BABY FRIENDLY HOSPITAL INITIATIVETHE ROLE OF WIC

Catherine Sullivan, MPH, RD, LDN IBCLC, FANDDirector, Assistant Professorcatherine_sullivan@unc.edu

CGBI: Who are we?

WHAT DOES THIS HAVE TO DO BREASTFEEDING?

The hospital setting and related policies and practices have been identified as key areas to intervene to improve breastfeeding outcomes.

There is a significant relationship between the numbers of Ten Steps in place at a birth facility and a mother’s breastfeeding success.

Many Maternity Centers Need Help

AHRQ-Comparative Effectiveness Review Number 210

Baby-Friendly Hospital Initiative (BFHI) is associated with improved rates of breastfeeding initiation and duration.

Health care staff education combined with postpartum home visits may be effective for increasing breastfeeding duration.

Health care staff education alone (with no additional breastfeeding support services)may not be effective for increasing breastfeeding initiation rates.

For women enrolled in the WIC Program, peer-support interventions offered by WIC agencies may improve rates of breastfeeding initiation and duration.

Breastfeeding is associated with reduced maternal risk of breast and ovarian cancer, hypertension, and type 2 diabetes.

Workplace, school-based, and community-based interventions and underlying socioeconomic factors need further research.

Feltner C, Weber RP, Stuebe A, Grodensky CA, Orr C, Viswanathan M. Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries. Comparative Effectiveness Review No. 210.

Return on InvestmentEquitable Care

Surgeon General’s Call to Action

Mother-Baby Dyad

Health Care System

FamilySupport

Public Health Infrastructure

Employment

CommunitySupport

Research

Healthy People 2020-Objectives Added in 2010

Objective 2006Baseline %

2020 Target %

Increase the proportion of employers that have worksite lactation support programs (added 2010)

25(2009)

38.0

Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life (added 2010)

24.2(2006

births)

14.2

Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and babies (added 2010)

2.9(2009)

8.1

Key Strategy:Create a breastfeeding-friendly health care system

Promoting, Protecting and Supporting Breastfeeding in NC

Vision: North Carolina mothers will be enabled to begin their children’s lives by breastfeeding- the best possible foundation for infant and young child feeding.

The Joint Commission

Perinatal Core Measure Set

PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization

Released the “Speak Up: What you need to know about breastfeeding” campaign to support breastfeeding

PC-05a Exclusive breast milk feeding during the newborn's entire hospitalization considering mother's

initial feeding plan----Retired as on 10/1/15

(The Joint Commission, 2014)

Baby-Friendly Hospital Initiative-BFHI

The Baby-Friendly Hospital Initiative is a global program

that was launched by the World Health Organization

(WHO) and the United Nations Children’s Fund in

1991.

. The program recognizes hospitals and birthing centers that offer an optimal level of care for infant feeding and

mother/baby bonding.

Requires that facilities implement the Ten Steps to

Successful Breastfeeding and the International Code of Marketing of Breastmilk

Substitutes.

Support for safe feeding practices for mothers who are not able to

or chose not to breastfeed.

(BFUSA, 2012)

Baby-Friendly Hospital Initiative-US• 545 Baby-Friendly Designated Facilities in the United

State out of 3,250 birthing facilities (>1,000,000 births)• Currently 25% of US births occur in Baby-Friendly

designated facilities USA exceeding Healthy People 2020 goal of 8.1%

• Recently designated facilities in 2 (new) states:– Arkansas – WEST VIRGINIA!

• Administered by Baby Friendly USA– Based on WHO/UNICEF Ten Steps to Successful Breastfeeding– www.babyfriendlyusa.org

Current Montana Baby-Friendly Hospitals

Barrett Hospital and Healthcare Blackfeet Community Hospital Central Montana Medical Center Community Hospital of Anaconda* Community Medical Center Glendive Medical Center Livingston HealthCare Marcus Daily Memorial Hospital North Valley Hospital St. Peter’s Hospital

World Health OrganizationComprehensive Structure of The Ten Steps:

Policy: Outlining practices to support

protection and promotion of breastfeeding Implementation of the

International Code of Marketing of Breastmilk Substitutes Routine quality improvement

procedures that have monitored the maternity care and infant feeding policies.

Staff Education and Competency Verification

Prenatal Education Immediate Skin to Skin and

initiation of breastfeeding after delivery. Support with Breastfeeding Supplementation Rooming-in Responsive feeding Artificial Nipples Support/ Care at discharge

Key Clinical Practices:

Step One: Have a written breastfeeding policy that is routinely communicated to all health care staff

This step helps to ensure accountability Eliminate unnecessary and intrusive interventions

that negatively affect the initiation of breastfeeding In nursing: “If it is not documented, it’s not done.” How is it communicated, posted Staff version versus consumer version Addresses all Ten Steps and WHO Code

Rosenberg et. al Study (2008)

Increased implementation of the Ten Steps is associated with increased breastfeeding.

