘Agree somewhat’’) and
state of physician training on breastfeeding care and im- Other (‘‘Neither agree nor disagree,’’ ‘‘Disagree somewhat,’’
plementation of evidence-based breastfeeding practices. ‘‘Strongly disagree’’). Regarding level of interest in different
lactation topics, response options were categorized as follows:
Key informant interviews Interested (‘‘Very interested,’’ ‘‘Somewhat interested’’) and
Opinions on the current state of breastfeeding-related edu- Other (‘‘Neutral,’’ ‘‘Less interested,’’ ‘‘Not interested’’). Re-
cation and training in undergraduate, graduate, and continuing garding characterization of education and training received,
medical education (CME) in the United States were sought response options were categorized as follows: Agree (‘‘Agree
from a key informant from each of nine organizations: AAP, strongly,’’ ‘‘Agree somewhat’’) and Other (‘‘Strongly dis-
AAFP, ACOG, NHMA, NMA, Accreditation Council for agree,’’ ‘‘Disagree somewhat,’’ ‘‘Does not apply,’’ ‘‘Can’t
Graduate Medical Education, American Medical Student remember’’). For the question regarding training received after
Association, American Medical Women’s Association, and formal medical education, respondents who reported they were
Dr. MILK (Mothers Interested in Lactation Knowledge, an still in training (n = 4) or did not receive breastfeeding training
online group of physicians). In-depth interviews lasting 45–60 after their medical education (n = 2) were excluded.
minutes using standardized questions were conducted by For the question regarding training received in medical
phone. Topics of interest were identified by the PAC members school and residency/fellowship, responses were stratified into
and Altarum. Altarum conducted, recorded, with permission, training received during medical school and received during
and transcribed the interviews. Common themes were identi- residency/fellowship. Within each of these strata, responses
fied when analyzing interview transcripts using NVivo version were further categorized into (1) reported receiving training, (2)
10 (QSR International, Melbourne, Australia). reported not receiving training, and (3) training status unknown,
which included respondents who reported ‘‘don’t know’’ as
well as those with inconsistent responses (e.g., selected ‘‘no
Membership survey
training or education on breastfeeding’’ but also selected an-
Representatives from AAP, ACOG, and AAFP, along with other response option). The ‘‘other’’ response options (n = 61)
Altarum, designed a membership survey informed by an were treated as missing for analysis of this question.
environmental scan of existing resources and materials on Statistical analysis was performed in SAS 9.4 (Cary, NC).
breastfeeding-related training of physicians and the key in- Chi-squared analyses were run to evaluate survey responses
 BREASTFEEDING LANDSCAPE ANALYSIS 3

by medical specialty (‘‘Pediatrics,’’ ‘‘Obstetrics/Gynecology,’’ mation on specialty (n = 7) and years in practice (n = 2) (note,
‘‘Family Medicine’’) and years in practice (<5, 5–10, 11–20, not mutually exclusive) and who were retired (n = 9) were
and >20 years). Of note, respondents who denoted an ‘‘Other’’ excluded, as was one respondent who was still a medical
medical specialty were excluded from the statistical analysis student. The final analytical sample was 816, for a response
when stratifying by specialty given their small number (n = 17) rate of 29%. Respondents who denoted a pediatric subspe-
and difference in training. cialty, including neonatology, were combined with pediat-
rics; similarly, subspecialties of obstetrics and gynecology
Results and family medicine were combined with their respective
primary specialty. Remaining responses (n = 17) were cate-
Key informant interviews gorized as ‘‘Other.’’
Several themes emerged from the key informant inter- The most common specialty of survey respondents was
views. Breastfeeding and lactation management were not pediatrics (68.0%), followed by family medicine (23.2%),
being prioritized or sufficiently covered currently in medical obstetrics/gynecology (6.7%), and other (2.1%) (Table 2).
education in the United States. While inclusion of breast- Almost one-third of respondents had been in practice >20
feeding topics in the curriculum improved during residency years with 25% each reporting being in practice <5 and 5–10
years. The practice location of survey respondents was geo-
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training, compared with medical school, there was still a lack

