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The Baby-Friendly Journey in a US Public Hospital

Vasquez, Maya J. BSN, RNC, IBCLC; Berg, Ocean R. MSN, RN, CNS

The Journal of Perinatal & Neonatal Nursing: January/March 2012 - Volume 26 - Issue 1 - p 37–46
doi: 10.1097/JPN.0b013e3182107179
FEATURE ARTICLES
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In May of 2007, San Francisco General Hospital & Trauma Center became the first Baby-Friendly certified hospital in San Francisco. This quality improvement program began in 1999 and took 8 years to complete. Challenges to completing this goal included a population that has myriad social issues including non–English-speaking clients, drug abuse, poverty, and homelessness. Further complications included a constantly changing group of perinatal healthcare providers with little-to-no breast-feeding knowledge, hospital practices that did not support rooming-in and skin-to-skin contact, and lack of overall patient breast-feeding education. This article describes the process of implementing The Baby-Friendly Hospital Initiative quality improvement program, achieving certification and subsequent increase in breast-feeding rates. Breast-feeding initiation rates went from 81% in 2002 to 98% in 2010. Exclusivity rates did not change.

San Francisco General Hospital and Trauma Center, San Francisco, California.

Corresponding Author: Maya J. Vasquez, San Francisco General Hospital, 6C Birth Center, 1001 Potrero Ave, San Francisco, CA 94110 (maya.vasquez@sfdph.org).

Disclosure: The authors have disclosed that thay have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Submitted for publication: July 26, 2010; Accepted for publication: January 14, 2011

In May of 2007, San Francisco General Hospital & Trauma Center (SFGH) became the first Baby-Friendly certified hospital in San Francisco, joining more than 20 000 Baby-Friendly hospitals and birthing centers worldwide1 and 100 hospitals in the United States (US).2 The World Health Organization strongly supports exclusive breast-feeding, defined as receiving only breast milk, noother food or drink even water for up to 6 months of age.3 The World Health Organization further promotes continued breast-feeding along with appropriate complementary foods up to 2 years of age or beyond.4 The World Health Organization and the United Nations Children's Fund created the Baby-Friendly Hospital Initiative (BFHI) in 1991 in recognition of the serious health consequences of formula feeding and to increase worldwide breast-feeding rates. The BFHI is a structured approach to the implementation of the International Code of Marketing of Breast Milk Substitutes, written and adopted by the World Health Organization in 1981.5 The intent of this code was to stop the worldwide promotion of formula and was in direct response to the aggressive marketing techniques by formula advertisers. Baby-Friendly was created to certify hospitals that were following the code and offer optimal levels of breast-feeding education and support to lactating women. Baby-Friendly USA was started in 1997 and is currently responsible for implementation in the United States. The BFHI is a hospital and birthing center based model for breast-feeding promotion. The interventions required are outlined in Table 1, the “Ten Steps to Successful Breast-Feeding.”6

Table 1

Table 1

Each step requires multiple processes to achieve and is extensively supported by evidence.7 The BFHI certifies hospitals and birthing centers as “Baby-Friendly” when they institute specific practices to provide optimal levels of support for breast-feeding infants and mothers.

An ever-expanding body of research indicates that breast milk is the superior form of nutrition for infants.815 Benefits for infants include decreased incidence of lower respiratory tract infections,8,9 otitis media, gastrointestinal infections,8,10 sudden infant death syndrome, asthma, atopic dermatitis, childhood leukemia, type 1 and 2 diabetes, and childhood obesity.8,11,12 Benefits for mothers include decreased incidence of breast and ovarian cancer and type 2 diabetes.12,13 Benefits of breast-feeding increase with exclusivity and duration; conversely insufficient or no breast-feeding affects the health of individuals and their quality of life in communities all over the globe.14 A recent cost analysis of breast-feeding benefits for children found that if 90% of infants in the United States were exclusively breast milk fed for 6 months, the national cost savings would be $13 billion annually and approximately 900 lives would be saved.15 Women of lower socioeconomic levels as quantified by eligibility for Women with Infants or Children (WIC), mothers with high school education or less and mothers under 20 years old are at greatest risk for not breast-feeding.16,17 Children of these women disproportionately bear the negative health consequences of not being breast-fed.

