A Geospatial Analysis of the Impact of the Baby-Friendly Hospital Initiative on Breastfeeding Initiation in North Carolina

A scoping review of policies to encourage breastfeeding, healthy eating, and physical activity among rural people and places in the United States

BACKGROUND

Rural U.S. residents experience a disproportionate burden of diet and physical activity (PA) related chronic disease compared to urban residents, due to resource and economic challenges. Diverse policy approaches for chronic disease prevention have been implemented to address barriers to breastfeeding, healthy eating, and PA. Therefore, the purpose of this paper is to describe policy supports for breastfeeding, healthy eating, and/or PA occurring in rural U.S. areas.

METHODS

A scoping review was conducted March-June 2020 to identify policy, systems, and environment change approaches occurring in the rural U.S. for breastfeeding, healthy eating, and PA. Search procedures were guided by the PRISMA-ScR, Arksey and O'Malley's work (2007), and a science librarian. Medline, PubMed, Web of Science, and Agricola were used to identify peer-reviewed research. ProQuest Dissertations and Theses A&I were used to identify dissertation research. Grey literature searches included Google, Google Scholar, government pages, and public health, federal nutrition assistance program, Cooperative Extension Services, and related webpages. Policy results are reported and inclusion criteria were: (1) breastfeeding, healthy eating, and/or PA focus; (2) about policy factors; (3) specific to U.S. rural populations/places; and (4) English language. Outcomes (study/source design, objective(s), methods/measurement, setting, population characteristics, behavioral focus, policy-specific results) were extracted into a standardized Excel document.

RESULTS

Results include 122 total sources: original research, with some sources referencing multiple behaviors, (n = 74 sources: 8 breastfeeding, 41 healthy eating, 42 PA), grey literature (n = 45 sources: 16 breastfeeding, 15 healthy eating, 27 PA), and graduate research (n = 3 sources: 1 breastfeeding, 2 healthy eating, 1 PA). Breastfeeding policy initiatives included policies or programs at hospitals, increasing access to resources, and improving culture or norms at workplaces. Healthy eating policy initiatives included increasing access to healthy foods, reducing financial burden, implementing programs, food assistance programs, and healthy food prescriptions at healthcare facilities. PA policy initiatives focused on Complete Streets, joint or shared use efforts, Safe Routes to Schools, master plans for greenways, trails, and/or transportation, school health plans, and childcare/school standards.

CONCLUSIONS

Results from this scoping review compile and offer commentary on existing policy solutions to improve breastfeeding, healthy eating, and/or PA in the rural U.S.

Missed care and equitable breastfeeding support: An integrative review of exposure to in-hospital care by patient characteristics and breastfeeding outcomes

AIM

To synthesize the literature on breastfeeding outcomes associated with exposure to internationally recognized best practices, such as the Baby-Friendly Hospital Initiative, for patients in the United States during the postpartum period, contextualized within the Missed Care Model.

DESIGN

The authors employed Whittemore and Knafl's integrative review framework and the 2020 PRISMA guidelines for data extraction, synthesis, reporting and assessment.

METHODS

Five electronic databases were searched for articles published between 2007 and 2023. Eligible articles reported on exposure to breastfeeding best practices and outcomes or the experiences, views, perceptions and attitudes of parents, nurses or lactation consultants regarding hospital breastfeeding support. Extracted data were compared to identify in-hospital exposure to breastfeeding best practices and breastfeeding outcomes, and differences in exposure and outcomes based on patient and provider characteristics.

RESULTS

Twenty-one quantitative, qualitative and mixed methods articles met inclusion criteria. A higher reported adherence to best practices was associated with greater odds of breastfeeding; some practices demonstrated greater effects overall or for specific groups. Higher exposures to best practices and higher breastfeeding rates were found for non-Hispanic white patients, and those with more education, private insurance and who live in urban areas. Disparities in support and outcomes were related to patients' race/ethnicity, language, weight and age. Qualitative findings reflected missed care concepts, such as internal processes related to habits and group norms, relevant to breastfeeding support.

CONCLUSION

Review findings also include an adapted Missed Care Model specific to breastfeeding support, which can inform future research related to providers' internal processes that may influence breastfeeding or equitable breastfeeding care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Missed care can be influenced by a variety of factors, including providers' internal values and beliefs. Study findings suggest the existence of inequities in breastfeeding care and underscore the need to address and eliminate breastfeeding disparities.

IMPACT

This study addressed how patient exposure to best practices in breastfeeding support relates to breastfeeding outcomes and whether exposure and outcomes differ by patient or provider characteristics, connecting this to the Missed Care in Breastfeeding Support Model. The main findings were that higher reported exposure to best practices in breastfeeding support related to improved breastfeeding outcomes; inequities exist in exposure to best practices; and patients and providers identify the importance of providers' internal processes in the delivery of breastfeeding support, which aligns with the Missed Care in Breastfeeding Support Model. Study findings will have the potential to impact how nurses, lactation consultants and other providers who deliver breastfeeding support in the postpartum hospital setting.