of adequate education and training provided. The extent of graphically diverse, representing all U.S. census divisions,
training, especially in breastfeeding-specific cultural com- with the South (33.7%) and the Midwest (25.4%) having the
petency and continuity of care, was described by respondents largest representation. A majority (84.7%) of respondents
as being institution-dependent and often heavily reliant on a agreed that providing breastfeeding care for patients is a
faculty breastfeeding ‘‘champion.’’ priority for their specialty (Table 2), including 88.2% (other),
Furthermore, the key informants perceived that breastfeed- 86.3% (pediatrics), 81.0% (family medicine), and 80.0%
ing topics were examined only superficially on medical li- (obstetrics/gynecology).
censing and board certification tests. Key informant-identified Ten key breastfeeding topics for the survey were devel-
barriers and opportunities to including breastfeeding and lac- oped by members of the PAC, with support from Altarum,
tation management into medical training are listed in Table 1. after reviewing feedback from key informant interviews.
Despite continued gaps in support for trainees who are Most of the respondents reported interest in the 10 breast-
breastfeeding themselves, key informants felt support for both feeding and lactation topics assessed, ranging from 80.1%
trainees and practicing physicians has improved over recent (safely giving recommendations for appropriate pacifier use)
years. Specifically, improvements in workplace accommoda- to 92.0% (clinical evaluation and treatment of breastfeeding
tions for breastfeeding physicians, such as dedicated space for problems) (Table 3).
breastfeeding or expression of breast milk, were noted, as was There were statistically significant differences in the types
break time during the United States Medical Licensing Ex- of breastfeeding training received during medical school and
aminations (USMLE)8 for milk expression. residency, both by specialty and by years in practice (Fig. 1).
Some respondents reported receiving breastfeeding educa-
tion in medical school (range 47.8% among obstetrics/
Membership survey
gynecology to 56.1% among family medicine). This was
Of the 2,800 individuals to whom the survey was distrib- higher during residency/fellowship (65.2% among obstetrics/
uted, 1,026 respondents started the survey. Of those, 833 gynecology and 85.4% among family medicine). More
surveys were completed. Respondents with missing infor- obstetrician/gynecologists reported not receiving training in

Table 1. Key Informant Identified Barriers and Opportunities

for Addition of Breastfeeding Content into Medical Education
Barriers Opportunities
Unwillingness to prioritize breastfeeding as part of medical Development of institution-specific breastfeeding
education and practice champions
Lack of physicians’ confidence in their skills and knowledge Training on practical aspects of breastfeeding and lactation
to provide breastfeeding counseling management
Lack of patient and public awareness of and support for Establishing curriculum standards on breastfeeding and
breastfeeding lactation management for medical schools
Selection of CME by physicians with an interest in Integration of breastfeeding into nutrition during basic
breastfeeding medical training
Lack of a unified message from all medical specialties that Inclusion of breastfeeding and lactation management into
breastfeeding is the primary and best nutrition for infants board certification examinations
Influence of formula companies within the medical Breastfeeding and lactation management training for the
education environment (e.g., national meetings) sends a whole care team
mixed message to trainees and the public
Lack of available lactation support providers, especially in
smaller practices and hospitals
Key informant interviews conducted, transcribed, and analyzed by Altarum Institute (Rockville, MD).
CME, Continuing Medical Education.
 4 MEEK ET AL.

Table 2. Characteristics of Respondents feelings of adequacy among the topics examined. For ex-
with Completed Membership Surveys, American ample, 81.2% of respondents felt they were adequately
Academy of Pediatrics/American College trained to refer breastfeeding mothers for appropriate sup-
of Obstetricians and Gynecologists/American port, whereas only 48.8% felt they received adequate training
Academy of Family Physicians Survey, to be able to counsel women and families of differing back-
2017 (N = 816)
grounds on breastfeeding. Over 60% of respondents felt
N % prepared to counsel about the following topics: breastfeeding
in general, referral for lactation support in the hospital or
Primary area of practicea 816 100 community, safe implementation of skin-to-skin care, safe
Pediatrics 555 68.0 implementation of rooming in, and counseling about appro-
Neonatology (subset of pediatrics) 228 — priate use of pacifiers for breastfeeding infants.
Obstetrics/gynecology 55 6.7 With respect to clinical evaluation and clinical treatment
Family medicine 189 23.2 of breastfeeding problems, only 53.3% and 49.9%, respec-
Otherb 17 2.1
tively, of respondents felt they had received adequate train-
Years in practice ing. Statistically significant differences by provider type were
<5 208 25.5 noted for providing clinical treatment of breastfeeding
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5–10 206 25.2

