Best Fed Beginnings: A Nationwide Quality Improvement Initiative to Increase Breastfeeding

Unpacking Breastfeeding Disparities: Baby-Friendly Hospital Designation Associated with Reduced In-Hospital Exclusive Breastfeeding Disparity Attributed to Neighborhood Poverty

OBJECTIVES

To examine US in-hospital exclusive breastfeeding (EBF) and the associations with Baby-Friendly designation and neighborhood sociodemographic factors.

METHODS

Hospital data from the 2018 Maternity Practices in Infant Nutrition and Care survey were linked to hospital zip code tabulation area (ZCTA) sociodemographic data from the 2014-2018 American Community Survey (n = 2,024). The percentages of residents in the hospital ZCTA were dichotomized based on the relative mean percentage of the hospital's metropolitan area, which were exposure variables (high/low Black hospitals, high/low poverty hospitals, high/low educational attainment hospitals) along with Baby-Friendly designation. Using linear regression, we examined the associations and effect measure modification between Baby-Friendly designation and hospital sociodemographic factors with in-hospital EBF prevalence.

RESULTS

US mean in-hospital EBF prevalence was 55.1%. Baby-Friendly designation was associated with 9.1% points higher in-hospital EBF prevalence compared to non-designated hospitals [95% confidence interval (CI): 7.0, 11.2]. High Black hospitals and high poverty hospitals were associated with lower EBF prevalence (difference= -3.3; 95% CI: -5.1, -1.4 and - 3.8; 95% CI: -5.7, -1.8). High educational attainment hospitals were associated with higher EBF prevalence (difference = 6.7; 95% CI: 4.1, 9.4). Baby-Friendly designation was associated with significant effect measure modification of the in-hospital EBF disparity attributed to neighborhood level poverty (4.0% points higher in high poverty/Baby-Friendly designated hospitals than high poverty/non-Baby-Friendly designated hospitals).

Promoting maternal-child health by increasing breastfeeding rates: a National Canadian Baby-Friendly Initiative Quality Improvement Collaborative Project

While breastfeeding has long been an important, globally recognized aspect of population health, disparities exist across Canada. The Baby-Friendly Initiative (BFI) is a WHO/UNICEF best-practice program that helps ensure families receive evidence-based perinatal care and is associated with improved breastfeeding rates. However, <10% of hospitals in Canada are designated as 'Baby-Friendly'.The Breastfeeding Committee for Canada (BCC) aimed to increase the number of hospitals that moved towards BFI designation by implementing a National BFI Quality Improvement Collaborative Project. Key activities included (1) implementing and evaluating the BFI Project with 25 hospital teams across Canada and (2) making recommendations for scaling up BFI in Canada.As of December 2023, three hospitals in the BFI Project have attained designation and six have started the official process towards designation with the BCC. Breastfeeding initiation rates remained high and stable (>80%); however, breastfeeding exclusivity rates did not meet targets. All BFI care indicators improved across participating facilities. All skin-to-skin indicators improved, with rates of immediate and sustained skin-to-skin meeting targets of >80% for vaginal births. BFI care indicators of documented assistance and support with breastfeeding within 6 hours of birth, rooming-in and education about community supports also met target levels. Leadership buy-in, parent partner engagement and collaborative activities of workshops, webinars and mentoring with BFI Project leadership were viewed as valuable.This BFI Project demonstrated that hospitals could successfully implement Baby-Friendly practices in various Canadian settings despite challenges introduced by the COVID-19 pandemic. Indicators collected as part of this work demonstrate that delivery of Baby-Friendly care improved in participating facilities. Sustainability and scaling up BFI implementation in both hospitals and community health services across Canada through implementation of a BFI Coach Mentor Program is ongoing to enable continued progress and impact on breastfeeding and maternal-child health.

A quality improvement project to improve voluntary milk donation in a human milk bank in South India

Background

Mother's milk is the ideal food for a neonate. When mother's milk is unavailable for any reason, pasteurised donor human milk (PDHM) is the next best option. This quality improvement (QI) project aimed at improving voluntary donation in a public human milk bank (HMB) in South India.

Methods

Between January 2018 and June 2019, the HMB received an average of 15 L of donor milk per month (0.5 L/day). Our aim was to increase voluntary donation by 50% from the baseline over a period of 8 months from July 2019 to March 2020 using QI methods. Two plan-do-study-act (PDSA) cycles were done during the intervention period (4 months). Interventions included the formation of micro teams in postnatal wards to promote exclusive breastfeeding and to liaison with the core QI team. We created a milk expression area in the postnatal ward, counseled postnatal mothers, and addressed supply chain issues like sterile pumping accessories.

Results

The average daily voluntary milk donation to HMB increased from 0.83 L/day in the baseline phase to 1.16 and 1.14 L per day in the intervention and postintervention phases, respectively. The mean (SD) monthly donated volumes increased from 28.2 (6.1) L to 34.1 (3.7) L; mean difference (95% CI) 5.9 (0.33-11.4); P = 0.03. The volume of PDHM disbursed from HMB increased from 26.6 (3.2) L/month to 32.2 (9.2) L/month, although not statistically significant (p = 0.15). The number of mothers donating milk did not increase during the study period.

Conclusions

A multipronged QI intervention effort focusing on exclusive breastfeeding improved voluntary milk donation in HMB bank. Multiple micro-teams and local networking facilitated the QI initiative.

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

BACKGROUND

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.

METHODS

This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.

RESULTS

A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.

CONCLUSION

At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

Policies and Practices in a Cohort of Mississippi Birthing Hospitals During the COVID-19 Pandemic

Background and Objectives: Guidance around maternity care practices and infant feeding during the COVID-19 pandemic changed over time and was sometimes conflicting. Hospital maternity practices influence breastfeeding, an important preventive strategy against viral illness. Most birthing hospitals in Mississippi are enrolled in CHAMPS, a quality improvement initiative to support breastfeeding and continuously collect maternity care data. The aims of this study were to (1) assess changes to maternity care policies in response to COVID-19, and (2) compare hospital-level breastfeeding, skin-to-skin, and rooming-in rates, at cohort hospitals, before and during the pandemic, overall and stratified by race. Methods: Hospitals responded to a survey on maternity policies in May and September 2020 (Aim 1); hospitals submitted data on breastfeeding and maternity care practices before and during the pandemic (Aim 2). We tested for differences in survey responses using chi-squared statistics and performed an interrupted time series analysis on breastfeeding and maternity care practices data. Results: Twenty-six hospitals responded to the May and September 2020 surveys. Hospitals used different sources to create maternity care policies, and policies differed between institutions. Trends in rates of any and exclusive breastfeeding in the hospital cohort plateaued during the pandemic, in comparison to previous gains, and rates of skin-to-skin and hospital rooming-in decreased. No differences were evident between races. Conclusions: Policies (Aim 1) and practices in the quality improvement cohort hospitals were inconsistent during the COVID-19 pandemic, and changes measured to practices were detrimental (Aim 2). Ongoing monitoring is recommended.

