Improving Exclusive Breastfeeding in an Urban Academic HospitalLaura P. Ward, MD, IBCLC, a Susan Williamson, RN, BSN, IBCLC, b Stephanie Burke, MS, RD, LD, IBCLC, b Ruby Crawford-Hemphill, RNC, BSN, MSA, c Amy M. Thompson, MDd

aPerinatal Institute, Division of Neonatology, Cincinnati

Children’s Hospital Medical Center, Cincinnati, Ohio; bWomen’s Health Services and cUCMC Patient Care

Services, University of Cincinnati Medical Center, Cincinnati,

Ohio; and dDepartment of Obstetrics & Gynecology,

University of Cincinnati College of Medicine, Cincinnati, Ohio

Dr Ward was the pediatrics physician champion,

developed the pediatric education modules,

oversaw the analysis and interpretation of the

data, drafted the initial manuscript, and revised the

manuscript; Ms Williamson was the Baby-Friendly

Task Force Chair, developed and implemented

nursing education and the practice plan, supervised

data collection, and collaborated in manuscript

revisions; Ms Burke developed the nursing and staff

education modules, developed and implemented

the practice plan, coordinated and supervised

data collection, participated in data analysis,

and collaborated in manuscript revisions; Ms

Crawford-Hemphill was the administration team

leader, helped develop and implement the practice

plan, and collaborated in manuscript revisions; Dr

Thompson was the obstetrics physician champion,

developed the obstetrician education modules,

developed and implemented the practice plan, and

revised the manuscript. All authors approved the

fi nal manuscript as submitted.

DOI: 10.1542/peds.2016-0344

Accepted for publication Jul 25, 2016

Address correspondence to Laura P. Ward, MD,

IBCLC, Cincinnati Children’s Hospital Medical Center,

Division of Neonatology, 3333 Burnet Ave, MLC 7009,

Cincinnati, OH 45229. E-mail: laura.ward@cchmc.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2017 by the American Academy of

Pediatrics

Breast milk is the optimal source of

nutrition for newborns, conferring

many health benefits to mothers and

infants. Breastfed infants have a lower

risk of infant mortality and childhood

illnesses, including respiratory and

gastrointestinal infections, otitis

media, and childhood leukemias. 1 – 4

Breastfed infants are also less likely

to develop diabetes and obesity.1, 5

Maternal benefits include lower risk

of postpartum hemorrhage, breast

and ovarian cancers, and type 2

diabetes. 1, 6

Despite these benefits, national

breastfeeding rates are below the

goals set by Healthy People 2020. 7

Ohio’s exclusive breastfeeding (EBF)

rates are in the lowest quartile

nationally. 8 In addition, racial and

socioeconomic disparities exist. 9, 10

Antenatal education and hospital

practices that support breastfeeding

significantly affect breastfeeding

success, exclusivity, and duration,

regardless of socioeconomic status.11

In addition, the number of practices a

mother experiences is associated with

improved breastfeeding duration and

exclusivity. 12

University of Cincinnati Medical

Center (UCMC) has long-standing

low rates of EBF, and in June 2012

we began participation in Best

Fed Beginnings (BFB), a quality

improvement collaborative targeting

abstractBACKGROUND AND OBJECTIVE: Breastfeeding has many well-established health

benefits for infants and mothers. There is greater risk reduction in health

outcomes with exclusive breastfeeding (EBF). Our urban academic

facility has had long-standing low EBF rates, serving a population with

breastfeeding disparities. We sought to improve EBF rates through a

Learning Collaborative model by participating in the Best Fed Beginnings

project.

METHODS: Formal improvement science methods were used, including the

development of a key driver diagram and plan–do–study–act cycles.

Improvement activities followed the Ten Steps to Successful Breastfeeding.

RESULTS: We demonstrated significant improvement in the median adherence

to 2 process measures, rooming in and skin-to-skin after delivery.

Subsequently, the proportion of infants exclusively breastfed at hospital

discharge in our facility increased from 37% to 59%. We demonstrated an

increase in sustained breastfeeding in a subset of patients at a postpartum

follow-up visit. These improvements led to Baby-Friendly designation at our

facility.

CONCLUSIONS: This quality improvement initiative resulted in a higher number

of infants exclusively breastfed in our patient population at “high risk

not to breastfeed.” Other hospitals can use these described methods and

techniques to improve their EBF rates.

QUALITY REPORTPEDIATRICS Volume 139 , number 2 , February 2017 :e 20160344

To cite: Ward LP, Williamson S, Burke S, et al.