11–20 164 20.1 problems, with fewer pediatricians perceiving they received
>20 238 29.2 adequate training ( p = 0.004). Fewer obstetrician/gynecolo-
gists reported that they received adequate training for giving
Geographical location of practice
North 147 18.0 recommendations for appropriate pacifier use for breast-
South 275 33.7 feeding infants ( p = 0.004). There were statistically signifi-
Midwest 207 25.4 cant differences for all characteristics of training when
West 142 17.4 stratified by years in practice, with a smaller proportion of
International 16 2.0 respondents who had been in practice >10 years perceiving
Missing 29 3.6 they had received adequate training. This may reflect recall
Agreedc breastfeeding care is a priority 691 84.7 bias but could be indicative of an improvement in breast-
in specialty feeding education over recent years, perhaps accelerated by
By specialty: the mandatory provider training that occurs in the process of
Pediatrics (including subspecialties) 479 86.3 Baby-Friendly designation.
Obstetrics/gynecology 44 80.0
(including subspecialties)
Family medicine 153 81.0 Discussion
Otherb 15 88.2
By years in practice In 2010, the USBC released the Core Competencies in
<5 170 81.7 Breastfeeding Care and Services for All Health Profes-
5–10 166 80.6 sionals,9 providing a framework for integrating evidence-
11–20 144 87.8 based breastfeeding knowledge, skills, and attitudes into
>20 211 88.7 standard training for health care professionals. Furthermore,
a
the 2011 Surgeon General’s Call to Action to Support
Subspecialties included within main specialty. Breastfeeding called for ‘‘basic support of breastfeeding as a
b
Includes: pediatric surgery (7), internal medicine-pediatrics (4),
pediatric dentistry (3), other (3) for total in primary area of practice. standard of care.’’10 Physicians who provide medical care for
c
Agreed included response options of: ‘‘Strongly agree’’ and women and children need to develop particular expertise to
‘‘Agree somewhat’’; percentages are relative to total respondents in promote and support breastfeeding.11
that group. Studies have demonstrated continued barriers to breast-
feeding support. The 2014 AAP Periodic Survey12 of practicing
pediatricians indicated respondents desired more education
both medical school (37.0%) and residency/fellowship focused on the management of breastfeeding. Physicians often
(19.6%) than did the other specialties. Those who had report relying on their personal breastfeeding experiences in
trained more recently were more likely to report receiving making recommendations for their patients.13 Physicians who
breastfeeding training (Fig. 1). The survey also examined have negative personal breastfeeding experiences may be more
breastfeeding education after formal medical education. likely to reject current breastfeeding recommendations or dis-
The majority of respondents reported obtaining education courage continued breastfeeding when problems arise.14
through self-study (73.0%), followed by education related The landscape analysis confirmed that gaps remain in the
to Baby-Friendly hospital designation (42.9%), non-CME medical education and training of physicians related to breast-
webinar/lecture on breastfeeding care topics (34.1%), and feeding support. Key informant interviews highlighted the need
CME on basic breastfeeding care competencies (32.0%) for integration of training throughout the continuum of medical
(Table 4). There were statistically significant differences in education. Respondents noted the lack of a unified message
the types of breastfeeding training received (i.e., mainte- from all medical specialties that breastfeeding is the primary
nance of certification, CME) after formal medical educa- and best nutrition for infants. Physicians also lacked confidence
tion, both by specialty and by years in practices. in their skills and knowledge to provide breastfeeding support.
Specific breastfeeding competencies and the respondent’s The inclusion of representatives from AAP, ACOG, and AAFP
perception on whether they felt adequately trained were ex- into the PAC was important to ensure that these messages are
amined (Table 5). There was a large variation in perceived integrated throughout all these organizations.
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Table 3. Reported Interest in Select Breastfeeding Topics, by Specialty and Years in Practice, American Academy of Pediatrics/American College
of Obstetricians and Gynecologists/American Academy of Family Physicians Survey, 2017
Family Practicing Practicing Practicing Practicing
Total Pediatrics Ob/Gyn medicine <5 years 5–10 years 11–20 years >20 years
(n = 811)a (n = 543) (n = 55) (n = 182) pb (n = 204) (n = 204) (n = 156) (n = 233) p
Breastfeeding in general 90.8 90.8 89.1 94.5 0.24 92.7 90.2 89.7 90.6 0.77
Clinical evaluation and treatment of breastfeeding problems 92.0 91.1 94.6 96.3 0.06 92.7 93.2 93.2 89.5 0.41
Counseling women and families of different religious, cultural, 86.7 86.3 81.8 93.1 0.02 85.8 88.3 91.4 83.1 0.09
or ethnic backgrounds on breastfeeding