Assessing the impact of a statewide effort to improve breastfeeding rates: A RE‐AIM evaluation of CHAMPS in Mississippi

Communities and Hospitals Advancing Maternity Practices (CHAMPS) is a public health initiative, operating in Mississippi since 2014, to improve maternal and child health practices and reduce racial disparities in breastfeeding. Using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, this study assessed CHAMPS, which used a Quality Improvement intervention at hospitals, and engaged intensively with local community partners. The study team assessed outcomes through quantitative data (2014–2020) from national sources, Mississippi hospitals, community partners and CHAMPS programme records, and qualitative data from focus groups. With 95% of eligible Mississippi hospitals enrolled into CHAMPS, the programme reached 98% of eligible birthing women in Mississippi, and 65% of breastfeeding peer counsellors in Mississippi's Special Supplemental Nutrition Programme for Women, Infants and Children. Average hospital breastfeeding initiation rates rose from 56% to 66% (p < 0.05), the proportion of hospitals designated Baby‐Friendly or attaining the final stages thereof rose from 15% to 90%, and 80% of Mississippi Special Supplemental Programme for Women, Infants, and Children districts engaged with CHAMPS. CHAMPS also maintains a funded presence in Mississippi, and all designated hospitals have maintained Baby‐Friendly status. These findings show that a breastfeeding‐focused public health initiative using broad‐based strategic programming involving multiple stakeholders and a range of evaluation criteria can be successful. More breastfeeding promotion and support programmes should assess their wider impact using evidence‐based implementation frameworks.

The breastfeeding promotion programme successfully engaged with 95% of birthing hospitals in Mississippi to increase breastfeeding initiation and exclusivity, skin‐to‐skin and rooming rates and to decrease racial disparities in breastfeeding.

Broad‐scale breastfeeding promotion and engagement initiatives can be successfully implemented and assessed using evidence‐based implementation science frameworks.

Widespread change in health care practices is possible when implemented in partnership with diverse institutions and community groups.

Predicting exclusive breastfeeding in maternity wards using machine learning techniques

BACKGROUND AND OBJECTIVE

Adequate support in maternity wards is decisive for breastfeeding outcomes during the first year of life. Quality improvement interventions require the identification of the factors influencing hospital benchmark indicators. Machine Learning (ML) models and post-hoc Explainable Artificial Intelligence (XAI) techniques allow accurate predictions and explaining them. This study aimed to predict exclusive breastfeeding during the in-hospital postpartum stay by ML algorithms and explain the ML model's behaviour to support decision making.

METHODS

The dataset included 2042 mothers giving birth in 18 hospitals in Eastern Spain. We obtained information on demographics, mothers' breastfeeding experiences, clinical variables, and participating hospitals' support conditions. The outcome variable was exclusive breastfeeding during the in-hospital postpartum stay. We tested algorithms from different ML families. To evaluate the ML models, we applied 10-fold stratified cross-validation. We used the following metrics: Area under curve receiver operating characteristic (ROC AUC), area under curve precision-recall (PR AUC), accuracy, and Brier score. After selecting the best fitting model, we calculated Shapley's additive values to assign weights to each predictor depending on its additive contribution to the outcome and to explain the predictions.

RESULTS

The XGBoost algorithms showed the best metrics (ROC AUC = 0.78, PR AUC = 0.86, accuracy = 0.75, Brier = 0.17). The main predictors of the model included, in order of importance, the pacifier use, the degree of breastfeeding self-efficacy, the previous breastfeeding experience, the birth weight, the admission of the baby to a neonatal care unit after birth, the moment of the first skin-to-skin contact between mother and baby, and the Baby-Friendly Hospital Initiative accreditation of the hospital. Specific examples for linear and nonlinear relations between main predictors and the outcome and heterogeneity of effects are presented. Also, we describe diverse individual cases showing the variation of the prediction depending on individual characteristics.

CONCLUSION

The ML model adequately predicted exclusive breastfeeding during the in-hospital stay. Our results pointed to opportunities for improving care related to support for specific mother's groups, defined by current and previous infant feeding experiences and clinical conditions of the newborns, and the participating hospitals' support conditions. Also, XAI techniques allowed identifying non-linearity relations and effect's heterogeneity, explaining specific cases' risk variations.

Postnatal Unit Experiences Associated With Exclusive Breastfeeding During the Inpatient Stay: A Cross-Sectional Online Survey

BACKGROUND

Efforts to provide accessible and effective infant feeding support are advancing to set up new families to meeting their goals. However, data continue to be limited for understanding how inpatient postpartum support and experiences contribute to exclusive breastfeeding during hospitalization.

RESEARCH AIMS

To explore postnatal unit experiences including skin-to-skin contact, overnight support, rooming-in, responsive clinicians, and understandable communication that correlate with early infant feeding outcomes among a sample of mothers who intended to breastfeed.

METHODS

This was a prospective cross-sectional survey study. Through secure online survey, participants submitted (N = 2,401) responses from November 2016 to May 2017 about their experiences with maternity healthcare and offered thoughts on the postnatal unit environment. Descriptive statistics were used to examine distributions of maternal characteristics, postpartum experience, and birthing facility characteristics.

RESULTS

Exclusive breastfeeding was positively correlated with the following postnatal unit experiences: mother did not ask that her infant be taken out of the postnatal unit room; infant staying in postnatal unit room except for treatment(s); mother got help from clinical staff when needed after pressing the call button; and nurse, midwife, and/or doctor always explained information to mother in ways that they understood.

CONCLUSION

Postnatal unit experiences associated with exclusive breastfeeding during postpartum hospitalization were rooming in; parents who did not ask for their infant to be taken out of the unit room; whether mothers received timely help from clinical staff; and information was explained in a way they could understand.

Mississippi CHAMPS: Decreasing Racial Inequities in Breastfeeding

Mississippi CHAMPS addressed racial inequities in breastfeeding by implementing community and hospital-based practice changes in accordance with the BFHI and by parallel community work.

