Improving Maternity Care Practices in New York: Answering the Surgeon General's Call to Action

Abstract

Hospitals providing maternity care influence breastfeeding mothers and infants during the critical, early postnatal period. Despite concerted public health efforts, there are persistent, large variations across New York State (NYS) hospitals in breastfeeding policies, maternity care, and infant feeding practices and in rates of breastfeeding initiation and exclusivity. An initiative addressing this issue is the Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative, which was designed and implemented by the NYS Department of Health (NYSDOH). The BQIH Learning Collaborative, adapted from the Institute for Healthcare Improvement Breakthrough Series, embedded evidence-based maternity care best practices in a learning and quality improvement model. The Ten Steps to Successful Breastfeeding served as the backbone for improvement with the aims of increasing the percentages of infants fed any breastmilk and exclusively fed breastmilk while decreasing the percentage of breastfed infants supplemented with formula. Twelve hospitals were selected to participate based on their breastfeeding metrics: 10 of the hospitals were low performing, and two were high performing on these breastfeeding measures. During the 18-month BQIH Learning Collaborative, process improvement occurred for several measures, including breastfeeding within the first hour after birth, breastfeeding mother/infant rooming-in, and receipt of formula samples/discharge bags. NYSDOH plans to spread this Collaborative to all hospitals providing maternity care in NYS. Comprehensive breastfeeding initiatives will continue in NYS in the effort to ensure that all breastfeeding mothers receive optimal support from healthcare providers and hospitals with the goal of making breastfeeding the norm for infant nutrition during the first year of life.

Introduction

Increasing breastfeeding initiation, exclusivity, and duration are public health priorities.^1,2 Breastfeeding improves the health of infants and mothers.³ For more than 30 years, New York State (NYS) has worked to institute state regulations and legislation to protect and support a woman's right to breastfeed in public, in the hospital, and at work.⁴ A performance monitoring system has been instituted to increase transparency and public reporting of hospital-specific breastfeeding measures.

The Ten Steps to Successful Breastfeeding⁵ are evidence-based hospital practices that lead to increased breastfeeding initiation and exclusivity and to longer breastfeeding duration. Although initiation of breastfeeding by new mothers in NYS (82.7% in 2011) exceeds the Healthy People 2020¹ goal of 81.9%, only 39.7% of healthy newborns are exclusively breastfed (2011 unpublished electronic birth certificate data from the Bureau of Biometrics and Statistics, New York State Department of Health). This means that more than half (52.1%) of breastfed babies also receive formula during the birth hospitalization. In fact, in a national, annual survey of all states, for the past 5 years NYS has had the second highest (worst) percentage of breastfed babies being supplemented with formula during the first 2 days of life.⁶ The majority of mothers decide to breastfeed or not before they are admitted for delivery. Whether women exclusively breastfeed or not is highly dependent on the hospital's maternity care practices. Formula supplementation of breastfed infants, which is shown to adversely affect exclusive breastfeeding and reduce breastfeeding duration,⁷ is largely under the control/influence of hospital practices, staff, culture, and environment. Nationally, two-thirds of women who report prenatally that they intend to exclusively breastfeed are not meeting their goals.⁸ In NYS, it appears that supplementation happens early and often in the hospital.

There are large disparities among NYS hospitals in breastfeeding policies, maternity care, and infant feeding practices and rates of breastfeeding initiation and exclusivity.^9,10 The challenge in NYS and elsewhere is to engage, activate, and motivate decision-makers to prioritize breastfeeding and make policy changes that can then be translated into systems and environmental supports and practices. One needs to change the hospital culture to make exclusive breastfeeding the norm. The barriers experienced by hospitals in instituting recommended breastfeeding practices range from lack of staff knowledge or skills to teach and support new mothers and babies to breastfeed successfully to more extensive systems and physical space constraints. Some NYS hospitals have taken on the challenge of changing their hospital's culture to support the new social norm of exclusive breastfeeding. To facilitate, structure, and guide hospital maternity care practice change, an 18-month Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative was developed.¹¹ This article describes the implementation of the BQIH Learning Collaborative in 12 NYS hospitals and the resulting practice changes.

