How Does Hospital Postpartum Care Affect Breastfeeding Outcomes?

1. How Does Hospital Postpartum Care Affect Breastfeeding Outcomes? Cynthia R Howard MD, MPH Associate Professor of Pediatrics and Community and Preventive Medicine University of Rochester School of Medicine and Dentistry

2. The Big Picture Stanley Ip, et al. Breastfeeding Medicine. October 2009, 4(s1): S-17-S-30. doi:10.1089/bfm.2009.0050.

3. Ever BF Acute Otitis Media GI infection Obesity Type 1 Diabetes SIDS Defined length of BF Asthma: (>=3 mo) Leukemia: (>=6mo) The Big Picture for Babies There are also benefits for mothers!!

4. The Baby Friendly Hospital Initiative • UNICEF/WHO Initiative • Targets hospitals and maternity units • Based on Ten Steps 1991

5. What Are The Ten Steps? • Recommended practices to support breastfeeding • Based on empiric evidence or (when this is lacking) expert opinion • Encompasses all aspects of perinatal care of moms/babies

6. The Ten Steps • Maintain a written breastfeeding policy that is routinely communicated to all health care staff • Train all health care staff in skills necessary to implement this policy • Inform all women about the benefits and management of breastfeeding • Help mothers initiate breastfeeding within a half-hour of birth • Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants

7. The Ten Steps • Give breastfeeding infants no food or drink other than breast milk, unless medically indicated • Encourage rooming-in -- mothers and infants should remain together twenty-four hours a day whenever feasible • Encourage unrestricted breastfeeding - when baby exhibits hunger cues or signals or on the request of the mother • Give no artificial nipples or pacifiers to breastfeeding infants • Refer mothers to established breastfeeding and/or mother’s support groups and services and foster the establishment of those services when they are not available

8. The Ten Steps • Written policy • Train staff • Educate pregnant women • Help initiate BF • Show how • Only Breastmilk • Rooming-in • On demand feeding • No bottles or pacifiers • Postpartum support

9. The Baby Friendly Initiative • Many thousands of hospitals worldwide • ~80 in the United States • Large tertiary care & small birth centers • Private & public • Several teaching hospitals • More hospitals have active certificates of intent 2009

10. PROBIT Trial JAMA. 2001 Jan 24-31;285(4):413-20 • 31 Hospitals randomized to BFHI or usual care • More than 16,000 moms/babies enrolled and followed for > 6 years • Exclusively BF at 3 months • 43% vs 6%; P<.001 • Exclusively BF at 6 months • 8% vs < 1%; P =.01 • Any BF 12 months • 20% vs 11% • Better Health Outcomes • GI infections 9% vs 13% • Atopic eczema 3% vs 6%

11. BFHI World Perspective • In Cuba, where 49 of the country's 56 hospitals and maternity facilities are baby-friendly, the rate of exclusive breastfeeding at four months almost tripled in six years - from 25 per cent in 1990 to 72 per cent in 1996 • In the first two years of BFHI implementation at the Central Hospital of Libreville in Gabon, cases of neonatal diarrhea fell by 15 per cent, diarrheal dehydration declined by 14 per cent and mortality fell by 8 per cent • In China, which now has more than 6,000 Baby-Friendly Hospitals, exclusive breastfeeding in rural areas rose from 29 per cent in 1992 to 68 per cent in 1994; in urban areas, the increase was from 10 per cent to 48 per cent • The Catholic University of Chile, Santiago, initiated one of the first baby-friendly hospitals. As a result, initiation of breastfeeding within the first two hours increased. With a strong Step 10, a monthly clinic, exclusive breastfeeding at 6 months increased from approximately 20% to over 60%.

12. Baby Friendly Hospitals in Developed Countries 2000 INDUSTRIALIZED COUNTRIES n=262 Australia 17 Austria 8 Belgium 0 Canada 1 Denmark 8 Finland 2 France 0 Germany 11 Greece 0 Iceland / Ireland 0 Israel 0 Italy 0 Japan 14 Korea (Rep.) 11 Lichtenstein / Luxembourg 1 Malta / Monaco / Netherlands 4 New Zealand 0 Norway 35 Portugal 0 San Marino / Singapore / Spain 4 Sweden 64 Switzerland 28 United Kingdom 29 United States 25

13. Research Team Ann Dozier, RN, PhD • Community and Preventive Medicine; University of Rochester Cynthia R Howard, MD, MPH • Pediatrics and Community and Preventive Medicine; University of Rochester, Rochester General Hospital Ruth A Lawrence, MD • Pediatrics and Obstetrics and Gynecology; University of Rochester Cynthia K Childs, MFA, MPH • Community and Preventive Medicine; University of Rochester Funded through APTR/CDC Cooperative Agreement T 1267

14. Study Question • Background • Maternity Care incorporating the Baby Friendly Ten Steps has been shown to increase breastfeeding duration • This study was designed to evaluate breastfeeding duration in women delivering at two community hospitals in Rochester NY, each with a well established but different maternity breastfeeding program Is a formal baby friendly program necessary for optimal postpartum breastfeeding support?