Hospitals with comprehensive breastfeeding policies are likely to have better breastfeeding support services and better breastfeeding outcomes.

Step 2-Train all health care staff in the skills necessary to implement this policy

Maternity nursing staff 20 hours total (5 hours supervised clinical experience) 15 sessions identified by UNICEF/WHO

Providers with privileges (L&D, maternity, NBN) Minimum of 3 hours Breastfeeding management education pertinent to

their role.

Ancillary and Support Staff Orientation

Step 2: Train all healthcare staff in skills necessary to implement breastfeeding policy

With training of all clinicians: Initiation rose from 84% to 93% (p = 0.0001) Mean duration rose from 3.7 to 5.6 months (p =

0.0001). Breastfeeding in the delivery room rose from 3%

to 37% (p = 0.0001). Patient satisfaction with breastfeeding guidance

in the hospital rose from 43% to 79% (p = 0.0001). Shinwell E et al. The effect of training nursery staff in breastfeeding guidance on the duration of breastfeeding in healthy term infants. Breastfeed Med. 2006 Winter;1(4):247-52.

STEP TWO: EFFECT OF BREASTFEEDING TRAINING FOR HOSPITAL STAFF ON EXCLUSIVE BREASTFEEDING RATES AT HOSPITAL DISCHARGE

41%

77%

0%10%20%30%40%50%60%70%80%90%

Pre-training, 1996 Post-training, 1998

Perc

enta

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Exclusive Breastfeeding Rates at Hospital Discharge

Adapted from: Cattaneo A, Buzzetti R. Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative. BMJ, 2001, 323:1358-1362.

Step 3-Inform all pregnant women about the benefits and management of breastfeeding.

Coordinate services/messages with community partners

Should begin in the first trimester when possible

Includes 10 important topics

Supportive Written material should be provided

Photo Source: United States Breastfeeding Committee

Birth

Limiting Birth Interventions

25

Induction & Augmentation

IV Fluids Limits movement of mother in labor Contributes to edema of the areola Contributes to increase in maternal & infant blood sugar and

inaccurate weight assessment

Pitocin Edema may move to extremities, which may lead to “flat”

nipples.Help soften the areola - Reverse Pressure Softening

Birth Interventions Analgesic Medications – can cause babies to be drowsy

and to have difficulty sucklingAnalgesia / NarcoticsEpidural anesthesia Spinals

“Assisted delivery” ForcepsVacuum extraction

Episiotomy

Suctioning

Step 4: Help mothers initiate breastfeeding within one hour

What If: Altering the way we

care for mothers and babies could conclusively change their lives?

Skin-to-Skin = Protection

What does skin-to-skin look like? Infant is naked on mother’s naked chest, there is no

bedding or clothing between them – light blanket over top of infant and mother

How does an infant look and behave when skin-to-skin compared to routine care?More activeMore awake Less cryingMore relaxedDeeper sleep

Morelius, Pediatrics, 2005

Homeostasis

Stabilizes the infant’s oxygen Keeps baby WARM or COOL

depending on their needs Stabilizes their blood

pressure Reduces crying, which helps

babies preserve energy (decrease risk of hypoglycemia)

Increases quiet alert state which leads to mother/infant interaction

Moore, Cochrane Database Syst Rev, 2007

Skin-to-Skin With Dad

Dads can do skin-to-skin - they love it!

In a study of 44 father-infant pairs, infants who were skin-to-skin with dads compared to infants placed in an incubator or cot (all babies delivered via c-section): Stabilized blood glucose Stabilized temp Stopped crying soonerWere calmer

Christensson, Acta Paediatr, 1996Erlandsson, BIRTH, 2007

31

Ski

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o sk

inR

outi

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Breastfeeding at discharge

Breastfeeding at 1-4 months

Breastfeeding at 12 months

Successful first feed

Bottom line: Mothers who held their infants skin-to-skin breastfed 43 days longer than mothers who did not.

Anderson GC, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2007;3.

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Avoid the Baby Burrito!