Improving Exclusive Breastfeeding in an Urban

Academic Hospital. Pediatrics. 2017;139(2):

e20160344

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facilities serving populations at

highest risk not to breastfeed. BFB

was led by the National Institute

for Children’s Health Quality in

partnership with the Centers for

Disease Control and Prevention

and Baby-Friendly USA (BFUSA).

Through BFB, we received coaching,

technical assistance, and guidance

from breastfeeding and quality

improvement experts and access to

shared knowledge.

Our objective was to incorporate

evidence-based hospital practices to

improve EBF rates to 90% by August

2014 and to achieve Baby-Friendly

designation by September 2014.

We used the Learning Collaborative

model where representatives from

similar health care organizations

share their experiences while

individually implementing best

practices. 13 Group learning sessions

alternate with local action cycles.

Learning sessions are led by national

content experts. We chose this

model because of its success in other

national health care collaboratives,

such as improving end-of-life care,

decreasing appointment wait times,

and reducing adverse events. Here,

we share our improvement methods,

experiences, and outcomes to assist

hospitals intending to make similar

improvements.

METHODS

Setting

UCMC is a large, urban academic

medical center that trains obstetric

and pediatric residents and serves

southwestern Ohio, northern

Kentucky, and southeastern

Indiana. Fifty-five percent of women

delivering at UCMC receive prenatal

care at the Center for Women’s

Health (CWH), a hospital-based

resident and midlevel provider

practice; the remainder receive

care at community health centers,

local health departments, and the

academic physicians’ office, all

staffed by UCMC faculty. In fiscal

year 2011 (the year of application

to BFB), there were 2352 deliveries;

30% of patients were white, 51%

black, and 7% Hispanic; 82% had

Medicaid coverage, and 15% were

privately insured. Because of these

characteristics, our interventions

needed to engage trainees, faculty,

staff, and hospital leadership. Our

hospital’s 7-year plan included

an initiative to pursue national

certification and recognition that

coincided with Ohio’s campaign to

lower the infant mortality rate.

Improvement Team

In July 2012, we assembled a

multidisciplinary team that included

an administrative leader, obstetrics

and pediatrics physicians, a mother–

infant nurse manager, labor and

delivery and postpartum staff nurses,

and lactation consultants. The team

evolved to include a Women, Infants,

and Children administrator and

peer. 14 The team developed a key

driver diagram ( Fig 1) and identified

improvement activities and plan–

do–study–act cycles to meet the

aims. 15 The UCMC Office of Research

Compliance determined that our

project was a quality improvement

initiative and not human subjects

research.

The team attended 3 BFB

Collaborative Learning sessions,

participated in regular webinars,

reported monthly data, implemented

and tested changes, and shared

resources with other hospital teams.

The desired BFB outcome was

Baby-Friendly designation of all

participating hospitals by September

2014. BFB surveyors conducted a

mock site visit to evaluate readiness

for a BFUSA assessment. They

reviewed infant feeding policies,

compliance with BFUSA guidelines,

and interviewed providers and

patients. Visit findings provided

opportunities to correct deficiencies

before the actual BFUSA assessment.

Improvement Activities

Our improvement activities

followed the Ten Steps to Successful

Breastfeeding, 16 endorsed

by the American Academy of

Pediatrics (AAP), the World Health

Organization, and other health care

organizations. A dose-dependent

relationship exists between

breastfeeding duration, exclusivity,

and the number of these steps a

mother experiences during the

delivery hospitalization. 12, 17

Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.

⚬ Policy written and implemented

(online Supplemental file).

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

⚬ Nursing education (for which

staff was compensated): online

breastfeeding modules (15

hours), skill laboratory (4

hours), breastfeeding policy

in-service (1 hour).

⚬ Pediatric providers: 2 hour

lectures for residents and

fellows, AAP slide sets

distributed with posttest 18 (3

hours).

⚬ Obstetric providers: American

College of Obstetrics and

Gynecology publications 19, 20

and breastfeeding videos

(taped neonatal grand rounds

and Stanford University

breastfeeding/hand

expression) 21 with posttest (4

hours).

⚬ New employees complete

training within 6 months of hire.

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

⚬ CWH staff education: Lactation

consultant lecture (3 hours).

⚬ Community (non-CWH)

nurse case managers: online

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PEDIATRICS Volume 139 , number 2 , February 2017

breastfeeding modules (20

hours), training by lactation

consultant (3 hours).

⚬ Policy written and implemented

outlining prenatal breastfeeding

education topics.

⚬ Prenatal education checklist

generated in electronic medical

record (EMR) to facilitate

efficient documentation.