5
Working with appropriate lactation support services either 89.2 89.2 83.0 92.9 0.09 88.7 89.8 92.5 86.8 0.35
in the hospital or in the community
Safely implementing skin-to-skin care 83.5 83.2 75.5 90.8 0.008 83.4 82.9 83.7 83.8 >0.99
Safely implementing rooming-in 80.3 79.5 77.4 87.0 0.06 79.5 78.5 78.5 83.7 0.47
Safely giving recommendations for appropriate pacifier use 80.1 79.3 73.6 86.0 0.06 77.6 85.3 78.0 79.3 0.19
Benefits of breastfeeding to mother and baby 89.7 89.8 94.3 90.3 0.07 88.3 87.8 90.6 91.9 0.46
Breast pump management 84.3 83.0 76.5 93.6 <0.001 89.3 89.7 84.2 75.2 <0.001
Values in bold are statistically significant.
a
Interest included response options of: ‘‘Very interested’’ and ‘‘Somewhat interested.’’ Of note, five respondents were excluded from analysis of this question since all individual responses were
missing (N = 811). Furthermore, denominators for individual responses vary slightly for this question due to missing answers (range n = 4–14).
b
‘‘Other specialties’’ not included in analysis stratified by specialty due to small sample size (n = 17).
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6
FIG. 1. Report of breastfeeding training in medical school and residency/fellowship, AAP/ACOG/AAFP Survey, 2017. AAP/ACOG/AAFP, American Academy of
Pediatrics/American College of Obstetricians and Gynecologists/American Academy of Family Physicians.
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Table 4. Reported Breastfeeding Training Received After Medical Education, by Specialty and Years in Practice, American Academy
of Pediatrics/American College of Obstetricians and Gynecologists/American Academy of Family Physicians Survey, 2017
Family Practicing Practicing Practicing Practicing
Total Pediatrics Ob/Gyn medicine <5 years 5–10 years 11–20 years >20 years
(n = 763)a (n = 528) (n = 52) (n = 169) pb (n = 180) (n = 194) (n = 158) (n = 231) p
% % % % % % % %
Maintenance of certification modules 22.2 25.4 32.7 10.1 <0.001 11.7 19.6 31.0 26.4 <0.001
for breastfeeding
Baby-Friendly Hospital designation 42.9 46.6 46.2 32.5 0.005 36.7 41.2 44.9 47.6 0.14
CME
Basic breastfeeding care competencies 32.0 35.6 17.3 25.4 0.003 16.1 34.0 36.1 39.8 <0.001

7
Advanced breastfeeding care competencies 16.0 18.2 3.9 12.4 0.01 6.7 15.0 17.1 23.4 <0.001
Cultural competency and health disparities 15.2 17.1 7.7 11.2 0.06 6.1 13.4 17.7 22.1 <0.001
in breastfeeding
Continuity of breastfeeding care 14.0 15.0 7.7 11.8 0.25 4.4 12.9 15.2 21.7 <0.001
Non-CME webinar/lecture on breastfeeding 34.1 36.4 19.2 31.4 0.03 24.4 30.4 36.1 43.3 <0.001
care topics
Self-study of breastfeeding care literature 73.0 72.0 59.6 81.7 0.003 76.1 74.2 70.9 71.0 0.60
Other 13.9 11.6 23.1 16.6 0.03 7.2 17.0 18.4 13.4 0.01
Don’t recall 4.1 3.4 9.6 3.6 0.08 6.1 3.1 2.5 4.3 0.33
Values in bold are statistically significant.
a
Respondents still in training (n = 4) and reporting no training after their medical education (n = 2) were excluded as were respondents who skipped the question (n = 47).
b
‘‘Other specialties’’ not included in analysis stratified by specialty due to small sample size (n = 14).
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Table 5. Respondents Who Agreed ‘‘Somewhat’’ or ‘‘Strongly’’ About Feeling They Had Received Adequate Breastfeeding Training,
by Specialty and Years in Practice, American Academy of Pediatrics/American College of Obstetricians
and Gynecologists/American Academy of Family Physicians Survey, 2017
Family Practicing Practicing Practicing Practicing
Total Pediatrics Ob/Gyn Medicine <5 years 5–10 years 11–20 years >20 years
a b
(n = 812) (n = 551) (n = 55) (n = 189) p (n = 207) (n = 206) (n = 164) (n = 235) p
% % % % % % % %
Characteristics of training received
Counsel women about breastfeeding in general 69.5 71.6 56.4 67.4 0.05 82.0 72.7 66.3 57.9 <0.001
Counsel women and families of different religious, cultural, 48.8 48.9 41.8 51.1 0.48 56.3 51.5 43.3 43.6 0.02
or ethnic backgrounds on breastfeeding