15. Background • Two Hospitals • Baby Friendly designated (BFHI) • Community Hospital (CH) with established breastfeeding program • Outcome • Breastfeeding duration and exclusivity at 6 months • The process evaluation focused on • The experiences of 400 BF women enrolled from each hospital post-delivery/before discharge

16. Program Evaluation

17. Program Evaluation Documents what patients receive or experience Avoids assumptions about what a program provides Where is there agreement?

18. Process Evaluation Methods • Three perspectives compared across the 10 steps of BFHI • Evaluation was completed before quantitative results were analyzed • To avoid biasing the interpretation of the evaluation

19. Process Evaluation Methods • Hospital administrators • 5 interviews with nursing/medical administrators at each hospital • Assessment included all 10 steps 10/10 Steps

20. Process Evaluation Methods • Inpatient nurses • BFH= 61; CH=43 • Working on inpatient/mother-baby unit • Anonymous survey, mailed to home address • Scored on 9 of the 10 Steps • Omitted Step 3 • No direct knowledge of whether the mother had been informed prenatally about the benefits of breastfeeding Nurses 9 of 10 Steps Mailed Survey

21. Process Evaluation Methods • Post partum mothers • BFH= 341; CH=321 • Completed an in-person interview & mailed survey 2 weeks after discharge • Captured hospital breastfeeding experience • 6 of 10 Steps (e.g. moms were not asked to comment on presence of written policies or training) Mothers 6/10 Steps Interview & Mailed Survey

22. Congruence on 6 of 10 Steps

23. Process Evaluation Methods • For comparisons, scores were standardized • Ratings above 90% were considered fully implemented • Partial implementation >75% • Between group differences of <20% indicated rating concurrence • Presentation simplified to < 80% or > 80% 80% is what Baby Friendly Looks for When Conducting Hospital Assessments

24. Example of Analysis STEP 6 Give newborn infants no food or drink other then breastmilk, unless medically indicated • Administrators • Do staff have a clear understanding of what the few acceptable reasons are for prescribing food or drink other than breast milk for breastfeeding babies? • Response options: Yes/No • Nurses • What are healthy breastfed babies given as a "first feeding"? –Breastmilk; • Response options: Always/Most of the time (75-100%), Sometimes , Seldom/Not at all (25% or less) • Mothers • Was your baby fed only breast milk during your hospital stay? • Response options: Yes/No

25. STEP 6:Give newborn infants no food or drink other then breastmilk, unless medically indicated Example of Analysis

26. Example of Analysis • Administrators and nurses at each hospital agreed that only breastmilk was to be given to well breastfed infants • BUT…..Mothers from both hospitals did not agree!!!! • These findings imply that program implementation may not be as consistent as the internal (administrators/nurses) assessments indicate

27. Hospital Administrator Scores

28. Baby Friendly Hospital • Based on the six steps rated by administrators, nurses and postpartum mothers • Administrators rated • 5 as Fully Implemented • 1 as Partially Implemented • Nurses rated • Agreed with all administrator ratings • Mothers rated • 4 of 5 implemented help initiating---show how---room-in--no pacifier

29. Community Hospital • Of the six chosen for comparison • Administrators rated • 5 as Fully Implemented • 1 as Partially Implemented • Nurses' ratings differed • 3 as Fully Implemented • They agreed with administrators on full implementation of 3 components • Mothers’ ratings • Of above 3 fully implemented by admin/nurses, mothers' ratings agreed with 1 • --show how to BF

30. Summary Baby Friendly • These hospitals had…. • some similarities based on program descriptions AND • their overall administrator scores were similar, BUT….. • they differed substantively on extent of implementation Community

31. Process Evaluation

32. Baby Friendly Hospital Births/Year ~2600 Teaching Yes LC Staffing 1:2166 FTE/births Formula Pack? No Nursery Level II Community Hospital Births/Year ~3400 Teaching Yes LC staffing 1:1214 FTE/births Formula Pack? Yes Nursery Level I Other Differences