⚬ Pocket scripts developed

for breastfeeding education

reflecting policy (Supplemental

Information A).

Step 4: Help mothers initiate breastfeeding within 1 hour of birth.

⚬ Skin-to-Skin (STS) Task Force

created.

⚬ Infant nurse role developed to

facilitate STS for all medically

appropriate deliveries regardless

of feeding plan.

Step 5: Show mothers how to breastfeed and maintain lactation, even if they are separated from their infants.

⚬ Initiate timely pumping within

6 hours of delivery if couplet

separated. Extra pumps and

hands-free pumping bras

obtained.

Step 6: Give infants no food or drink other than breast milk, unless medically indicated.

⚬ Developed acknowledgment

form for families, explaining the

risks of non–medically indicated

supplementation (Supplemental

Information B).

⚬ Created physician order for

supplementation and smart

phrase documentation in EMR

(Supplemental Information C).

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

⚬ Nursery was staffed only

for procedures and was

subsequently named the

Newborn Observation Unit to

minimize separation, optimize

family recognition of feeding

cues, and prevent delayed

feedings.

⚬ Computer workstations on

wheels obtained for family-

centered rounds.

⚬ Infant location documented in

EMR.

e3

FIGURE 1Key driver diagram.

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Step 8: Encourage breastfeeding on demand.

⚬ Infant-led feedings encouraged

for breastfed and formula-fed

infants.

⚬ Nursing personnel, including

labor and delivery staff, trained

in latching techniques and

positions.

Step 9: Give no pacifiers or artificial nipples to breastfeeding infants.

⚬ Pacifiers eliminated from the

postpartum unit, except for

medical indications. Scripts

developed to respond to

maternal requests for pacifiers;

smart phrases developed in

the EMR for documentation

of counseling (Supplemental

Information C).

⚬ Alternative feeding methods

introduced (syringe, cup, and

supplemental nursing system).

⚬ Case managers counseled

patients in prenatal visits

regarding risk of early pacifier

use.

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

⚬ A Women, Infants, and Children–

funded peer provided part-time

counseling.

⚬ Outpatient lactation visits

promoted.

⚬ Telephone support system

(warm-line) provided to patients

upon discharge.

⚬ Hospital-based breastfeeding

support group developed.

Study Population

There were 4181 total deliveries

during the study period. The study

population included all infants cared

for on the postpartum unit at UCMC

from July 2012 through December

2014. Infants were excluded for NICU

transfer or maternal contraindication

to breastfeeding (Supplemental

Information D).

Outcome Measures

The primary outcome measure was

the percentage of infants exclusively

fed breastmilk. Infants were excluded

from this measure if the mother

exclusively formula fed from birth,

after being informed of the benefits

of breastfeeding. If supplements were

medically indicated, breastfeeding

was considered exclusive. A secondary

outcome measure was the percentage

of mothers reporting breastfeeding at

a CWH postpartum visit.

We identified 2 process measures.

Rooming-in was the percentage of

infants separated from their mothers

for ≤1 hour per day; STS was the

percentage of infants placed STS with

their mothers within 5 minutes of

birth, until the first breastfeed or 1

hour of life.

Data Collection

From July 2011 to June 2012, we

reviewed 30 charts per month to

establish a baseline EBF rate for

the year preceding BFB. From July

2012 to October 2012 we selected

every fourth medical record from

monthly delivery reports (n =

50). Starting in November 2012,

30 infant charts were reviewed,

per BFB project guidelines. 22

We extracted the following data

from the infant hospital charts:

breastfeeding assistance, exclusivity,

supplementation, rooming-in,

feeding on cue education, and

discharge lactation support referral.

Maternal charts were reviewed

to assess breastfeeding intent,

prenatal breastfeeding education,

and STS compliance at delivery.

We performed an EMR query for

sustained lactation success. This

included charts of CWH patients

seen postpartum with a documented

feeding plan from November 2012 to

December 2014. The data collection

periods for inpatient and outpatient

were different because of the 6-week

postpartum period and coincidental

implementation of an EMR system at

our hospital.

Data Analysis

Statistical process control charts and

run charts evaluated the impact of

interventions on the outcomes over

time. These tools can evaluate the

effectiveness of change over time and

distinguish common cause variation

(causes that are random in the process

over time) from special cause variation

(causes that are not part of the process

but arise due to the process). 23

Observed changes in the mean and

median line are considered statistically

significant when the line shifts on a

chart by 8 points in either direction,

6 consecutive points either increase

or decrease, or 14 consecutive points

alternate above or below the line.