8
Provide clinical evaluation of breastfeeding problems 53.3 52.1 56.4 56.5 0.53 61.7 54.7 50.6 46.6 0.01
Provide clinical treatment of breastfeeding problems 49.9 46.3 56.4 59.7 0.004 55.3 54.9 46.3 43.3 0.03
Refer breastfeeding mothers to appropriate lactation 81.2 80.5 80.0 86.0 0.23 94.1 85.3 81.7 66.0 <0.001
support services either in the hospital or in the community
Safely implement skin-to-skin care 70.4 69.4 63.6 77.3 0.06 83.4 77.9 65.0 56.0 <0.001
Safely implement rooming-in 73.3 73.1 65.5 79.5 0.07 82.4 81.6 69.9 60.5 <0.001
Safely give recommendations for appropriate pacifier 68.8 70.4 49.1 71.1 0.004 83.3 72.3 65.0 56.0 <0.001
use for breastfeeding infants
Values in bold are statistically significant.
a
Respondents who skipped the question (n = 4) were excluded from the analysis. Furthermore, denominators for individual responses vary slightly for this question due to missing answers (range
n = 2–10).
b
‘‘Other specialties’’ not included in analysis stratified by specialty due to small sample size (n = 17).
 BREASTFEEDING LANDSCAPE ANALYSIS 9

Key informants noted the reliance on breastfeeding Breastfeeding Handbook for Physicians.18 The AAP
champions among the faculty to teach breastfeeding content. Breastfeeding Residency Curriculum,19 developed in col-
They also reported the need to develop more institution- laboration with ACOG and AAFP, may be contributing to the
specific breastfeeding champions to integrate breastfeeding increase in education that was reported during residency
throughout the curriculum, especially in the face of com- training from more recent trainees.
peting demands for time and space in the educational pro- The percentage of survey respondents who reported re-
gramming. This represents an opportunity for faculty ceiving breastfeeding training after the completion of grad-
development to support integration of breastfeeding in the uate medical education was low. Self-study of the medical
medical education curriculum. Key informant interviews also literature was reported by 73.0% of respondents, while 42.9%
stressed the need for curriculum standards on breastfeeding in of the respondents reported training as part of the Baby-
medical school, as part of nutrition training, and for inclusion Friendly Hospital designation process. More family physi-
of lactation management in state licensure and board certi- cians and pediatricians reported self-study after their formal
fication examinations. medical education than did obstetrician/gynecologists, how-
Results indicate that 90.8% of survey respondents would ever, pediatricians and obstetrician/gynecologists were more
be interested in more breastfeeding training in general, with a likely to report receiving training as a part of Baby-Friendly
high proportion of respondents interested in all surveyed designation than were family physicians, possibly due to
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topics (range: 80.1–92.0%). Improvement could include hospital-based positions.