Twenty Years Baby-Friendly: Personal Reflections on Change

Background: Boston Medical Center (BMC) is an inner-city hospital located in Boston, Massachusetts. In 1995, like many maternity hospitals in the United States, 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 any limitations on the presence of the formula industry in the hospital. This all changed in 1999 when BMC became the first Baby-Friendly designated hospital in Massachusetts and the 22^nd in the nation. Objective: Describe challenges encountered on the hospital's journey to Baby-Friendly and subsequent re-designations and share strategies used to overcome them. Materials and Methods: Policy changes and new programs instituted over the twenty-year period are described as well as personal reflections on change by the author. Results: Over the time period chronicled, improvements in breastfeeding initiation and exclusivity rates were observed. From 1997 to 2019, the breastfeeding initiation rate increased from 53% to 90% and the exclusive breastfeeding rate increased from 6% to 50-60%. Delivery volume at the hospital increased from 1600 to 2850 births per year in the same time period. Following the Ten Steps is an important way to decrease racial disparity gaps. Conclusions: Change is possible in the hospital setting. Achieving and maintaining Baby-Friendly designation is a successful strategy to increase maternity unit breastfeeding rates.

Differences in Exclusive Breastfeeding Rates in US Hospitals According to Baby-Friendly Hospital Initiative Designation and Area Deprivation Index Category

Background: Disparities in breastfeeding persist placing a greater burden of disease on non-Hispanic black and Hispanic women and infants. Targeted implementation of the Baby-Friendly Hospital Initiative (BFHI) in areas at risk for poor breastfeeding outcomes has been shown to improve disparities in breastfeeding. The area deprivation index (ADI), a measure of the relative socioeconomic disadvantage of a neighborhood, may be useful in exploring the accessibility of BFHI hospitals in highly deprived areas and the differences in exclusive breastfeeding (EBF) rates in hospitals with and without the BFHI designation across deprivation categories. Objective: To evaluate the geographical distribution of BFHI and non-BFHI hospitals across ADI categories and explore the differences in EBF rates in BFHI and non-BFHI hospitals across ADI categories. Methods: Hospital EBF rates obtained from the Joint Commission included 414 BFHI and 1,532 non-BFHI hospitals. State ADI rank scores were determined for each hospital's census block group. Descriptive statistics were used to describe the geographic distribution of BFHI hospitals across three ADI categories (low, medium, and high). EBF rates across ADI categories and BFHI designations were compared using multiway analysis of variance. Results: The distribution of BFHI was similar across all ADI categories, ranging from 18% to 24%. EBF rates were 4.9% lower in highly deprived areas compared to areas with lower deprivation (p < 0.01). BFHI was associated with significantly higher EBF rates across all ADI categories (6.9%-11.2%, p < 0.01). Conclusion: ADI may be a useful tool for targeting the implementation of BFHI in hospitals in highly deprived areas to reduce breastfeeding disparities.

Sudden Unexpected Infant Death: Keeping the Newborn Safe in Hospital and at Home

Sudden unexpected infant death is a leading cause of death in infancy. Both safe sleep practices and breastfeeding can help decrease the risk, although the current practice of educating parents about the recommendations has not resulted in universal adherence. Prenatal counseling provides opportunities to discuss recommendations as well as troubleshoot common barriers to breastfeeding and safe infant sleep with goals to gradually change attitudes, address social norms, and prepare new parents. A conversational, motivational approach to discussions about the importance of safe sleep and continued breastfeeding, with explanations as to the reasoning behind these recommendations, can help parents incorporate optimal practices into their lifestyles in a way that is sustainable for adherence.

Promoting equity in breastfeeding through peer counseling: the US Breastfeeding Heritage and Pride program

BACKGROUND

In the United States, Black and Hispanic mothers have lower breastfeeding rates compared with White mothers. To address breastfeeding inequities, the Breastfeeding Heritage and Pride program (BHP) provides breastfeeding support for predominately low-income minority mothers in Connecticut and Massachusetts. We described the process of designing BHP, the program model, and its impact on breastfeeding outcomes.

METHODS

This BHP case study is based on in-depth interviews with BHP designers and implementers, peer counselors, and clients; a literature review of BHP impact evaluation studies; and a review of BHP materials. To guide the analysis and organize results, we used the Community Energy Balance Framework, an equity-oriented, multi-level framework for fostering healthy lifestyles.

RESULTS

The Hispanic Health Council designed BHP to address barriers to breastfeeding identified through formative qualitative research with the Latino community, namely lack of role models, limited social support, embarrassment when breastfeeding in public, lack of breastfeeding knowledge, and a norm of formula feeding. According to the BHP model, clients receive education and support through in-person home and hospital visits supplemented by phone calls, beginning prenatally and continuing through one year postpartum. Counseling is delivered by peer counselors, women who have successfully breastfed, have similar cultural roots and life experiences as the clients they serve, and have completed intensive training on lactation management and communication skills. International Board Certified Lactation Consultants provide clinical guidance and ongoing training to peer counselors, as well as direct support to clients, if more specialized knowledge and clinical expertise is needed. Clients facing housing and food insecurity or other socio-economic obstacles that may negatively influence breastfeeding and health and well-being more broadly are connected to other health and social services needed to address their social determinants of health needs, including health care access and food and rent assistance programs. To continuously improve service delivery, BHP has a robust monitoring and evaluation system. In two randomized-controlled trials, BHP was shown to improve breastfeeding initiation and duration of any and exclusive breastfeeding.

CONCLUSIONS

BHP highlights the importance of community-engaged formative research for informing breastfeeding program design. It also provides an evidence-based example of a program model that offers a continuum of breastfeeding support, considers cultural-contextual influences on breastfeeding and social determinants of health, and incorporates continuous quality improvement.

Association Between Breastfeeding Discouragement and Breastfeeding Behaviors

OBJECTIVE

To examine the association between subjective norms and breastfeeding behaviors and to assess whether individual characteristics modify this association.

DESIGN

Retrospective cohort study.

SETTING

Florida, 2004 to 2005; Louisiana, 2004; and Ohio, 2009 to 2010.

PARTICIPANTS

Stratified systematic sample of respondents who completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey from three states (N = 5,378).

METHODS

We used PRAMS data to examine the associations between three independent variables (breastfeeding discouragement by others and number and type of normative referents) and three breastfeeding behaviors (breastfeeding initiation and breastfeeding duration at 4 weeks and 10 weeks after birth) using multivariable log binomial regression. We also examined whether maternal characteristics modified the association between breastfeeding discouragement by others and breastfeeding behaviors.

