Twenty Years Baby-Friendly: Personal Reflections on Change

Introduction

Leading quality management thinker W. Edward Deming said, “Every system is perfectly designed to get the results it gets.” Boston Medical Center (BMC) is an inner-city safety-net hospital located in Boston, Massachusetts (Table 1). In 1995, BMC had policies that routinely separated mothers from their babies, limited breastfeeding education for staff, provided no hospital-funded lactation consultants, and did not initiate limitations on the presence of the infant formula industry in the hospital. In fact, the sales representatives in this industry routinely distributed food and gifts to staff and free formula and formula products to the hospital. The breastfeeding rate on the Mother Baby Unit was unknown. When we collected data, we found that the exclusive breastfeeding rate was 5.5%. Indeed, Deming was right. Every system is perfectly designed to get the results it gets.

In an attempt to do a better job for women who came to the hospital and wanted to breastfeed, a Breastfeeding Task Force was formed in 1997. We eventually learned about the Baby-Friendly Hospital Initiative and its framework, the Ten Steps to Successful Breastfeeding. The keys are: (1) safely keep mothers and babies together; (2) educate staff on lactation medicine; and (3) be in compliance with the International Code of Marketing of Breast milk Substitutes (the Code), including paying fair market value for formula and formula products. Naively, we thought, “We can do that.” Little did we know what we were up against. But, we did it. BMC gained Baby-Friendly status in 1999, becoming the first maternity facility in Massachusetts and the 22nd in the nation to receive the WHO/UNICEF designation. Achieving redesignation for the third time in 2019 marked 20 years as a Baby-Friendly hospital.^1–3 The goal of this article is to describe challenges encountered on the Baby-Friendly journey and share strategies used to overcome them (Table 2).

Facing Resistance and Celebrating Success

In the first years, as we worked on the Ten Steps to Successful Breastfeeding, every proposal and almost every day were difficult because there was so much resistance to change. Going to work felt more like walking into a boxing ring than a hospital. Times were different then; even the mention of the word “breastfeeding” was met with eye rolls, sighs, and disinterest. That all of the changes proposed were to support breastfeeding made it even more volatile. Having three Co-Chairs of the Task Force, each in a leadership position in the Mother Baby Unit, proved to be an important strategy. One was the Nursing Director of Maternal Child Health; another was the Physician Director of the Pediatric Service on the Mother Baby Unit; and a third was a pediatrician and breastfeeding advocate. Another key member of the Task Force was a staff member who was an extremely knowledgeable breastfeeding advocate. Her expertise was crucial in helping to navigate the change.

First, we wrote an infant feeding policy. We called colleagues at Evergreen Hospital in Kirkland, Washington (the first Baby-Friendly hospital in the United States) to ask them if they would share their policy with us. They did. Resources are now available for hospitals to use, including the Academy of Breastfeeding Medicine Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding.^4,5

Next up was rooming-in.^6,7 The status quo on the BMC Maternity Unit, in 1997, was that one nurse cared for the mother and another nurse, the nursery nurse, cared for the baby. This meant that quickly after birth, the baby was brought to the nursery for the admission examination and bath. After that, but often hours later, the mother and baby were reunited. This delay was due to a unit policy that stated that only staff with special identification tags was allowed to transport newborns in their bassinets from one location to another. The nursery nurse was not allowed to leave the nursery, and staff with the tag was often busy with other tasks. Once the mother and baby were reunited, the infant was repeatedly wheeled back into the nursery for examinations, routine screenings, and blood work. The unit resembled a walking path for nurses or aides pushing babies in bassinets—back and forth, back and forth, back and forth they went. The nursery nurse, that is, the baby specialist, had her desk in the nursery all set up for the tasks she needed to do for each baby. Getting tasks done was the priority; supporting feeding didn't make the list. To be fair, we were operating as every other maternity unit in the state was operating, parents just assumed that was the way it was done, and if the baby got stuck in the nursery and became hungry—which often happened—the bottle of formula could be given in the nursery just as easily as in the mother's room.

