By Jill A. Gutmann December 4, 2012

A Policy Analysis of the Baby-Friendly

Hospital Initiative (BFHI) in Ohio

Capstone Committee William A. Mase, Dr.P.H., M.P.H., M.A., Chair Susan Pinney, Ph.D.

A special thank you to my little Daria, the nursing queen, who makes me love nursing and want to share and make assessable the joys and pleasures of it with all mothers! To my husband, who has been the greatest breastfeeding supporter and advocate .

Purpose of this study: Is to provide generalizable knowledge as to whether BFHI is a

possibility for Ohio hospitals to initiate in order to improve breastfeeding rates in Ohio to meet the Surgeon General’s “2011 Call to Action” and the Healthy People 2020 goals.

Background on Lactation Breast milk is the best and most ideal food for human babies. Babies benefit in numerous ways from breast milk and

mothers benefit in numerous ways from nursing. Breastfed babies experience lower rates of many illnesses such

as: urinary and respiratory infections, diarrhea, and bacterial meningitis.

Benefits to mothers of nursing and pumping include: reduced risk of breast and ovarian cancer, and helping moms lose weight postpartum

Surgeon General’s 2011 “Call to Action”

National Breastfeeding Rates: The number of women breastfeeding in the United States has

been increasing consistently since the early 1990’s, although recently these gains have begun to level-off.

74.6% of US women initiated breastfeeding, 44.3% of US women breastfed at six months, and 23.8% of US women breastfed for one year (CDC Report Card- 2011).

The “Healthy People 2020” goals are for 81.9% of women to initiate breastfeeding, 60.6% of women to breastfeed for six months, and 34.1% of women to breastfeed for one year (“Maternal, Infant, and Child Health- Healthy People”).

National Trends in Breastfeeding Rates

A Public Health Concern: In 2000, the US Surgeon General said, “The nation must address these low breastfeeding rates as a

public health challenge and put into place national, culturally appropriate strategies to promote breastfeeding (Grummer-Strawn and Shealy).”

In January 2011, US Surgeon General releases the “Call to Action” “Given the importance of breastfeeding for the health and well-

being of mothers and children, it is critical that we take action across the country to support breastfeeding.”

(U.S. Department of Health and Human Services)

Regional Variations in Breastfeeding The state of Ohio is one of

the lowest performing states, 44th out of 50 for having ever breastfed.

62.3% of Ohioans ever breastfed

39.5% were breastfeeding at six months

25.6% breastfed for at least twelve months.

CDC's Breastfeeding Report Card-2012,

What can be done to address this? The Centers for Disease Control and

Prevention 2011 Breastfeeding report card suggests: “Birth facility policies and

practices significantly impact whether a woman chooses to start breastfeeding and how long she continues to breastfeed. Several specific policies and practices, in combination, determine how much overall support for breastfeeding a woman birthing in a given facility is likely to receive and how likely her baby is to receive formula in the first 2 days.”

Two Initiatives:

1. The mPINC survey

2. Baby-Friendly Hospital Initiative 1. BFHI is an international program

established in 1991 and revised in 2006.

2. Sponsored by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for lactation based on the WHO/UNICEF Ten Steps to Successful Breastfeeding for Hospitals

BFHI- Ten Steps Maintain a written breastfeeding policy that is routinely communicated to all

health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of

breastfeeding. Help mothers initiate breastfeeding within one hour of birth. Show mothers how to breastfeed and how to maintain lactation, even if they are

separated from their infants. Give infants no food or drink other than breastmilk, unless medically indicated. Practice “rooming in”-- allow mothers and infants to remain together 24 hours a

day. Encourage unrestricted breastfeeding. Give no pacifiers or artificial nipples to breastfeeding infants. Foster the establishment of breastfeeding support groups and refer mothers to

them on discharge from the hospital or clinic

Ohio in 2011- 0nly 4.1% of Births

In April of 2012 , Mayor Bloomberg announced that the New York City (NYC) Health Department would launch an initiative to encourage city hospitals to obtain “"Baby-Friendly"” designation.

