Abstract
Abstract
Objective:
To compare and contrast military hospital and civilian hospital experiences of achieving Baby-Friendly designation, and to examine administration and staff responses as well as institutional and patient postimplementation outcomes.
Materials and Methods:
Staff, administration, and chairs of Baby-Friendly committees at both hospitals were interviewed.
Conclusion:
Motivating factors and perceived administrative support were similar at both institutions. Both sites saw an increase in exclusive breastfeeding rates upon discharge to a rate of 80–90%, and both noted an overall increase in delivery rates, which may also be attributed to achieving Baby-Friendly designation. Significant differences included the amount of time it took to achieve Baby-Friendly status, the number of specialties represented on the Baby-friendly committee, the percentage of employees who received training, pediatrics involvement and support, and funding sources for staff training.
T
At the University of Missouri Women's and Children's Hospital (WCH), delivering providers noted that newborn infants would “disappear” after deliveries into the resuscitation rooms for long periods of time. Feeling strongly that this interfered with bonding and breastfeeding initiation, they formed a committee that implemented “10 Steps To Successful Breastfeeding” as developed by Baby-Friendly USA. After seeing dramatic improvements in breastfeeding rates and maternal satisfaction related to the bonding process, the committee went on to pursue Baby-Friendly designation. Obstetricians largely drove the committee, with the slow gain of support of other staff members. The committee, in its final stages, comprised obstetricians, nursing staff, administrative staff, lactation consultants, and pediatricians. The administration at WCH was supportive of the effort, and their support was described as “critical” to the timely completion of the project. Staff training involved 20 hours of education for women's health nurses, 3 hours of education for other healthcare providers, online training for housekeeping and laboratory staff, and inpatient presentations for emergency room and radiology staff.
There were multiple hurdles to achieving Baby-Friendly status. Funding the process at WCH was a significant obstacle in the beginning, but with the acquisition of a grant from the National Institute for Children's Health Quality, the 20 hours of overtime pay needed to cover training each nurse was resolved. The committee was also slow to gain the support of pediatric and neonatal intensive care unit staff as they raised concern regarding delay in newborn assessments and logistical issues with bedside rounding. These issues were eventually resolved and in 2015, at the end of a 2.5 year long accreditation journey, Baby-Friendly status was achieved.
Before the initiative, WCH had one International Board Certified Lactation Consultant (IBCLC) with inpatient rounding responsibilities on staff, in addition to a free outpatient lactation clinic. During the accreditation process, 10 additional nurses completed IBCLC certification. With this improvement, there is now an IBCLC staffing either the Labor and Delivery or Postpartum units nearly 24 hours a day. All mothers are taught hand-expression technique while inpatient and the hospital equipped six lactation rooms throughout its facilities. During their postpartum hospital stay, all mothers are given pumping supplies and access to a hospital-grade pump. After discharge, mothers are able to obtain breast pumps through private insurance or Missouri Medicaid.
In 2014, only 50% of mothers were breastfeeding upon discharge from WCH, and approximately half of those breastfeeding were also supplementing with formula. After Baby-Friendly designation was achieved in 2015, the breastfeeding rates at discharge quickly improved from 50% to 80–90%. From a financial standpoint, WCH also realized a potential advantage to implementing this new program. Upon achievement of Baby-Friendly certification, the institution immediately began marketing itself as “Columbia's Only Baby-Friendly Hospital” and delivery numbers increased steadily over the following year. Within 1 year of designation, the delivery volume surpassed the local competing hospital and reached an all-time high of more than 200 deliveries in 1 month. Although it could not be definitively stated that the increase in deliveries was directly related to Baby-Friendly status and related marketing, most staff felt that it was a factor in the increased delivery numbers.
At Fort Belvoir Community Hospital (FBCH) in Virginia, the Baby-Friendly initiative was brought in by a newly appointed department chair of obstetrics and gynecology. Having previously had favorable experiences with the program, she decided to initiate the certification process at this institution. The initiative was well supported by the administration and staff—which included the employment of three different hospital commanders during this endeavor. Multiple departments collaborated and were represented on the committee, including the chairs of OB/GYN, pediatrics, anesthesia, as well as patient representatives and staff from the departments of nursing, laboratory, nutrition, and radiology. The pediatrics staff were fully supportive of the process and Baby-Friendly initiative, and they were considered “early adopters” of the initiative. Employee training involved 20 hours of education for women's health nurses, 3 hours of education for other healthcare providers, and online training for housekeeping and laboratory staff. In addition, each new employee received education on the Baby-Friendly initiative during his or her orientation. As with most military hospitals, there was a high rate of employee turnover due to active duty personnel, thus necessitating regular waves of training and education. Costs incurred by this, and by mandatory nursing training, were a substantial budgetary concern. In addition, nurses could not work overtime at this institution, so they needed up to 6 months to complete their mandatory training. Baby-Friendly accreditation was achieved in 2014, 4.5 years from process initiation.
Before the initiative, FBCH had one IBCLC with inpatient rounding responsibilities, as well as outpatient OB clinic lactation consultants. The facility is in the process of hiring another full-time IBCLC with a possibility of a third, specifically for outpatient pediatrics clinic. During their postpartum hospital stay, mothers have access to hospital-grade breast pumps and are taught hand-expression techniques. Upon discharge, Tricare insurance provides single-user breast pumps to mothers.
After Baby-Friendly designation, FBCH saw an increase in exclusive breastfeeding rates at discharge to consistently over 90%. It should be noted, however, that anytime an IBCLC was not available to cover the inpatient consults, breastfeeding rates dropped. Since the Baby-Friendly designation was achieved in 2014, FBCH has seen an increase in the number of deliveries, from ∼130 per month to 150 per month. They are in direct competition with Walter Reed—another military hospital nearby—which is not yet a Baby-Friendly hospital, although they are working toward this designation. Informal patient interviews show that patients are choosing FBCH over other military or civilian competitors because of the Baby-Friendly designation.
Conclusion
The motivations for achieving Baby-friendly status were essentially the same at both facilities. Both institutions noted that the Baby-Friendly Hospital Initiative followed evidence-based practice, and that the designation would hold them accountable to providing ideal mother–baby bonding and breastfeeding education. Administrative support was touted by both committees as key elements in their success in achieving Baby-Friendly designation. Both hospitals also observed a growth in patient volume and breastfeeding initiation and exclusivity rates. However, there were hidden costs in implementing the two programs. At FBCH, this involved extensive employee training. WCH, however, reported that by rejecting “free” formula samples, they now incur ∼$40,000 per year in formula acquisition costs.
Each institution met challenges en route to Baby-Friendly designation. FBCH received robust support from its pediatrics department, whereas WCH cited hesitation from pediatricians. The makeup of the committees was different, with FBCH having a more diverse multidisciplinary team. Funding differed, as WCH received a grant for expenses and FBCH covered their own expenses. The time from process initiation to completion was notably longer for FBCH, likely due to staff turnover and training schedules. Another notable difference is the staff members who received training, with FBCH training all new staff members at their orientation. Through the process, WCH oversaw the training of significantly more IBCLC nurses who were able to facilitate 24/7 inpatient lactation assistance compared with the limited availability of inpatient lactation consultants at FBCH.
As seen with these two hospitals, pursuing Baby-Friendly designation can be met with a variety of challenges—both expected and unexpected. These challenges certainly differ between civilian and military hospitals. However, the desirable outcomes of increased breastfeeding rates and increased patient volume were observed at both institutions.