Balancing Expectations – Enforcing “Reasonable Break Time for Nursing Mothers” (Week 7)

The Affordable Care Act: Addressing the Unique Health Needs of WThe Patient Protection and Affordable Care Act (ACA) has been a controversial first chapter in National healthcare reform. The aims of this legislation are to increase stability of the current healthcare infrastructure, bolster programs aimed at preventive care, and to improve affordability of coverage for those who do not otherwise have realistic access. One of the preventive care provisions of ACA Section 4207 “Reasonable Break Time for Nursing Mothers” as an amendment to section 7 of the FMLA.  Having a provision does not equate to immediate, comprehensive, or even good faith attempts to comply. Challenges with implementation stem from a significant lack of specific verbiage within the legislation.

Interpretation of the philosophy and intention of laws by appointed resource managers and agencies greatly influences the regulations drafted and enforced to realize the goals of the legislation (Kraft & Furlong, 2013). Legislation with specific and action-oriented verbiage interpreted and regulated by agencies which align with the views of the governing executive responsible for enacting legislation often find expedient and thorough implementation (Kraft & Furlong, 2013; Murtagh & Moulton, 2011). In situations where verbiage is less clear and/or agencies or executives are balancing complex and frequently economically motivated expectations of constituents and special interests, implementation may never be realized (Kraft & Furlong, 2013).

As an amendment to FMLA section 7 – Fair Labor Standards Act (FLSA), Section 4207 suffers at the outset from 3 of 4 distinct and critical limitations to supporting increased breastfeeding in the workplace identified by Murtagh and Moulton (2011).

  1. Only 50-60% of lactating employees with children less than 18 months old are entitled to FMLA/FLSA due to length of time in the current job, number of hours worked, proximity to place of employment, and exempt status.
  2. Those who are not likely to be covered by existing FMLA protections are also those least likely to breastfeed based upon correlation of race, age, education, and income.
  3. FMLA leave is unpaid. It is already widely known that children born to families of higher income are more likely to be breastfed at all and for greater duration. Failing to provide more support for paid leave fails to address this critical gap in support.

The fourth barrier identified by Murtagh and Moulton pertains to inflexibility of breaktime for expression of milk, which is alleviated by the ACA – in theory.

The Federal agency responsible for implementation of section 4207 is the Wage and Hour Division (WHD) of the Department of Labor. As of February 27, 2014, the WHD has made no effort to issue regulation regarding what “reasonable break time” means. The United States Breastfeeding Council provides a link to Fact Sheet 73 from WHD, although this resource fails to provide any specific guidance or to do much more than quote section 4207. Further content by USBC provides links to resources for bringing complaints against employers for failing to comply with section 4207. There have to date been at least 169 workplace investigations, 71 confirmed violations, and there a growing number of lawsuits regarding failure to comply. One of these cases, supported by the ACLU, which has already provided recommendations on section 4207, on behalf of Bobbi Bockoras of Pennsylvania, recently made National news in an NBC Special Report.

Closing thoughts

Section 4207 is a small start. It fails in language to include all lactating persons, to provide enforceable action items, and to provide specific recourse for those who are discriminated against. A greater good would come of expanding and substantiating the benefits provided for under the FMLA and FLSA to include paid leave and flexible scheduling where applicable, and to reduce the number of employees who would benefit from lactation accommodation who are currently excluded from FLMA and FLSA. It is essential that gaps in implementation and mechanisms for penalizing companies failing to comply be addressed.


Kraft, M. E & Furlong, S. R. (2013). Public policy: Politics, analysis, and alternatives. Washington, D.C: CQ Press. Fourth Edition.

Murtagh, L. & Moulton, A.D. (2011). Working mothers, breastfeeding, and the law. Government, Politics, and Law. Vol 101 (2).


What does PAMS mean to you? (Supplemental)

I would like to put two questions out as a food-for-thought exercise.

How does or has PAMS impacted your life and that of your family? (For those who may not participate in PAMS, who do you think the major players are and why in the social movement that is PAMS?)