The new change was couplet care. With couplet care, the same nurse cares for the mother and the baby. All examinations, tests, and blood work are done with the baby in the mother's room. The one “mother-baby nurse” becomes the dyad's caregiver. Because not all nurses on the unit were comfortable caring for newborns, not to mention supporting breastfeeding, this change caused a lot of tension. Eventually all nurses on the unit received the training they needed to be able to care for both the mother and the baby. The Nurse Manager communicated the plan to her staff and enforced the need for completion of the training. The Nurse Educators ran the training program and certified competence. (Then, in addition to this training, the entire maternity nursing staff needed to complete the 20 hours of lactation training required by Baby-Friendly USA. This will be discussed in more detail in a subsequent section.)

Meeting the requirement of uninterrupted skin-to-skin contact for the first hour of life also proved to be difficult. From a nursing perspective, once the baby was born the clock started running to obtain the APGAR scores, vital signs, weight, apply the eye ointment, and give the vitamin K shot. Then the baby went off to the nursery for the admission examination and the newborn bath. Completing the checklist was important because another baby could be arriving soon. Allowing the baby to stay in Labor and Delivery with the mother for the first hour of life was not the norm. Some mothers were also not keen on having a gooey baby skin-to-skin on their body right after birth. Uninterrupted skin-to-skin contact for the first hour of life needed champions who supported and modeled the practice and education for staff and parents about why this was so important.^8–10 Later, when we became aware of case reports in the literature of Sudden Unexpected Postnatal Collapse, the unit completed additional competencies on safe skin-to-skin holding.^11,12

Banning the bags, the free diaper discharge bag that the formula sales representative gave the unit, became another hotly debated issue. ¹³ Despite research showing that handing out the bag was associated with lower breastfeeding rates ¹⁴ —some pediatric colleagues joined in with nursing colleagues to argue that we were depriving poor women of “a valuable gift.” Eventually the free bag was removed from the unit and replaced by a $17 BMC bag with diapers, a water bottle, and information on breastfeeding. Several years later, the decision was made to not give out a bag at all. Indeed, our great care is our gift.

The free bag was just one of many free items BMC was receiving from the formula industry. Paying for the formula and formula products was a big change, one that required administration approval. Again, to be fair to BMC, in the late 1990's, we were practicing maternity care exactly like everyone else in Massachusetts and most of the nation. ¹⁵ This included accepting formula and formula products for free. Before the 1990's, three different brands of formula had been used at BMC, with usage based on rotating brands every 4 months. Fortunately, by 1997, the Unit was only using one brand which made negotiations a bit easier.

The first request made to administration by the Task Force to pay for the formula products was denied because of a $100,000 per year price tag being quoted by the infant formula sales representative. However, at this point many more women were breastfeeding making it seem inconceivable that so much formula was being used. For the Task Force's second attempt, we gathered data that proved the cost would be about $25,000 per year. The Department Chairs from Pediatrics, Obstetrics, and Family Medicine and the Medical CEO (who happened to be a pediatrician) spoke up. It helped that the hospital president truly believed in BMC's logo of Exceptional Care Without Exception and argued that this simply was the right thing to do. The proposal was approved. We subsequently published an article on our experience and the concept of fair market value. ¹⁶

With everything in order, we welcomed two assessors who came to BMC for 2 days to assess our compliance. Then we waited for the results.

On a snowy day in December 1999, approximately two and a half years from when we started, two officials from Baby-Friendly USA came to BMC to present the award. We took a moment to cut a cake and celebrate this great achievement—but really, our work had just begun. We learned that Baby-Friendly is a designation you received and then keep working on.

To our surprise, 3 years later, on August 6, 2002, the Assistant Secretary of Health, U.S. Department of Health and Human Services, announced that the Baby-Friendly Hospital at BMC was chosen as a best practice model for the nation. The “Best Practice Initiative” showcased model programs in public health from around the country. We cut another cake.

