Let’s Start at the Let’s Start at the Very Beginning…Very Beginning…

Breastfeedingand the

Built Environment

The information and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC.

DNPAO six principal target areas• Increase physical activity• Increase the consumption of fruits and vegetables• Decrease the consumption of sugar sweetened

beverages• Increase breastfeeding initiation, duration, and

exclusivity• Reduce the consumption of high energy dense foods• Decrease television viewing

Once upon a Once upon a time…time…

Breastfeeding is Breastfeeding is beyond the realm of beyond the realm of public health.public health.

Infant feeding is a personal Infant feeding is a personal choice.choice.

ButBut...

2.8

1.6 1.6

1.3 1.31.3

1.0

2.0

3.0

GI Infection Type II

Diabetes

SIDS Acute Otitis

Media

Obesity Cardiovascular

Disease

Lack of breastfeeding substantially increases health risks to infants.

Source: AHRQ, 2007

Breastfeeding = Control

Grp

Never breastfed versus ever breastfed

1.8

1.7

1.4

1.2

1.0

2.0

Obesity Asthma (family

history)

Asthma (no history) Leukemia

Source: AHRQ, 2007

Breastfeeding = Control

Grp

Inadequate breastfeeding substantially increases health risks to infants.

Never breastfed versus breastfed at least 3 months*

*Includes studies of never v. bf ≥4 mo and bf ≥6 mo

3.6

2

1.7

1.0

2.0

3.0

4.0

Severe Lower Respiratory

Infection

Acute Otitis Media Atopic Dermatitis

Source: AHRQ, 2007

Breastfeeding = Control

Grp

Exclusive formula feeding versus exclusive breastfeeding*

*Exclusive bf of at least 3 months

Mixed feeding substantially increases health risks to infants.

Then what’s going on?

Moms Moms just don’t understand just don’t understand how important it is to how important it is to breastfeed.breastfeed.

Moms Moms just don’t understand just don’t understand what they need to do to what they need to do to breastfeed.breastfeed.

Not quite…Not quite…

Problem:Problem:The way maternity care is The way maternity care is delivered can make it very delivered can make it very hard to start and continue hard to start and continue breastfeeding. breastfeeding.

Problem:Problem:Medical care processes, Medical care processes, policies, and practices, as policies, and practices, as well as routine practices, well as routine practices, traditions, habits, and even traditions, habits, and even design, systems, and design, systems, and expectations are not always expectations are not always conducive to healthy infant conducive to healthy infant care. care.

Problem:Problem:Medical care processes, Medical care processes, policies, and practicespolicies, and practices, as , as well as routine practices, well as routine practices, traditions, habits, and even traditions, habits, and even design, systems, and design, systems, and expectations expectations are not always are not always conducive to healthy infant conducive to healthy infant care.care.

Problem:Problem:MedicalMedical care processes, care processes, policies, and practices, as policies, and practices, as well as well as routine practices, routine practices, traditions, habitstraditions, habits, and even , and even design, systems, and design, systems, and expectations expectations are not always are not always conducive to healthy infant conducive to healthy infant care.care.

Problem:Problem:MedicalMedical care processes, care processes, policies, and practices, as policies, and practices, as well as routine practices, well as routine practices, traditions, habits, and even traditions, habits, and even design, systems, and design, systems, and expectations are not always expectations are not always conducive to healthy infant conducive to healthy infant care.care.

