BIRTH AND BEYOND CALIFORNIA: BIRTH AND BEYOND CALIFORNIA: Using Quality Improvement to Increase Hospital Breastfeeding Initiation RatesUsing Quality Improvement to Increase Hospital Breastfeeding Initiation Rates

Karen Ramstrom, DO, MSPH; Suzanne Haydu, MPH, RD; Leona Shields, PHN, MN, NP; Carina Saraiva, MPH; Jeanette Panchula, BSW, RN, PHN, IBCLC ; Michael P. Curtis, PhD; Sangi Rajbhandari, MPH

California Department of Public Health; Maternal, Child & Adolescent Health Program

• Breastmilk is the appropriate nutrition for human infants.

• Evidence clearly shows babies are healthier.1

• Mothers are also healthier when their bodies complete the reproductive cycle by breastfeeding.

Implementation of Model Hospital Breastfeeding Policy Recommendations7

Policy Improvement

at 6 Month

Follow-up†

(n=20 Hospitals)

1 Hospital promotes and supports breastfeeding 14

2 Nurses, certified nurse midwives, physicians and other health professionals with expertise regarding the benefits and management of breastfeeding educate pregnant and postpartum women when the opportunity for education exists

15

3 The hospital encourages medical staff to perform a thorough breast exam on all pregnant women (and breastfeeding mothers) and to provide anticipatory guidance for conditions that could affect breastfeeding.

9

4 Hospital perinatal staff support the mother’s choice to breastfeed and encourage exclusive breastfeeding for the first 6 months

14

5 Nurses, certified nurse midwives, and physicians encourage new mothers to hold their newborns skin to skin during the first two hours following birth and as much as possible thereafter, unless contraindicated

12

6 Mothers and their infants are assessed for effective breastfeeding and mothers are offered instruction in breastfeeding 12

7 Artificial nipples and pacifiers are discouraged for healthy breastfeeding infants 9

8 Sterile water, glucose water, and artificial milk are not given to a breastfeeding infant without the mother’s informed consent and/or physician’s specific order

10

9 Mothers and infants are encouraged to remain together during the hospital stay 10

10 At discharge, mothers are given information regarding community resources for breastfeeding support 11

Benefits of BreastfeedingBenefits of Breastfeeding

Location Matters: Regions with the Lowest Exclusive Breastfeeding Rates TargetedLocation Matters: Regions with the Lowest Exclusive Breastfeeding Rates Targeted

1 Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153 AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality. April 2007. Available at: www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf

2 California Department of Public Health, Genetic Disease Screening Program, Newborn Screening Data, 1994-20073 California Department of Public Health, Genetic Disease Screening Program, Newborn Screening Data, 20064 State of California, Department of Public Health, Birth Records. Live Births, California Counties, 2005 (Table 2-18). Available at:

http://www.cdph.ca.gov/data/statistics/Documents/VSC-2005-0218.pdf 5 Centers for Disease Control and Prevention. Breastfeeding-Related Maternity Practices at Hospitals and Birth Centers – United States, 2007. MMWR 2008; 57:621-625.6 WHO/UNICEF Baby Friendly Hospital Initiative in the U.S. http://www.babyfriendlyusa.org 7 Inland Empire Breastfeeding Coalition and Inland Counties Regional Perinatal Program(2005). Providing Breastfeeding Support: Model Hospital Policy Recommendations (3rd ed.). California Department Public Health, Maternal,

Child and Adolescent Health Division. Available at: cdph.ca.gov/BreastFeeding

ReferencesReferences

PURPOSE: To Implement Evidence-based Maternity Care Policies that Support Breastfeeding.PURPOSE: To Implement Evidence-based Maternity Care Policies that Support Breastfeeding.

Success StoriesSuccess Stories

Conclusion and Health ImplicationsConclusion and Health Implications

• Statewide surveillance data can be utilized as a tool to increase hospital administrator awareness and interest in promoting breastfeeding and to target areas of greatest need.

• Local, regional and state collaboration can empower low-performing hospitals to address maternity care policies and practices that support breastfeeding

• Materials developed for this project utilizing Federal Title V Block Grant funds will be available on our web-site for use by others.

Visit the Birth and Beyond California Project web-site at:

http://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Pages/ BirthandBeyondCaliforniaDescription.aspx

The first national Maternity Practices in Infant Nutrition and Care (mPINC) Survey confirmed that birthing facilities across the U.S. have maternity practices that are not supportive of breastfeeding.5

Hospital Breastfeeding Policies Matter Hospital Breastfeeding Policies Matter

A new mother’s ability to successfully breastfeed her Infant can be affected by the implementation of policies and practices at the hospital in which she delivers.Common barriers to breastfeeding initiation include:

• Lack of policies that support and promote breastfeeding

• Staff turnover and lack of staff training on supporting new mothers to initiate breastfeeding

• Physical separation of the mother-infant pair

• Routine use of pacifiers, water and formula

AcknowledgementsAcknowledgements

MCAH acknowledges Regional Perinatal Programs of California (RPPC) in Regions 5, 6, and 8, the staff of the Birth and Beyond California and Breastfeeding Task Force of Greater Los Angeles, for their on-going dedication to this project.

PRELIMINARY RESULTSPRELIMINARY RESULTS

• As of December 2009, 369 hospital staff from 20 participating hospitals completed the training with an overall increase in knowledge attained.

- 87 hospital staff trained to become future trainers

• All participating hospitals developed quality improvement teams.