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EVIDENCE-BASED LITERATURE

The Baby-Friendly “Ten Steps to Successful Breast-Feeding” has been shown to increase breast-feeding initiation and duration.18,19 Boston Medical Center was the first public hospital in the United States to achieve Baby-Friendly status. Boston Medical Center's patient population is similar to that of SFGH, serving primarily low-income women of color and new immigrants. After the initiation of Baby-Friendly practices, the incidence of breast-feeding rose from 58% in 1995 to 86.5% in 1999. There was an increase in exclusive breast-feeding from 5.5% to 33.5% respectively.20 A follow-up survey in 2001 found that the gains made by becoming Baby-Friendly had been maintained.21

This is consistent with findings in a variety of other hospitals worldwide.2225 A survey of postpartum women in Switzerland found positive effects on duration of breast-feeding when infants roomed-in with their mothers, breast-fed within the first hour of life, fed on demand and were not offered pacifiers. Negative effects on breast-feeding included formula supplementation and gifts of formula at discharge. Conclusions from the survey were that Baby-Friendly's “Ten Steps to Successful Breast-Feeding” increased breast-feeding rates.22 A similar study in Scotland found that being born in a Baby-Friendly hospital significantly increased the chances of being breast-fed.23 In Brazil, researchers found that Baby-Friendly practices increased breast-feeding initiation and exclusivity rates.24 The largest study to date was a randomized controlled trial in Belarus, known as the Promotion of Breast-Feeding Intervention Trial.25 Researchers randomly assigned an experimental intervention on the basis of the Baby-Friendly model to 16 hospitals, while also studying a control group of 15 hospitals, which did not receive this intervention. 16 491 mother-infant pairs were followed for 1 year. Results found that the experimental group were significantly more likely to be exclusively breast-fed at 3 and 6 months and were also more likely to have some breast-feeding at 12 months.

The only survey to date of all United States Baby-Friendly hospitals reveals that infants born at these hospitals were more likely to be breast-fed than their counterparts born in non–Baby-Friendly hospitals. Although the number of hospitals studied was small because there were only 29 certified hospitals in 2001, it was observed that Baby-Friendly hospitals did make a positive impact overall, including an increased rate of breast-feeding for women of color and increased rates in regions of the country in which breast-feeding rates were historically low.26

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THE SETTING

San Francisco General Hospital and Trauma Center has provided essential healthcare services since 1872 and is considered a safety-net hospital for San Francisco's poorest citizens. It is a 300-bed acute care hospital owned by the city and county of San Francisco, located in the inner city Mission District. Ninety-four percent of women who deliver in the birth center are of color, 88% are at 150% of the federal poverty level or below, and 61% are non–English-speaking based on fiscal year 2008–2009 data. Pregnant women delivering at the facility have challenging, multifaceted social problems including homelessness, lack of social support, poverty, domestic violence, very low educational levels, and undocumented immigration status. Psychiatric illness and substance abuse are common comorbidities in this population of women.

The SFGH Birth Center has approximately 1 350 births annually. It provides labor and delivery services to a citywide network of public health clinics. The nurses, providers and other team members in the birth center, infant care center, prenatal and pediatric clinics strive to provide humanistic, cost-effective, and culturally competent care to an ethnically and linguistically diverse group of women and their families.

The SFGH is a teaching hospital, providing clinical education and training for medical students, residents, and certified nurse midwifery students affiliated with the University of California at San Francisco. The hospital is also a clinical placement site for students enrolled in registered nursing, licensed vocational nursing, and graduate level nursing programs from many local colleges and universities. There is a constant flow of students, novice caregivers, and rotating clinical faculty through the clinics, birth center and infant care center. These transient team members depend in large part upon the permanent staff nurses, clinical nurse specialists, and international board certified lactation consultant (IBCLC) for guidance in providing breast-feeding education and support for the patients.