In-hospital supplemental feeds reduce breastfeeding opportunities.(Nylander, et al. 1991)

In-hospital BehaviorsControl(ad lib

supplementing)

Intervention

(med indicated supplementing)

4.8 feeds Supplementary feeds/24 h on day 2

1.1 feeds

188 ml Volume of supplement on day 2 23 ml

100% Supplementing on day 2 2%

565 ml Total supplement consumed days 1-3

68 ml

4.3 feeds Breastfeeds/24 hr on day 2 6.4 feeds47 ml Volume of breast milk on day 2 132 ml2% Night-time breastfeeding 98%

Breastfeeding at 8 weeksPercent of mothers (interviewed at 8 wks postpartum about hospital experiences)

(Murray et al., 2007)

Hospital ExperienceNo Yes66 Breastfeeding in the 1st hour 77

65 No supplemented feeding 81

62 Rooming-in 74

69 No pacifiers 78

64Phone number given to

mothers75

Approx mean diff = 12%

small scale small scale – – signagesignage

Breastfeedingand the

Built Environment

small scale small scale – – linen linen serviceservice

Breastfeedingand the

Built Environment

large scale large scale – – care care systemssystems

Breastfeedingand the

Built Environment

Assessing the maternity Assessing the maternity care built environment:care built environment:

The CDC survey of The CDC survey of mmaternityaternity

PPractices inractices inIInfantnfantNNutrition and utrition and CCareare

EarlyEarlyskin-to-skin-to-

skin skin contactcontact

EarlyEarlyskin-to-skin-to-

skin skin contactcontact

No83%

Yes17%

NB: Routine newborn procedures include Apgar, foot printing, ID banding, etc.

Almost all facilities unnecessarily separate mothers and infants within the first 30 minutes of life.

Are mother and baby usually skin-to-skin while staff are completing routine newborn procedures?

Problem:Problem:Medical care processes, Medical care processes, policies, and practices, as policies, and practices, as well as routine practices, well as routine practices, traditions, habits, and even traditions, habits, and even design, systems, and design, systems, and expectations are not always expectations are not always conducive to healthy infant conducive to healthy infant care.care.

Solution?Solution?

Standard healthy infant Standard healthy infant nutrition and care assures all nutrition and care assures all mothers and babies receive mothers and babies receive care that utilizes best care that utilizes best practices and is free of practices and is free of policies, practices, and policies, practices, and environmental influences environmental influences that undermine maternal that undermine maternal and child health and and child health and wellbeing. wellbeing.

Solution:Solution:

Standard healthy infant Standard healthy infant nutrition and carenutrition and care assures all assures all mothers and babies receive mothers and babies receive care that care that utilizes best utilizes best practicespractices and is free of and is free of policies, practices, and policies, practices, and environmental influences environmental influences that undermine maternal that undermine maternal and child health and and child health and wellbeing.wellbeing.

Solution:Solution:

Standard healthy infant Standard healthy infant nutrition and carenutrition and care assures all assures all mothers and babies receive mothers and babies receive care that utilizes best care that utilizes best practices and practices and is free of is free of policies, practices, and policies, practices, and environmental influences environmental influences that undermine maternal that undermine maternal and child health and and child health and wellbeing.wellbeing.

Solution:Solution:

large scale large scale – – maternity carematernity care

Breastfeedingand the

Built Environment

Breastfeedingand the

Built Environment

ProgramsProjectsPolicies The Baby-Friendly Hospital Initiative

Ten Steps to Ten Steps to Successful Successful

BreastfeedingBreastfeeding

Breastfeedingand the

Built EnvironmentProgram –Program – Inform Inform (step 3)

Help Help (step 4)

Show Show (step 5)

Encourage Encourage (step 8)

Foster supportFoster support (10)

Breastfeedingand the

Built EnvironmentProject –Project – Train Train

staff staff (step 2)

Practice BF Practice BF (step 6)

Room-in Room-in (step 9)

No pacifiers No pacifiers (step 9)

Breastfeedingand the

Built EnvironmentPolicy –Policy – written written

policy that is policy that is routinely routinely communicatecommunicated to all health d to all health care staff care staff (step 1)

30.0%

26.9%

21.5%

13.7%

6.2%

3.2%

15.5%

0 1 2 3 4 5 6

Number of Baby-Friendly steps mothers reported experiencing

Perc

ent of

mot

hers

who

bre

astfed

< 6

wee

ksThe number of Baby Friendly steps in place predicts risk of

breastfeeding cessation.(DiGirolamo et al., 2008)