What would it mean to you to see a policy acknowledging the realities of PAMS?

Do not feel like this must be a warm and fuzzy response. It inspires me to think critically about the actors, issues, circumstances, and areas of opportunity in hearing about all the different colors and experiences.

Securing Social Welfare – Liquid Gold (Week 6)

Adapted from “Barriers to Breastfeeding in the WIC Population” Hedberg (2013)

Social Support Infrastructure for Nutrition of Infants

One of the most important social support programs in the United States is the the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Like the Supplemental Nutrition Assistance Program (SNAP), it is intended to provide gap-coverage for families of limited socio-economic means to purchase wholesome and nutritious foods which may otherwise be beyond their reach (Kraft & Furlong, 2013; Food and Nutrition Service (USDA), 2014). Unlike SNAP, WIC is a discretionary program, rather than an entitlement program (Kraft & Furlong, 2013). A discretionary program must have funding renewed every year by House and Senate Appropriations Committees at the Federal level whereas an entitlement program is exempt from annual review and not appropriated to states per se (Longest, 2010). The nature of WIC funding is such that the Federal budget appropriates a set dollar amount per state each year for program funding. If enrollment exceeds funding, families are placed on a prioritized waiting list for available funds based on the age of the child(ren) in the family.

Of the many expenditures of WIC, powdered infant formula accounts for at least $2.6 billion (USD) per year, with an increase of $127 million (USD) per year in recent years. The combined prevalence of formula feeding in the WIC population, and of the population relying on WIC (>50% of infants born each year) results in 57-68% of all formula purchased in the United States being done so through WIC (Oliviera et al., 2010). This is a significant up-front financial burden. The burden does not, unfortunately, stop here. Infants who are fed formula grow up to be children with more chronic and acute illness, greater incidence of diabetes, and higher likelihood of progressive chronic illnesses as adults (Ip et al., 2007). To reiterate, more than half of the children born in the United States are born into families receiving entitlement and discretionary social assistance for nutrition and health support (Oliviera et al., 2010). One in ten adolescents suffer from a chronic illness, and these young people are able to discuss the impacts of their illness on health, insurability, family finances, negative social perceptions of peers, and life-long consequences (Lindsay et al., 2011). Bartick and Reinhold (2010) analyze the cost of suboptimal breastfeeding in the United States, encompassing all of these aspects and many more beyond the scope of this discussion, to a minimum of $3.6 billion (USD) of compounded financial and quality of life burden annually. It is an unfortunate reality that much of the social responsibility hinges on the WIC program. Slow changes are making positive impacts in reducing WIC recipient dependence on formula by increasing the breastfeeding initiation, exclusivity, and duration. Excellent commentary on this topic by a candid expert can be found here.

What are the options?

In the absence of exclusive breastfeeding within the family, health care professionals frequently default to a recommendation of human milk provided through a milk bank. In cases where sufficient need can be established for the infant or young child in question, some state Medicaid programs will pay for the cost of donor milk. This milk is at least $4.50 (USD) per ounce. Clearly, even if supply were able to meet the demand of the millions of children in the country served by WIC who currently do not receive breastmilk, this is not a realistic fiscal option. Donor milk provided through PAMS, theoretically, could be. The milk is provided to recipient families at no cost*, and many donors offer several thousand ounces during their participation (Bond, 2014). With infrastructure to support localized PAMS donors in serological screening and potentially biological screening of the milk itself, it is conceivable that such a program could be feasible. Provision of human milk has been shown consistently to reduce the disease severity and incidence in fragile infants, and it is possible that provision of donor milk to otherwise healthy infants could reduce the disparity of health burden between those who primarily breastfeed (financially secure White families) and those who primarily formula feed (minority and financially insecure families) (Lindsay et al., 2011; Nelson, 2013).