RESULTS

Respondents who reported that others discouraged them from breastfeeding were more likely to initiate breastfeeding (adjusted relative risk (RR) = 0.78, 95% confidence interval [CI] [0.64, 0.96]) than those who were not discouraged. Furthermore, in the total sample, breastfeeding discouragement from others was not associated with breastfeeding discontinuation by 4 weeks and 10 weeks after birth. Breastfeeding discouragement from health care providers was associated with a greater incidence of noninitiation among respondents who reported breastfeeding discouragement from others (adjusted RR = 2.82, 95% CI [1.88, 4.22]).

CONCLUSIONS

Findings suggest that women may be motivated to initiate breastfeeding because of their beliefs and emotions despite being discouraged by others. However, discouragement by health care providers was associated with decreased initiation. This underscores a need for the continued implementation and scale-up of evidence-based maternity care practices and education of providers and the public to support breastfeeding.

Impact of Institutional Breastfeeding Support in Very Low-Birth Weight Infants

Background and Objectives: Feeding of human milk is associated with improved health outcomes in preterm infants. Mothers of preterm infants have difficulty establishing and maintaining an adequate milk supply. Our institution participated in Best Fed Beginnings (BFB), a national breastfeeding quality improvement collaborative, in 2012. Although most practice changes targeted healthy term infants, we hypothesized that mother's milk feeding (MMF) to preterm infants would also improve. Our objective was to compare MMF in very low-birth weight (VLBW) infants at discharge before and after our participation in BFB. Materials and Methods: We completed a retrospective chart review of VLBW infants born between January 2006 and June 2016. The primary outcome measure was the percentage of VLBW infants receiving MMF at hospital discharge. We used Fisher's exact test to determine the difference before and after 2012 and performed the Kruskal-Wallis test to determine changes in median time to pump initiation in mothers of VLBW infants. Multiple logistic regression was used to determine variables associated with the primary outcome. Results: A total of 1,077 VLBW infants were eligible. After launching BFB, MMF at discharge increased in VLBW infants, from 35.2% to 46.0%, p < 0.001. Median time to pump initiation decreased from 11 to 5 hours after 2012, p = 0.0001. Factors significantly associated with receiving MMF at discharge included birth post-BFB; private insurance; non-Black race; shorter length of stay; older maternal age; and mother's milk as first feeding. Conclusions: Hospital culture supportive of breastfeeding impacts not only healthy term infants but also VLBW infants. Earlier initiation of milk expression significantly improves provision of MMF to preterm infants at discharge.

Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020

Racial and ethnic disparities in women's health have existed for decades, despite efforts to strengthen women's reproductive health access and utilization. Recent guidance by the American College of Obstetricians and Gynecologists (ACOG) underscores the often unacknowledged and unmeasured role of racial bias and systemic racial injustice in reproductive health disparities and highlights a renewed commitment to eliminating them. Reaching health equity requires an understanding of current racial-ethnic gaps in reproductive health and a concerted effort to develop and implement strategies to close gaps. We summarized national data for several reproductive health measures, such as contraceptive use, Pap tests, mammograms, maternal mortality, and unintended pregnancies, by race-ethnicity to inform health-equity strategies. Studies were retrieved by systematically searching the PubMed (2010-2020) electronic database to identify most recently published national estimates by race-ethnicity (non-Hispanic Black or African American, Hispanic or Latinx, and non-Hispanic White women). Disparities were found in each reproductive health category. We describe relevant components of the Affordable Care Act (ACA) and the Preventing Maternal Deaths Act, which can help to further strengthen reproductive health care, close gaps in services and outcomes, and decrease racial-ethnic reproductive health disparities. Owing to continued diminishment of certain components of the ACA, to optimally reach reproductive health equity, comprehensive health insurance coverage is vital. Strengthening policy-level strategies, along with ACOG's heightened commitment to eliminating racial disparities in women's health by confronting bias and racism, can strengthen actions toward reproductive health equity.

Experiences of Breastfeeding among Disabled Women

BACKGROUND

Although breastfeeding has been extensively studied, there remains a paucity of data about the breastfeeding experiences of disabled women. Despite indications of similar pregnancy rates, disabled women seem to breastfeed at lower rates. Emerging research on the intersection of breastfeeding and disability has begun to shed light on how aspects of disability may impact breastfeeding.

METHODS

This digital and participatory action research study used semistructured video or telephone interviews to evaluate the experiences of breastfeeding among 24 disabled women through descriptive content analysis. The cross-disability sample was composed of women with self-identified intellectual, developmental, physical, sensory, and psychiatric disabilities. Some women had multiple disabilities.

RESULTS

Qualitative analysis revealed four themes relating to breastfeeding among disabled women: 1) communication difficulties with lactation consultants, 2) milk supply and latch problems, 3) intense pressure to breastfeed, and 4) positive interactions with health care providers.

CONCLUSIONS

This study provides new information about the breastfeeding experiences of women with disabilities. Our findings suggest that disabled women should be better supported in their breastfeeding decisions and require greater access to disability-affirmative and informative clinical resources and accessible communication.

Improving exclusive breast feeding in the first 24 h of life using Plan-Do-Study-Act cycle in a tertiary care hospital

BACKGROUND

Breast milk is the most ideal form of nutrition for neonates, but the rate of early initiation of breast feeding is as low as 41.6% in India. We aimed to improve the proportion of new-borns on exclusive breast feeds in first 24 h after birth in our hospital from a baseline rate of 33% to more than 90% by 6 weeks using concepts of quality improvement (QI) initiative.

METHODS

We implemented this QI initiative using Plan-Do-Study-Act (PDSA) cycles and the project was conducted from 07 May 2017 to 17 Jun 2017. All singleton term neonates with birth weight above 2.5 kg were included. Neonates requiring any form of resuscitation at birth, respiratory distress requiring any form of respiratory support, and neonates requiring observation in NICU for any other reason were excluded. We ran PDSA cycles (including educating residents and nurses on breast feeding, initiating skin to skin contact and breast feeding in first hour of birth, demonstrating all mothers face to face about attachment and positioning and restriction on issue of formula milk) to improve breast feeding exclusivity.

RESULTS

A total of 199 neonates were enrolled, over a span of 6 weeks. We could achieve sustained exclusive breast feeding in first 24 h of life in more than 90% of the enrolled neonates by adhering to the QI initiative.

CONCLUSION

This QI project using PDSA methodology has significantly improved the rates of exclusive breast feeding in first 24 h of life in normal neonates roomed in with their mothers.

Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth

OBJECTIVE

To determine if implementation of skin-to-skin care and the Baby-Friendly Hospital Initiative (BFHI) contributes to sudden unexpected infant death (SUID) and asphyxia in the first 6 days after birth.

