using data to drive change - california wic...

Using Data to Drive Change:California Continues to Increase In-hospital

Exclusive Breastfeeding Rates

Breastfeeding promotion is a vital part of California’s charge to improve short and long-term maternal and child health. For more than a decade, policy-makers and advocates have used publicly reported data to guide, evaluate,

and monitor work to improve breastfeeding rates in our large and diverse state. Together, local and statewide education, interventions, and support efforts have steadily increased in-hospital exclusive breastfeeding rates, bringing the benefits of exclusive breastfeeding to nearly 300,000 California families. To maintain our current momentum, consistent and comparable data on breastfeeding exclusivity and duration are needed to build on the successes achieved in California hospitals and drive change in medical, workplace, and childcare environments.

October 2016

A Policy Update on California Breastfeeding and Hospital PerformanceProduced by the California WIC Association and the UC Davis Human Lactation Center

A Pol icy Update on Cal i fornia Breastfeeding and Hospital Performance 2

Using Data to Set National Goals and Priorities for Action

Decades of research studies confirm that

breast milk provides all the nutrients and other factors that a newborn needs to grow, develop, and build a strong immune system.1-8

Breastfeeding exclusively – that is, breast milk is the baby’s only food – for the

first six months of life, is particularly effective in reducing unnecessary health care expenditures.8 Breastfeeding significantly reduces children’s risk for infections and chronic diseases such as diabetes, asthma, and obesity.1,9

Breastfeeding also reduces mothers’ risk for type 2 diabetes and breast and ovarian cancers.9,10 Breastfed children require fewer visits to the doctor and take fewer medications than children who are formula fed.8 Recently, it was estimated that $3.0 billion (in 2014 dollars) in medical costs would be saved if all U.S. infants were fed according to the current pediatric guidelines.10

In recognition of the opportunity to improve the health of millions of Americans, the Healthy People 2020 framework includes targets for breastfeeding initiation, duration, and exclusivity as well as objectives in supporting areas.11 According to data collected by the National Immunization Survey (NIS) 2014-2015,12 (Figure 1) California has achieved the 2020 benchmarks for breastfeeding initiation, breastfeeding at 12 months, and exclusive breastfeeding at 3 months. California is within 2% of the goal for breastfeeding rates at 6 months.13 However, these benchmarks are interim goals, not endpoints, which will be reset to direct national efforts through the next decade.

Data show that exclusive breastfeeding during the hospital stay is one of the most important influences on how long babies are breastfed exclusively after discharge.14-19 Mothers can be prevented from achieving their infant-feeding goals by hospital practices such as separating mothers from their babies, delaying the first feeding, and routinely providing formula supplementation, even for infants whose mothers intend to breastfeed exclusively.14-16 The Centers for Disease Control and Prevention (CDC) has used data to set national goals to improve mothers’ access to optimal outcomes by tracking the proportion of babies born in facilities with supportive policies and the proportion of healthy babies receiving formula supplementation in the first 2 days. California already has exceeded the benchmark for the proportion of babies born in breastfeeding supportive facilities and is within 1% meeting the goal for reduced supplementation rates.13

Figure 1: Centers for Disease Control and Prevention: Data Sources

When: Every year

Sample & Contact Method: National random dial survey of more than 25,000 households with children 19 to 35 months

Reporting: State and national level

Related measures: Breastfeeding initiation, exclusivity, duration

URL: http://www.cdc.gov/breastfeeding/data/nis_data/index.htm

National Immunization Survey (NIS)12 Maternity Practices in Infant Nutrition and Care Survey (mPINC)23

When: Every 2 years

Sample & Contact Method: Survey sent to every hospital in the US. Key informant asked to fill out and return

Reporting: State and national level

Related measures: Hospital policies and practices, early supplementation

URL: http://www.cdc.gov/breastfeeding/data/mpinc/maternity-care-practices.htm

The way we work in public health is,

we make the best recommendations

and decisions based on the best

available data.