Closing Thoughts

Providing nutrition and health support for families in fragile financial circumstances is a worthy and necessary expenditure. Provision of formula through WIC creates a paradox in which the child must be fed, but social constructs of lactation and employment do not support the achievement of both breastfeeding and employment simultaneously. The provision of infant formula enables employment, and provides adequate infant nutrition in the short term, while perpetuating a cycle of chronic and acute illness, potential disability from these chronic illnesses, and continued dependence on an already strained social support system. WIC is doubly tasked with ensuring infants are fed, and reducing dependence on infant formula to do so. This task essentially happens in a void of greater social, financial, cultural, and political support evident in the near complete absence of systemic breastfeeding support infrastructure. PAMS currently exists in an unknown role and relationship to this social quandary.

* Recipient families will frequently reimburse the cost or reciprocate storage bags/containers, and pay shipping costs where applicable.


Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics, 125(5), e1048-e1056.

Bond, A.B. (2014). Unpublished data.

Furlong, S. R., & Kraft, M. E. (2013). Public policy: Politics, analysis, and alternatives. Washington, D.C: CQ Press. Fourth Edition.

Hedberg, I. C. (2013). Barriers to breastfeeding in the WIC population. MCN. the American Journal of Maternal Child Nursing, 38(4), 244-249. doi:10.1097/NMC.0b013e3182836ca2.

Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., … & Lau, J. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence report/technology assessment, (153), 1.

Lindsay, S., Kingsnorth, S. and Hamdani, Y. (2011), Barriers and facilitators of chronic illness self-management among adolescents: a review and future directions. Journal of Nursing and Healthcare of Chronic Illness, 3: 186–208. doi: 10.1111/j.1752-9824.2011.01090.x

Longest, B. B. (2010). Health policymaking in the united states. Fifth Edition. Chicago: Health Administration Press.

Nelson, M. M. (2013). The Benefits of Human Donor Milk for Preterm Infants. International Journal of Childbirth Education, 28(3).

Oliviera, V., Frazao, E. and Smallwood, D. (2011). Rising infant formula costs to the WIC program: Recent trends in rebates and wholesale prices. United States Department of Agriculture. Economic Research Report Number 93.

Setting the PAMS Agenda (Week 5)

Per Longest (2010), creation of policy happens in two distinct phases:

1. Generation of policy

2. Implementation of policy

Policy generation begins with detailing ideas for policy, setting agendas for translating those ideas into legislation, drafting said legislation, and ushering draft(s) through the House and Senate in order to have them enacted. Once a law has been enacted, implementation is undertaken in it specifics by various actors in the executive branch. These actors may include health agencies, law enforcement agencies, and social workers, among others. Policy is also set within organizations, such as these actors, following a similar process.

Setting the Agenda

The ultimate goal of this blog and of related academic activities is to generate a draft policy statement for review by the Breastfeeding Committee of the American Academy of Nursing. My fledgling efforts and processes are briefly described.

1. Choosing a problem

Using the six criteria of problem choice, compassion is the most appropriate in addressing the agenda nature of PAMS such that – Current institutional means of allocating human milk and the present infant feeding options accepted by the health establishment do not meet the needs of a growing number of families. The result has been to turn to the practice of PAMS. The recommendations of PAMS networks involve appropriate healthcare professionals in individual PAMS practice. Nurses have the greatest contact and so the greatest ability to interact with PAMS participants. There is no current policy for guidance for nurses to engaging PAMS participants in discussions of specific benefits and risks.

2. Identify the needed alteration or addition to organizational policy

Based on the “general issues” identified by Wieck (1992), PAMS agenda is a matter of needing to understand with more clarity the practice and perceived need for PAMS leveraging greater imagination and commitment to the means already available. This is in direct opposition to the alternative situation within this general issue where a new concept would be needed to meet the needs of PAMS participants.