Materials and Methods

Breastfeeding measures

Hospitals are required to report infant feeding on the birth certificate as a categorical variable: breastmilk only; formula only; breastmilk plus formula, sugar water, or anything else; and no formula AND no breastmilk. To approximate a population of healthy infants, infants who were admitted to the Neonatal Intensive Care Unit for any reason or infants who were either transferred into or out of the hospital are excluded from annually aggregated hospital-specific infant feeding measures. These measures include percentage who receive any breastfeeding (includes infants who were fed breastmilk only OR breastmilk plus formula), exclusive breastfeeding (includes infants fed breastmilk only), and formula supplementation of breastfed infants (among infants who receive any breastmilk, the percentage who received breastmilk plus formula). Hospitals were divided into tertiles based on the aggregated yearly percentages of “any breastfeeding”: low (40–60%), middle (61–74%), and high (>74%); and among breastfed infants, the tertiles were based on the percentage who were supplemented with formula: high (>45%), middle (19–45%), and low (<18%).

Hospital selection

In 2008, 140 hospitals in NYS provided maternity care services; there were 245,741 live births. The BQIH Learning Collaborative was limited to hospitals outside New York City (NYC) because the NYC Department of Health and Mental Hygiene was conducting a separate but complementary initiative to improve hospital maternity care and increase breastfeeding initiation and exclusivity. In 2008 (unpublished electronic birth certificate data from the Bureau of Biometrics and Statistics, New York State Department of Health), of the 140 hospitals in NYS providing maternity care services, 40 were located in NYC; these were excluded, leaving 100 hospitals. In an attempt to potentially reach as many infants as possible through this initiative, smaller hospitals were excluded. Hospitals with fewer than 400 births annually (n=25) were excluded, leaving 75 hospitals. Learning Collaboratives have traditionally been undertaken with high-performing organizations. For this Learning Collaborative, however, hospitals were selected based on low performance related to formula supplementation of breastfed infants (i.e., high rate of formula supplementation) and breastfeeding initiation (i.e., low rate of any breastfeeding). In selecting hospitals geographic diversity was considered.

Data measurement plan

Each hospital selected a random sample of 50 charts from “healthy” infants (as defined above) and reported type of birth (vaginal or cesarean section) and required process and outcome measures. Data were downloaded monthly to a secure Web site. Measures were reported separately by type of birth: among vaginal births, the percentage of infants fed breastmilk within 1 hour of birth; and among cesarean section births, the percentage of infants fed breastmilk within 2 hours. Measures reported for breastfeeding infants/mothers included: percentages of mothers who received breastfeeding instruction, were directly observed breastfeeding and assessed every shift, were offered breastfeeding support upon discharge, and provided formula samples upon discharge; and percentages of infants receiving breastmilk at eight or more feedings per 24 hours, rooming-in at least 18 hours/day (≥6 hours per 8-hour shift), and given pacifiers. The percentage of hospital staff who had received training on breastfeeding and lactation support was also reported.

Infant feeding measures included the percentages of infants fed only breastmilk (exclusive breastfeeding), fed only formula, and fed breastmilk plus formula.

Development of the BQIH Learning Collaborative

The BQIH Learning Collaborative utilized widely recommended evidence-based maternity care practices^2,3,12 and a modified version of the Institute for Healthcare Improvement Breakthrough Series Learning Collaborative Model.¹³ The BQIH Collaborative was a short-term (18-month) learning system and structure that brought the selected NYS hospitals' staff together to learn how to implement recommended hospital maternity care practices. This included the application of quality improvement tools and techniques to change care systems and close the gap between current and recommended practices. The development and design of the BQIH Learning Collaborative are described in depth elsewhere.¹¹

Implementation of the BQIH Learning Collaborative

Hospitals selected to participate formed teams with five core members, including the Director of Women's Services or Nurse Manager from Maternity, a physician lead from both the Departments of Pediatrics and Obstetrics, a Lactation Consultant, and a senior hospital administrator. Teams committed to have regular internal meetings and participate in all BQIH Collaborative improvement activities.