In the early 2000s, breast-feeding initiation rates were higher than national data (81% in 2002 vs 71% nationally27). However, despite prenatal counseling regarding the benefits of breast-feeding, only 70% of patients who delivered at San Francisco General Hospital were exclusively breast-feeding at the time of discharge. A family practice physician raised concerns about women whose intent to breast-feed was undermined by postpartum staff suggestions to offer formula. This galvanized other providers who had similar concerns. A small group of key stakeholders including maternity and infant staff nurses, certified nurse midwives and physicians from the community based clinics came together to discuss ways to improve exclusive and sustained breast-feeding rates. After stringent review of the evidence regarding best practices, this group proposed that the hospital utilize the Baby-Friendly Hospital Initiative as the structure for a quality improvement project to increase initiation and duration of breast-feeding. This article describes the process of engaging in the Baby-Friendly Hospital Initiative at this public institution as a quality improvement project and will show the positive effects of programmatic changes relative to breast-feeding rates.

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CHALLENGES TO THE QUALITY IMPROVEMENT PROGRAM

Regardless of women's intentions to breast-feed before delivery, in the early 1990's breast-feeding was rarely supported in the existing perinatal culture. Nursing routines surrounding infant feeding were shaped by inadequate knowledge about human lactation, the benefits of breast-feeding, and successful initiation and ongoing support of breast-feeding. Medical residents did not receive uniform and accurate education regarding breast-feeding, especially regarding support of breast-feeding in infants with higher acuity. New mothers were frequently encouraged to provide bottles of formula for any perceived or actual breast-feeding problems, were exposed to formula advertising in patient education materials and were sent home with a formula company supplied diaper bag that included free samples of formula. A task-oriented approach to nursing care and a division of labor between the birth center and infant care center nurses often resulted in poor communication regarding breast-feeding problems, maternal concerns, and achievement of breast-feeding goals. Maternal efforts to establish successful breast-feeding were disrupted when infants were taken to the infant care center for routine assessments, screenings and baths. Once infants were in the nursery, it was easy for nurses and physicians to cluster tasks and the separation from mother often became extended for several hours. When infants became fussy, they were frequently given formula because it was not considered harmful. Many nurses believed that they were providing a positive and critical intervention. This practice led to prolonged separation of the mother and infant and resulted in a lost opportunity to maintain breast-feeding in the critical hours following delivery.

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THE BABY-FRIENDLY HOSPITAL INITIATIVE AT THE SFGH

The quality improvement project toward Baby-Friendly certification began in 1999. Audits showed that the 5 most challenging quality initiatives were staff education, prenatal education, rooming-in efforts, skin-to-skin contact, and ending the routine use of artificial nipples (pacifiers and bottles). The original stakeholder group expanded into a hospital-based task force. This was comprised of registered nurses, physicians, certified nurse midwives, social workers, lactation consultants, healthcare educators, nurse managers, the clinical nurse specialist, nursing directors, nutritionists, and the WIC breast-feeding coordinator. The initiative was funded and supported by all levels of the administrative leadership including the Director of San Francisco's Department of Public Health. Each of the Ten Steps to Successful Breast-Feeding was studied and quality interventions were designed to fully implement each step. Implementation of Baby-Friendly was not without cost. A Baby-Friendly hospital is required to pay for all formula given to infants whose mothers chose not to breast-feed, or were unable to breast-feed because of maternal illness or neonatal problems. Administrative support for the Baby-Friendly Hospital Initiative facilitated the implementation of many crucial interventions, including paying for formula (most US hospitals receive free or severely discounted formula from formula companies in exchange for exclusive access and product placement rights) and no longer providing formula company supplied discharge bags to postpartum women.

Other steps were more time consuming, including intensive staff education and training. Despite best efforts, the hospital failed to meet all the standards to be certified when Baby-Friendly USA initially surveyed the facility in 2006. Deficiencies were noted regarding prenatal education and skin-to-skin throughout the hospital stay. Members of the Baby-Friendly Task Force refocused, formulated a stronger quality action plan, and within a year practices were improved and certification was granted.