3. Determine the nature of representation within the agenda organization

The American Academy of Nursing defines itself in its mission statement as “[serving] public and nursing profession by advancing health policy and practice through the generation, synthesis, and dissemination of nursing knowledge.” The driving force of policy generation coming from and dedicated to serving directly the needs of the public are indicative of dynamic representation (Bevan & Jennings, 2014). Generation of policy within this structure fits a variation of Model 2 of Brosius & Weimann’s (1996) two-step agenda-setting flow such that –

Public Agenda (PAMS Guidance) -> Early Recognizers (AAN Breastfeeding Committee) -> Organization Agenda (AAN Policy Statement)

Having a grasp of this representation process is essential information for those proposing items to add to organizational agendas. Understanding where the problems or theories which generate agenda items and to whom agenda items are appropriately addressed is the critical first step in generating policy.

4. Identify likely challenges to setting agenda items

Institutional friction, simply put, is the resistance to change from the current operation within an organization (Bevan & Jennings, 2014). In the case of PAMS, this friction is likely to come from the current recognition of acceptable infant feeding options by the American Academy of Pediatrics as (1) milk from biological/birth parent, (2) milk from a human milk bank, (3) commercial infant formula (Eidelman et al., 2012).

Attention Scarcity results from the “finite nature of attention” necessitating prioritizing decision making and responsiveness within an organization. Impact of attention scarcity depends on the hierarchical relationship of the current problem to the “most important problem” that the organization seeks to engage with. Participation in PAMS is still relatively novel and practiced by a growing, but significant minority of families in the United States. The recency of the practice leaves many questions regarding the potential public health impact of PAMS as currently practiced unanswered at this time.

5. Critically evaluate the viability of moving forward with the proposed agenda item

Goodness of fit – Goal 1 of the AAN strategic plan (2014-2017) is to “[i]nfluence the implementation of healthcare reform with the goal of achieving the Triple Aim of improving the patient experience of care, improving the health of populations; and reducing the per capita cost of health care.” The patients in this instance are PAMS participants seeking recognition and facilitation of feasibility regarding their needs and wants in caring for their infants. Ip and colleagues (2007) detail the additional health burden on families resulting from suboptimal breastfeeding including (but not limited to) otitis media, childhood leukemia, asthma, diabetes, and gastrointestinal infection. Bartick & Reinhold (2010) indicate that the annual cost in the US of this same suboptimal breastfeeding is $3.6 billion dollars (or more) realized in large part by increased rates of the aforementioned chronic and acute illnesses.

Ability to overcome challenges – Institutional friction can likely be reduced with reliance on the variance of international human milk allocation models (Bond unpublished, 2013) and the broader WHO (2003) guidelines regarding infant feeding which includes well screened donors/wet-nurses as acceptable options in infant feeding. Attention scarcity is not as easily determined. It is my belief that because this agenda item was solicited, and that it is supported by experienced members of the AAN Breastfeeding Committee, that this obstacle can be overcome with their guidance.

All things being considered, this agenda item is reasonable and likely viable to move forward in the next steps of becoming a policy! On to drafting these ideas into a cohesive statement and actionable items for review and enactment.


Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics, 125(5), e1048-e1056.

Bevan, S., & Jennings, W. (2014). Representation, agendas and institutions. European Journal of Political Research, 53(1), 37-56. doi:10.1111/1475-6765.12023.

Bond, AB. (2013). Comparison of screening methods of donors and human milk in human milk banking models. Unpublished.

Brosius, H., & Weimann, G. (1996). Who sets the agenda?: Agenda-setting as a two-step flow. ( No. 23). 23(5), 561-580. doi:10.1177/009365096023005002.

Eidelman, A. I., Schanler, R. J., Johnston, M., Landers, S., Noble, L., Szucs, K., & Viehmann, L. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-e841.
Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., … & Lau, J. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence report/technology assessment, (153), 1.
Weick, K. E. (1992). Agenda setting in organizational behavior: A theory-focused approach. Journal of Management Inquiry, 1(3), 171-182. doi:10.1177/105649269213001.
World Health Organization, & UNICEF. (2003). Global strategy for infant and young child feeding. World Health Organization.