Components of the Learning Model include Learning Sessions and Action Periods.¹⁴ Learning Sessions, either in person or virtual, are an opportunity to learn from expert faculty and each other, share experiences, and plan for changes to be tested during subsequent Action Periods. Each of the five Learning Sessions was followed by an Action Period, during which the hospital teams apply the Model for Improvement¹³ to rapidly test key changes to the hospital system, on a small scale, and evaluate the effect of the changes prior to full implementation and spread. Hospital improvement teams participated in group and individual consultation with expert faculty during the Action Period. Improvement advisors from the National Initiative for Children's Healthcare Quality partnered with NYSDOH for this effort.

In order to test and implement changes in hospital processes and systems the Model for Improvement¹³ was applied. The basics are as follows: (1) what are we trying to accomplish?; (2) how will we know that a change is an improvement?; and (3) what changes can we make that will result in improvement? The Plan-Do-Study-Act cycle was used for conducting the rapid, small-scale tests of change to implement the desired changes in the system.

The aim of the BQIH Learning Collaborative, specific to the participating hospitals, was to increase breastfeeding, especially exclusive breastfeeding, among mothers/infants by improving hospital breastfeeding policies and practices to be consistent with NYS hospital regulations, state legislation, and recommended best practices such that between birth and hospital discharge there would be an increased percentage of infants fed any breastmilk, increased percentage of infants exclusively fed breastmilk, and decreased percentage of breastfed infants (i.e., fed breastmilk) supplemented with formula. These outcome measures were documented in the medical record and reported on the electronic birth certificate.

Results

Hospital selection

Review of aggregated, hospital-specific breastfeeding metrics revealed a wide range (1–99%) for the measure of formula supplementation of breastfed infants (Fig. 1). Hospitals in the highest two tertiles for formula supplementation of breastfed infants (>45% or 19–45%) and the lowest two tertiles of any breastfeeding (40–60% or 61–74%) were identified as low performing for breastfeeding metrics. Hospitals with low formula supplementation of breastfed infants (<18%) and with high any breastfeeding (>74%) were identified as high performing for breastfeeding metrics. This identified 23 low-performing and five high-performing hospitals, which were invited to apply to participate. Seventeen hospitals applied, and 12 hospitals were chosen to participate; 10 low-performing and two high-performing were enrolled, one of which was Baby Friendly.

FIG. 1.

Distribution of NY hospitals (outside NYC) by percentage formula supplementation of healthy breastfed infants (2008 Electronic Birth Certificate data, Bureau of Biometrics and Statistics, New York State Department of Health).

The much lower breastfeeding metrics for the 10 participating, low-performing hospitals versus nonparticipating hospitals confirm that the selection criteria were met (Table 1). The maternal demographic measures for race/ethnicity, insurance, and marital status are similar between participating low-performing and nonparticipating hospitals.

Table 1.

Feeding of Healthy Infants and Demographics of Mothers at Participating Versus Nonparticipating Hospitals

	Hospitals n (%)
		Participating
Measure	Nonparticipating (n=63)	High performing (n=2)^a	Low performing (n=10)^b
Total births	80,345 (100)	4688 (100)	20,412 (100)
Any breastmilk	59,831 (74)	3414 (73)	14,932 (37)
Only breastmilk	46,573 (58)	3187 (68)	6,480 (32)
Both breastmilk and formula	13,258 (17)	227 (5)	8452 (41)
Formula supplementation	13,258 (22)	227 (7)	8452 (57)
Non-white and mixed race	18,540 (23)	893 (19)	5,867 (29)
Hispanic	12,998 (16)	347 (7)	3,951 (19)
Medicaid and Family Health Plus	25,602 (32)	801 (17)	6,268 (31)
Mother unmarried	30,994 (39)	1371 (29)	6,852 (34)

Data are from electronic birth certificate data, Bureau of Biometrics and Statistics, New York State Department of Health, 2008, hospitals with >400 births, excluding New York City.

