The ongoing Breastfeeding-Friendly Healthcare Initiative (BFHC) is an important CGBI endeavor designed to support North Carolina hospitals' efforts to implement the Ten Steps to Successful Breastfeeding and to define best practices for impactful and sustainable implementation of the Ten Steps.
To this end, CGBI is engaged with twelve hospitals representing all perinatal care regions in North Carolina. Participating hospitals serve a racially-diverse community where at least 60% of community members are eligible for Medicaid based on income.
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The Ten Steps to Successful Breastfeeding constitute an evidence-based quality-improvement initiative to increase breastfeeding rates in healthcare systems and beyond,i, ii, iii resulting in improved infant health and reduced infectious disease rates on a population level. First introduced at the 1988 Interagency Workshop on Health Care Practices Related to Breastfeedingviii these steps have been shown to be effective worldwide and in the US, including in settings with predominantly financially needy patients. The launch of the Ten Steps in the US in 1992 was held at the invitation of the Principal Investigator on this proposal who had served as the Technical Secretariat for the series of meeting where the Ten Steps were first confirmed.
Recent large-scale studies have found that even partial implementation of the Ten Steps in hospital increases breastfeeding rates and produces benefits that self-sustain beyond initial implementation. Studies have validated that with each additional two steps in place, breastfeeding rates and achievement of breastfeeding intention, even among primiparas, are significantly improved.iv These findings challenge the existing paradigm that full adherence to all steps is necessary for impact and indicate the need for an adapted step-wise program to encourage progress towards breastfeeding-friendly health care systems.
The global program that recognizes the achievement of the Ten Steps is known as the Baby-friendly Hospital Initiative (BFHI).v Only those maternities that fully implement the Ten Steps are eligible for designation by Baby-Friendly USA, the NGO responsible for assessing Baby Friendly healthcare facilities in the US today. This designation requires significant financial outlays on the part of the hospital for the training, assessment, granting and maintainance of the credential.vi Although the intent of the US Government in signing the Innocenti Declaration was to certify all hospitals by 1995vii, in the the 18 years since BFHI was introduced in the US, less than 3% have been certified (about 90 out of 3281) while the average worldwide is more than 25%.vii According to a Carolina Global Breastfeeding Institute study of North Carolina hospital administrators, as well as anecdotal evidence from other states, this ‘all-or-nothing’, costly accreditation process is a major deterrent for hospitals and leads to lack of interest in initiating work on this evidence-based package. In summary, the focus on designation, instead of processes of implementation, obstructs progress toward breastfeeding-friendly maternity care in the United States.
i Kramer MS, Matush L, Vanilovich I et al; PROBIT Study Group. Effects of prolonged and exclusive breastfeeding on child height, weight,adiposity, and blood pressure at age 6.5 y: evidence from a large randomized trial. Am J Clin Nutr. 2007 Dec;86(6):1717-21.
ii Phillip BL, Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics.2005 Sep;116(3):628-34.
iii Philipp BL, Malone KL, Cimo S, Merewood A. Sustained breastfeeding rates at a US baby-friendly hospital. Pediatrics. 2003 Sep;112(3 Pt 1):e234-6.
iv UNICEF. Appendix 3: Protecting, Promoting and supporting breastfeeding: the special role of Maternity Services: A joint WHO/Unicef Statement. In: Proceedings of the Interagency Workshop on Health Care Practices related to Breastfeeding, December 7-9,1988; (eds) Labbok M, McDonald M. IJOG, 1990, 31(Suppl.1):171-183.
v DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008 Oct;122 Suppl 2:S43-9.
vi WHO/UNICEF. Baby-Friendly Hospital Initiative: Revised, updated and expanded for integrated care. WHO, 2009. Accessed October 11 2009, (URL) http://www.who.int/nutrition/publications/infantfeeding/9789241594950/en/index.html
vii BFUSA, (URL) http://www.babyfriendlyusa.org/eng/index.html
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Ten Steps to Successful Breastfeeding (adapted by CGBI)
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The nine project hospitals in BFHC are home to more than 25,000, or nearly 1/5 of all births in North Carolina and much higher percent of the low-wealth births. All are committed in working toward self-sustaining, systemic change in breastfeeding services. BFHC will result in at least one ‘best practices site’ in each of the six perinatal care regions that cover the state. These facilities will serve as models for other hospitals in their regions.
The BFHC project design has two phases of intervention in six hospitals to support achievement of the “Ten Steps,” or ten breastfeeding supportive practices shown to impact breastfeeding success. The project has a strong evaluation component, with baseline data collection, end of first phase and end of second phase data collection, and an iterative process to Act, Assess, and Adapt in an ongoing manner. Following data collection, the findings are used to modify and adapt elements of the intervention, allowing hospital specific modifications as well.
Provider training is a key element of this project. We provide coordinated offerings of skills-based training for healthcare providers, sensitization of policy-makers, and basic skills and knowledge seminars for the larger population of healthcare providers. Feedback from the assessments was shared with leadership teams, and was used to tailor interventions on a site-specific basis, targetting education to the specific needs of the site.
This project is also making great strides toward increasing community awareness and support for quality breastfeeding services, enhancing sustainability by creating consumer demand. We convened and maintain a NC Stakeholders’ Group, comprised of health system, community and government leaders, to enhance impact and sustainability. Since the April, 2009 inaugural meeting, the group has been providing ongoing feedback, outreach to other opinion leaders/policy makers, and informing demand creation for breastfeeding-friendly practices and to overcome barriers, and develop plans for regional stakeholder meetings.
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We are actively evaluating and documenting the process and outcomes of BFHC, identifying best practices for dissemination, and collaborating with regional stakeholders’ groups and ‘best practices sites’ to expand breastfeeding-friendly practices to maternity facilities and communities across NC.
Breastfeeding-Friendly Healthcare project is a translational research study with a two-phased quasi-experimental intervention design. Hospitals were systematically assigned to Phase 1 or Phase 2 groupings, for early and later intervention, respectively. Baseline between groups comparisons were carried out using statistical and non-parametric tests. Research findings have been submitted for publication.
Funded by The Duke Endowment and The Kate B. Reynolds' Charitable Trust
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The Interstate Collaborative for Widespread Implementation of the Ten Steps is designed to address the need to accelerate the systematic implementation of the Ten Steps to Successful Breastfeeding as essential maternity care practices associate with optimal breastfeeding.
The short-term aims of the collaborative is to: 1) define best practices for implementation of the Ten Steps to Successful Breastfeeding on a state-by-state basis through collaboration among states with active programs, and 2) develop a specific research agenda for further study of opportunities and challenges to systematized implementation of evidence-based breastfeeding support in America’s hospitals.
The long term aims are to: 1) advance adherence to evidence-based and innovative strategies to increase breastfeeding rates in United States’ maternity centers, and 2) increase the number and quality of studies regarding the effectiveness of the World Health Organization's Baby-Friendly Hospital Initiative in the United States to reduce costs and increase impact.
“The final report of the Interstate Collaborative 2011 efforts are available for free download here. Note that there are four documents: the Final Report, Appendix A: Presentations and Handouts, Appendix B: Identified Barriers to Implementation of the Ten Steps to Successful Breastfeeding, and State-By-State Reports for Interstate TEN STEPS Collaborative. Please Cite as: Taylor E, Colgan B, Labbok M, with members of the Interstate Collaborative. Findings and Recommendations from the 2011 Meeting of the The Interstate Collaborative to Support Widespread Implementation of the Ten Steps to Successful Breastfeeding. Chapel Hill, NC: Carolina Global Breastfeeding Institute; 2012.”
Funded by the United States’ Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ)
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