STUDY DESIGN

Survey data were used to determine a correlation between BFHI and deaths from SUID and asphyxia among infants <7 days in the US and Massachusetts. Using data from the Centers for Disease Control and Prevention, implementation of BFHI was tracked from 2004-2016 and skin-to-skin care was tracked from 2007-2015. Using data from Centers for Disease Control and Prevention WONDER and the Massachusetts Department of Public Health, SUID and asphyxia were tracked from 2004-2016.

RESULTS

Nationally, births in Baby-Friendly facilities rose from 1.8% to 18.3% and the percentage of facilities in which most dyads experienced skin-to-skin care rose from 40% to 83%. SUID prevalence among infants <7 days was rare (0.72% of neonatal deaths) and decreased significantly from 2004-2009 compared with 2010-2016, from 0.033 per 1000 live births to 0.028, OR 0.85 (95% CI 0.77, 0.94). In Massachusetts, births in Baby-Friendly facilities rose from 2.8% to 13.9% and skin-to-skin care rose from 50% to 97.8%. SUID prevalence decreased from 2010-2016 compared with 2004-2009: OR 0.32 (95% CI 0.13, 0.82), with 0 asphyxia deaths during the 13-year period.

CONCLUSION

Increasing rates of breastfeeding initiatives and skin-to-skin care are temporally associated with decreasing SUID prevalence in the first 6 days after birth in the US and Massachusetts.

Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: Public Policy Implications

OBJECTIVES

To compare the impact of Baby-Friendly designation vs rates of in-hospital breastfeeding initiation on breastfeeding outcomes at 3, 6, and 12 months postdischarge.

STUDY DESIGN

Breastfeeding outcome data from the 2018 Centers for Disease Control (CDC) Breastfeeding Report Card were used as a basis for determining outcomes from the corresponding 2015 birth cohort. Linear regression models were used to determine the strength of association of breastfeeding initiation and Baby-Friendly hospital penetrance and attainment of postdischarge breastfeeding rates. All hospital births from all 50 states, 3 territories, and the District of Columbia were included in the study.

RESULTS

Statewide breastfeeding initiation rates were positively associated with targeted breastfeeding outcomes. Similar associations were not found for Baby-Friendly hospital designation penetrance.

CONCLUSIONS

To attain the Healthy People 2020 breastfeeding objectives, future public policy initiatives should consider the interaction of population demographics, individual hospital programs, and public health strategies used to support breastfeeding in states reporting high breastfeeding initiation rates.

National Trends in the Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infants

IMPORTANCE

Human milk confers important health benefits to very low-birth-weight (VLBW) infants (≤1500 g). The extent to which the use of human milk has changed over time and the factors associated with human milk use nationally in this population are poorly understood.

OBJECTIVES

To describe US trends in the provision of human milk at hospital discharge for VLBW infants during the past decade according to census region and maternal race/ethnicity, quantify associations of census region and maternal race/ethnicity with the provision of human milk at hospital discharge, and examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted of 346 248 infants, born at 23 to 29 weeks' gestation or with a birth weight of 401 to 1500 g, who were cared for at 802 US hospitals in the Vermont Oxford Network from January 1, 2008, to December 31, 2017. The US census region was categorized as West, Midwest, Northeast, and South (reference). Maternal race/ethnicity was categorized as non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian and Pacific Islanders, and Native American.

MAIN OUTCOMES AND MEASURES

Any provision of human milk at hospital discharge, defined as the use of human milk as the only enteral feeding or the use of human milk in combination with fortifier or formula.

RESULTS

Of the 346 248 infants in the study (172 538 boys and 173 710 girls), 46.2% were non-Hispanic white, 30.1% were non-Hispanic black, 18.3% were Hispanic of any race, 4.7% were Asian and Pacific Islanders, and 0.8% were Native American. Any provision of human milk at hospital discharge increased steadily among all infants, from 44% in 2008 to 52% in 2017. There were increases across all US census regions and racial/ethnic groups. Any provision of human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19), compared with the South, and was higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) and lower among Hispanic (among singleton births: adjusted prevalence ratio, 0.98; 95% CI, 0.96-1.01; among multiple births: adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91), Native American (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69), and non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60), compared with non-Hispanic white mothers. These results were robust to adjustment for birth year and infant characteristics. Wide regional and state variations were found in any provision of human milk at hospital discharge.

CONCLUSIONS AND RELEVANCE

Overall prevalence of any provision of human milk at hospital discharge among VLBW infants has steadily increased during the past decade. Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.

Associations Between Breastfeeding Initiation and Infant Mortality in an Urban Population

Background: Breastfeeding promotion and support are not universally accepted in the United States as a strategy to reduce infant mortality. We investigated associations between breastfeeding and infant mortality in an urban population with high infant mortality and low breastfeeding rates. Methods: A retrospective epidemiologic study linked birth-infant death data for 148,679 live births in Shelby County, Tennessee from January 2004 to December 2014. Births <500 g, deaths ≤7 days, deaths because of congenital anomalies or malignant neoplasms, and records with missing breastfeeding status were excluded. Main outcomes were infant death before the first birthday, neonatal death <28 days, and postneonatal death ≥28 days by ever or never breastfed. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for breastfeeding initiation were adjusted for maternal factors and infant factors. Results: Initiation of breastfeeding was associated with a significant reduction in total infant mortality (OR = 0.81, 95% CI = 0.68-0.97, p = 0.023). Neonatal mortality was also significantly reduced with any breastfeeding (OR = 0.49, 95% CI = 0.34-0.72, p = 0.001). Postneonatal mortality was not significantly associated with breastfeeding initiation in the overall population (OR = 0.95, 95% CI = 0.78-1.17, p = 0.65), but was significant in the nonblack population (OR = 0.63, 95% CI = 0.41-0.98, p = 0.039). An association was observed between breastfeeding initiation and infant mortality from infectious disease (OR = 0.49, 95% CI = 0.32-0.77, p = 0.002). Conclusions: In an urban area with high infant mortality and low breastfeeding rates, initiation of breastfeeding was significantly associated with reductions in overall infant mortality, neonatal mortality, and infection-related deaths. Breastfeeding promotion, protection, and support should be an integral strategy of infant mortality reduction initiatives.

Addressing Racial Inequities in Breastfeeding in the Southern United States

BACKGROUND

Race is a predictor of breastfeeding rates in the United States, and rates are lowest among African American infants. Few studies have assessed changes in breastfeeding rates by race after implementing the Ten Steps to Successful Breastfeeding (hereafter referred to as the Ten Steps), and none have assessed the association between implementation and changes in racial disparities in breastfeeding rates. Our goal was to determine if a hospital- and community-based initiative in the Southern United States could increase compliance with the Ten Steps, lead to Baby-Friendly designation, and decrease racial disparities in breastfeeding.