High performing, hospitals with low formula supplementation of breastfed infants and high percentage of any breastfeeding.

Low performing, hospitals with high formula supplementation of breastfed infants and low percentage of any breastfeeding.

BQIH Learning Collaborative

The BQIH Learning Collaborative was 18 months in length, conducted from June 2010 to November 2011. Breastfeeding within the first hour, for infants born by vaginal delivery, was one of the most common changes selected by hospitals to test. Some of the strategies associated with the change concept breastfeeding within the first hour include documentation of infant feeding method in the medical record upon admission, initiation of skin-to-skin contact by placing the infant naked, prone against the mother's chest, delaying routine procedures, and encouraging mothers to breastfeed for their infant's first feeding after birth. Figure 2A is the run chart of monthly data for this measure for Hospital A. At the start of the Learning Collaborative, 33% of healthy infants born vaginally at Hospital A were breastfed within the first hour of birth. After testing increasing skin-to-skin contact immediately after birth, it became evident that there was unclear documentation of breastfeeding initiation. As part of the improvement work, the team from Hospital A developed new documentation to include height, weight, Apgar score, duration of mother/infant skin-to-skin time, and breastfeeding and incorporated these measures into the electronic medical record. By the end of 2010 staff had been educated on the benefits and process of facilitating early and more prolonged skin-to-skin contact, which resulted in a consistent level of care being delivered by nurses in labor and delivery. By March 2011, prenatal classes were highlighting the importance of skin-to-skin contact, and parental requests increased for mother/infant skin-to-skin in the delivery room.

FIG. 2.

Data run charts for Breastfeeding Quality Improvement in Hospitals Learning Collaborative, Hospitals A and B: (A) infants fed breastmilk in the first hour (among vaginal deliveries) and (B) infants rooming-in (among breastfed infants).

Mother/infant rooming-in was also a change that was commonly chosen by hospitals. Rooming-in is challenging due to new mothers' expectation, systems of care, and physical layout of hospital rooms and floors. Some of the strategies to achieve the change concept for rooming-in include practice rooming-in throughout the facility unless medically contraindicated, do not routinely separate healthy mothers and infants, and care for the infant at the mother's bedside by using portable scales and bath equipment. It is evident in Figure 2B that in June and July 2010, rooming-in was not practiced by Hospital B. In the fall of 2010, staff initiated small tests of change by discontinuing routine collection of infants for return to the nursery at 10 p.m. each night. As a result, infants were staying with their mothers later and even all night. The number of nursing/breastfeedings that occurred during the night increased. Coinciding with this, administration granted the staff permission to make rooms “private” if census allowed by utilizing only one of the two beds. In addition, over the next year through multiple tests of change at Hospital B, practices changed such that infant admissions and assessments began taking place in the delivery room, and the culture shifted to support nonseparation of the mother and infant.

Elimination of formula samples and bags at discharge was another change pursued by many hospitals. Prior to the start of the Collaborative, three hospitals had already eliminated distributing formula samples/bags at time of discharge. After the first Learning Session in July 2010, two additional hospitals eliminated the bags. As more of the hospital teams began working with their administrations to eliminate the formula bags a competitive spirit surfaced, motivating other teams to work on the same change and leading to three additional hospitals eliminating bags during January–March 2010 (Fig. 3).

FIG. 3.

Percentage of breastfeeding mothers at 12 participating NY hospitals who received free formula at hospital discharge.

In August 2011, a letter from the NYSDOH Commissioner was sent to all hospitals calling on them to examine their practices of formula supplementation of breastfed infants and calling attention to the NYS Hospital Codes Rules and Regulations,¹⁴ which has guidelines regarding provision of discharge formula samples and bags. At about the same time, hospitals were also receiving results of the Maternity Practices in Infant Care and Nutrition survey,¹⁵ which also measures the provision of discharge formula samples and bags. Consequently, two additional hospitals eliminated distribution of formula bags. In October 2011, one additional hospital eliminated distributing the formula bags at time of discharge. It should be noted that although the collaborative officially ended in November 2011, the final hospital (which did not distribute bags to exclusively breastfeeding mothers) has moved forward and is in the process of eliminating distribution of formula bags at discharge.