Steps measured: Early bf initiation Exclusive breastfeeding

Rooming-in On-demand feedings

No pacifiers Information provided

Breastfeedingand the

Built Environment

ProgramsProjectsPolicies

The WIC ProgramBreastfeeding Breastfeeding Promotion and Promotion and

SupportSupport

Assessing breastfeeding Assessing breastfeeding and the built environment:and the built environment:

The CDC Breastfeeding Report The CDC Breastfeeding Report CardCard

A state-by-state snapshot:A state-by-state snapshot:

BreastfeedingBreastfeedingprotection, promotion, and protection, promotion, and support. support.

ProtectionProtection: Removing barriersRemoving barriers

Maternity care Maternity care practices,practices,

Legislation Legislation

Promotion:Educating why and how

Health professionalsBreastfeeding

expertsHealth departmentsState breastfeeding

coalitionsEmployers

Legislators, state employees,health professionals,

breastfeeding experts, employers, family and friends.

Support:Helping, encouraging, celebrating.Being a champion.

Nine Process IndicatorsNine Process Indicators Hospital supportHospital support Professional supportProfessional support Mother-to-mother supportMother-to-mother support LegislationLegislation InfrastructureInfrastructure

Five Outcome IndicatorsFive Outcome Indicators Progress toward HP 2010 GoalsProgress toward HP 2010 Goals

Hospital SupportHospital Support

●Average mPINC score

●Percent of live births at BFHI facilities

Professional andProfessional andMother-to-Mother Mother-to-Mother SupportSupportIBCLC’s and LLL groups per 1,000 live births

The Breastfeeding ReportCard does not currentlymeasure physician support.

Legislation and Legislation and InfrastructureInfrastructure

Legislation: Breastfeeding in public, lactation and employment

FTE’s dedicated toBreastfeeding

State breastfeedingcoalitions

Breastfeeding: Data: Breastfeeding Report Card | DNPAO | CDC

Many hands make light Many hands make light work…work…CDCCDC

Romeo ChristianRomeo ChristianDeborah DeeDeborah DeeRon ErgleRon ErgleCarol Carol MacGowanMacGowanPaulette MurphyPaulette MurphyRon NuseRon NuseKelley ScanlonKelley ScanlonAndrea SharmaAndrea SharmaKatherine Katherine ShealyShealyThelma SimsThelma SimsGuijing WangGuijing Wang

BattelleBattelleJennifer CohenJennifer CohenMary Kay DuganMary Kay DuganDiane ManninenDiane ManninenEileen MilesEileen Miles

State Health State Health DepartmentsDepartmentsMary ApplegateMary ApplegateJennifer DellaportJennifer DellaportKen RosenbergKen RosenbergLaurie TiffinLaurie TiffinRosanne SmithRosanne Smith

Hospitals/HealthHospitals/Health ProfessionalsProfessionalsLauren BaroneLauren BaroneKarin CadwellKarin CadwellDebbi HeffernDebbi HeffernElaine LockeElaine LockeAnne MerewoodAnne MerewoodCarol MelcherCarol MelcherBarbara PhilippBarbara PhilippMolly PesslMolly PesslAmy SpanglerAmy SpanglerCindy Turner-MaffeiCindy Turner-Maffei

Breastfeeding CoalitionsBreastfeeding CoalitionsKirsten BerggrenKirsten BerggrenBecky MannelBecky MannelKaren PetersKaren PetersAmelia PsmytheAmelia PsmytheKim RadtkeKim RadtkeMegan RennerMegan Renner

Universities/Med. Universities/Med. SchoolsSchoolsElizabeth AdamsElizabeth AdamsAndrea Crivelli-KovachAndrea Crivelli-KovachAnn DiGirolamoAnn DiGirolamoLaurie Feldman-WinterLaurie Feldman-WinterAlla GrindblatAlla GrindblatJane HeinigJane HeinigCelia QuinnCelia Quinn

Thank you!Thank you!