Delay the Bath

Our success in delaying the bath was memorable because, for the first time, in my opinion, the resistance to change eased up. This was not a requirement of the Ten Steps but proved to be a valuable change. In 2009 we heard about a hospital located about 30 minutes north of Boston that was “delaying the bath.” I did not even know that was an option, for as long as I could remember, newborns at our institution had been bathed in the nursery at ∼2 hours of life as part of the admission process. Members of the Task Force took a field trip to Melrose-Wakefield Hospital to learn more. They were delaying the bath for 12 hours and, since starting the practice, thought they were seeing a decrease in the number of the infants with hypothermia and hypoglycemia. While not studied, that made sense, as the healthy infant's blood sugar nadirs at around 2 hours of life. In May 2010, we began delaying infant baths at BMC until at least 12 hours of life. I recall that first day when I arrived on the Unit, braced for resistance. This time, we used the Plan-Do-Study-Act (PDSA) strategy for a change, a process used in the Model for Improvement, a key component of quality improvement. The website for the Institute for Healthcare Improvement contains numerous resources. We asked one mother to try this with the help of one nurse and one physician. The mother who agreed to try this had just had a cesarean birth. She insisted on getting out of bed to help with the bath of her newborn which was done in her room. Afterward, we obtained feedback from the mother and staff to discuss how they felt it went and made tweaks to the plan. The next day we tried two delayed baths and met to discuss how it went. Soon we had a new policy in place. Of note, the mothers loved it. Over time we also noticed a decrease in hypoglycemia and there seemed an increase in exclusive breastfeeding rates, which we decided to study.

Using a retrospective study design that drew data from 6 months before the implementation of the delayed bath, and 6 months afterward, we found that 702 infants met the inclusion criteria. Before the bath was delayed, infants were bathed at an average of 2.4 hours of life. Afterward, infants were bathed at an average of 13.5 hours of life. In-hospital exclusive breastfeeding rates increased from 32.7% to 40.2% (p < 0.05) after the bath was delayed. Multivariate logistic regression analysis showed that infants born after implementation of delayed bathing had odds of exclusive breastfeeding 39% greater than infants born before the intervention (adjusted odds ratio [AOR] = 1.39; confidence interval [95% CI] 1.02–1.91) and 59% greater odds of near-exclusive breastfeeding (AOR = 1.59; 95% CI 1.18–2.15). The odds of breastfeeding initiation were 166% greater for infants born after the intervention than for infants born before the intervention (AOR = 2.66; 95% CI 1.29–5.46). ¹⁷

Recently we changed the timing so infants are now bathed any time between 12 and 24 hours of life, still in the mother's hospital room, with parent participation. Immediately after the bath, the infant is placed skin-to-skin with the mother. Parents can ask for their baby to not be bathed at all, but many enjoy learning how to do it from our staff. (In 2019, we started swaddle baths using turtle tubs.)

Breastfeeding Education

Step 2 of the Ten Steps to Successful Breastfeeding is staff education. Baby-Friendly USA requires 20 hours of education for nurses, consisting of 15 hours of didactic learning and 5 hours of clinical instruction. Providers (doctors, midwives, nurse practitioners, physician assistants) need 3 hours on lactation topics.

In the early years we offered a homegrown learning experience for both nurses and providers. New nurses attended a course offered by myself, lactation consultants, and unit staff educators. Once the course was completed, each nurse would shadow with one of the lactation consultants. In 2015, the hospital decided to pay for each new nurse to take an online course that met the teaching requirements. Shadowing with the lactation consultants continued.

We met the provider training requirement of 3 hours in the early years by offering yearly Grand Rounds for the Departments of Family Medicine, Pediatrics, and Obstetrics and Gynecology. In most cases, I was the speaker. For the most recent redesignation in 2019, the Task Force asked all providers to complete a refresher course. This was not required by Baby-Friendly but we wanted to make sure we had solid documentation. Every member of the provider group (about 100 physicians, midwives, and nurse practitioners) completed Bella Breastfeeding: Provider Training. This is a peer-reviewed online course on OPENPediatrics, a free web-based digital learning platform designed for health care professionals around the world. ¹⁸ The learner received teaching on the topics now required by Baby-Friendly USA: benefits of exclusive breastfeeding; physiology of lactation; how the provider's specific field of practice impacts lactation; how to find safe medications for use during lactation; and who the provider can refer a mother to for help. The course is composed of 15 short learning modules, each with a several question pretest and post-test. At the end of the course, and if a score of >80% on the test questions is achieved, the learner prints out a certificate of completion that we compile in a binder. The course is free, and completion is required of new hires within 6 months of starting their work on the unit. In the spirit of full disclosure, I am the author of Bella Breastfeeding: Provider Education, which was made possible by a grant from the W.K. Kellogg Foundation.