Process improvement for breastfeeding within the first hour of birth for vaginally delivered infants and within 2 hours of birth for cesarean section-delivered infants, for mother/infant rooming-in, and for distribution of formula discharge samples and bags was documented for the entire BQIH Learning Collaborative over the 18-month time period (Fig. 4).

FIG. 4.

Change in process measures at 12 participating NY hospitals over time. C/Section, cesarean.

Discussion

Hospital maternity care practices impact breastfeeding exclusivity and duration during a critical period. NYS has been at the forefront in the efforts to improve maternity care practices in hospitals during the last 5 years. The BQIH Learning Collaborative model is a novel example of an effective approach to address this problem. It is the first state health department-sponsored collaborative using the Institute for Healthcare Improvement methodology, to focus on increasing exclusive breastfeeding. NYSDOH developed and implemented, in partnership with the National Initiative for Children's Healthcare Quality, the BQIH Learning Collaborative and the associated improvement tools. The Collaborative involved routine sharing of results among teams through Learning Sessions in which teams learn from each other about which changes and supporting implementation strategies have been successful and which have not. This results in a dynamic improvement strategy in which many teams working on related problem areas can learn from each other in a way that facilitates rapid dissemination of successful practices.

Twelve NYS hospitals, 10 with low performance on breastfeeding metrics, participated in the BQIH Learning Collaborative. There were demonstrated improvements in multiple process measures, including breastfeeding within the first hour of birth, mother/infant rooming-in, and distribution of formula sample bags. Although many hospitals made improvements, there is still significant work to do. Policy and systems changes were required to achieve the documented improvements. The goal of the NYSDOH is to devise a comprehensive guide for implementation of hospital maternity care best practices. The BQIH Collaborative pilot is being used to evaluate strategies for change to determine if there is an importance ranking or sequence for implementing changes that will lead to greater improvement in breastfeeding support and care in hospitals. Further analysis of the BQIH Collaborative is currently ongoing. NYSDOH plans to scale up this initiative and, in cooperation with NYC Department of Health and Mental Hygiene, spread the BQIH Collaborative over the next 5 years to reach remaining NYS hospitals that provide maternity care and support those hospitals that pursue “Baby-Friendly” designation. The success of the BQIH Collaborative has also served as a foundation for the work by the National Initiative for Children's Healthcare Quality and the Centers for Disease Control and Prevention for the “Best Fed Beginnings”—to work with 90 U.S. hospitals to become Baby-Friendly.

Strengths of the BQIH Learning Collaborative include the structure and design. It was adapted from the Institute for Healthcare Improvement model to meet NYS's specific needs. Because the target in NYS was low-performing hospitals, it was necessary to increase the length of the typical learning collaborative and provide hospital staff with additional technical assistance. The limitations to this Collaborative model include the resource requirements of both money and staff to support activities and the potential for sustaining improvements beyond the BQIH Learning Collaborative implementation period.

Promotion, protection, and support of breastfeeding, especially exclusive breastfeeding, is an ongoing effort in NYS. Despite the success of the BQIH Learning Collaborative, additional efforts beyond the hospital are needed to fully transform maternity care practices to support breastfeeding through evidence-based care. Both the prenatal and postnatal periods are important. In NYS, enhancing community resources that support breastfeeding is a priority. Increasing the availability of lactation consultants within the community will ensure women have access to professional resources and ongoing lactation support prenatally, as well as during the postdischarge period. Provision of tools to support breastfeeding women when they return to work is paramount. NYS continues to encourage certified childcare centers and homes to become breastfeeding friendly. Additionally, efforts at both the state and national level need to include implementation of policies and practices that are consistent with the “International Code of Marketing of Breastmilk Substitutes,” which restricts the marketing of breastmilk substitutes (i.e., infant formula), to ensure that mothers are not discouraged from breastfeeding. The ultimate goal in NYS is to make breastfeeding the norm for infant nutrition.