www.cdc.gov/breastfeedingwww.cdc.gov/breastfeeding

www.cdc.gov/mpinc www.cdc.gov/mpinc

ImprovingImprovingHealthy Infant Healthy Infant

Care in Medical Care in Medical SettingsSettings

ImprovingImprovingHealthy Infant Healthy Infant

Care in Medical Care in Medical SettingsSettings

Vendor Formula Packages Equivalent Volume

Total Packages Coupons

Mead Johnson 8 cans @ 13 oz8 Packets @ .65 oz 786 oz 16 $45

Abbott 7 cans @ 12.9 oz 650 oz 7 $155

Nestlé3 cans @ 12 oz each2 cans @ 13 oz each

1 can @ 25.8 oz632 oz 6 $75

Heinz 2 cans @ 25.8 oz1 case (12 bottles) @ 2 oz 396 oz 26 $15

Member’s Mark 1 package @ 4.4 oz 32 oz 1Parent’s Choice 1 package @ 4.3 oz 31 oz 1

Grand Total 2527 oz 57 pkg $290

One mom’s tally – 6 months One mom’s tally – 6 months of mailof mail

One mom’s tally – 6 months One mom’s tally – 6 months of mailof mail“Samples” total =2527 oz (19.75 gal) prepared

= 79 days= 2.6 months’ supply

Coupons total = $290= 12 cans= 2016 oz (15.75 gal)

prepared= 63 days= 2.1 months’ supply

TOTAL = 4,543 ounces (35.5 gallons)Enough formula to completely feed a baby for 4.7 months

Source: Bergmann et al. Intl J Obes, 2003

Note:Note:

These calculations are based on the These calculations are based on the following assumptions:following assumptions:

1 can of 23 oz Powdered Infant 1 can of 23 oz Powdered Infant Formula makes approximately 168 Formula makes approximately 168 fluid oz when prepared, and, as of fluid oz when prepared, and, as of March, 2010, costs about $21.March, 2010, costs about $21.

Averaged out, an infant between 0 Averaged out, an infant between 0 and 6 months of age consumes and 6 months of age consumes approximately 32 oz of formula per approximately 32 oz of formula per day.day.

Practical Support for Workplace Legislation

Colorado Physical Activity and Nutrition Program Reports on YouTube Video

Eric AakkoCDC Conference, March, 2010

Colorado’s Workplace Lactation Law

• Passed in 2008

• Requires employers to• Provide reasonable time for mothers to express milk at work (unpaid or paid break

and/or meal time) • Make reasonable efforts to provide suitable, private space for this purpose (close

proximity, not a toilet stall)• Not discriminate against women for expressing milk in the workplace

• Initial publicity was strong• However, overall awareness is lower than we’d like

• Inquiries to Coalition• Employer adoption• Mother demand

Project Overview

VideoMotivate, educate, inspireHelp mothers overcome the hurdle of initiating a breastfeeding conversation at workEducate mothers and employers about Colorado’s workplace lawEducate employers about workplace lactation programs in general

Funded by:

Video: How We Did It

Putting the ideas on paper• Wrote the grant and secured funding• Fleshed out the concept (video outline)• Hired the video production company• Refined the concept• Recruited moms• Wrote interview prompts

Video: Lessons Learned

• Partnering with the right video company is key• Teamwork is essential – core team of ‘Three Amigos’• Moms were delighted to tell their stories• Real, from-the-heart testimonials work better than role-plays• Don’t over-think the video outline• One long shooting day worked well

• Schedule moms about every 30-45 minutes• Surprisingly high turn-out – ’Five Minutes of Fame’• Interview in front of green screen, followed by “B roll” shoot• Childcare and snacks• Location with multiple large rooms

• Distribution and viewership will determine success (hint, hint!)

YouTube Video

• Mothers tell their stories• Overview of the law• Employer video

The Business Case for Breastfeeding

The Business Case for Breastfeeding empowers mothers of infants who return to work after delivery to successfully express milk in a private location with worksite lactation support. Ultimately, we have a win win situation for all.

