How the Ten Steps to a Breastfeeding Family Friendly Community Are Transforming Durham’s Birth Outcomes

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A note on the numbers (September 2026): Durham County reported a 62.3 percent reduction in infant mortality over eight years. 2024 was an exceptional year and the rate will settle differently over time, but it is a moment worth celebrating, and human milk feeding is one strand of the County’s coordinated investment behind it.

Durham’s birth outcomes have improved over the same eight years the community has spent building a coordinated, countywide system to support human milk feeding and maternal health. We cannot say how much of that change the system produced. We can say what the community built, and that it was in place while the numbers moved.

The Ten Steps to a Breastfeeding Family Friendly Community form the backbone of that work. This framework, created by the Carolina Global Breastfeeding Institute and adapted locally, guides communities in building environments where breastfeeding, chestfeeding, and human milk feeding are fully supported.

This is systems change. Durham is where we are finding out whether it works.

1. Leadership & Accountability (Step 1)

Durham is one of the few North Carolina communities with:

  • A public human milk feeding strategic plan
  • Multiple proclamations affirming breastfeeding support
  • A cross-sector leadership structure involving the Health Department, BFFC, NCBC, doulas, IBCLCs, and grassroots parent leaders

These commitments create durable policy direction and stability across political and budget cycles.

2. A Welcoming Public Environment (Step 2)

More than 250 “Breastfeeding Welcome Here” signs and clings signal community-wide acceptance.
Signage reduces stigma and tells parents they can nurse anywhere without fear, a small but real protection against early weaning.

3. Health System Leadership (Step 3)

Durham partners directly with:

  • Primary care providers
  • WIC
  • Birth center and midwifery groups

This alignment ensures consistent, evidence-based guidance. Providers understand where to send families for support, and community resources reinforce the recommendations families receive in clinic.

4. High-Quality Prenatal Education (Step 4)

Prenatal education efforts reach thousands of families annually through:

  • Community events
  • Walking groups and baby cafés
  • CBO outreach
  • CHWs, doulas, and peer counselors

These touchpoints are designed to build early lactation confidence and reduce medically unnecessary formula supplementation.

5. Skilled Lactation Support (Step 5)

Durham has a disproportionately high number of:

  • IBCLCs
  • Peer supporters
  • Bilingual lactation providers
  • Free or low-cost lactation clinics
  • Culturally grounded community groups like Lactancia Latina

A strong lactation workforce catches feeding problems early, before they escalate into hospitalization or maternal stress.

6. Annual Gaps-in-Care Assessment (Step 6)

This step, unique to Durham, is how the system keeps improving.
Each year the coalition reviews:

  • Where families fall through the cracks
  • Where providers need help
  • Where disparities persist
  • Which systems require new investment

This continuous improvement approach is rare in public health. In Durham it is routine.

7. Workplace Support (Step 7)

Dozens of Durham businesses are now breastfeeding-friendly and equipped with policies, signage, and spaces.
Workplace support helps parents maintain milk supply during a critical period and prevents early cessation.

8. Childcare Center Engagement (Step 8)

More than 80 childcare centers have received training or materials through Breastfeed Durham.
This ensures:

  • Proper milk handling
  • Infant feeding cues
  • Safe pace-feeding
  • A supportive environment for working parents

Childcare is often where breastfeeding ends. In Durham, childcare providers are equipped to protect it.

9. Community Support Systems (Step 9)

Durham’s community network includes:

  • Doulas
  • CHWs
  • Peer counselors
  • Parent groups
  • Milk sharing networks
  • Walking groups
  • Emergency-prepared infant feeding kits

This broad web of support reduces isolation and fills gaps outside clinic walls.

10. Emergency Preparedness for Infant Feeding (Step 10)

Durham is one of the only communities in the country equipped with:

  • SAFE Team partnerships
  • Infant feeding sanitation kits
  • CHW/doula protocols
  • Hospital collaboration during disasters

During Hurricane Helene, this kind of preparation is what held in Western North Carolina.
The Ten Steps are not just about breastfeeding. They are about protecting infants when systems fail.

Why This Matters

The Ten Steps are built to move the outcomes that matter most:

  • Preterm birth
  • Infant mortality
  • Chronic disease prevention
  • Maternal mental health
  • Health system utilization
  • Equity and resilience

Between 2019 and 2024, Durham County’s infant mortality rate fell from 7.7 to 2.9 deaths per 1,000 live births. That is a single county with small numbers. 2019 was the worst year in the series and 2024 an exceptional one, and the rate will settle differently over time. We do not claim the Ten Steps caused that change. We claim that the community built the system that was in place while it happened, and that the pattern deserves the independent evaluation now getting under way. The full numbers, with their limits, are in Celebrating Durham.

Durham is showing the rest of North Carolina what it looks like when a community invests in coordinated, structural maternal and infant health.

This is what public health looks like when it works.