For the residents, the pediatric and family medicine residents receive the necessary 3-hour training during their 2-week rotation in the Mother Baby pediatric rotation. New Ob/Gyn residents complete the Bella course during their orientation in June, before their start on the unit in July.

The Second Redesignation

BMC came up for redesignation of the Baby-Friendly award in 2014. This served as an opportunity to carefully assess what we were doing and continue with improvements, many of which were not required by Baby-Friendly but were projects the Unit was interested in doing.

The Early Bloomer Program

Late preterm is defined as an infant born 34.0–36.6 weeks gestational age. At BMC, an infant born <35 weeks gestational age is admitted to the NICU for the entire stay. An infant born ≥35.0–35.6 weeks is admitted to the NICU until determined stable (usually 12–24 hours). Once stable, the infant is transferred to the Mother Baby Unit. An infant born ≥36.0–36.6 weeks, who is well, is admitted directly to the Mother Baby Unit.

Upon the dyad's arrival on the unit, the mother of an Early Bloomer receives a bag containing: a special striped hat; an Early Bloomer Parent Guide; an Early Bloomer sign to hang on the bassinet; a colostrum spoon; and a QRc code that links to a hand expression video.

Orders are placed in Epic electronic health record (EPIC) using the Late Preterm Order Set (Table 3). Lactation is immediately consulted. The infant is eligible for donor milk, and consent is obtained. Frequent, safe skin-to-skin holding is encouraged. Hand expression is taught, encouraged, and supported after every feeding. If the newborn is not feeding effectively, then pumping is initiated at 6 hours of life to achieve adequate supply. A supplemental feeding plan is used if there are concerns about feeding, weight loss, or hyperbilirubinemia (Table 3). The newborn bath is delayed at least 24 hours, or longer, if feeding difficulties, low blood sugars, or low temperatures are present. The circumcision is also delayed for 24–36 hours or longer if poor feeding presents. The mother baby dyad is identified daily at unit huddles. A team huddle involving the mother, mother baby nurse, lactation consultant, and member of the pediatric team is held every 12 hours as needed or if problems arise. Early discharges are strongly discouraged.

The program has been well received by parents and staff. Research is underway to evaluate its effectiveness.

EPIC Baby-Friendly Page

In audits conducted before the 2019 redesignation, we realized we needed to continue to improve our documentation. BMC EPIC staff created a Baby-Friendly page that contained areas to document everything needed: skin-to-skin on the postpartum ward, supplementation, pacifiers, and rooming in (The supplemental feeding plan is outlined in Table 4). The “rooming in interrupted” section has three areas to complete: the reason for the separation (mother or baby) with a drop-down of frequent reasons for separation; where the baby or the mother went; and how long the mother or baby was out of the room (<1, 1–2, 2–4, 4–12, and 24 hours). This has proven popular with the nursing staff because it is easy to use.

Fair Market Pricing

The issue of Fair Market Value is a complicated one. For years, Baby-Friendly USA required that we do our own pricing based on the cost of infant formula and formula products in our geographic area. The calculations were time consuming and confusing. Several years before our 2019 site assessment, Baby-Friendly USA announced a second option for determining Fair Market Value called Minimum Threshold Pricing. For this option, Baby-Friendly USA set minimum amounts that needed to be paid for each item. We choose this before the 2019 site assessment (Table 5). The Nursing Director of Maternal Child Health took charge of this task and convened numerous meetings with staff from purchasing and dietary. It was also enormously helpful that our contact working in Supply Procurement and Contracting had come to BMC from a hospital in Colorado that was designated Baby-Friendly. He joined the Task Force as well.

Then, on a spring-like day in May, we met the two assessors from Baby-Friendly USA at the front door. A hospital wide email blast announced the visit to the entire hospital. We were ready and proud to share with them all of our accomplishments.