…how we made it work for our moms

Presented by..

Carol Hendrix, BS, IBCLC

WIC Breastfeeding Coordinator

North Georgia Health District

Dalton, Georgia

How I got started….In June 2008 Arlene Toole and Mary Jackson were trained to implement the program statewide and initiate group training.

Strategic plan for implementing the BCBF in our community:

Low hanging fruit

Early adopters

Biggest bang for the buck

Before caption goes here After caption goes here

.

Effective Outreach Opportunities for Implementation of BCBF

•Human Resources

•Wellness Programs

•Health/Plant Nurses

•Personal Visits

•Breastfeeding EmployeesBreastfeeding Employees

Power of Employees to Make Change

•WIC Pump Program

•Breastfeeding Helpline

•LC contact with plant HR or Nurse

•WIC Nutritionist and hospital referrals

•Employees encouraged to speak out

1st Worksite with Large Employee Base

Shaw Industries

•35% to 40% of Employees are Female

•70% of Females Employed are of Childbearing Age (3,000 in 5 counties)

Shaw Industries BCBF Implementation

•Communication with HR & occupational nurse

•Converted empty office into lactation room

•Multi-user pump, radio, and refrigerator added to room

•Employees e-mailed about lactation room

Shaw Industries at Present…•Lactation room fully used

•Support group initiated

•Program awaiting approval for full implementation with documented financial justification (PI – Process Improvement)

•Lines of communication developed for moms returning to work at plants where no lactation room yet established

2nd Worksite with Large Employee Base

Mohawk Industries

•Over 1,000 Employees in our Community

•35% to 40% of Employees are Female

•70% of Females Employed are of Childbearing Age

Mohawk Industries BCBF Implementation

•HR uninterested 6/2008

•Contacted plant nurse for a WIC mom returning to work 7/2009

•Nurse converted empty office into a lactation room using multi-user pump 8/2009

•Moms on day and night shifts utilized room

Mohawk Industries at Present…

•Lactation room in use

•Network communication growing between plant nurses

•Continuing referrals of moms returning to work

Businesses Considering Lactation Rooms…

• Beaulieu of America

• Shiroki North America

Other Issues to Consider…•Obtain WIC and hospital-based LC support

•Utilize strength of Georgia breastfeeding legislation

•Emphasize flexible employee breaks

What worked for us…•Establish relationship with plant nurse

•HR and nurses are key decision makers

•Give room incentive items (pump, educational materials, posters, etc.)

•Offer continued support

•Do not underestimate power of employees to make change!

Our New Peer Counselors in 2010

Maternity Care Practices in Hospitals:

A quality improvement project

Kyle Unland

Program Manager, NPAO

Kyle.Unland@DOH.WA.GOV

A bit of background for Washington State

• Maternity Practices in Infant Nutrition and Care (mPINC) scores for Washington hospitals is lower than the national average

• Exclusive breastfeeding rates below HP 2010 goal

• Only 4 out of 60 Washington hospitals are “Baby Friendly” as defined by WHO

• Early supplementation is a problem in hospitals

NPAO State Plan

Gathering stakeholders

• NPAO

• WIC

• MCH

• Breastfeeding Coalition of Washington

Yakima Valley Memorial HospitalLow hanging fruit with maximum

potential

What happened at YVMH

Before training, hospital:

• Reviewed mPINC scores

• Conducted a chart audit

BCW Training:

• Featured CDC data• Presentation by physician• Results of the audit• Attended by physicians,

hospital administration, local WIC and MSS staff, maternity staff, state WIC and NPAO staff

Pilot results

• Active mutli-disciplinary task force formed at YVMH to improve practices

• Evaluation is on-going

• Maternity care staff interested in attending more breastfeeding training and are scheduled for it

Next steps• Expanding work to four hospitals

• Continuing to evaluate progress

• Engaging the Washington State Hospital Association

• Increase collaboration with WIC