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QUALITY INITIATIVES: KEY COMPONENTS

Staff education

The Baby-Friendly Hospital Initiative requires that all perinatal nurses receive at least 18 hours of lactation education and physicians and advanced practice nurses caring for breast-feeding families have at least 3 hours of training. In 2002, the nurse managers of the birth center and infant care center committed fully to being Baby-Friendly by mandating the required 18 hours of lactation education for the nurses on their respective units. The 18-hour “Curriculum in Support of the Ten Steps to Successful Breast-Feeding,” created by Baby-Friendly USA, was purchased. Three staff members organized and taught ongoing 3-day workshops to 100 perinatal nursing staff members. To ensure that they all received the mandatory 18 hours of lactation education, 20 nurses at a time attended each 6-hour session. Clinical coverage was arranged for the 20 attendees who were in class. The financial commitment included paying for the instructors and all of the attendees during class plus staffing coverage for the 2 units.

Currently, the course is provided every 6 to 12 months. The curriculum, as listed in Table 2, has been modified over the years to reflect current breast-feeding research, as well as incorporating points specific to the SFGH patient population.

Table 2

Table 2

The course is attended by newly hired registered nurses employed in the birth center and infant care center and all maternal child public health nurses, as well as many clinic nurses, healthcare educators, social workers, and volunteer doulas.

Although nurses continue to successfully complete the 18-hour course requirements, there have been ongoing difficulties surrounding compliance with other types of providers (clinical faculty, obstetricians, pediatricians, family medicine physicians, and advanced practice nurses) in completing the mandatory 3-hour training program. Some female faculty asserts that they do not need additional lactation education because of personal experiences with breast-feeding. Other providers object to attending the class because their partners breast-fed and they believe that observing this at home gave them enough information to instruct women in breast-feeding.

Initially, the attending physicians were asked to complete an online course, approved for this purpose by Baby-Friendly USA. About 50% took the course and, while they learned much about breast-feeding, the course did not cover the resources available at the hospital. To rectify that situation a medical student, in collaboration with the lactation consultant, created 3 PowerPoint modules and in 2005 began a formal training program utilizing these modules. Physicians and advanced practice nurses were invited to evening educational seminars and noon teaching conferences in which the 3 modules were presented and questions were answered and incentives were provided for attendance.

To increase the numbers of providers completing the training, pediatric, and obstetric physician champions insisted that their staff take the training. Ninety percent of attending physicians and other providers received training through live and online trainings. Given that SFGH is a training hospital for the University of California at San Francisco, resident physicians rotate through the facility every 4 to 6 weeks (depending on area of concentration) and constitute a large and constantly changing group to educate. Initially, the lactation consultant presented content at noontime conferences and faculty integrated more breast-feeding curriculum into their core teaching. Eventually, 2 students interning with the Perinatal Services Coordinator for the Department of Public Health, were able to transform the 3 PowerPoint presentations into an online training program, as shown in Table 3.

Table 3

Table 3

As of June 2008, faculty and residents are required to complete the 3 online modules. Student nurse midwives participate in didactic content provided by the lactation consultant and have observation time included. Nursing students and volunteer doulas receive introductory education on breast-feeding and Baby-Friendly practices.

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Prenatal education

For a hospital to be certified as Baby-Friendly, prenatal patients must be able to describe 3 breast-feeding benefits and 3 management techniques by the 36th week of pregnancy. Results from surveys performed in the prenatal clinic before inspection revealed a disparity between the high number of women who understood benefits of breast-feeding versus the few who knew the “how to” management techniques of breast-feeding. Quality prenatal education bridges this gap. Given budgetary constraints and a client population with diverse educational needs, approaching prenatal education from multiple angles has been an effective approach.

Approximately 50% of prenatal clients receive care from the nurse midwifery practice. Certified nurse midwives (CNMs) are educated to provide extensive education to pregnant women. Many midwifery clients are part of the Centering Pregnancy program, a novel, group approach to prenatal care that is patient-led. A midwife facilitator provides medical care and directs educational content whereas patients naturally teach one another how to breast-feed and what to expect via shared experiences. The group facilitator directs and encourages conversation and highlights aspects of breast-feeding that are known to be important to cover prenatally.