METHODS

Hospitals in Mississippi, Louisiana, Tennessee, and Texas were enrolled into the Communities and Hospitals Advancing Maternity Practices initiative from 2014 to 2017 and received an intensive quality improvement and technical assistance intervention to improve compliance with the Ten Steps. Community partners and statewide organizations provided parallel support. Hospitals submitted monthly aggregate data stratified by race on breastfeeding, skin-to-skin care, and rooming in practices.

RESULTS

The disparity in breastfeeding initiation between African American and white infants decreased by 9.6 percentage points (95% confidence interval 1.6-19.5) over the course of 31 months. Breastfeeding initiation increased from 66% to 75% for all races combined, and exclusivity increased from 34% to 39%. Initiation and exclusive breastfeeding among African American infants increased from 46% to 63% (P < .05) and from 19% to 31% (P < .05), respectively. Skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only.

CONCLUSIONS

Increased compliance with the Ten Steps was associated with a decrease in racial disparities in breastfeeding.

The effect of maternity practices on exclusive breastfeeding rates in U.S. hospitals

The Baby-friendly Hospital Initiative (BFHI) includes a set of 10 evidenced-based maternity practices that when used together have been shown to improve breastfeeding outcomes. In 2007, the Centers for Disease Control and Prevention launched the Maternity Practices in Infant Nutrition and Care (mPINC) survey to assess and monitor these and other evidenced-based maternity practices. The purpose of this study was to explore individual maternity practices measured in the 2013 mPINC survey, along with hospital demographic information, and their relationships with exclusive breastfeeding (EBF) rates, using a sample of United States (U.S.) hospitals. We obtained mPINC survey data from 69 BFHI hospitals and 654 non-BFHI hospitals in the U.S., and EBF rates from The Joint Commission, a leading hospital accreditation agency. On the basis of linear regression analysis, we found that most maternity practices studied were significantly associated with EBF rates (max adjusted R2  = 14.9%). We found a parsimonious model with an adjusted R2 of 47.3%. This study supports the need for a systematic approach in providing breastfeeding support as no one maternity care practice was able to explain the variability in EBF rates as well as a collection of maternity care practices.

Infant feeding-related maternity care practices and maternal report of breastfeeding outcomes

BACKGROUND

Evidence-based maternity practices and policies can improve breastfeeding duration and exclusivity. Maternity facilities report practices through the Maternity Practices in Infant Nutrition and Care (mPINC) survey, but individual outcomes, such as breastfeeding duration and exclusivity, are not collected.

METHODS

mPINC data on maternity care practices for 2009 were linked to data from the 2009 Pregnancy Risk Assessment Monitoring System (PRAMS), which collects information on mothers' behaviors and experiences around pregnancy. We calculated total mPINC scores (range 0-100). PRAMS data on any and exclusive breastfeeding at 8 weeks were examined by total mPINC score quartile.

RESULTS

Of 15 715 women in our sample, 53.7% were breastfeeding any at 8 weeks, and 29.3% were breastfeeding exclusively. They gave birth at 1016 facilities that had a mean total mPINC score of 65/100 (range 19-99). Care dimension subscores ranged from 41 for facility discharge care to 81 for breastfeeding assistance. In multivariable analysis adjusting for covariates, a positive relationship was found between total mPINC score quartile and both any breastfeeding (quartile 2: odds ratio [OR] 1.40 [95% confidence interval {CI} 1.08-1.83], quartile 3: OR 1.50 [95% CI 1.15-1.96], quartile 4: OR 2.12 [95% CI 1.61-2.78] vs quartile 1) and exclusive breastfeeding (quartile 3: OR 1.41 [95% CI 1.04-1.90], quartile 4: OR 1.89 [95% CI 1.41-2.55] vs quartile 1) at 8 weeks.

CONCLUSIONS

These data demonstrate that evidence-based maternity care practices and policies are associated with better breastfeeding outcomes. Maternity facilities may evaluate their practices and policies to ensure they are helping mothers achieve their breastfeeding goals.

Trends in rooming-in practices among hospitals in the United States, 2007-2015

BACKGROUND

Rooming-in, or keeping mothers and infants together throughout the birth hospitalization, increases breastfeeding initiation and duration, and is one of the Ten Steps to Successful Breastfeeding.

METHODS

The Centers for Disease Control and Prevention's (CDC) Maternity Practices in Infant Nutrition and Care (mPINC) survey is a biennial census of all birth facilities in the United States and its territories. Data from the 2007-2015 mPINC surveys were used to assess trends in the prevalence of hospitals with most (≥90%) infants rooming-in more than 23 hours per day (ideal practice). Hospital practices among breastfed infants not rooming-in at night and reasons why hospitals without ideal rooming-in practices removed healthy, full-term, breastfed infants from their mothers' rooms were also analyzed.

RESULTS

The percentage of hospitals with ideal practice increased from 27.8% in 2007 to 51.4% in 2015. Most breastfed infants who were not rooming-in were brought to their mothers at night for feedings (91.8% in 2015). Among hospitals without ideal rooming-in practices, the percentage removing 50% or more of infants from their mothers' rooms at any point during the hospitalization decreased for all reasons surveyed during 2007-2015; however, in 2015, hospitals still reported regularly removing infants for hearing tests (73.2%), heel sticks (65.5%), infant baths (40.2%), pediatric rounds (35.5%), and infant photos (25.4%).

CONCLUSIONS

Hospital implementation of rooming-in increased 23.6 percentage points during 2007-2015. Continued efforts are needed to ensure that all mothers who choose to breastfeed receive optimal lactation support during the first days after giving birth.

'Why do we need a policy?' Administrators' perceptions on breast-feeding-friendly childcare

OBJECTIVE

Mothers' return to work and childcare providers' support for feeding expressed human milk are associated with breast-feeding duration rates in the USA, where most infants are regularly under non-parental care. The objective of the present study was to explore Florida-based childcare centre administrators' awareness and perceptions of the Florida Breastfeeding Friendly Childcare Initiative.

DESIGN

Semi-structured interviews were based on the Consolidated Framework for Implementation Research and analysed using applied thematic analysis.

SETTING

Childcare centre administrators in Tampa Bay, FL, USA, interviewed in 2015.ParticipantsTwenty-eight childcare centre administrators: female (100 %) and Non-Hispanic White (61 %) with mean age of 50 years and 13 years of experience.

