Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population

Missed care and equitable breastfeeding support: An integrative review of exposure to in-hospital care by patient characteristics and breastfeeding outcomes

AIM

To synthesize the literature on breastfeeding outcomes associated with exposure to internationally recognized best practices, such as the Baby-Friendly Hospital Initiative, for patients in the United States during the postpartum period, contextualized within the Missed Care Model.

DESIGN

The authors employed Whittemore and Knafl's integrative review framework and the 2020 PRISMA guidelines for data extraction, synthesis, reporting and assessment.

METHODS

Five electronic databases were searched for articles published between 2007 and 2023. Eligible articles reported on exposure to breastfeeding best practices and outcomes or the experiences, views, perceptions and attitudes of parents, nurses or lactation consultants regarding hospital breastfeeding support. Extracted data were compared to identify in-hospital exposure to breastfeeding best practices and breastfeeding outcomes, and differences in exposure and outcomes based on patient and provider characteristics.

RESULTS

Twenty-one quantitative, qualitative and mixed methods articles met inclusion criteria. A higher reported adherence to best practices was associated with greater odds of breastfeeding; some practices demonstrated greater effects overall or for specific groups. Higher exposures to best practices and higher breastfeeding rates were found for non-Hispanic white patients, and those with more education, private insurance and who live in urban areas. Disparities in support and outcomes were related to patients' race/ethnicity, language, weight and age. Qualitative findings reflected missed care concepts, such as internal processes related to habits and group norms, relevant to breastfeeding support.

CONCLUSION

Review findings also include an adapted Missed Care Model specific to breastfeeding support, which can inform future research related to providers' internal processes that may influence breastfeeding or equitable breastfeeding care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Missed care can be influenced by a variety of factors, including providers' internal values and beliefs. Study findings suggest the existence of inequities in breastfeeding care and underscore the need to address and eliminate breastfeeding disparities.

IMPACT

This study addressed how patient exposure to best practices in breastfeeding support relates to breastfeeding outcomes and whether exposure and outcomes differ by patient or provider characteristics, connecting this to the Missed Care in Breastfeeding Support Model. The main findings were that higher reported exposure to best practices in breastfeeding support related to improved breastfeeding outcomes; inequities exist in exposure to best practices; and patients and providers identify the importance of providers' internal processes in the delivery of breastfeeding support, which aligns with the Missed Care in Breastfeeding Support Model. Study findings will have the potential to impact how nurses, lactation consultants and other providers who deliver breastfeeding support in the postpartum hospital setting.

REPORTING METHOD

The authors adhered to relevant 2020 PRISMA reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Promoting maternal-child health by increasing breastfeeding rates: a National Canadian Baby-Friendly Initiative Quality Improvement Collaborative Project

While breastfeeding has long been an important, globally recognized aspect of population health, disparities exist across Canada. The Baby-Friendly Initiative (BFI) is a WHO/UNICEF best-practice program that helps ensure families receive evidence-based perinatal care and is associated with improved breastfeeding rates. However, <10% of hospitals in Canada are designated as 'Baby-Friendly'.The Breastfeeding Committee for Canada (BCC) aimed to increase the number of hospitals that moved towards BFI designation by implementing a National BFI Quality Improvement Collaborative Project. Key activities included (1) implementing and evaluating the BFI Project with 25 hospital teams across Canada and (2) making recommendations for scaling up BFI in Canada.As of December 2023, three hospitals in the BFI Project have attained designation and six have started the official process towards designation with the BCC. Breastfeeding initiation rates remained high and stable (>80%); however, breastfeeding exclusivity rates did not meet targets. All BFI care indicators improved across participating facilities. All skin-to-skin indicators improved, with rates of immediate and sustained skin-to-skin meeting targets of >80% for vaginal births. BFI care indicators of documented assistance and support with breastfeeding within 6 hours of birth, rooming-in and education about community supports also met target levels. Leadership buy-in, parent partner engagement and collaborative activities of workshops, webinars and mentoring with BFI Project leadership were viewed as valuable.This BFI Project demonstrated that hospitals could successfully implement Baby-Friendly practices in various Canadian settings despite challenges introduced by the COVID-19 pandemic. Indicators collected as part of this work demonstrate that delivery of Baby-Friendly care improved in participating facilities. Sustainability and scaling up BFI implementation in both hospitals and community health services across Canada through implementation of a BFI Coach Mentor Program is ongoing to enable continued progress and impact on breastfeeding and maternal-child health.