Celebrate Success

Change in the hospital setting is hard. When we finally achieved a victory, we celebrated by taking a moment to congratulate ourselves and the staff by cutting a cake. We cut a cake for many victories: the first breastfeeding/pumping room; getting the Baby-Friendly certificate of intent in 1998; and for getting an unexpected government award. We cut a big cake and threw a party for our first Baby-Friendly designation. We drank milk and ate cookies when donor milk arrived in the NICU. We cut a cake to celebrate new breast pumps. We took a lot of pictures, published a lot of stories, and congratulated staff who made it all happen. We had a pizza party and some more cake when the assessors left the hospital in May 2019 and with the announcement of successful redesignation in September 2019, making it 20 years as a Baby-Friendly hospital.

Challenges

Change is difficult. We encountered numerous challenges along the way. In my 13 years as the Pediatric Medical Director of the Mother Baby Unit, I worked with nine nurse managers. Some were knowledgeable and supportive of breastfeeding and Baby-Friendly but others were not. The free formula-industry diaper bags returned twice so we got to ban them three times. New hires often brought with them their old way of doing things. Staff turnover in the dietary and purchasing departments meant always needing to be on top of Fair Market Pricing. Babies to the nursery and supplementation were regular discussions. As Baby-Friendly USA recommends, we always set safety as the priority along with supporting mothers. Over the years, maternity unit leadership carefully investigated infant falls, any other safety issues that arose, and maternal complaints. Patient satisfaction scores were closely monitored. Regular audits of the exclusive breastfeeding rate on the Unit at times were disappointing despite our best efforts. We saw improvements when a supplemental feeding plan was instituted, ²³ hand expression increased, and the unit started using donor milk. The frequent audits and paper work required by Baby-Friendly USA are time consuming.

We were able to keep up with changing clinical recommendations because, over the 20-year period described in this article, the Perinatal Committee, the Maternity Unit's multidisciplinary governing body, always followed evidence-based recommendations made by medical organizations.

In addition, over these 20 years, Baby-Friendly USA adopted new mechanisms for designation and modified their Guidelines and Evaluation Criteria. To keep up, the BMC Task Force referred to the Baby-Friendly USA portal, called Baby-Friendly USA, many times to obtain clarity on issues and followed the most current Guidelines and Evaluation Criteria document. BMC also belongs to the Massachusetts Baby-Friendly Collaborative, a group with representatives from about half of the maternity hospitals in the state, that meets monthly to discuss Baby-Friendly issues and share ideas and resources.

Conclusion

We found, as others have reported on Baby-Friendly results, improvements in breastfeeding initiation and exclusivity rates.^24–27 From 1997 to 2019, the breastfeeding initiation rate increased from 53% to 90%, and the exclusive breastfeeding rate increased from 6% to 50–60%. We also saw, first hand, that following the Ten Steps is an important way to decrease racial disparity gaps. ²⁸ Delivery volume at BMC increased from 1,600 to 2,850 births per year in the same time period. We continue to have a Level 1 Nursery space because it is required by Massachusetts Department of Public Health rules and we need it at times for sick babies or to watch a baby if the mother is sick. However, the space is often empty.

Leadership guru Robin Sharma said, “All change is hard at the first, messy in the middle and so glorious at the end.” We are a different maternity unit than 20 years ago. Our policies and systems aren't creating the problems. There is a willingness among staff to embrace change. We know breastfeeding and we do it well. Our nurses, in particular, are spectacular. Supporting a woman who comes in really wanting to breastfeed is easy. Encouraging those who are not so sure remains harder but we certainly try. Relative calm replaced chaos which made other changes like using neonatal glucose gel for hypoglycemia, nonpharmacologic care for Neonatal Opioid Withdrawal Syndrome, ²⁹ and the Kaiser risk calculator for early onset sepsis easier to implement.

That my first grandson was born at BMC in April 2019 and received the top-notch, evidence-based care that we had worked so hard on was awesome. ³⁰ Knowing that every mother receives this care—no matter her age, race, marital status, economic status, sexual preference, language preference, or any other variable—is glorious.