Step 5-Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infant

Support for breastfeeding families Assess breastfeeding techniques Assistance no later than 6 hours after birth Educate mothers prior to discharge (Outlined in

Guidelines and Criteria) Support for High Risk/Special needs Milk expression within 6 hours Provide milk to infant as soon as medically ready Manual expression within 1 hour is recommended

(BFUSA, 2016)

Moms must have access to trained providers

Must be taught how to maintain lactation when separated from baby

Should begin pumping of separation is greater than 6 hours

Step 5 continued…

Source: United State Breastfeeding Committee

Step 5-Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infant

Support for families who feed formula Written and verbal instruction should include: Safe preparation Handling and storage Safe feeding Non-brand specific

(BFUSA, 2016)

STEP FIVE: Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants. (HAND EXPRESSION)

Adapted from: Righard L and Alade O. (1992) Sucking technique and its effect on success of breastfeeding Birth 19(4):185-189.

0%

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Correct sucking technique at dischargeIncorrect sucking technique at discharge

P

STEP SIX. Give newborn infants no food or drink other than breastmilk, unless medically indicated

The amount of human milk removed at each feed determines the rate of milk production in the next few hours.

Milk removal must be continued during separation to maintain supply.

Infants given supplements are at increased risk for early termination of breastfeeding

Encourage breastfeeding in response to feeding cues and feedings no longer than three hours apart

Rare contraindications to breastfeeding

“JUST GIVE A LITTLE FORMULA…”

“You’re tired, you should rest. We’ll feed the baby in the nursery tonight.”

“A little formula here in the hospital won’t hurt.”

Risks of Supplementation

Interfere with the establishment of maternal milk supply (delayed lactogenesis)

Increase risk of engorgement Alter infant bowel flora May cause nipple confusion/preference Interfere with maternal-infant attachment Undermines maternal confidence in her ability

to fully provide for her baby’s nutritional needs Shortened duration of EXCLUSIVE and ANY

breastfeeding

Infant Formula Marketing: Impact on Breastfeeding Do infant formula samples shorten the duration of

breastfeeding? Breastfeeding mothers who received free formula samples

at discharge were less likely to still be breastfeeding at one month (78% vs. 84%, p=0.07)

Breastfeeding mothers who received free formula samples at discharge were more likely to introduce solid foods by 2 months (18% vs. 10%, p=0.01)

The above trends were more significant among less educated mothers, first time mothers, and mothers who had been ill post partum.

Bergevin et al., Do infant formula samples shorten the duration of breast-feeding? Lancet. 1983 May 21;1(8334):1148-51

“Never underestimate the power of nurses. If they are sold and serviced properly, they can be strong allies. A nurse who supports Ross is like an extra sales person.”

Source: United State Breastfeeding Committee

N.C. Breastfeeding CoalitionGolden Bow Awards

2009-2018

0

10

20

30

40

50

60

70

80

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

88 Eligible Maternity Centers

Number of Golden Bow

Newborn Observation Unit

What message does this send???

Step 7-Practice rooming in - allow mothers and infants to remain together 24 hours a day.

Rooming in 24h/day standard care for healthy term infants, regardless of feeding choice.

Supports: Learn feeding cues Feeding on demand Handle/comfort infant Dyad recognition Photo Source: United States Breastfeeding Committee

Step 7: Practice rooming in- allow mothers and infants to remain together 24 hours a day

No. 1 associated variable with breastfeeding success, costs, infection, etc.

Higher full breastfeeding rates (multiple studies) Increased milk production (Mapata et al 1988,

Yamauchi 1990) Mothers and babies sleep better when they can

smell each other.

Step 8: Encourage breastfeeding on demand

Whenever the baby or mother wants, with no restrictions on the length or frequency of feeds.

Newer terms: On cue, Baby-led feeding Meconium, less wt.loss, milk letdown est., less

jaundice Frequency and length of suckling are associated with

total intake Feeding by cue and encouragement to night feed are

associated with higher frequency (Illingworth, Labbok, others).

Step 8-Encourage breastfeeding on demand.

All families should be encouraged to feed on cue (regardless of feeding choice) Important to help breastfeeding families: Establish Milk Supply Infant satiety Reduce the risk of engorgement

Feeding Cues

Soft sounds: grunts Wiggling Hand to mouth Lip smacking Sucking motions Rooting

52

Feeding Cues

CRYING is a LATE feeding cue!53

Step 9-Give no pacifiers or artificial nipples to breastfeeding infants

Artificial nipple use may make breastfeeding more difficult. (altered suckling pattern) Potentially interfere with cue based feeding Mother may have a decreased milk supply

with introduction of artificial nipple. (skip feedings)

Step 9: Give no artificial teats or pacifiers to breastfeeding infants

Studies are mixed on pacifier/artificial nipple use Not clear if use is causative or an outcome of poor

feeding More important in the preterm situation and where

suck is less than optimal Pacifier and teat use associated with dental problems.