On June 28, 2012, Illinois Governor Pat Quinn signed House Bill 4968. The bill calls on every hospital that provides birthing services to “adopt an infant feeding policy to promote breastfeeding.” The bill asks hospitals to consider guidance from the Baby-Friendly Hospital Initiative in developing their policies (O’Mara).

BFHI in the news:

The research suggests: The California WIC association found, “Disparities in in-hospital rates of

exclusive breastfeeding are not found in hospitals that have implemented the policies and practices of the Baby-Friendly Hospital Initiative, while the opposite is true in hospitals that are in the same geographic region but are not designated as Baby-Friendly (California WIC).”

Perrine and colleagues found that, “Two-thirds of mothers who intend to exclusively breastfeed are not meeting their intended duration. Increased Baby-Friendly hospital practices, particularly giving only breast milk in the hospital, may help more mothers achieve their exclusive breastfeeding intentions.”

Saadeh(2012) found, “The BFHI has led to increased rates of exclusive breastfeeding, which are reflected in improved health and survival. The BFHI has had great impact on breastfeeding practices among both healthy and sick infants.”

Ohio- BFHI As of September 12, 2012 there are currently four "Baby-

Friendly" Hospitals in the State of Ohio and 143 throughout the United States.

The four hospitals in Ohio that have received designation are: Lakewood Hospital (Cleveland, OH), Southview Hospital (Kettering, OH), Mercy Hospital Anderson (Cincinnati, OH), and Mercy Hospital Fairfield (Cincinnati, OH). As of mid-November, two additional hospitals in Ohio have

received designation: Hillcrest Hospital and Fairview Hospital in Cleveland. Both are affiliated with the Cleveland Clinic.

Methods: The researcher conducted three semi-structured, hour-long

telephone interviews with lactation staff representing all four hospitals in Ohio with BFHI designation. One of the interviewees was involved in aiding two hospitals in

obtaining BFHI designation. After completing the interviews, the researcher

independently identified categories and performed a theme analysis of the qualitative data.

The findings from the interviews, combined with the policy analysis, provide data for making generalizable findings about BFHI and its application in Ohio hospitals.

General Observations: The Baby-Friendly Hospital Initiative was viewed positively

among all research participants. Top Reasons to become “Baby-Friendly”

1. Increase initiation of breastfeeding 2. Provides support, promotes breastfeeding, and supports

breastfeeding 3. Health and wellness for mom and baby 4. Good marketing to say the hospital is "Baby-Friendly" 5. Babies just do better- far fewer babies in the nursery, less

monitoring of babies 6. Joint commission has made exclusive breastfeeding as one of

their core measures.

General Observations: Issues with becoming “Baby-Friendly” 1. Costs

1. Cost was the biggest barrier. 2. It is expensive to apply for designation, to train staff, and to

maintain the designation.

2. Time Consuming

Outcomes after Designation Every hospital saw increases in breastfeeding initiation. Two of the hospitals experienced around twenty

percentage point increases in their breastfeeding rates (from the mid-60’s to the mid-80’s).

Two others had been growing slowly (at about 1 percentage point every two years since the institutions began keeping track in 1990). After receiving designation, those hospitals experienced four percentage point increases in one year.

Theme Analysis: Theme 1- Policy

Written Lactation Policy

Baby Friendly USA Support

Timing to Designation

Written Lactation Policy: Hospitals implementing "Baby-Friendly" should seek to: 1.Implement model policies which are available from Baby-Friendly USA. 2.Use Baby-Friendly USA as a resource, when a challenge arises.

Timing: Hospitals implementing "Baby-Friendly" should seek to: 1. Complete an internal audit to gain a better understanding of what already exists and what steps need to be implemented. 2. Have hospital leadership remain cognizant of the impact of size. For example smaller hospitals can typically obtain designation faster.

Theme Analysis: Theme 2- Hospital Personnel

Decision Maker Buy-in

Physicians

Nurses

Theme Analysis: Theme 2- Hospital Personnel

Decision Makers: Hospitals implementing "Baby-Friendly" should seek to: 1.Recognize that there is no one best approach to BF as the decision to achieve BFHI can come from top down or bottom-up. 2.Minimize staff turnover, which can cause disruptions and delay implementation.