The Historical Roles of Institutions and Actors and New Applications in Milk-Sharing Policy (Week4)


Actors involved in the generation of health policy include individuals, interest groups, state elected officials, state judiciary branches, federal elected officials, and federal judiciary members (Kraft & Furlong, 2013). Determining the exact role of each of these actors is difficult, due to the mutual responsibility shared between various actors and levels of government in drafting and operationalizing policy. The role of private citizens as individuals, citizens organized into interest groups, or cooperative groups organized into a cohesive lobbying body varies depending on the nature of the policy and level of engagement of interested parties outside the ranks of elected officials. Engagement in the political process has been discussed in terms of social capital – the degree of connectedness and cohesiveness of a community built on trust from repeated social interactions (Bjornskov, 2006) – with direct respect to impact on the legal process.

Angie Bond and Recipient Boy (2011)

Angie Bond and Recipient Boy (2011)

Social and Political Capitol

Li and colleagues (2005) elaborate the relationship between social determinants such as race/ethnicity, socioeconomic status, and self identified social class and individual abilities and mechanisms of accessing social capital. Teney and Hanquinet (2012) examine these determinants in conjunction with social networks to determine 6 classes of social capital in youth approaching adulthood – Indoor class (little to moderate peer association), Sociable class (little connection with religion, active in social activities), Religious class (primary social interaction takes place through religious affiliation, vocational education is a social norm), Clubber class (highly involved in social activities such as sports and parties with highest SES), Committed class (formal commitment to associations and organizations with the most diverse social capital but relatively high SES in general), and Isolated class (no meaningful social associations). Of these six classes, the Religious and Committed classes exhibited the most frequent and effective political inclination and participation, although the kind and intention of participation varied in ways that are not immediately relevant to this blog.

It is hypothesized that these factors hold true in most political and age groups (Teney and Hanquinet, 2012). If this is the case, with respect to PAMS, it will be critical to determine the class(es) of participants in order to effectively reach and activate them in the health policy process. By tailoring efforts to engage the target audience for involvement in the policy making process, health policy writers, consultants, and legislators can maximize the social capital not only of the process input and feasibility, but in word of mouth acceptance of drafted policy. Conversely, representatives seeking to generate policy in a vacuum of social knowledge and input can equally effectively approach the process in ways that would not garner interested and thus fail to activate other actors.

Specific strategies to engage social capital to political ends can be seen in a variety of programs. Community outreach, diverse political staffers, ever changing modes of communication (speeches and radio to twitter and virtual town halls) are some examples of this altered political leverage from the top down, typically to proactively gain or maintain a political position on social policy which is already established. Grass-roots organizations for activating social capital into political capital spring up most frequently re-actively in opposition to an established or impending change in social policy.

Closing Thoughts

Presently, the PAMS community is strictly reactive, rising to meet policy challenges as they appear as a dispersed group. This strategy is not likely to be effective in the event that several states or a federal agency choosing to become involved with PAMS policy. Support for the practice does not exist in the United States explicitly or under reservation/qualification of degree. It would be premature at this point to speculate on the political ca

pital of participants in PAMS. This area of interest is tangential to the research currently under way which will provide some of this information. Future research and social efforts will need to increase focus on the voice of the practice in impacting local and national views and policy. Challenges in meeting this need include the dispersed nature o

f participants, social stigma, and lack of central organization. Strengths lie in the diversity of participants and the ability to access participants through pre-existing social networks which have already garnered social capital through trust-worthy interactions in research and community maintenance for facilitating PAMS. Only by shifting the historical role of participants as reactive actors to proactive participants in the political policy process can the collective anxiety and stigma be relieved.


Bjørnskov, C. (2006). The multiple facets of social capital. European Journal of Political Economy, 22(1), 22-40. doi:10.1016/j.ejpoleco.2005.05.006

Kraft, M. E., & Furlong, S. R. (2013). Public policy: Politics, analysis, and alternatives (4th ed.). Thousand Oaks, CA: CQ Press.

Teney, C., & Hanquinet, L. (2012). High political participation, high social capital? A relational analysis of youth social capital and political participation. Social Science Research, 41(5), 1213.