-Tom Frieden

OVERALL 69 83

LABOR AND DELIVER CARE 63 86

FEEDING OF BREASTFED INFANTS 77 86

BREASTFEEDING ASSISTANCE 82 92

CONTACT BETWEEN MOTHER AND INFANT 78 90

FACILITY DISCHARGE CARE 49 71

STAFF TRAINING 61 72

STRUCTURAL AND ORGANIZATIONAL 70 84

Dimension of Care 2007 2013 Score Score

3A Pol icy Update on Cal i fornia Breastfeeding and Hospital Performance

Using Data to Drive and Monitor Improvements in California Hospital Policies

Researchers have demonstrated that the policies promoted by the Baby-Friendly Hospital Initiative

(BFHI)20 are associated with increases in breastfeeding initiation, duration, and exclusivity.15 Nearly all of the studies indicate that well-monitored implementation of BFHI policies results in increased breastfeeding rates during and beyond the hospital stay.15,16 The number of Baby-Friendly hospitals in California has increased dramatically,21 from only 12 in 2006 to more than 80 in 2016, and the proportion of babies born in these hospitals has more than tripled since 2010.13 Still, efforts are continuing throughout the state to promote and support hospitals moving forward to improve their policies. By 2025, all California hospitals are required by law to have the Baby-Friendly designation, or adopt similar comprehensive policies that support breastfeeding families.22

Improvements in hospital policies have been reflected in increasing scores on the CDC Maternity Practices in Infant Nutrition and Care (mPINC) Survey (Figure 1).23 CDC epidemiologists collect data through the mPINC survey to monitor outcomes from national efforts to improve perinatal care. Between 2007 and 2013 (the most recent published report), the California composite score rose from 69 (ranking 11th in the US) to 85 (ranking 7th in the US).23 Data from the mPINC survey are also used by CDC to track changes in specific policies and practices. While improvements occurred within all dimensions of

care assessed by the mPINC survey (Figure 2), data from California show the biggest improvements occurred in labor and delivery care, the removal of discharge packs containing formula samples, new staff training, and the development and dissemination of evidence-based policies. Areas needing improvement also were identified for California hospitals; less than 25% reported that they supplemented breastfed infants only rarely or allowed infants to remain in the room with their mothers for assessments and procedures.23

Using 2013 data, the California Department of Public Health Maternal Child and Adolescent Health Division (MCAH) has created and posted mPINC reports for counties with at least 5 maternity facilities and each of the Regional Perinatal Programs of California (RPPC) regions.24

The county reports demonstrate that local efforts have paid off, with county scores in Riverside, Sacramento, San Bernardino, San Diego and San Joaquin Counties exceeding the statewide average. Regionally, the highest scores are found in the following RPPC regions: Kaiser Permanente-Southern-California, Kaiser Permanente-Northern-California, and the Mid-Coastal region.24

Figure 2: mPINC Dimensions of Care Scores in California, 2007 and 201323

Source: CDC Survey of Maternity Practices in Infant Nutrition and Care (mPINC) State Reports. http://www.cdc.gov/breastfeeding/data/mpinc/state_reports.html

What gets measured, gets managed.

-Peter Drucker


Using Surveillance Data to Identify Breastfeeding Disparities in California Hospitals

Public health agencies rely on surveillance data to plan, prioritize, and evaluate their work. Surveillance

data differ from experimental data and from one-time surveys. Surveillance data, rather than local surveys, are used when health officials want to track important health indicators. Health surveillance data are collected over time, using standardized methods, and at specific intervals. Because these data typically are collected by many people, variations in data collection timing and approach are anticipated and accepted because the data are used in broad ways to look at statewide trends, rather than individual behaviors. The data collected by the California Newborn Screening Program (NBS)25 include breastfeeding surveillance data that help policy makers monitor how breastfeeding rates change over many years and within different target groups in a state with nearly 250 maternity hospitals (Figure 3).

In 2015, nearly 94% of California babies began life breastfeeding, yet about 27% of those babies were given formula before they were discharged from the hospital, typically 24 to 48 hours after birth.25 Although it is expected that some infants in each hospital will have medical conditions that require supplementation with formula, in 17 California hospitals, more than 50% of breastfed infants are given supplements during the short hospital stay. In other hospitals, supplementation rates among healthy breastfed infants are quite low.25

While disparities remain, changes in hospital policies and practices have resulted in increased exclusive breastfeeding rates among all California women. From 2010 to 2015, exclusive in-hospital breastfeeding rates among all California women rose by 12% (representing over 50,000 mothers). The highest increases occurred among Hispanic (15.1%) and African-American (11.8%) mothers.25

Differences in breastfeeding rates have persisted in

different parts of the state, with the highest exclusive breastfeeding rates found among hospitals in the northern part of the state, particularly in mountain and coastal communities. The lowest exclusive breastfeeding rates occur in the Central Valley and in southern California. However, ongoing efforts have resulted in dramatic increases in counties with historic low rates (Figure 4).

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Imperial Kern Los Angeles San Joaquin

2010

2015Our ability to do great things with data will make a real difference in every

aspect of our lives. -Jennifer Pahlka

California in-hospital breastfeeding rates are monitored using data collected by the Newborn Screening (NBS) Program. All non-military hospitals providing maternity services are required to complete the NBS Test Form.