training on practical aspects of breastfeeding management When respondents were stratified by the number of years
through hands-on, clinical skill-based training. Bunik et al. in practice, there were statistically significant differences.
showed that integration of experiential training can improve Those in practice less than 5 years were much more likely to
attitudes about breastfeeding support.15 Use of simulation, agree that they received adequate training to counsel women
patient-centered rounds, and skills-based workshops during about breastfeeding than those in practice more than 20
educational and CME programming could help address ed- years, with a linear association. It is likely that breastfeeding
ucational gaps in clinical assessment and management of education has improved in the last decade with the signifi-
breastfeeding. cant increase in number of hospitals in the United States
Of all respondents, 84.7% indicated that breastfeeding care implementing breastfeeding-supportive maternity care
was a priority in their particular specialty, which may be an practices as part of the Baby-Friendly Hospital designation
overestimation because those who view breastfeeding as by Baby-Friendly USA.20 Only 55.3% of those in practice
important may have been more likely to respond to the sur- less than 5 years, however, agreed that they were trained
vey. When broken out by specialty, 86.3% of the pediatri- adequately to provide clinical treatment of breastfeeding
cians and 80.0% of obstetrician/gynecologists responded problems.
positively to this item. Although obstetrician/gynecologists Limitations of these results include the fact that while key
represented a small percentage of the total sample of re- informant interviews were conducted with a broad range of
spondents, it remains concerning that *20% of this special- representatives, there were restrictions on the total numbers
ty’s respondents did not agree that breastfeeding care was a of one-on-one interviews, so there may be selection bias in
priority for their specialty. Because most women make de- the responses obtained. The survey of AAP, ACOG, and
cisions about breastfeeding long before delivery, education AAFP members was not disseminated to all members of
efforts by obstetricians are important. ACOG has taken steps those organizations. The professional membership associa-
to improve breastfeeding resources for members and the tions were used to distribute the surveys, so physicians who
public. Ongoing ACOG efforts in breastfeeding support in- choose not to affiliate with their membership organization
clude founding the Breastfeeding Expert Work Group in were excluded. Given that the survey was disseminated to
2014; creation of an online breastfeeding toolkit in 201616; some organizational members who likely have an interest in
publication of ACOG Committee Opinions, such as ‘‘Opti- breastfeeding, there could be selection bias in that members
mizing support for breastfeeding as part of obstetric practice’’ interested in breastfeeding may be more likely to remember
(2018)2; ACOG clinical guidance about relevant topics; their education and training in this area. The survey did not
maintenance of breastfeeding web pages with links and re- examine race/ethnicity, nor did it address specific work en-
sources; and support for early and more frequent postpartum vironment of practicing physicians, for example, hospital-
visits,17 including those involving lactation. based or ambulatory practice.
Overall, 69.5% of respondents reported that they had re- Recall bias regarding medical training on breastfeeding
ceived adequate training in counseling women about may be more pronounced among those in practice for longer
breastfeeding in general, but only 53.3% agreed ‘‘strongly’’ periods of time. More recent graduates were most likely to
or ‘‘somewhat’’ that they could provide clinical evaluation of recall the education received in breastfeeding topics. Fur-
breastfeeding problems. Only 49.9% could provide clinical thermore, some survey respondents had difficulty answering
treatment of breastfeeding problems. More respondents felt some questions, which may have led to misclassification of
comfortable with their knowledge base than their ability to responses. Removing those responses from analysis of select
manage patients clinically. More family physicians and ob- questions was done to address this concern. The survey re-
stetrician/gynecologists reported receiving adequate training sults are not generalizable to all physicians in these fields.
to treat clinical problems than did pediatricians ( p = 0.004). Furthermore, they do not represent the full spectrum of
The AAP’s Section on Breastfeeding develops clinical medical specialties, only those most likely to have consistent
statements and reports, maintains web resources, and provi- contact with breastfeeding women and children.
des online and live CME educational programming in The analysis provides the foundation for further efforts to
breastfeeding. The AAP and ACOG jointly developed the develop a comprehensive plan to enhance physician
 10 MEEK ET AL.

education in breastfeeding. The 2018 AAP Physician En- breastfeeding as part of obstetric practice. Obstet Gynecol
gagement and Training focused on Breastfeeding Action 2018;132:e187–e196.
Plan21 outlines key recommendations to achieve a more 3. American Academy of Family Physicians. Breastfeeding,
comprehensive approach to breastfeeding education. The Ac- Family Physicians Supporting (Position Paper). https://
tion Plan aims to integrate breastfeeding education and clinical www.aafp.org/about/policies/all/breastfeeding-support.html
care consistently throughout the continuum of medical edu- (accessed February 26, 2020).
cation and across multiple specialties. Broadly, these steps 4. World Health Organization. Breastfeeding. https://www.who
include identification, development and dissemination of cur- .int/topics/breastfeeding/en (accessed February 26, 2020).
ricular materials, tools and resources, including revising and 5. Centers for Disease Control and Prevention. Breastfeeding:
updating the existing AAP Breastfeeding Residency Curricu- Why it matters. https://www.cdc.gov/breastfeeding/about-
breastfeeding/why-it-matters.html (accessed February 26,
lum.20 The plan includes a systematic process of faculty de-
2020).
velopment to enhance breastfeeding education at all levels of
6. Feltner C, Weber RP, Stuebe A, et al. Breastfeeding Pro-
the medical education continuum. Finally, the plan aims to grams and Policies, Breastfeeding Uptake, and Maternal
improve the culture of breastfeeding support for trainees and Health Outcomes in Developed Countries [Internet]. Rock-
practicing physicians who are breastfeeding their own children ville, MD: Agency for Healthcare Research and Quality
as a component of enhancing physician well-being.
Downloaded by UPPSALA UNIVERSITETSBIBLIOTEK from www.liebertpub.com at 05/09/20. For personal use only.