Conversely, obstetricians in the SFGH prenatal clinic are not as knowledgeable about, nor as accustomed to providing education about breast-feeding. Chart audits showed minimal documentation of breast-feeding education by physicians. Results were shared with faculty leaders in clinic and they mandated that residents chart breast-feeding teaching. To facilitate documentation of prenatal education, a “Prenatal Care Flow” form was created for use during prenatal appointments. This form has multiple topics, including labs to be drawn and educational content to be covered and is organized by gestational age. It lists specific breast-feeding teaching cues for providers including benefits and management techniques. The intent of the form is to assist providers to give appropriate and consistent education based on gestational age and patient's ability to receive information at each stage of pregnancy. There is ongoing poor documentation of prenatal breast-feeding education by some providers and this remains an area for continuous quality improvement.

For years the prenatal clinic has offered breast-feeding classes to pregnant women in English and Spanish and healthcare educators and dieticians give individual counseling. Given the deficiencies identified in the 2006 survey to provide adequate prenatal education, a healthcare educator and a CNM created the “Expectant Parent's Club.” The club is a series of 6 classes that covers several topics and has a class dedicated to breast-feeding curriculum. The club was originally offered in English, Spanish, and Cantonese/Mandarin and it was remarkably well-received. Currently, because of budget constraints, changes in clinic staffing and loss of grant monies, this class is not fully funded, however, a pared down version continues to be well-attended.

Approximately 90% of SFGH's perinatal women receive supplemental food and education from the federal the WIC program. Patients enrolled in WIC during their second trimester of pregnancy are required to take a breast-feeding course. The WIC also provides individual counseling regarding breast-feeding and supplies hospital grade electric pumps to women separated from their infants for medical reasons, or if the mother is returning to work or school. The WIC staff has been active members of the Baby-Friendly Task Force. The WIC's educational handouts are utilized in clinics, the birth center and infant care center.

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Rooming-in efforts

San Francisco General Hospital was slow to adopt the couplet-staffing model. Before 2000, nursery nurses admitted and cared for all infants in the infant care center. Most well infants roomed in with their mothers; however, there were major periods of separation. Two hours after delivery they were taken to the infant care center for at least 4 hours to be assessed, receive routine newborn medications, and be bathed. Infants were commonly left under a warmer after their first bath while the nurse cared for other patients prolonging separation. The pediatricians performed their assessments and newborn examinations by taking the infants from their mother's room back to the Infant Care Center and all blood draws were performed in the Infant Care Center.

In an attempt to decrease separation and meet the BFHI requirement of rooming-in for 23 of 24 hours a day, couplet care was implemented as a quality improvement project. Intensive training of birth center nurses was initiated to prepare them to perform newborn assessments, baths, perform hematocrit, and glucose monitoring and draw newborn screening tests. At the same time Infant Care Center staff were oriented through didactic classes and clinical rotations to perform postpartum care for women.

During this difficult transition period several months of audits were performed by placing hanging clipboards on every infant crib and having all staff members document each time the infant was separated from the mother, with both the time and rationale noted. Results of the audits were widely circulated. The results increased staff awareness related to the extent of separation of an infant from his mother and highlighted which staff were frequently removing infants from their mother's rooms and why. One of the most positive outcomes of this intervention was that when nurses noticed their peers and other providers taking infants out of rooms they questioned the need for separation. Hanging clipboard audits revealed that infants were still frequently taken to the Infant Care Center by pediatricians for admission and discharge examinations. The rationale was that all the equipment and supplies were located in the Infant Care Center and not at the bedside. In response, neonatal leadership helped obtain a portable ophthalmoscope and all other necessary examination supplies. Pediatricians now perform admission and discharge examinations at the mother's bedside. An added benefit is that pediatricians now use this one-on-one time to teach families about their amazing infant.

All infants born by cesarean section were admitted to the Infant Care Center and postsurgery remained a time of prolonged separation of mother and infant. To help minimize this time, recovery guidelines were written to improve communication between the 2 units. The guidelines instructed the circulating nurse (from the birth center) to call the infant's nurse as soon as the mother returned from the operating room and was able to be reunited with her infant. This has been moderately successful but remains an area of needed improvement.