Data are collected at the time of NBS specimen collection, usually 24 to 48 hours since birth. Staff must select from 3 categories to describe all infant feeding since birth: 1) only human milk, 2) only formula, and 3) human milk and formula.

MCAH Epidemiologists analyze these data and publish breastfeeding rates by hospital, county and the state every year. Data for 2010 through 2015 should not be compared to data published in prior years due to revisions to the test form as well as changes in the data analysis methodology during this time period. Counties and facilities with fewer than 50 births with known type of feeding are not included in the annual reports.

The numerator for "Exclusive Breastfeeding" includes records marked 'Only Human Milk'. The denominator excludes cases with unknown method of feeding and those receiving TPN at time of specimen collection. Infants in the NICU at the time of the test are not included in the calculation.

Figure 3: California Newborn Screening Breastfeeding Surveillance Data25

Figure 4: Increases in Exclusive Breast-feeding (2010-2015) in Select Central Valley and Southern California Counties

Source: California Department of Public Health Genetic Disease Screening Program, Newborn Screening Data, 2010 & 2015.

National Data California/Programmatic Data

National Immunization Survey12 Infant Feeding Practices II (and follow-up)29 National Health and Nutrition Survey (NHANES)30 Joint Commission - National Quality Measures - Perinatal Core Measures31

Early Head Start32 WIC Infant and Toddler Feeding Practices Survey 233

CDPH WIC Division26 Maternal Infant Health Assessment28 California Perinatal Quality Care Collaborative34 CDPH Genetic Disease Branch – Newborn Screening Program25 Comprehensive Perinatal Services Program35

Black Infant Health (BIH)36


Increased Breastfeeding Rates Beyond the Hospital Stay: California WIC

Once mothers leave the hospital, both data collection and access to breastfeeding support vary widely.

Figure 5 lists 12 examples of surveys and organizations that collect infant feeding data, nationally or only in California. Because of differences in the way questions about infant feeding are asked, the timing of those questions, and the populations chosen, it is not possible to meaningfully compare the outcomes obtained by one source to another. As an example, according to the NIS, 88.3% of women initiated breastfeeding in California based on their telephone survey of 335 women in the state (out of nearly 15,000 women surveyed nationwide) in 2012.12 During the same year, the rate of “any breastfeeding” in California based on Newborn Screening data (including 433,828 women), was 92.2%.25 An even greater difference was seen in 2012 between data sources for the exclusive breastfeeding rates at 3 months. According to the NIS, the rate was 56%.12 The rate from

the Maternal Infant Health Assessment (based on a sample of about 7000 women) was 26.5%.28 The lack of consistent and comparable post-discharge data makes it more difficult for advocates and policy makers to identify best practices and track trends. In our large and diverse state, timely data are needed to ensure that the positive impact of changing hospital policies is not diminished by decision-makers’ lack of information about local and regional needs of new mothers returning home.

Figure 5: Examples of Breastfeeding Data Sources

Data are Needed to Build on California’s In-hospital Success

Policy improvements in California hospitals have resulted in greater numbers of women throughout

the state still breastfeeding exclusively as they leave the hospital. Accordingly, the California Department of Public Health WIC Division has expanded breastfeeding support services, outreach, and education to meet the needs of participants. While the percentage of participants who self-report that they are “fully

breastfeeding” varies widely, rates have increased 2% to 5% over the last 5 years among participants in nearly all regions.26 For many low-income women, WIC is the only source of breastfeeding support once they have left the hospital.27However, WIC cannot act alone. Greater support is needed among medical organizations and employers. Data are needed from these environments to promote and monitor institutional change.

6 A Pol icy Update on Cal i fornia Breastfeeding and Hospital Performance

Using Data to Create Collective Impact

The term “collective impact” refers to long-term commitments from institutions, advocates and

community organizations to work together toward solving complex problems.37 Strategies developed and implemented using collective impact methodology often focus on changes across sectors described in the Socio-Ecological model. Figure 6 represents how the Socio-Ecological Model may be applied to breastfeeding support. To increase breastfeeding exclusivity and duration, mothers and infants need support from providers, family, friends, workplaces, and the broader society around them.

Collective impact efforts require 5 elements:

1. A common agenda: Using the available evidence, partner organizations can clarify issues and create a shared vision for steps needed to address the issues. Example: Using local data, a regional breastfeeding coalition determines that lack of workplace support is a primary barrier to increasing breastfeeding duration and that working with major employers will create momentum for other businesses to make needed change.