(US), 2018. (Comparative Effectiveness Review, No. 210.)

7. Brown A. Breastfeeding as a public health responsibility: A
Conclusion review of the evidence. J Hum Nutr Diet 2017;30:759–770.
Through key informant interviews and a survey, the land- 8. United States Medical Licensing Examination. 2019 Bul-
scape analysis shows that medical education in breastfeeding letin of Information. Examinees Who Require Additional
remains inadequate and that physicians in multiple specialties Break Time. https://www.usmle.org/pdfs/bulletin/2019
desire more training in breastfeeding, especially clinical skills bulletin.pdf (accessed February 26, 2020).
training, to improve provider confidence and competence. The 9. United States Breastfeeding Committee. Core competen-
analysis provides the foundation for a comprehensive plan to cies in breastfeeding care and services for all health pro-
fessionals. Rev ed. Washington, DC: United States
enhance physician education in breastfeeding.
Breastfeeding Committee, 2010. www.usbreastfeeding
Acknowledgments .org/core-competencies (accessed February 26, 2020).
10. U.S. Department of Health and Human Services. The Surgeon
The authors acknowledge Sarah Lifsey and Sheryl Mathis, General’s Call to Action to Support Breastfeeding, 2011.
from the Altarum Institute at the time of this work, for their https://www.cdc.gov/breastfeeding/resources/calltoaction.htm
roles in collecting, analyzing, and reporting these data. The (accessed February 26, 2020).
authors also thank the key informants and professional orga- 11. Centers for Disease Control and Prevention. Strategies to
nization members who provided their insight and experiences Prevent Obesity and Other Chronic Diseases: The CDC
on breastfeeding education and training. Finally, the authors Guide to Strategies to Support Breastfeeding Mothers and
thank the Physician Education and Training on Breastfeeding Babies. Atlanta: U.S. Department of Health and Human
Project Advisory Committee members and their organizations Services, 2013. https://www.cdc.gov/breastfeeding/pdf/BF-
for their time and continued support of this project. Guide-508.PDF (accessed February 26, 2020).
12. Feldman-Winter L, Szucs K, Milano A, et al. National trends
Disclaimer in pediatricians’ practices and attitudes about breastfeeding:
1995 to 2014. Pediatrics 2017;140:e20171229.
The findings and conclusions in this report are those of the 13. Freed GL, Clark SJ, Sorenson J, et al. National assessment
authors and do not necessarily represent the official position of physicians’ breast-feeding knowledge, attitudes, train-
of the American Academy of Pediatrics or the Centers for ing, and experience. JAMA 1995;273:472–476.
Disease Control and Prevention, the American College of 14. Dixit A, Feldman-Winter L, Szucs KA. ‘‘Frustrated,’’
Obstetricians and Gynecologists, and the American Academy ‘‘depressed,’’ and ‘‘devastated’’ pediatric trainees: US ac-
of Family Physicians. ademic medical centers fail to provide adequate workplace
breastfeeding support. J Hum Lact 2015;31:240–248.
Disclosure Statement 15. Bunik M, Gao D, Moore L. An investigation of the field trip
model as a method for teaching breastfeeding to pediatric
No competing financial interests exist. residents. J Hum Lact 2006;22:195–202.
16. The American College of Obstetricians and Gynecologists.
Funding Information Breastfeeding Toolkit. https://www.acog.org/About-ACOG/
This study was supported by Cooperative Agreement ACOG-Departments/Toolkits-for-Health-Care-Providers/
Number, 6 NU38OT000167-05-03, funded by the Centers for Breastfeeding-Toolkit?IsMobileSet=false (accessed Feb-
Disease Control and Prevention. ruary 26, 2020).
17. The American College of Obstetricians and Gynecologists.
References Postpartum Toolkit. https://www.acog.org/About-ACOG/
ACOG-Departments/Toolkits-for-Health-Care-Providers/
1. Eidelman AI, Schanler RJ, Johnston M; American Academy Postpartum-Toolkit (accessed February 26, 2020).
of Pediatrics Section on Breastfeeding. Breastfeeding and 18. American Academy of Pediatrics, The American College
the use of human milk. Pediatrics 2012;129:e827–e841. of Obstetricians and Gynecologists. Breastfeeding Hand-
2. The American College of Obstetrics and Gynecology book for Physicians. Schanler RJ, ed. Elk Grove Village:
Committee Opinion No. 756: Optimizing support for American Academy of Pediatrics, 2014.
 BREASTFEEDING LANDSCAPE ANALYSIS 11