Footnotes

Acknowledgments

We thank Cynthia R. Howard, M.D., M.P.H., Associate Professor in the Department of Pediatrics at the University of Rochester School of Medicine and Dentistry, for her clinical expertise and Charles J. Homer, M.D., M.P.H., Patricia Heinrich, R.N., M.S.N., and Patricia Simino-Boyce, R.N., Ph.D., of the National Initiative for Children's Healthcare Quality for their contributions to the development of the BQIH Learning Collaborative. We thank also Sara Bonam Welge, M.S., R.D., Division of Chronic Disease Prevention, New York State Department of Health, for her expertise and critical review. We acknowledge the work of hospital providers and staff at the 12 BQIH participating hospitals, and especially Eileen Magri, M.S.N., R.N., NE-BC, and Karen Hylton-McGuire, RNC-NIC, M.S., IBCLC, R.L.C., from Winthrop University Hospital and Kathleen Kane, R.N., Ph.D., and Paula Loeb, IBCLC, from Nyack Hospital. This work was supported in part by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, American Recovery and Reinvestment Act of 2009, Communities Putting Prevention to Work State Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control, and Behavioral Risk Factor Surveillance System DP09-901/3U58DP001963-01S2, Cooperative Agreement 5U58/DP001414-03 from the Centers for Disease Control and Prevention, and the New York State Department of Health.

Disclosure Statement

No competing financial interests exist.

References

U.S. Department of Health and Human Services. Healthy People 2020: Maternal, Infant and Child Health, 2011. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicID=26. 2012 June .

Office of the Surgeon General U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. U.S. Department of Health and Human Services: Washington, DC, 2011.

Section on Breastfeeding Medicine. Breastfeeding and the use of human milk. Pediatrics, 2012; 129:e827–e841.

Dennison

, FitzPatrick

. On the front line: New York State policies and initiatives to increase breastfeeding. Breastfeed Med, 2011; 6:271–276.

World Health Organization UNICEF. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. Geneva: World Health Organization, 1989.

Division of Nutrition Physical Activity Obesity. Breastfeeding Report Card—United States, 2011. Centers for Disease Control and Prevention: Atlanta, 2012.

DiGirolamo

, Grummer-Strawn

et al. Effect of maternity-care practices on breastfeeding. Pediatrics, 2008; 122,Suppl 2:S43–S49.

Perrine

, Scanlon

, Li

et al. Baby-Friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics, 2012; 130:54–60.

Kacica

, Kreiger

, Johnson

. Breastfeeding practices in New York State maternity hospitals: Results from a statewide survey. Breastfeed Med.Epub ahead of print May 23, 201210.1089/bfm.2011.0149.

10.

Hawke

, Dennison

, Hisgen

. Development of the New York State Model Hospital Breastfeeding Policy. Breastfeed Med, 2012(in press)10.1089/bfm.2012.0030.

11.

FitzPatrick

, Dennison

, Bonam-Welge

et al. Development of the Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative in New York State. Breastfeed Med(Manuscript submitted, 2012).

12.

Division of Child Health Development, World Health Organization. Evidence for the Ten Steps to Successful BreastfeedingWHO/CHD/98.9Geneva: World Health Organization, 1998.

13.

Institute for Healthcare Improvement. The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. Boston: Institute for Healthcare Improvement, 2003.

14.

Department of Health New York State. NY Codes Rules and Regulations, NYCRR, Title10, 405.21-Perinatal Services (1984, 2004) http://w3.health.state.ny.us/dbspace/NYCRR10.nsf/11fb5c7998a73bcc852565a1004e9f87/8525652c00680c3e8525652c00630816?OpenDocument. 2012 June 1.

15.

Centers for Disease Control Prevention. CDC National Survey of Maternity Practices in Infant Nutrition and Care (mPINC) www.cdc.gov/breastfeeding/data/mpinc/index.htm. 2012 June .