Although staffing inadequacies continue to curtail full implementation of couplet care, there have been dramatic improvements in the amount of time that infants remain rooming-in with their mothers. It is rare to see a well infant in the infant care center. Currently staff members perform most newborn admissions in the labor and delivery rooms. If the admission happens in the Infant Care Center the infants return to their mother much more quickly than previously. Routine lab draws are either performed at mother's bedside or in an empty room in the birth center.

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Skin-to-skin contact

Skin-to-skin contact or the practice of placing a naked baby on a parent's bare chest is a critical component of Baby-Friendly care, because it has been shown to improve breast-feeding behaviors and physiologically stabilize infants.2830 Baby-Friendly requires that healthy term infants are placed skin-to-skin and that staff assist with breast-feeding within 1 hour of birth. It also requires that infants stay skin-to-skin for prolonged periods following birth and that this be used as a first intervention for breast-feeding problems. The SFGH failed to meet Baby-Friendly skin-to-skin standards in 2006. To address this inadequacy the newborn assessment tool was changed to include documentation of skin-to-skin after delivery along with the infant's vital signs. It was simple enough for staff to immediately place infants born vaginally skin-to-skin. More challenging was prolonged skin-to-skin and skin-to-skin for infants born via cesarean section.

Because of direct admission to the Infant Care Center infants born by cesarean were routinely dressed in T-shirts and tightly swaddled.

Parental concern about infants getting cold, as well as staff perceptions that it was a culturally inappropriate practice, hindered the implementation of skin-to-skin. To educate staff, extensive research data were used to create in-services that reviewed rationale for skin-to-skin as well as strategies for implementation. Simple changes in practice such as not routinely putting T-shirts on infants and teaching staff to securely place infant skin-to-skin on mother helped staff fully implement skin-to-skin. Once staff realized improvements in breast-feeding behaviors, they became skin-to-skin champions.

Currently most infants are kept skin-to-skin throughout the hospital stay and fathers participate in this intervention as well. Inspired by the results of postpartum skin-to-skin, a quality improvement project was initiated this year to place infants skin-to-skin in the operating room suite right after cesarean sections. Initial data collection has showed positive results in decreased formula supplementation, quicker postoperative reunification, and maternal satisfaction.

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No artificial nipples

One of the catalysts for the initiation of the Baby-Friendly Task force was a provider reporting that patients, who intended to exclusively breast-feed, were given bottles and pacifiers while in the hospital and on discharge. Baby-Friendly hospitals are required to support exclusive breast-feeding by not routinely giving out pacifiers or using artificial nipples when supplementing infants. Evidence shows that early introduction of artificial nipples decreases duration and exclusivity of breast-feeding.3133

This was a difficult change in practice. Healthcare providers are educated to quantify intake and bottle-feeding allows easy measurement of fluid intake. Breast-feeding requires much more confidence that the amount an infant is receiving is sufficient. Pacifiers are easy to give out and calm most fussy infants. Unfortunately use of bottles and pacifiers in the first month postpartum causes inadequate stimulation to mother, which reduces milk supply.

Education was a tool for change and staff participated in didactic sessions and annual updates dedicated to the physiology of lactation, medical indications for supplementation, and alternative feeding techniques. Understanding how much infants need to eat, as well as normal infant behaviors in the first few days of life has helped staff feel more comfortable with the management of lactation, as illustrated in Table 4.

Table 4

Table 4

Transition from bottle to alternative supplementation methods was slow but steady. With support and training nurses became skilled at breast-feeding friendly supplementation. Currently if supplementation is necessary a syringe with breast milk or formula attached to a 5 French feeding tube at the breast (the facility's version of the supplemental nursing system) is used. Benefits of this system include mother infant contact with each feed. Providers in the pediatric clinic report that mothers supplementing with this system are anxious to give it up and will happily return to exclusive breast-feeding, whereas mothers supplementing via bottle tend to view it as a permanent feeding method, and are more likely to continue to supplement breast-feeding with formula even when it is no longer medically indicated.