Comparing Group Versus Individual Prenatal Care on Breastfeeding Practice and Motivational Factors

OBJECTIVE

Although breastfeeding in the first 6 months postpartum benefits both infants and mothers, breastfeeding rates remain low. This study examined whether group prenatal care was associated with an increased breastfeeding initiation and duration compared with those receiving usual, individual prenatal care. A secondary aim was to investigate whether sociodemographic and motivational factors were associated with breastfeeding initiation and duration across prenatal care groups.

METHODS

Pregnant women in their third trimester (n = 211) from an innercity university medical center participated. Prenatal care type was identified from the medical chart, and data on breastfeeding duration at 1, 3, and 6 months postpartum were collected. Breastfeeding motivational factors were assessed with a survey. Logistic regressions and independent-samples t tests were used for data analyses.

RESULTS

After controlling for demographic factors, group prenatal care was associated with increased breastfeeding at 6 months postpartum (odds ratio = 2.66; P = .045) compared with individual care. Breastfeeding intention (P < .001), competence (P = .003), and autonomous motivation (P < .001) were significantly higher, while amotivation (P = .034) was significantly lower in group compared with individual prenatal care.

CONCLUSIONS

Breastfeeding persistence was higher among women receiving group prenatal care, potentially due to motivational factors. Future studies should investigate how breastfeeding motivational factors could be effectively targeted in prenatal care to increase breastfeeding persistence.

Development of Interventions to Support Provincial Implementation of the Baby-Friendly Initiative: A Study Protocol

Breastfeeding is internationally recognized as the optimal form of infant nutrition. The Baby-Friendly Initiative (BFI) is an evidence-informed program that leads to improved breastfeeding outcomes. Despite the benefits of breastfeeding, Nova Scotia has one of the lowest breastfeeding rates in Canada. Additionally, only two birthing hospitals in the province have BFI designation. We aim to address this gap using a sequential qualitative descriptive design across three phases. In Phase 1, we will identify barriers and facilitators to BFI implementation through individual, semi-structured interviews with 40 health care professionals and 20 parents. An analysis of relevant policy and practice documents will complement these data. In Phase 2, we will develop implementation interventions aimed at addressing the barriers and facilitators identified in Phase 1. An advisory committee of 10-12 administrative, clinical, and parent partners will review these interventions. In Phase 3, the interventions will be reviewed by a panel of 10 experts in BFI implementation through an online survey. Feedback on the revised implementation interventions will then be sought from 20 health system and parent partners through interviews. This work will use implementation science methods to support integrated and sustained implementation of the BFI across hospital/community and rural/urban settings in Nova Scotia. This study was not registered.

Breastfeeding experiences of patients in baby-friendly certified hospital settings: protocol for a scoping review

INTRODUCTION

The Baby-friendly Hospital Initiative is a global programme that is meant to support breastfeeding within organisations. Most of the current literature is focused on implementation and uptake of the programme; however, little is known about the patient experience of breastfeeding within these settings. By exploring this current gap in the literature, we may discover important contextual elements of the breastfeeding experience. The objective of this protocol is to provide a framework for a scoping review where we aim to understand the extent and type of evidence in relation to the patient experience of breastfeeding in Baby-friendly Hospital Initiative (BFHI)-certified settings.

METHODS AND ANALYSIS

The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The databases to be searched for relevant literature include MEDLINE, Embase, PsycINFO, CINAHL and Scopus in April 2023. A grey literature scan will include reviewing documents from professional organisations/associations. For all sources of evidence that meet the inclusion criteria, data will be extracted and presented in a table format. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Participants in this review will include any individual who delivered their baby in a BFHI-certified setting. Exploring the patient experience will involve reviewing their subjective perceptions of events related to breastfeeding. These events must occur in a BFHI-certified hospital, and therefore, home births and other outpatient settings will be excluded.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review protocol or the final review. Knowledge gained from this research will be disseminated through the primary author's PhD dissertation work, as well as manuscript publications and conference presentations.

"We All Believe in Breastfeeding": Australian Midwives' Experience of Implementing the Baby Friendly Hospital Initiative

BACKGROUND

The education and support of new mothers during the in-hospital stay for childbirth is a critical time to establish breastfeeding. The Baby-Friendly Hospital Initiative was launched in 1991 to encourage maternity services to support and educate mothers to breastfeed by implementing Ten Steps to Successful Breastfeeding.