33. So…… What? • This analysis reinforces the importance of documenting implementation to correctly interpret and attribute findings to a particular programmatic intervention • This evaluation may help explain between-hospital differences • May also define which components contribute to any outcome differences

34. NO SIGNIFICANT DIFFERENCES IN BASELINE POPULATION CHARACTERISITCS

35. Study ResultsBreastfeeding Outcomes • Breastfeeding Outcomes • Exclusive BF in the hospital • Any breastfeeding duration to six months • Analyses conducted using SAS • Chi-square used for bivariate analyses • Any breastfeeding duration to six months (Cox proportional survival analyses) • Variable selection was done in stepwise method, with entry of variables with a significance value of p < 0.25 and value for retention of p < 0.15 • Exclusive BF in the hospital (Logistic Regression)

36. Exclusive Breastfeeding in Hospital • Exclusive BF in the hospital was significantly more likely in the BFH (70%) vs CH (56%) p=.0002 • Early Exclusive BF after discharge (2 weeks) was also significantly more likely in mothers cared for at the BFH

37. Exclusive BF During the Hospital Stay All of these factors except for Mom’s age and weight are part of the Ten Steps

38. Breastfeeding to Six Months • 60% of women were still breastfeeding at six months postpartum • BFH 59.4% • CH 61.8% • NO SIGNIFICANT DIFFERENCES!!!!

39. Breastfeeding to Six Months Variable Tested Hazard Ratio p-value Maternal education 0.729 <.0001 Length of BF goal 0.618 <.0001 BF in first hour 0.670 .0049 Low confidence about BF 1.424 <.0001 Exclusive BF in hospital 0.640 .0015 Inner city resident 1.254 .2034 Felt pressured by 1.316 .2427 nurses to BF Hazard Ratios > 1 indicate an adverse impact on BF at 6 months

40. Process Evaluation

41. Process Evaluation 10 Steps Joint Commission Hospital Specific Rates Exclusive BF

42. Hospital Experiences of Moms Intending to Exclusively BF (n=915) Declercq E et. al. Am J Public Health. 2009;99:929–935 primiparas n=338; multiparas n-577

43. Hospital Support & Breastfeeding Success Among US Mothers 2005 • Help Initiating • Showing How • Encourage Feeding on Demand • Referral Support • Only BF/Avoiding Supplements • No Pacifiers • No Formula Samples • Global Question about Staff supporting BF 4 5 8 10 6 9 3 Differences in fulfillment are statistically significant across numbers of policies (P < .01). From: Hospital Practices and Women’s Likelihood of Fulfilling Their Intention to Exclusively Breastfeed Declercq E et. al. Am J Public Health. 2009;99:929–935

44. Process Evaluation 10 Steps Outpatient and Community Support

45. Social-ecological Model

47. An Ecologic Approach to Breastfeeding Support “The debate is over about the importance of breastfeeding for health outcomes for women and children in the United States. There is no debate. Yes, there is still a need for more research. We certainly need to know more about breastfeeding and how we’re able to support it. But we don’t need any more evidence in order to reach a conclusion about whether or not breastfeeding has important health outcomes that matter for the individual and for the population of children and women in this country. The real questions are: How do we support women and families in breastfeeding and exclusively breastfeeding? What can the healthcare system itself do? What is our responsibility? How are we currently supporting it, and how are we currently sabotaging it? What can employers do? What can society in general do? What can policy makers and the government do? That’s an ecological approach to answering this question.” —David Meyers, M.D., FAAFP Agency for Healthcare Research and Quality During the First Annual Summit on Breastfeeding June 11, 2009 ‘The debate is over about the importance of breastfeeding for health outcomes for women and children in the United States’

48. An Ecologic Approach to Breastfeeding Support “The real questions are: How do we support women and families in breastfeeding and exclusively breastfeeding? What can the healthcare system itself do? What is our responsibility? How are we currently supporting it, and how are we currently sabotaging it? What can employers do? What can society in general do? What can policy makers and the government do? That’s an ecological approach to answering this question.”

49. Babies Are Born to Breastfeed What can government do? What can health care do? What can society do? What can business do?

50. Take Home Points • Process evaluation is a useful tool when attempting to examine how and why programs affect health outcomes • A hospital program incorporating the Ten Steps increased short term exclusive breastfeeding in comparison to a well established program not based on the Ten Steps • Exclusive BF in the hospital is the first step to Exclusive BF for six months. For best outcomes hospital maternity care around breastfeeding should incorporate the Ten Steps • BFH don’t necessarily provide better long term BF outcomes