Citrus County Breaking Barriers to Breastfeeding Support

State: FL Type: Promising Practice Year: 2019

Located on Gulf Coast of Florida, Citrus County has a population of around 144,000 people. The majority of Citrus County residents identify as non-Hispanic white and 43% of households in Citrus County are living paycheck to paycheck. Citrus County has a variety of poor health indicators, including poor maternal and infant health outcomes and risk factors. With facilitation from Florida Department of Health Citrus (FDOH-Citrus), our community came together in 2016 to address high rates of infant mortality. Part of this ongoing work included promoting breastfeeding as a protective factor against infant mortality and setting a goal of providing breastfeeding resources and support to all Citrus County mothers. In 2017, Citrus County saw approximately 1,000 births, 70% of which were covered by Medicaid (compared to 49% percent across the state). As of 2017, 75% of mother's initiate breastfeeding in Citrus County, lower than the state rate of 86%, as reported by hospital birth records.

Citrus County has two local hospitals, which both provide delivery services, but neither have comprehensive lactation support to initiate breastfeeding in the hospital. Through a partnership between FDOH-Citrus and the two hospitals that serve county residents, FDOH-Citrus was able to hire an International Board Certified Lactation Consultant (IBCLC) in early 2017 to lead breastfeeding promotion efforts in the county and provide breastfeeding support services within the county hospitals and to all maternal service program clients at FDOH-Citrus through direct assessment and support as well as the operation of a county-wide infant feeding support line to help mothers through common breastfeeding challenges. At the time of hire, breastfeeding initiation rates for WIC clients was 75%. As of September, of 2018 breastfeeding initiation rates in WIC clients was 82%. Additionally, with the support of the IBCLC, both county hospitals have now committed to pursuing breastfeeding-friendly policies, with one committed to pursuing Baby-Friendly designation, and both have prohibited the distribution of formula samples to newly delivered parents in their facilities. The IBCLC has also conducted trainings for hospital delivery teams, maternal services program staff, FDOH-Citrus staff, local daycares on breastfeeding-friendly policies and practices, and more. 

Many factors contributed to the success of this practice. FDOH-Citrus leadership have been primary drivers and supporters of this work. The local hospitals supported FDOH-Citrus efforts to provide county wide lactation support regardless of a mother's participation in a maternal program or which hospital they delivered in. 

The long-term impact of this practice will not be seen for many years but we anticipate an improvement in maternal and infant health from promotion of breastfeeding. While primarily providing breastfeeding support and resources, the IBCLC also provides safe sleep information, through facilitation of the Baby Box program which offers a safe sleep space and education to all Citrus County families. We anticipate that this blended approach will reduce infant mortality rates by addressing one of the biggest risk factors for infant deaths in the county. Citrus County has also seen greater levels of community partnership on this issue because of the practice. FDOH-Citrus and the hospitals are working closely together on this and other health issues facing county residents. Community support for this work has also increased and was fully demonstrated by the Board of County Commissioners proclaiming August as Breastfeeding Support Month.

Increasing breastfeeding rates a goal of Healthy People 2020 with healthier babies and women leading to a healthier community. A common practice to increase breastfeeding rates is to have specialized lactation support, like IBCLC's, hired in local hospitals or within a local WIC program. This practice can limit the availability of this specialized support to patients of a particular hospital or program. Due to Citrus County's smaller size, the local hospitals and WIC program did not have enough need to justify the cost of having their own IBCLC available for their patients. To extend the reach of specialized breastfeeding support to all mothers in Citrus County, it was determined that FDOH-Citrus was best positioned to host the position with partnership from the two local hospitals and financial support from the WIC program allowing the IBCLC to work across agencies and programs. The IBCLC is available to all 1100 delivered parents each year; at the bedside after birth, WIC clients, and Baby Box program. Through this practice, specialized breastfeeding support is now available to all Citrus County parents without restriction. 

The IBCLC's unique position within FDOH-Citrus also allowed for program incorporation like Baby Boxes, maternal mental health and Substance Exposed Newborns (SEN). The IBCLC's position and networking is able to address barriers or reasons they think they can't breastfeed. Families that picks up a Baby Box have access to the IBCLC and targeted information on making breastfeeding work for them. Families get this information normally in the third trimester and are informed of the breastfeeding help available at the bedside and in the community.

With the breastfeeding and infant care education the IBCLC is able to address and give resources on maternal mental health, something that is not widely understood in the community. Maternal mental health was available to only small pockets of the community but with the IBCLC's education the community is beginning to understand that the lack of support for maternal mental health is a barrier to breastfeeding. Engaging the community on how maternal mental health effect the family has led to greater support of finding services and reducing stigma. 

A Citrus County SEN Taskforce has developed to address issues that affect maternal and child health. This Taskforce was developed with local counties to pull resources and education. The IBCLC has been able to education members of all Taskforces on how breastfeeding is an important part of care for SEN babies and their mothers. 