(Labbok, Drane, others) Bottle use associated with ear infection AAP Guidelines

Support Works….

Source: United State Breastfeeding Com

Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

Early postnatal or clinic checkup Home visits Telephone calls Community services Outpatient breastfeeding clinic

Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic Peer counseling programs Mother support groups Help set up new groups Establish working relationships with those already in

existence Family support system Social and religious community support

The International Code of Marketing of Breast-milk Substitutes

(WHO, 2015)

No advertising of breastmilk substitutes

No free samples to families or health workers

No promotion of products inhealthcare facilities

No gifts or samples tohealthcare workers

No free or low-cost supplies of breastmilk substitutes

Take home messages…

Skin-to-skin, rooming-in, breastfeeding support, and hand expression are all simple, free, evidence-based practices that are good for mothers and babies.

The experiences women and infants have around pregnancy, birth, and breastfeeding influence them for a lifetime.

What we all do matters very, very much.

Breastfeeding-Friendliness

Supportive breastfeeding policies and clear discharge guidelines will provide the framework necessary for preserving and protecting breastfeeding for women, infants and families.

Model State Programs

Texas Ten Step Colorado Can Do 5! California Birth and Beyond Keystone Ten (PA) North Carolina Maternity Center

Breastfeeding-Friendly Designation (NC MCBFD)

DurhamAlamanceAlexander

Alleghany

Anson

Ashe

Avery

Beaufort

Bertie

Bladen

Brunswick

Buncombe

Burke

Cabarrus

Caldwell

Carteret

Caswell

Catawba Chatham

CherokeeClay

Cleveland

Columbus

Craven

Cumberland

DareDavidson

Davie

Duplin

Edgecombe

ForsythFranklin

Gaston

Gates

Graham

Granville

Greene

Guilford

Halifax

Harnett

Haywood

Henderson

Hertford

Hoke

Hyde

Iredell

Jackson

Johnston

Jones

Lee

Lenoir

Lincoln

McDowell

Macon

MadisonMartin

Mecklenburg

Mitchell

MontgomeryMoore

Nash

NewHanover

Northampton

Onslow

Orange

Pamlico

Pender

Person

Pitt

Polk

Randolph

Richmond

Robeson

Rockingham

Rowan

Rutherford

Sampson

Scotland

Stanly

StokesSurry

Swain

Transylvania

Tyrrell

Union

Vance

Wake

Warren

Washington

Watauga

Wayne

Wilkes

Wilson

Yadkin

Yancey

North Carolina 9/2018Bag Free Maternity Centers >90% of live

births

Indicates Counties with more than one bag free maternity center

Counties with no Maternity Center

Reminders: The Role of WIC/Public Health Collaborating on Steps 1,3,5,6,8,10A place on the multidisciplinary teamPrenatal education: self advocacy, feeding on demand,

anticipatory guidanceNo freebies/marketing-WIC adheres to the Code

Peer Counseling/coordination of care Training Centers

The Role of WIC/Public Health

WIC Hospital Outreach Handout State developed crib card Peer CounselorsService Delivery Model

QUESTIONS?

Additional References

• Baby Friendly USA: https://www.babyfriendlyusa.org/find-facilities• DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding.

Pediatrics 2008;122(Suppl 2):S43–9.• CDC. Maternity Practices in Infant Nutrition and Care (mPINC) survey. Atlanta, GA: US Department

of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/breastfeeding/data/mpinc.

• CDC. Vital signs: hospital practices to support breastfeeding—United States, 2007 and 2009. MMWR 2011;60:1020–5.

• Grummer-Strawn LM, Shealy KR, Perrine CG, et al. Maternity care practices that support breastfeeding: CDC efforts to encourage quality improvement. J Womens Health. 2013;22:107–12.

• Labbok M, Taylor E, Nickel N. Implementing the Ten Steps in Hospitals Serving Low-Wealth Patients. I. Operational research design and baseline findings. International Breastfeeding Journal. 2013 May 20;8(1):5.

• Labbok MH. Global baby-friendly hospital initiative monitoring data: update and discussion. Breastfeed Med 2012 Aug;7:210-22.

• Nickel NC, Taylor EC, Labbok M, Weiner BJ, Williamson NE. Applying organization theory to understand barriers and facilitators to the implementation of baby-friendly: A multi-site qualitative study. 2013 Aug;29(8):956-64. doi: 10.1016/j.midw.2012.12.001. Epub 2013 Feb 20.