Buy-in: Hospitals implementing "Baby-Friendly" should seek to: 1.Keep staff informed of changes and steps being taken. 2.Foster organizationally relevant approaches (multi-pronged and direct approaches). 3.Inform the staff about "Baby-Friendly" early and often throughout the process.

Nurses: Hospitals implementing "Baby-Friendly" should seek to: 1.Provide continuing education to respond to the needs of the staff 2.Provide continuing education with flexible times. 3.Insure that lactation consultants are available to answer questions. 4.Assist nurses during the process of adapting to new workflows.

Physicians: Hospitals implementing "Baby-Friendly" should seek to: 1.Provide continuing education at flexible times. 2.Provide continuing education in a variety of delivery modalities (e.g. on-line)and with multiple options . 3.Award and reward physicians for adopting desired "Baby-Friendly" behaviors. 4.Provide literature on lactation at physician offices in place of literature distributed by formula manufacturers.

Theme Analysis: Theme 3- Patient Education

Prenatal Education: Hospitals implementing "Baby-Friendly" should seek to: 1.Provide material on lactation at physician offices in place of literature distributed by formula manufacturers. Post-natal Education and Support: Hospitals implementing "Baby-Friendly" should seek to: 1.Develop support groups that attract new and expecting mothers. 2.Have a lactation consultant available at support group meetings. 3.Make a scale available at support group meetings. 4.Make the post-natal support programs open to all new mothers, regardless of infant feeding choice. 5.Create a support group for mothers returning to work, as these mothers have unique needs. Culture Hospitals implementing "Baby-Friendly" should seek to: •Be aware and sensitive of the different cultures of patient populations. •Make Baby-Friendly material available in different languages.

Pre-natal Education Post-natal Education & Support Culture

Success Breastfeeding

Discussion From the evidence in the literature coupled with the findings

from the interviews, it seems the question is not whether a hospital should become "Baby-Friendly", but rather how a hospital should go about achieving a designation.

I provide nine recommendations

Recommendations: 1-3 1. A hospital must be aware of all of the

costs associated with obtaining Baby-Friendly Hospital designation.

2. Hospital policy development is an ongoing process.

3. The decision maker can be from the top down or bottom up.

Recommendations: 4-6 4. Staff need to be informed and included in

the process. 5. Continuing education programs for nurses

and physicians need to be available at flexible times and with multiple options.

6. Incentivize new behaviors for physicians and nurses.

Recommendations: 7-9 7. Provide material on lactation at physician

offices in place of literature distributed by formula manufacturers.

8. Support groups need to have a draw for them to be effective.

9. Each hospital must assess what steps of the Ten Steps need to be accomplished and be realistic about the challenges that each step will present.

Limitations & Future Research Limitation:

1. The sample size of four hospitals is not representative of all types of hospitals in Ohio. 1. Most notably, there are no academic medical centers.

2. All hospitals in the sample are relatively small, with 2000 or fewer births per year.

3. Participants may have had recall issues, since designation occurred for three of the hospitals several years before the interview.

Future Research:

1. Include hospitals that are in the process of obtaining designation could expand the pool of available hospitals to interview.

2. Interview hospitals that began the process and stopped or halted progress, to get a more complete picture of the process of becoming "Baby-Friendly" and challenges and obstacles that hospitals might encounter.

Conclusions: The Ten Steps of the Baby-Friendly Hospital Initiative have

benefited the four Ohio Early adopters by creating facilities that provide best practice care to new mothers and newborns.

The process of becoming "Baby-Friendly" is not focused on changing society, but on changing hospitals to focus efforts towards promoting, protecting, and supporting lactation. The Centers for Disease Control and Prevention state, " Birth facility policies and

practices significantly impact whether a woman chooses to start breastfeeding and how long she continues to breastfeed.”

The time is now to take the right "Ten Steps" forward for Ohio mothers and babies.

("Breastfeeding Report Card—United States, 2012").