RESEARCH AIM

To explore midwives' experiences of implementing the Baby-Friendly Hospital Initiative in a Baby-Friendly accredited public hospital in Australia.

METHODS

In this prospective, cross-sectional qualitative study we used focus groups to explore midwives' experiences. Midwives (N = 26) participated in two focus groups conducted between October and November 2019. Data were analyzed using thematic analysis.

RESULTS

Time as a critical resource, and continuity of care, were crosscutting themes that framed midwives' experiences in supporting mothers to breastfeed their babies. Time constraints were experienced both through the health system structure and the BFHI accreditation process. Despite the challenges, the overarching theme-that we all believe in breastfeeding-fueled midwives' motivation.

CONCLUSION

Health services policy and practice need to consider ways to enable continuity of midwifery care and adequate time for midwives to support women to breastfeed their babies.

Factors That Influence Posthospital Infant Feeding Practices Among Women Who Deliver at a Baby Friendly Hospital in Southern United States

Introduction: The Baby Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, little is known about posthospital infant feeding practices among women who deliver at baby friendly hospitals. Therefore we sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation. Methods: This was a prospective cohort study of women aged 14 and over, who delivered at the University of Alabama at Birmingham. The primary outcome was mode of infant feeding categorized as exclusive breastfeeding (EBF), combination breastfeeding and formula feeding (CF), and exclusive formula feeding (EFF) at the PPV. Secondary outcome was EBF discontinuation rate. Patients who initiated formula and/or who stopped breastfeeding were asked what influenced their decision. Results: At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2-38.8); 34.6% (28.0-41.9) were CF, and 33.8% (27.3-41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support. Conclusion: Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.

What Women Really Think About Breastfeeding and Breast Pumping: A Qualitative Analysis of Women Who Deliver at a Baby-Friendly Hospital

Introduction: The Baby-Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, posthospital exclusive breastfeeding (EBF) rates remain low. We aimed to analyze thoughts and attitudes toward breastfeeding at the postpartum visit among women who deliver at a Baby-Friendly hospital. Methods: Women ≥14 years who delivered a live-born infant at our center were eligible. Participants completed an infant feeding questionnaire at the postpartum visit recording patient and delivery characteristics, antepartum care and infant feeding details, reasons for breastfeeding discontinuation or formula initiation, workplace environment, and cultural beliefs about breastfeeding. Thematic coding via line-by-line analysis of the free responses was performed using NVivo12 by QSR international. Results: Of 263 participants, 110 responded to the open-ended question. Of these, 53 and 46 were negative-toned and positive-toned, respectively. Negative breastfeeding responses related to the mother addressed the need for more support, low milk supply, pressure to breastfeed and feelings of guilt if unsuccessful, maternal health issues, painful breastfeeding, and high time requirements. Negative breastfeeding responses about the baby included concerns about infant health, latching issues, and disinterest. Positive responses focused on the support system, maternal weight loss, health benefits for baby, and mom-baby bonding. Some women (27) commented specifically on pumping. Negative comments noted that pumping led to less milk production, was time consuming, and was too much work. Positive comments about pumping noted that it is a convenient alternative to breastfeeding. Conclusion: Efforts to improve posthospital EBF rates in accordance with national guidelines must acknowledge the complex experience of breastfeeding mothers.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

The American College of Nurse-Midwives' Benchmarking Project: A Demonstration of Professional Preservation and Improvement

Maternal and newborn outcomes in the United States are suboptimal. Care provided by certified nurse-midwives and certified midwives is associated with improved health outcomes for mothers and newborns. Benchmarking is a process of continuous quality assurance providing opportunities for internal and external improvement. Continuous quality improvement is a professional standard and expectation for the profession of midwifery. The American College of Nurse-Midwives Benchmarking Project is an example of a long-standing, midwifery-led quality improvement program. The project demonstrates a program for midwifery practices to display and compare their midwifery processes and outcomes of care. Quality metrics in the project reflect national quality measures in maternal child health while intentionally showcasing the contributions of midwives. The origins of the project and the outcomes for data submitted for 2019 are described and compared with national rates. The American College of Nurse-Midwives Benchmarking Project provides participating midwifery practices with information for continuous improvement and documents the high quality of care provided by a sample of midwifery practices.