REPORTING METHOD

The authors adhered to relevant 2020 PRISMA reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Exploring Infant Feeding Experiences and Maternity Care Practices in Appalachia

OBJECTIVES

Our aim was to explore postpartum individuals' experiences and perceptions of breastfeeding and International Board Certified Lactation Consultants' (IBCLC) knowledge and perceptions of maternity care practices and perceived barriers to breastfeeding among their patient populations in Appalachia.

METHODS

Semistructured interviews were conducted with seven IBCLCs and seven postpartum individuals. Interviews were recorded and transcribed. Thematic analysis was conducted to determine emergent themes and subthemes related to knowledge/perceptions, experiences, and barriers to breastfeeding among postpartum individuals, as well as emergent themes associated with the knowledge and perceptions of maternity care practices, easy-/difficult-to-implement Baby-Friendly Hospital Initiative maternity care practices, and perceived barriers to breastfeeding among IBCLCs.

RESULTS

Postpartum individuals recruited from an Appalachian obstetrics/gynecology clinic were aware of the benefits of breastfeeding, but their infant feeding journeys were more stressful than they expected, and they had limited access to lactation support and breastfeeding education/information. IBCLCs identified the benefits of the Baby-Friendly maternity care practices but mentioned some risks, especially when there is a lack of communication and coordination among providers. Environmental and informational barriers were identified by both postpartum individuals and IBCLCs as breastfeeding challenges potentially amenable to change.

CONCLUSIONS

To support postpartum mothers in the Appalachian region, environmental barriers (eg, lack of lactation support) and informational barriers (eg, lack of prenatal education) need to be addressed.

The impact of the baby friendly hospital initiative on healthcare utilization among newborns insured by Medicaid in Delaware

BACKGROUND

The Baby Friendly Hospital Initiative was created to enhance breastfeeding, although its impact on infant healthcare utilization is unclear. Breast feeding infants are vulnerable to readmission soon after birth secondary to dehydration and hyperbilirubinemia. Breastfeeding can also protect infants from unnecessary health care utilization later in life by preventing infection. The objective of this study was to examine the impact of the Baby Friendly Hospital Initiative on readmissions and emergency department utilization among Medicaid births in Delaware.

METHODS

The study was a quasi-experimental design. Medicaid claims files were used to study births at five hospitals in Delaware born between January 1, 2014, and December 31, 2018, and covered under Medicaid at time of birth. Three hospitals were designated Baby Friendly, two were not and served as controls. Outcomes included Emergency Department (ED) utilization and readmissions within 30 days and one-year of birth hospitalization. Exposure to the Baby Friendly Hospital Initiative was determined by year and hospital of birth. Logistic regression and interrupted time series segmented regression analysis with controls were used to assess the effect of Baby Friendly Hospital Initiative on healthcare utilization.

RESULTS

In total, 19,695 infants were born at five hospitals with 80% (15,939) born at hospitals that were designated Baby Friendly. ED utilization and readmissions over the 1st year of life for breastfeeding related diagnosis at the Baby Friendly hospitals occurred in 240 (1.5%) and 226 (1.4%) of infants, respectively. Exposure to the Baby Friendly Hospital Initiative was associated with increased odds of all cause 30-day readmission (AOR: 1.15; 95% CI: 1.03-1.28) but not readmissions over the 1st year of life. While 30-day ED visits did not change after BFHI, one-year ED visits were reduced (0.91, 95% CI 0.86-0.97). A significant negative trend was seen over time for ED utilization post BFHI compared to controls (B: -5.90, p < 0.01).

CONCLUSION

There was a small observed increase in the odds of all cause 30-day readmissions with no change in one-year readmissions after BFHI in Delaware. Although there were no observed changes in 30-day ED utilization, there was a reduction in one-year ED utilization following the implementation of the Baby Friendly Hospital Initiative in Delaware birth hospitals. Our data help to inform policy and decision making for statewide systems of care that may be used to support breast feeding.

Positive Emotions During Infant Feeding and Breastfeeding Outcomes

BACKGROUND

Few studies have examined the role of maternal emotions in breastfeeding outcomes.

RESEARCH AIM

We aimed to determine the extent to which positive maternal emotions during human milk feeding at 2 months were associated with time to any and exclusive human milk feeding cessation and overall breastfeeding experience.

METHODS

A sample of 192 women intending to breastfeed for at least 2 months was followed from the third trimester until 12 months postpartum. Positive emotions during infant feeding at 2 months were measured using the modified Differential Emotions Scale. Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) for time to any and exclusive human milk feeding cessation associated with a 1-point increase in positive emotions. Linear regression was used to estimate the association between positive emotions and maternal breastfeeding experience reported at 12 months.

RESULTS

Among those human milk feeding at 2 months, positive emotions during feeding were not associated with human milk feeding cessation by 12 months (aHR = 0.94, 95% CI [0.64, 1.31]). However, among women exclusively human milk feeding at 2 months, a 1-point increase in positive emotions was associated with a 35% lower hazard of introducing formula or solid foods by 6 months (aHR = 0.65, 95% CI [0.46, 0.92]). Positive emotions were associated with a significantly more favorable maternal report of breastfeeding experience at 12 months. Results were similar in sensitivity analyses using maternal feelings about breastfeeding in the first week as the exposure.

CONCLUSIONS

A positive maternal emotional experience of feeding is associated with breastfeeding outcomes.