- Currently, all hospitals are implementing one or more evidence-based breastfeeding policies

• Hospitals participated in monthly Regional Network Meetings

- Cooperatively addressed barriers and shared successes

† Policy improvement, as reported by PACLAC, of 20 participating hospitals, based on comparison between initial and 6 month follow-up of Model Hospital Breastfeeding Policies Self-Appraisal Questionnaire.

From 1994 to 2006, the percent of women choosing to initiate breastfeeding in the hospital rose from 76.5% to 86.6%, while those exclusively breastfeeding (infant fed only breastmilk, no other foods or fluids) during the short time they were in the hospital remained stagnant at approximately 43%.2

The percentage of newborns exclusively breastfed were lowest in Regional Perinatal Programs of California (RPPC) Regions 6 (26.5%), 8 (30.2%) and 5 (33.1%) (Figure 2).3

* This project is modeled after the Baby Friendly Hospital Initiative6 and Loma Linda’s Perinatal Services Network’s Birth and Beyond Project. Model Hospital Policy Recommendations7 can be used to assist hospital staff and quality assurance teams in revising policies that affect the breastfeeding mother. The policies recommended are considered to be best practices.

Birth and Beyond California Project* OverviewBirth and Beyond California Project* Overview

Figure 2. RPPC Regions targeted for the Birth and Beyond California Pilot Project

INYO

KERN

SAN BERNARDINO

FRESNO

RIVERSIDE

SISKIYOU

TULARE

LASSEN

MODOC

MONO

SHASTA

IMPERIAL

TRINITY

SAN DIEGO

TEHAMA

HUMBOLDT

PLUMAS

MONTEREY

LOS ANGELES

MENDOCINO

MADERA

BUTTE

LAKE

MERCED

KINGS

TUOLUMNE

SAN LUIS OBISPO

VENTURA

GLENN

PLACER

SONOMAYOLO

SANTA BARBARA

EL DORADO

NAPA

MARIPOSA

COLUSA

SIERRA

STANISLAUS

NEVADA

YUBA

ALPINE

SOLANO

ORANGE

ALAMEDA

SAN BENITO

SAN JOAQUIN

SANTA CLARA

DEL NORTE

CALAVERASMARIN

SUTTER

SACRAMENTO AMADOR

CONTRA COSTA

SAN MATEO

SANTA CRUZ

SAN FRANCISCO

RPPC Region 5 *

RPPC Region 6 *

RPPC Region 8 *

These three RPPC Regions account for half of all California births.4

Exclusive Breastfeeding (%)

56.0 - 73.7

41.9 - 55.9

33.2 - 41.8

26.5 - 33.1

A labor and delivery nurse of 32 years who believed she didn’t need the class sat the first day with her arms crossed. The next week, after practicing skin-to-skin, she described how amazed and relieved she was because she did not have to get the baby to the breast, but instead the babies figured out what to do.

The 12 RPPC are designed to assist the State Maternal Child and Adolescent Health Program to assure the well-being of pregnant women and their babies and to promote access to appropriate levels of high quality care. They foster linkages between perinatal service provides, provide birthing hospitals performance feedback and assist providers and facilities to partner on quality improvement activities.

Recovery Room Nurse

One nurse participating in the BBC training reported that she had assisted with 6 c-sections in one day and assisted all 6 babies in self-attaching after skin-to-skin. She was emotional as she described one mom in particular who had not been able to breastfeed her first baby and had tears of joy as her newborn latched on and breastfed.

L & D nurse of 32 years

A newborn took a long time, 45 minutes, but did the whole crawl, thrusting and using his hands and making eye contact with his mom and finally latched on. The mother, who had been withdrawn and not talking, opened up at that moment to express her relief and to talk about her concerns because her baby had been born with a slight clubbed foot. She had been afraid he might have also have trouble breastfeeding. Mother of a baby with

a club foot

• Obtain administrative buy-in and support

• Create a multidisciplinary QI teamfocusing on maternity issues

• Initiate a hospital-led regional network tosupport policy change

• Develop, revise and monitor breastfeedingpolicies and practices

• Train staff on skin-to-skin, bonding,attachment and breastfeeding safely

• Sustain ongoing training by developingstaff educators within each hospital

• Validate nurse professionalism to supportpatient confidence/competence

• Promote systems change: families needprivacy and time together

• Identify methods for effectivelycollaborating with hospitals

What We Who We Do Reach

What WeInvest

Conduct HospitalAdministratorTrainings

Provide technicalassistance toQualityImprovement/Assurance (QI/QA)Teams

Conduct HospitalStaff Trainings

Conduct Train-the-Trainer Workshops

Organize andFacilitate HospitalBreastfeedingNetwork QualityImprovement GroupMeetings

HospitalAdministrators

QI/QA TeamMembers

Hospital Staff

Hospital Birth& Beyond CAChampions/Trainers

Mothers, Infantsand theirFamilies

Steps to Success

Title V MCAH BlockGrant Funding

Maternal, Child andAdolescent HealthProgram Staff

Regional PerinatalPrograms ofCalifornia staff

StandardizedTraining Curriculumand Trainers

ProgramImplementation andEvaluation Toolkit

*Model HospitalPolicies6,7

An obstetrician with many years experience missed the delivery and arrived 15 minutes after the baby had been placed skin-to-skin. Nursing staff explained skin-to-skin to the doctor who said, “Okay,” and sat back and watched. The baby self-attached and he said that this was the first time in all his years of delivering babies that he had ever seen a baby self-attach. His comment to the nurse was, “Sometimes we (medical staff) interfere too much.”

Physician