19. American Academy of Pediatrics. Breastfeeding Residency Address correspondence to:

Curriculum. https://www.aap.org/en-us/advocacy-and-policy/ Joan Younger Meek, MD, MS
aap-health-initiatives/Breastfeeding/Pages/Breastfeeding- Department of Clinical Sciences
Curriculum.aspx (accessed February 26, 2020). Florida State University College of Medicine
20. Baby-Friendly USA. https://www.babyfriendlyusa.org (ac- Orlando Regional Campus
cessed February 26, 2020). 250 E. Colonial Dr., Suite 200
21. American Academy of Pediatrics. Physician Education and Orlando, FL 32801
Training on Breastfeeding Action Plan. https://www.aap.org/ USA
en-us/Documents/AAP-Physician-Education-and-Training-
Breastfeeding-Action-Plan.pdf (accessed February 26, 2020). E-mail: [email protected]

Appendix

Appendix Table A1. Physician Training on Breastfeeding Care and Implementation

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Select Survey Questions

1. Please rate your level of interest in the following breastfeeding and lactation topics: Very interested
Breastfeeding in general Somewhat interested
Clinical evaluation and treatment of breastfeeding problems Neutral
Counseling women and families of different religious, cultural, or ethnic backgrounds on Less interested
breastfeeding
Working with appropriate lactation support services either in the hospital or in the community Not interested
Safely implementing skin-to-skin care
Safely implementing rooming in
Safely giving recommendations for appropriate pacifier use
Benefits of breastfeeding to mother and baby
Breast pump management
2. The following questions ask you to characterize the breastfeeding training you have Strongly disagree
received. In your medical education, do you feel you received adequate breastfeeding
training to be able to:
Counsel women about breastfeeding in general Disagree somewhat
Counsel women and families of different religious, cultural, or ethnic backgrounds Agree somewhat
on breastfeeding
Provide clinical evaluation of breastfeeding problems Agree strongly
Provide clinical treatment of breastfeeding problems Does not apply
Refer breastfeeding mothers to appropriate lactation support services either in the hospital or in Can’t remember
the community
Safely implement skin-to-skin care
Safely implement rooming in
Safely give recommendations for appropriate pacifier use for breastfeeding infants
3. Please assess the breastfeeding training you have received after your medical education. (Check all that apply.)
Maintenance of certification
Baby-Friendly Hospital certification
Continuing medical education (online or in-person)
Basic breastfeeding care competencies
Advanced breastfeeding care competencies
Cultural competency and health disparities in breastfeeding
Continuity of breastfeeding care
Non-CME webinar/lecture on breastfeeding care topics
Self-study of breastfeeding literature
Don’t recall
Other (please describe): ________________________
4. The following question assesses the breastfeeding training you received while in medical Received as a
school and as a resident or fellow. (Check all that apply.) medical student
Clinical experience related to breastfeeding Received as a
resident or fellow
Direct observation of a breastfeeding mother
Hospital rounds that included caring for breastfeeding mothers
Lactation-specific rounds
Lecture on pediatrics, obstetrics, or family medicine that included breastfeeding
Mandatory lecture dedicated to breastfeeding
Optional lecture dedicated to breastfeeding
No training or education on breastfeeding
Don’t recall
Other