Education and physical changes in the environment helped eliminate pacifier use in the healthy infant population. Pacifiers were removed from the birth center so that registered nurses had to walk to the infant care center to obtain pacifiers for patients. Usage has declined dramatically. Pacifiers and bottles are rarely observed being used with well infants. The Baby-Friendly surveyors commented that they observed few bottles and pacifiers throughout the institution, which is an identifying aspect of a Baby-Friendly Hospital.

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DISCUSSION

In 2002, when the institution fully committed to the Baby-Friendly quality improvement project by implementing the 18-hour “Curriculum in Support of the Ten Steps to Successful Breast-Feeding” for nursing staff, 81% of mothers at SFGH initiated breast-feeding in the hospital and 70% exclusively breast-fed. In February of 2010, the breast-feeding initiation rate was 98% with an exclusivity rate of 68% as listed in Table 5.

Table 5

Table 5

While colleagues at other hospitals voice surprise when they hear how high the SFGH breast-feeding rate is, work continues on improving exclusivity.

Education is paramount. Frequent patient concerns of not having enough milk is addressed with evidenced-based patient teaching, as listed in Table 6, including explanations regarding normal weight loss, voiding and stooling patterns, normal infant behaviors, and the physiology of lactogenesis. Staff addresses patient fears about not having enough milk with educational messages such as “your baby has a very small stomach at birth,” “your baby is nursing frequently to tell your body to make enough milk,” and “we are watching your baby's diapers and weight and we will be sure to let you know if baby is not getting enough.”

Table 6

Table 6

Implementation of the Baby-Friendly Hospital Initiative is a long and challenging journey. Errors were made along the way, including insisting that mothers exclusively breast-feed. It is much better to educate and empower. In this quality improvement project, potential allies were lost by rigidly trying to force the process. Ongoing challenges include how to increase exclusivity rates, provider education, and documentation of prenatal teaching. Staffing challenges continue and complete implementation of couplet care has been unsuccessful.

What has worked has been continuity of core task force members. Coalitions have been built. For instance, public health nurses have embraced their role as breast-feeding counselors and are critical to the ongoing success of breast-feeding in our community. The task force has been successful at motivating people to do finite, critical tasks at key moments. For example, a medical student created pocket sized cue cards with basic breast-feeding management information for providers, which enhanced staff retention of information learned at trainings. A group of staff nurses organized a bake sale and breast-feeding information table, which generated enthusiasm and knowledge about Baby-Friendly throughout the institution. Increased hospital awareness has dramatically changed overall hospital culture. For example, the postanesthesia care unit staff now routinely question any surgeon's order to discard breast milk for a period of time after surgery. Lactating employees more frequently use staff pumping areas. Nurses on nonperinatal units frequently request breast pumps and lactation consults for their lactating women.

The entire hospital worked diligently in preparation for a 3-day survey by BFHI staff in March of 2006. Breast-feeding fairs were held, brochures were printed and attached to pay stubs, and a huge banner was hung in the lobby to increase staff awareness. The hospital education department produced breast-feeding posters that were posted throughout areas where pregnant and lactating women might frequent. Unfortunately, results of this inspection found deficiencies in a few key areas and initially the hospital did not pass inspection.

In May 2007, after a second intensive site survey, the SFGH was finally certified as a Baby-Friendly Hospital. A day of festivities in September of that year celebrated successes and included testimonials from current and past patients, physicians and other staff, and a ribbon cutting ceremony to officially open a breast-feeding Support Center. The SFGH is currently recognized as a leader in breast-feeding promotion in Northern California.

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SUMMARY

The Baby-Friendly Hospital Initiative is a quality improvement project that increases initiation and exclusivity of breast-feeding. This project has many complex variables and requires hospital wide changes. Initiation and maintenance can be challenging. Key components to success are addressing barriers early on, forming a dedicated multidisciplinary team, obtaining administrative support, and investing time. Rewards are numerous and include increased staff knowledge about breast-feeding, increased initiation of breast-feeding, and improved health for infants, mothers, and communities.

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    Keywords:

    breast-feeding; infant; health promotion; newborn; public hospital

    © 2012 Lippincott Williams & Wilkins, Inc.