2. Mutually reinforcing activities: Partner organizations create a plan for interventions, programs, and actions that will work synergistically toward solving major issues. Example: Using data from supervisors and employees in larger organizations, coalition members, health plans, and advocates develop a strategy to educate managers about breastfeeding.

3. Continuous communication: Partner organizations create schedules and systems for meaningful communication to share challenges, successes and solutions. Example: Participating organizations are assigned major employers to target for education and support. Group members meet regularly with other groups to address successes and challenges they encounter.

4. A support organization: Partner organizations identify or create a core organization with staff and resources to handle the administrative and logistical details associated with coordinating

multiple organizations and activities. Example: A non-profit coalition is formed to supply staff and services to ensure the sustainability of the collective effort.

5. Shared data: Partner organizations identify measures and standardize data collection methods to insure that comparable outcomes and process data are generated. These data are then used to understand which interventions are important contributors to group success and to monitor outcomes. Example: Employers’ policies and practices are assessed and documented in a standardized way; data related to employees’ breastfeeding duration and exclusivity are collected using common methodologies.

While collective impact describes methodologies and resources used by organizations to create synergistic impacts on many issues, the model can be applied to efforts to increase breastfeeding rates among all California women. If medical organizations, public health organizations, and insurers agreed upon measures and methodologies, breastfeeding data could be used to identify the policies and practices that increase duration and exclusivity.

Societal support, laws, and government

policies

Employer support and hospital policies and

practices

Support from professionals, friends,

and family

Mother-Baby

Figure 6: Breastfeeding Support and the Socio-Ecological Model


Action Recommendations for California Policy Makers and Advocates

Most of the nearly 250 maternity hospitals in California continue to make changes to improve breastfeeding support for the mothers and infants they serve. As a result, statewide increases in in-hospital exclusive breastfeeding rates have benefited families throughout the state, including those at greatest risk for poor health outcomes. Public health agencies and community partners must work together to ensure that staff, administrators, policy-makers, and advocates have the consistent and comparable data on breastfeeding exclusivity and duration needed to expand their work to better support breastfeeding families.

The California Department of Public Health (CDPH) must continue to make in-hospital breastfeeding rates available to the public, to continue to drive quality improvement within hospital systems and to monitor the effects of legislation requiring all hospitals to adopt policies aligned with the 10 Steps to Successful Breastfeeding by 2025.

Surveillance systems should be developed to obtain consistent and comparable data on breastfeeding duration and exclusivity throughout the infant’s first year of life. These data should be made available to the public at a local and regional level annually.

The Department of Health Care Services, Insurance and Managed Health Care should work with CDPH and state epidemiologists to identify breastfeeding data that health plans should be required to collect and report on an annual basis.

Whenever possible, data obtained from publicly funded breastfeeding-related evaluation and quality improvement projects should be disseminated to expand the use of best practices.

Electronic medical records (EMR) should track breastfeeding rates and infant-feeding data.

Relevant data from multiple sectors should be used to reduce health disparities among women and children across the state.

Resources and coordinated data systems are needed to ensure that breastfeeding support at WIC is better integrated with health systems serving low-income families.

WIC should continue to partner with other state and local agencies to assess needs and implement infant-feeding interventions for all mothers and infants.

Data should be collected to track process indicators to monitor implementation outcomes related to lacta-tion accommodation, school-based support, policy changes in pediatric environments, and breastfeeding training for child care providers.

Policy makers and advocates should use data to guide and implement collective impact initiatives to promote optimal infant-feeding practices into the first year and beyond.

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This project was supported by Kaiser Foundation Hospitals

Photograph Sources: United States Breastfeeding Coalition, R. Gonzalez-Dow, Istockphoto.com

1. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. (http://www. surgeongeneral.gov) 2. Yang I, Corwin EJ, Brennan PA, Jordan S, Murphy JR, Dunlop A. The Infant Microbiome: Implications for Infant Health and Neurocognitive Development. Nurs Res. 2016; 65(1):76-88.3. Goldman AS. The immune system in human milk and the developing infant. Breastfeeding Med 2007; 2:195-204. 4. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. American Academy of Pediatrics policy statement. Pediatrics 2005; 115:496-506. 5. World Health Organization. The global strategy for infant and young child feeding. Geneva: World Health Organization, 2003. 6. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90.7. Kelishadi R, Farajian S. The protective effects of breastfeeding on chronic non-communicable diseases in adulthood: A review of evidence. Adv Biomed Res. 2014 Jan 9;3:3. doi: 10.4103/2277-9175.124629.8. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics 2010; 125:e1048-1056. 9. Ip S, Chung M, Roman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD. Agency for Healthcare Research and Quality, 2007. Evidence Report/ Technology Assessment No. 153.10. Bartick MC, et al. Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal Child Nutr 2016 Sep 19. Doi: 10.1111/mcn.12366 (epub). 11. Office of Disease Prevention and Health Promotion. www.healthypeople.gov/2020 12. Centers for Disease Control and Prevention. National Immunization Survey. http://www.cdc.gov/vaccines/imz-managers/nis/13. Centers for Disease Control and Prevention. Breastfeeding Report Card 2016. https://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdf14. Grummer-Strawn LM, Shealy KR, Perrine CG, MacGowan C, Grossniklaus DA, Scanlon KS, Murphy PE. Maternity care practices that support breastfeeding: CDC efforts to encourage quality improvement. J Womens Health (Larchmt). 2013 Feb;22(2):107-12. 15. Bartick M, Stuebe A, Shealy KR, et al. Closing the quality gap: Promoting evidence-based breastfeeding care in the hospital. Pediatrics 2009; 124:e793-e802. 16. Perrine CG, et al. Baby-friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics. 2012 Jul; 130(1):54-60. 17. Cramton R, Zain-Ul-Abideen M, Whalen B. Optimizing successful breastfeeding in the newborn. Curr Opin Pediatr 2009; 21:386-396. 18. Aluwalia IB, Morrow B, D’Angelo D, Li R. Maternity care practices and breastfeeding experiences of women in different racial and ethnic groups; Pregnancy Risk Assessment and Monitoring System (PRAMS).

Matern Child Health J 2012 Nov;16(8):1672-8. 19. Gagnon AJ, Leduc G, Waghorn K, et al. In-hospital formula supplementation of healthy breastfeeding newborns. J Hum Lact 2005; 21:397- 405. 20. World Health Organization, United Nations Children’s Fund. Protecting, promoting, and supporting breastfeeding: The special role of maternity services. Geneva: World Health Organization, 1990. 21. Baby Friendly USA. (http://www.babyfriendlyusa.org/.) 22. SB 402 (De León) Breastfeeding. http://leginfo.legislature.ca.gov/faces/ billNavClient.xhtml?bill_id=201320140SB402. 23. Centers for Disease Control and Prevention. Maternity Practices in Infant Nutrition and Care (mPINC) 2011. http://www.cdc.gov/breastfeeding/data/ mpinc/reports.htm 24. California Department of Public Health. Maternity Practices in Infant Nutrition and Care (Regional and County data). https://www.cdph.ca.gov/data/statistics/Pages/CaliforniamPINCSurveyData.aspx25. California Department of Public Health, Center for Family Health, Genetic Disease Screening Program, Newborn Screening Data, 2016. 26. California Department of Public health, WIC Division. August 2016. 27. Hedberg IC. Barriers to breastfeeding in the WIC population. MCN. 2013; 38: 244-249.28. Maternal, Child and Adolescent Health (MCAH) Program of the California Department of Public Health, MIHA, the Maternal and Infant Health Assessment 2012. (www.cdph.ca.gov/MIHA.) 29. Centers for Disease Control and Prevention. Infant Feeding Practices Study II and 6 Year Follow up. (http://www.cdc.gov/breastfeeding/data/ifps/index.htm)30. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. (http://www.cdc.gov/nchs/nhanes/index.htm)31. The Joint Commission National Quality Measures. Perinatal Core Measures Set. (https://manual.jointcommission.org/releases/TJC2013A/PerinatalCare.html)32. Early Head Start. Early Childhood Health and Wellness. (https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/nutrition)33. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infant and Toddler Feeding Practices Study 2 (ITFPS-2): Intention to Breastfeed. (http://www.fns.usda.gov/special-supplemental-nutrition-program-women-infants-and-children-wic-infant-and-toddler-feeding)34. California Perinatal Quality Care Collaborative. (https://www.cpqcc.org/)35. California Department of Public Health. Comprehensive Perinatal Services Program. (http://www.cdph.ca.gov/programs/CPSP/Pages/default.aspx)36. California Department of Public Health. Black Infant Health Program. (http://www.cdph.ca.gov/programs/bih/Pages/default.aspx)37. Flood J et al. The collective impact model and its potential for health promotion: Overview and case study of a healthy retail initiative in San Francisco. Health Educ Behav. 2015; 42: 654-88.

References

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Middle heart: C=100 M=58 Y=0 K=21

Type outside hearts : C=100 M=57 Y=0 K=40

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