RESULTS

Our initial efforts focused on 2 key

hospital practices changes: STS and

rooming-in. Before BFB, STS after

delivery was rarely practiced. The

STS Task Force, made up of key

stakeholders, established weekly

meetings to discuss small tests

of change. The STS Task Force

acknowledged challenges voiced

by delivery personnel and adapted

practices to satisfy STS goals

and provider concerns. Although

improvement in STS was achieved

quickly with vaginal deliveries, we

observed slower progress in cesarean

deliveries. Mock drills demonstrated

the complex documentation,

monitoring, and supportive role of the

circulator nurse at cesarean delivery;

a dedicated infant nurse allowed for

STS in the operating room without

compromising patient safety. Since

STS was instituted for all infants, staff

and families shared their observations

of innate newborn behaviors, and

consequently several patients changed

their feeding plans from formula

to breastfeeding. This unexpected

consequence, along with data from

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PEDIATRICS Volume 139 , number 2 , February 2017

plan–do–study–act cycles, increased

acceptance of STS benefits. With these

measures implemented by 8 months,

the median STS rate was 24.5%; by 15

months, STS increased to 59% for all

modes of delivery ( Fig 2).

Before project initiation, infants

rarely roomed in with their mothers,

and causes and duration of couplet

separation were not documented in

the EMR. During early discussions,

provider-cited reasons for separation

included newborn teaching rounds,

newborn assessments, circumcision,

and the perception that mothers

preferred uninterrupted rest.

Additionally, providers referenced

the nursery as a place to care for

multiple infants whose mothers

lacked family support. A pediatrician

tested newborn teaching rounds in

patient rooms and reported back

to the physician group to address

concerns. We obtained portable

equipment to facilitate performance

of newborn assessments. Our

obstetrician champion engaged the

postpartum team to adopt a patient-

centered rather than provider-

centered approach to circumcisions.

Specifically, this approach included

individualized timing rather than

provider-convenient, designated

times for circumcisions. Nurses

performed bedside postcircumcision

checks rather than using the

Newborn Observation Unit.

Acknowledging that hospital staff

frequently interrupt mothers’

sleep, we instituted daily quiet

times to promote maternal rest. We

explained that rooming-in empowers

mothers to care for their infants and

encourages maternal recognition

of feeding cues, without affecting

maternal sleep. 24 – 26 Through these

initiatives, we improved rooming-in

to a median rate of 70% at 7 months

and 98% at 15 months ( Fig 3).

In the year preceding BFB, the baseline

rate of EBF was 37%, and within 6

months of the project, EBF increased

to 59% ( Fig 4). After observing an

unexplained deviation in March

2014, we subsequently audited all

newborn charts to ensure validity and

eliminate sampling error. We found a

small but significant improvement in

our secondary outcome of sustained

breastfeeding in women with prenatal

care at CWH. The median number of

women reporting breastfeeding at an

outpatient visit rose from 42% to 50%

in 18 months ( Fig 5).

DISCUSSION

Before our initiative, the cultural norm

did not include EBF, rooming-in, or STS

after delivery. Through participation in

the BFB Learning Collaborative model,

we successfully implemented evidence-

based hospital practices and increased

breastfeeding rates measured at

hospital discharge and a postpartum

visit. These changes provided

the foundation for Baby-Friendly

designation at our urban academic

health center in December 2014.

By June 2015, only 31 of 89 Learning

Collaborative hospitals achieved

Baby-Friendly designation. 22 We

e5

FIGURE 2Percentage of infants placed skin-to-skin after delivery.

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FIGURE 3Percentage of infants who room in.

FIGURE 4Percentage of infants who are exclusively breastfed.

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PEDIATRICS Volume 139 , number 2 , February 2017

believe our organizational leadership

and concurrent, mutually beneficial

initiatives were key factors in our

success. We strategically associated

this department quality improvement

project with the hospital mission

to provide life-changing, patient-

centered care. Our participation in

BFB aligned our practices with the

Joint Commission Perinatal Core

Measures on EBF, 27 a publicly reported

accountability measure. The timing

of this project coincided with public

health efforts to lower the infant

mortality rate in Hamilton County and

Ohio, which our leadership champion

used to solidify the hospital’s financial

commitment and justify the increased

budget for maternity and neonatal

services. Practically, this required the

Purchasing Department to negotiate a

fair market price for formula, purchase

online modules, and cover payroll costs

for nursing education time.

The obstetrics and pediatrics

departments absorbed physician

training expenses.

