ASPPH logo


Member Research & Reports

Member Research & Reports

South Florida: Childcare Centers Lack ‘Breastfeeding Friendliness’

Health professionals can agree, breastmilk is magical.

Its numerous benefits — protecting against ear infections, lowering risk of diabetes, decreasing childhood obesity, improving the health of the mother postpartum, the list goes on —are all backed by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP).

The U.S. Surgeon General’s Call to Action to Support Breastfeeding identified childcare providers as “essential in supporting mothers” to continue breastfeeding after returning to work and urged states to adopt national standards.

Yet, when mothers return to work and place their baby in childcare, they face barriers to continue breastfeeding, according to University of South Florida College of Public Health’s Dr. Stephanie Marhefka, associate professor of community and family health.

In “’Why do we need a policy?’ Administrators’ perceptions on breastfeeding-friendly childcare,” published in Public Health Nutrition, she explored Florida-based childcare center administrators’ perceptions on breastfeeding and their perceptions of the barriers to implement programs that encourage mothers to continue.

Dr. Marhefka and her team spoke with 28 childcare administrators of licensed child care centers across Hillsborough and Pinellas counties about the Florida Breastfeeding Friendly Childcare Initiative (FL-BFCCI) — a program established by the Florida Department of Health Office of the Child Care Food Program in 2012 to support Florida’s breastfeeding law.

To become designated breastfeeding friendly, centers must complete a self-assessment consisting of six yes or no statements and submit a copy of their center’s breastfeeding policy. Requirements include things such as feeding infants on cue and having a staff trained on preparation and storage of breast milk.

“Basically, the center has to be an environment that welcomes breastfeeding,” Dr. Marhefka said. “They must provide a quiet, comfortable place that mothers can feed their babies or express breastmilk and they have to have written materials and a policy that reinforces the idea that breastfeeding is welcome.”

There are currently 284 centers out of 6,798 child care centers in Florida with this designation.

However, Dr. Marhefka found that of those centers they interviewed, none carried the special designation.

She found that administrators were unaware of the FL-BFCCI and did not perceive the need for their centers to pursue the designation.

Only six centers thought designation should be their highest priority, despite 23 of the centers indicating that implementing the BFCCI requirements would be manageable.

“One of the things we found was that they didn’t think this would be a big priority of their centers,” she said.

Administrators often said their centers were already breastfeeding friendly, yet did not fully understand the reasons for the FL-BFCCI or what it means to be breastfeeding friendly, according to Dr. Marhefka.

“Some even said they ‘already do all this,’ but then also said moms can just ‘turn and face the wall,’ [to breastfeed],” she said. “There seems to be some attempts to try to accommodate this idea of being breastfeeding friendly, but not really understanding the spirit of what being breastfeeding friendly really is — to create a space where not only is breastfeeding welcome, but its considered completely normal. That sense of normalcy was really missing from the narratives from these administrators.”

Its these perceptions of acceptance versus the ideal level of acceptance — and the stigma surrounding breastfeeding — that can impede a mother’s ability to continue breastfeeding her child successfully once the baby enters childcare, Dr. Marhefka said.

“I really believe that childcare workers have the potential to be public health liaisons to help moms who are trying to breastfeed to be successful in these environments or they could discourage moms from doing it, so if we could use policy and regulation as technical assistance and other support, I think we can get to the place where these childcare workers are infant feeding champions,” she said.

Dr. Marhefka also said the goal is not to create more stigma toward mothers who are formula feeding either.

“We’re trying to create a situation where everyone can feel the benefits of both,” she said.

While programs like the FL-BFCCI and an optional designation are a good first step, Dr. Marhefka said, we are in a need of a cultural shift.

“We need our licensing and regulation to not only require that these environments are breastfeeding friendly, but also some kind of quality assurance that they really are environments where breastfeeding is accepted as normal, healthy behavior,” she said.

Dr. Marhefka, who’s passion for researching this topic stemmed from the discrimination she faced as a breastfeeding mother with children in childcare, said she plans to speak with parents next.

“I was committed to breastfeeding for a year for my children,” she said. “That’s not the case for many moms and if you don’t have the conviction, you might just give up.”


Marhefka, S. L., Sharma, V., Schafer, E. J., Turner, D., Falope, O., Louis-Jacques, A., Wachira, M. M., Livingston, T., Roig-Romero, R.M. (2018). ‘Why do we need a policy?’ Administrators’ perceptions on breast-feeding-friendly childcare. Public Health Nutrition, 1-11. doi:10.1017/S1368980018002914


Story by Anna Mayor, USF College of Public Health