RESULTS

Most administrators perceived potential implementation of the Florida Breastfeeding Friendly Childcare Initiative as simple and beneficial. Tension for change and a related construct (perceived consumer need for the initiative) were low, seemingly due to formula-feeding being normative. Perceived financial costs and relative priority varied. Some centres had facilitating structural characteristics, but none had formal breast-feeding policies.

CONCLUSIONS

A cultural shift, facilitated by state and national breast-feeding-friendly childcare policies and regulations, may be important for increasing tension for change and thereby increasing access to breast-feeding-friendly childcare. Similar to efforts surrounding the rapid growth of the Baby Friendly Hospital Initiative, national comprehensive evidence-based policies, regulations, metrics and technical assistance are needed to strengthen state-level breast-feeding-friendly childcare initiatives.

The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature

There is no doubt regarding the multiple benefits of breastfeeding for infants and society in general. Therefore, the World Health Organization (WHO) in a conjoint effort with United Nations International Children's Emergency Fund (UNICEF) developed the "Ten Steps to Successful Breastfeeding" in 1992, which became the backbone of the Baby Friendly Hospital Initiative (BFHI). Following this development, many hospitals and countries intensified their position towards creating a "breastfeeding oriented" practice. Over the past two decades, the interest increased in the BFHI and the Ten Steps. However, alongside the implementation of the initiative, extensive research continues to evaluate the benefits and dangers of the suggested practices. Hence, it is our intention to make a critical evaluation of the current BFHI and the Ten Steps recommendations in consideration of the importance of providing an evidence-based breastfeeding supported environment for our mothers and infants.

Trends in Maternity Care Practice Skin-to-Skin Contact Indicators: United States, 2007-2015

BACKGROUND

Mother-infant skin-to-skin contact (SSC) immediately after birth helps transition infants to the post-uterine environment and increases the likelihood of breastfeeding initiation and duration. This study examines trends in U.S. maternity practices related to SSC, and variations by facility demographics.

METHODS

Data were from the Maternity Practices in Infant Nutrition and Care (mPINC) surveys (2007-2015), a biennial assessment of all U.S. maternity facilities. Facilities reported how often patients were encouraged to practice mother-infant SSC for ≥30 minutes within 1 hour of uncomplicated vaginal birth and 2 hours of uncomplicated cesarean birth, and how often routine infant procedures are performed while in SSC. We calculated the percentage of maternity facilities reporting these indicators for ≥90% of patients across the United States for each survey year. Estimates by facility characteristics (size, type, and state) were calculated for 2015 only.

RESULTS

The percentage of facilities reporting "Most (≥90%)" women, which were encouraged to practice early SSC, increased from 2007 to 2015 following both vaginal (40.4% to 83.0%) and cesarean (29.3% to 69.9%) births. The percentage of facilities reporting routine infant procedures were performed "Almost always (≥90%)," while mother and infant were SSC increased from 16.6% to 49.5% (2007 to 2015) for vaginal births and from 2.2% to 10.7% (2009 to 2015) for cesarean births. Variations in SSC practice by facility type, size, and state were noted.

CONCLUSIONS

Significant progress has been made in increasing hospital encouragement of early SSC for both vaginal and cesarean births. Continued efforts to support evidence-based maternity practices are needed.

A Statewide Quality Improvement Collaborative to Increase Breastfeeding Rates in Tennessee

BACKGROUND AND OBJECTIVES

Tennessee has low breastfeeding rates and has identified opportunities for improvement to enhance maternity practices to support breastfeeding mothers. We sought a 10% relative increase in the aggregate Joint Commission measure of breastfeeding exclusivity at discharge (TJC PC-05) by focusing on high-reliability (≥90%) implementation of processes that promote breastfeeding in the delivery setting.

METHODS

A statewide, multidisciplinary development team reviewed evidence from the WHO-UNICEF "Ten Steps to Successful Breastfeeding" to create a consensus toolkit of process indicators aligned with the Ten Steps. Hospitals submitted monthly TJC PC-05 data for 6 months while studying local implementation of the Ten Steps to identify improvement opportunities, and for an additional 11 months while conducting tests of change to improve Ten Steps implementation using Plan-Do-Study-Act cycles, local process audits, and control charts. Data were aggregated at the state level and presented at 12 monthly webinars, 3 regional learning sessions, and 1 statewide meeting where teams shared their local data and implementation experiences.

RESULTS

Thirteen hospitals accounting for 47% of live births in Tennessee submitted data on 31,183 mother-infant dyads from August 1, 2012, to December 31, 2013. Aggregate monthly mean PC-05 demonstrated "special cause" improvement increasing from 37.1% to 41.2%, an 11.1% relative increase. Five hospitals reported implementation of ≥5 of the Ten Steps and two hospitals reported ≥90% reliability on ≥5 of the Ten Steps using locally designed process audits.

CONCLUSION

Using large-scale improvement methodology, a successful statewide collaborative led to >10% relative increase in breastfeeding exclusivity at discharge in participating Tennessee hospitals. Further opportunities for improvement in implementing breastfeeding supportive practices were identified.

The effect of Baby-friendly status on exclusive breastfeeding in U.S. hospitals

In 2014, a leading hospital accreditation agency, mandated hospitals publicly report their exclusive breastfeeding (EBF) rates. This new regulation provided an opportunity to explore differences in EBF outcomes using a standardized definition across a large hospital sample in the United States. The purpose of this study was to examine the relationships between population demographics and the Baby-friendly (BF) hospital designation on EBF rates in hospitals throughout the United States. We obtained EBF rates from 121 BF hospitals and 1,608 hospitals without the BF designation. Demographic variables were computed using census tract data for the population surrounding each hospital. Relationships were explored using linear regression. We found that EBF rates were positively correlated with a bachelor's degree, log income, and those who identified as White or Asian and negatively correlated with those without college attendance, individuals living below the poverty line, and those who identified as African American or Hispanic. For all models, the BF designation of a hospital was associated with higher EBF rates (p < 0.01; effect sizes, 0.11-0.49) with the exception of the model containing log income. Using a multiple linear regression model that was allowed to contain more than one independent variable, we were able to explain 22% of the variability in EBF rates. The BF hospital designation was associated with significantly higher EBF rates independent of demographic variables. Support for hospitals to attain the BF hospital designation is a meaningful public health goal.

Prevalence and Trends in Donor Milk Use in the Well-Baby Nursery: A Survey of Northeast United States Birth Hospitals

BACKGROUND AND OBJECTIVES

Pasteurized donor human milk ("donor milk") is an alternative to formula for supplementation of breastfed infants. We conducted a survey to determine (1) prevalence, trends, and hospital-level correlates of donor milk use for healthy newborns in the northeast United States and (2) clinician knowledge and opinions regarding this practice.