• Nickel NC, Labbok MH, Hudgens MG, Daniels JL. The extent that noncompliance with the Ten Steps to Successful Breastfeeding influences breastfeeding duration. J Hum Lact 2013;29(1):59-70.

https://www.babyfriendlyusa.org/find-facilitieshttp://www.cdc.gov/breastfeeding/data/mpinchttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6030a4.htm?s_cid=mm6030a4_whttp://www.ncbi.nlm.nih.gov/pubmed?otool=uncchlib&term=Implementing%20the%20Ten%20Steps%20in%20Hospitals%20Serving%20Low-Wealth%20Patients.%20I.%20Operational%20research%20design%20and%20baseline%20findingshttp://www.ncbi.nlm.nih.gov/pubmed?otool=uncchlib&term=Global%20baby-friendly%20hospital%20initiative%20monitoring%20data:%20update%20and%20discussionhttp://cgbi.sph.unc.edu/files/2013/11/Labbok_BFHI_BF-MED_2012.pdfhttp://www.ncbi.nlm.nih.gov/pubmed?otool=uncchlib&term=Applying%20organization%20theory%20to%20understand%20barriers%20and%20facilitators%20to%20the%20implementation%20of%20baby-friendly:%20A%20multi-site%20qualitative%20studyhttp://cgbi.sph.unc.edu/files/2013/11/Nickle_Midwifery_2013.pdfhttp://www.ncbi.nlm.nih.gov/pubmed?otool=uncchlib&term=The%20extent%20that%20noncompliance%20with%20the%20Ten%20Steps%20to%20Successful%20Breastfeeding%20influences%20breastfeeding%20durationhttp://cgbi.sph.unc.edu/files/2013/11/Nickle_Noncompliance_JHL_2013.pdf

Baby Friendly Hospital Initiative�The Role of WICCGBI: Who are we?Slide Number 3Slide Number 4WHAT DOES THIS HAVE TO DO BREASTFEEDING?Many Maternity Centers Need HelpAHRQ-Comparative Effectiveness Review Number 210Return on Investment�Equitable CareSurgeon General’s Call to ActionHealthy People 2020- �Objectives Added in 2010Promoting, Protecting and Supporting Breastfeeding in NCThe Joint Commission Baby-Friendly Hospital Initiative-BFHISlide Number 14Baby-Friendly Hospital Initiative-US�Current Montana Baby-Friendly Hospitals �World Health Organization�Comprehensive Structure of The Ten Steps:Step One: Have a written breastfeeding policy that is routinely communicated to all health care staffRosenberg et. al Study (2008)�Step 2-Train all health care staff in the skills necessary to implement this policy�Step 2: Train all healthcare staff in skills necessary to implement breastfeeding policySTEP TWO: EFFECT OF BREASTFEEDING TRAINING �FOR HOSPITAL STAFF ON EXCLUSIVE BREASTFEEDING RATES AT HOSPITAL DISCHARGEStep 3-Inform all pregnant women about the benefits and management of breastfeeding. �Slide Number 24Limiting Birth InterventionsInduction & AugmentationBirth InterventionsStep 4: Help mothers initiate breastfeeding within one hour����What If:Skin-to-Skin = ProtectionHomeostasisSkin-to-Skin With DadSlide Number 32Avoid the Baby Burrito!Step 5-Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infant�Slide Number 35Step 5-Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infantSTEP FIVE: Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants. (HAND EXPRESSION)STEP SIX. Give newborn infants no food or drink other than breastmilk, unless medically indicated“JUST GIVE A LITTLE FORMULA…”Risks of SupplementationInfant Formula Marketing: �Impact on BreastfeedingSlide Number 42Slide Number 43Slide Number 44N.C. Breastfeeding Coalition�Golden Bow Awards�2009-2018Newborn Observation UnitSlide Number 47Step 7-Practice rooming in - allow mothers and infants to remain together 24 hours a day. �Step 7: Practice rooming in- allow mothers and infants to remain together 24 hours a dayStep 8: Encourage breastfeeding on demandStep 8-Encourage breastfeeding on demand. �Feeding CuesFeeding CuesStep 9-Give no pacifiers or artificial nipples to breastfeeding infants�Step 9: Give no artificial teats or pacifiers to breastfeeding infantsSlide Number 56Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicStep 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinicThe International Code of Marketing of Breast-milk Substitutes Take home messages…Breastfeeding-FriendlinessModel State ProgramsSlide Number 63North Carolina 9/2018�Bag Free Maternity Centers >90% of live births�Reminders: The Role of WIC/Public HealthThe Role of WIC/Public HealthSlide Number 67Slide Number 68Additional References