IBCLC's have been in practice for over 30 years but due to funding sources and program restrictions rarely do they cross boundaries or bridge the gap in maternal and child health. With the FDOH-Citrus leadership understanding the importance to breastfeeding being accessible to women and families on many levels and programs has led to new ways of working towards greater breastfeeding support.


The goal of this project was to have an IBCLC to offer clinical expertise to mothers, hospital staff, WIC and the community to increase breastfeeding initiation and duration is the goal of the project. A position was created to provide county wide breastfeeding education and support at the level of an IBCLC. This program is intended for all members of the community with targeted lactation specific support for families expecting babies and with young infants. The program was also directed towards both local hospitals, their nursing staff and the community at large.

Within the first month of hire the IBCLC was visiting hospitals and their staff to work towards bedside patient support for comprehensive lactation services. During the first several months the IBCLC was working with the local Breastfeeding Taskforce and engaged in community meetings throughout the county. The IBCLC was able to develop and distribute county specific breastfeeding and infant care educational materials including an Infant Feeding Resource guide, within the first 3 months of hire. This guide contains all local non-profit resources for breastfeeding support as well as easy to use on-line videos and websites. Within the first year the IBCLC was able to get both hospitals to begin the process for Baby Steps to Baby Friendly, a task that previously neither hospital was willing to address. 

In the second year, the IBCLC continued the existing projects but was able to focus on breastfeeding normalization. Citrus County has a small minority population but efforts are made to have more breastfeeding educational material targeted for minorities. The local Tampa Bay Breastfeeding Taskforce has life-size breastfeeding cutouts that they loan out for display that depict a diverse population of breastfeeding mothers. FDOH-Citrus consistently hosts cutouts with Women of Color and fathers supporting them breastfeeding. The IBCLC continued to build community partnerships and utilized them to address drug use during pregnancy. With the IBCLC's program substance use has been addressed and a Citrus SEN Taskforce has developed. 

With the support of leadership in FDOH-Citrus during Breastfeeding Support Month 2018 all divisions of the FDOH-Citrus had a door decorating contest with the winning door design becoming an vehicle wrap. The winning door theme was "Babies Bloom When Breastfed." In November of 2018 FDOH-Citrus was able to promote their new Babies Bloom When Breastfed "mobile breastfeeding billboard" featuring a breastfeeding baby, the Infant Feeding Line and Benefit of Breastfeeding. 

Startup cost included the cost of salary for the IBCLC, computer and technical supplies totaling approximately $55,000. Additional cost like education materials and supplies were as needed and part of community education. Community stakeholders, volunteers and agencies meet on a regular basis with the IBCLC and program management to address barriers for standard breastfeeding education and support in the county. During these meetings policy development and standardization is addressed. A letter to introduce the IBCLC to providers were distributed. IBCLC sought out and met with OB and pediatric providers to inform them of the services available. The local newspaper had several stories about breastfeeding, including the IBCLC, and the support available. 

The community is excited to have an IBCLC available to their programs and the families they support, some of the programs include; Early Head Start, Healthy Start, Healthy Families, Early Learning Coalition, local women's shelter, and La Leche League.

The community worked together to identify and promote breastfeeding as an important protective factor against infant deaths, creating more community awareness of the need for breastfeeding support and resources for local mothers. At the beginning of this initiative Citrus County had zero hospitals working for breastfeeding friendly practices. In the first year of the IBCLC working towards breastfeeding supportive community both hospitals had signed contracts for Baby Steps to Baby Friendly. Shortly after that both hospitals received their first Star for the Florida Breastfeeding Coalition Quest for Quality Maternity Care Award. 

State and WIC data was used to track breastfeeding rates. State rates come out annually and track initiation, they have not been updated for 2018.

Florida WIC breastfeeding rates come out quarterly and have seen a substantial breastfeeding initiation increase. Citrus County WIC breastfeeding initiation the first quarter after the IBCLC started were from March 2017 at 74.5%. The current data from September 2018 show breastfeeding initiation at 81.6%. Additionally, the smaller population of Hispanic and Black demographics also increased. Florida WIC began breaking down breastfeeding rates by demographic at the end of June 2017. Citrus County Hispanic breastfeeding initiation rate was one of the lowest in the state at 78% at the end of June 2017. The most recent quarter from the end of September 2018 shows Hispanic breastfeeding rates at 85%. Citrus County already had a high Black breastfeeding initiation rate at 80% at the end of June 2017 but with efforts to increase breastfeeding across all demographics the Black initiation rate for the end of September 2018 was 90% in Citrus County. 

Since the IBCLC has started, there have been over 1,200 client contacts and hundreds of community meetings. 

FDOH-Citrus leadership is committed to the breastfeeding support in Citrus County. The IBCLC position was provisional when first created. Due to the positive impact of the IBCLC in the community that position was made permanent part of the FDOH-Citrus budget. WIC currently provides 10% of the IBCLC's salary and FDOH-Citrus provides the rest. FDOH-Citrus has the goal of getting the county hospitals to provide a portion of the IBCLC's salary to help sustain the position long term. 

At a NACCHO conference