METHODS

We conducted parallel surveys of clinicians (88% nurse and/or lactation consultant) at (1) all birth hospitals in Massachusetts (MA) and (2) all birth hospitals served by a northeast United States milk bank. We asked about hospital use of donor milk for newborns ≥35 weeks' gestation and receiving Level I care in well nursery, hospital-related factors we hypothesized would be associated with this practice, and clinician knowledge and opinions about donor milk use.

RESULTS

35/46 (76%) of MA birth hospitals and 51/69 (74%) of hospitals served by the milk bank responded; 71 unique hospitals were included. Twenty-nine percent of MA birth hospitals and 43% of hospitals served by the milk bank reported using donor milk for healthy newborns. Hospitals that used donor milk for healthy newborns had higher exclusive breastfeeding at hospital discharge than hospitals that did not (77% versus 56%, p = 0.02). Eighty-three percent of respondents agreed or strongly agreed that using donor milk is an effective way to increase the hospital's exclusive breastfeeding rate.

CONCLUSIONS

Many northeast United States birth hospitals currently use donor milk for healthy newborns. This practice is associated with higher exclusive breastfeeding at hospital discharge. Relationships with breastfeeding after discharge and related outcomes are unknown.

Baby-Friendly as a Regional Collaborative Quality Improvement Project in an Academic Medical Center Environment

In 2012, the state of South Carolina lacked any Baby-Friendly designated hospitals. The Medical University of South Carolina had a strong lactation service since 2002 but continued to struggle with improving breastfeeding rates. The Baby-Friendly Hospital Initiative was the catalyst to increase breastfeeding rates at this academic medical center. In 2012, membership in the Best Fed Beginnings Learning Collaborative heightened awareness of the importance of interdisciplinary collaboration. Participation in the regional collaborative provided evidence-based breastfeeding education and best clinical practices that supported the maternal-infant dyad. These improved practices are achieved by implementation of the Ten Steps to Successful Breastfeeding. The collaborative model accelerated change, and the goals to reach 80% of each metric were met. The exclusive breastfeeding rate increased by 30%. As a result of swiftly achieving designation, the institution was then able to focus on sustainability issues and efforts to expand breastfeeding support into the community. The purpose of this article is to review one hospital's journey while providing guidance to other organizations undergoing the process of becoming Baby-Friendly. The invaluable membership in the Best Fed Beginnings Learning Collaborative quality improvement initiative proved to be a major incentive and source of support in efficiently achieving Baby-Friendly status.

Capillary Blood Ketone Levels as an Indicator of Inadequate Breast Milk Intake in the Early Neonatal Period

OBJECTIVE

To determine the utility of capillary blood ketone levels as an indicator of inadequate intake of breast milk in the early postnatal period.

STUDY DESIGN

Levels of capillary blood beta-hydroxybutyrate (βOHB), the main ketone body in the blood, were measured with a bedside ketone meter in 585 full-term neonates aged 48-95 hours who were breastfed exclusively. Relationships between weight-loss percentage, blood sodium, glucose, pH, partial pressure of carbon dioxide, base-deficit levels, and βOHB levels were investigated. The diagnostic accuracy of βOHB for predicting excessive weight loss (weight loss ≥10% of birth weight) and hypernatremic dehydration (blood sodium level ≥150 mEq/L) was determined.

RESULTS

βOHB levels were correlated positively with weight-loss percentage and blood sodium levels and were correlated negatively with blood glucose levels. The diagnostic accuracy of βOHB was 0.846 (optimal cut off, 1.55 mmol/L; sensitivity, 80.9%, specificity, 74.0%) for predicting excessive weight loss and 0.868 (optimal cut off, 1.85 mmol/L; sensitivity, 94.3%; specificity, 69.9%) for predicting hypernatremic dehydration according to the area under the receiver operating characteristic curve. Multiple logistic analysis revealed that βOHB and weight loss percentage were the only independent predictors of hypernatremic dehydration. Increases in βOHB levels also were associated with worsening metabolic acidosis and hypocapnia.

CONCLUSION

High βOHB levels were associated with inadequate intake of breast milk in the early postnatal period. The use of bedside capillary blood ketone levels may be clinically useful as an indicator of dehydration, energy depletion, and acid-base imbalance in breastfeeding infants in the early postnatal period.

A 2017 Update: Centers for Disease Control and Prevention's Contributions and Investments in Breastfeeding

Given that breastfeeding is important to the health of infants and their mothers, the Centers for Disease Control and Prevention's (CDC) goal is to ensure that new mothers understand the benefits of breastfeeding and, when they choose to breastfeed, have the supports they need to successfully initiate and continue breastfeeding until they reach their goals. This report summarizes CDC's current contributions and investments in breastfeeding.

National Trends in Pediatricians' Practices and Attitudes About Breastfeeding: 1995 to 2014

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics (AAP) has affirmed breastfeeding as the preferred method of infant feeding; however, there has been little systematic examination of how pediatricians' recommendations, affiliated hospitals' policies, counseling practices, and attitudes toward breastfeeding have shifted over the past 2 decades. These trends were examined from 1995 to 2014.

METHODS

Data are from the Periodic Survey (PS) of Fellows, a nationally representative survey of AAP members. PS #30 (1995; response rate = 72%; N = 832), PS #57 (2004; response rate = 55%; N = 675), and PS #89 (2014; response rate = 51%; N = 620) collected demographics, patient and practice characteristics, and detailed responses on pediatricians' recommendations, affiliated hospitals' policies, counseling practices, and attitudes toward breastfeeding. By using bivariate statistics and logistic regression models, the analysis investigated changes over time with predicted values (PVs).

RESULTS

From 1995 to 2014, more pediatricians reported their affiliated hospitals applied for "baby-friendly" designation (PV = 12% in 1995, PV = 56% in 2014; P < .05), and more reported that they recommend exclusive breastfeeding (65% to 76% [P < .05]). However, fewer respondents indicated that mothers can be successful breastfeeding (PV = 70% in 1995, PV = 57% in 2014; P < .05) and that the benefits outweigh the difficulties (PV = 70% in 1995, PV = 50% in 2014; P < .05). Younger pediatricians were less confident than older pediatricians in managing breastfeeding problems (P < .01).

CONCLUSIONS

Pediatricians' recommendations and practices became more closely aligned with AAP policy from 1995 to 2014; however, their attitudes about the likelihood of breastfeeding success have worsened. These 2 divergent trends indicate that even as breastfeeding rates continue to rise, continued efforts to enhance pediatricians' training and attitudes about breastfeeding are necessary.