Before BFB, many individuals

supported breastfeeding mothers

but functioned in silos. We

encountered numerous challenges

in our efforts to implement practice

changes. The didactic and clinical

skill sessions across multiple units

involved considerable time and

labor. Maintaining documentation

compliance required unremitting

vigilance and accountability. No

additional personnel were hired for

these activities, so workloads shifted

to maintain clinical coverage while

accommodating the extended duties of

data collection and education required

for the project. The intrinsic motivation

of many individuals was a critical, but

difficult to measure, key to our success.

For salaried members of the STS

Task Force and staff, including

pediatric and obstetrics residents,

no additional time was allotted for

meetings and training. We believe

critical buy-in was gained from

these groups, given the public health

benefits of breastfeeding and the

evolving demographics of resident

physicians. Six obstetric residents

became parents during our project.

Nationally, more residents become

parents during residency than

ever before, 28 and similar personal

motivation is probably shared by

other residency training hospitals.

A residency training hospital

supportive of breastfeeding for its

patients indirectly supports the

breastfeeding of resident trainees

and their future patients.

It is worth noting the increase in

our EBF rates was significant but

not as large as improvements we

experienced with STS and rooming

in, and we did not meet our goal of

90%. Our experience mirrored that

of other collaborative hospitals,

because the average increase in

EBF rates across all BFB facilities

was only 27%. 22 We found that

families continue to request

non–medically indicated formula

e7

FIGURE 5Percentage of CWH patients breastfeeding at an outpatient postpartum visit. WIC, Women, Infants, and Children.

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despite our counseling, and many

have the prenatal intention of both

breastfeeding and formula feeding.

We suspect there are broader

cultural and generational biases to

be addressed well before pregnancy,

delivery, and even conception.

We must acknowledge certain

limitations to our results. The

data sampling measures may not

accurately reflect the EBF rate.

Our outpatient data suggest that

sustained breastfeeding increased, as

other authors in the literature have

described, 29 although this outcome

was measured only in a subgroup of

patients receiving prenatal care in

our clinic. In addition, this measure

is based on maternal report and does

not describe exclusivity. Although

exact timing of the postpartum

visit was not available, most visits

occurred within 6 weeks. Because

of practical constraints, the baseline

for this outcome was generated with

EMR implementation rather than

project initiation. It is possible the

baseline could be lower, resulting

in greater improvement; given

the preexisting culture, we do not

suspect the baseline would be higher.

Some barriers we faced implementing

the Ten Steps 16 were unique to urban

or academic health facilities. Our

demographics and hospital dynamics

may not generalize to all facilities,

especially those already serving

populations with high breastfeeding

rates. 30 In fact, our own evolving

demographics may provide false

reassurance of sustainability. By 2014,

our deliveries increased by 7.8%,

which included a greater percentage

of privately insured patients. We

cannot rule out the possibility that

these changes factored into the

improvements we experienced.

Despite these demographic changes,

added complexity remains in caring

for underserved populations in the

context of an academic medical

center with many faculty and resident

physicians transitioning monthly.

Another noteworthy challenge

has been reconciling AAP

recommendations to consider

pacifier use to prevent unexplained

infant death 31 while promoting step

9. Although the AAP recommends

delaying pacifier use until 1 month

for breastfed infants, 31 we have found

that this recommendation might

represent a mixed message with

regional infant mortality reduction

efforts for parents, families, nurses,

physicians, and public health officials.

Nevertheless, we are dedicated to

collaborating with all stakeholders,

and we strive for a unified approach

as we move forward.

Baby-Friendly designation marks

not the end of a journey but rather

an ongoing pathway for which

sustainability has distinct barriers.

Overall, we are gratified by the

changed attitudes and diminished

biases among our staff, physicians,

and families. This project fostered

standardized communications

with patients and families and

collaborative interaction between

providers. As an added benefit, we

found the educational processes

required for Baby-Friendly

designation improved staff retention,

helped recruit nurses, and promoted

resident physician well-care.

CONCLUSIONS

This initiative represents a

multitiered approach to improve

the health of our community and

to address existing disparities.

Although challenging, Baby-Friendly

designation is achievable, and it

sets the standard for breastfeeding

support and mother–infant care. It is

particularly important for academic

centers training future health care

providers to adopt best maternity

practices to improve health outcomes

for mothers and infants.

e8

ABBREVIATIONS

AAP:  American Academy of

Pediatrics

BFB:  Best Fed Beginnings

BFUSA:  Baby-Friendly USA

CWH:  Center for Women’s

Health

EBF:  exclusive breastfeeding

EMR:  electronic medical record

STS:  skin-to-skin

UCMC:  University of Cincinnati

Medical Center

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: Best Fed Beginnings was supported by the Centers for Disease Control through the National Institute for Children’s Health Quality.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

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