Acknowledgements. Dr. Mase for his endless hours of effort and support through the process of completing this work.

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2 Acknowledgements I would like to acknowledge: Dr. Mase for his endless hours of effort and support through the process of completing this work. My daughter Daria Ziva, who traveled with me along the journey towards earning my Masters in Public Health. Whether it was attending a class, going to a conference, or writing a paper; Daria was always by my side. Daria makes me love nursing and inspires me to share and make assessable the joys and pleasures of it with all mothers! My fabulous husband, Brent. His support and encouragement as a breastfeeding advocate and as a supporter of my work, allowed me to complete this project and my degree. My mother and grandmother Minnette for all of their time, energy, and support watching Daria while I was trying to complete this project. ii

3 Abstract: Objectives: This research provides generalizable knowledge as to whether the Baby Friendly Hospital Initiative (BFHI), a global initiative aimed at improving maternity services to best enable mothers to successfully breastfeed babies, is a possibility for Ohio hospitals to initiate in order to improve breastfeeding rates in Ohio to meet the Surgeon General s 2011 Call to Action and the Healthy People 2020 goals. Methods: Following a literature review and policy analysis, the researcher conducted three semistructured, hour-long telephone interviews with lactation staff representing all four hospitals in Ohio with BFHI designation. Results: After receiving Baby-Friendly designation each of the hospitals saw increases in lactation initiation. All participants felt positively about the BFHI and the process of obtaining designation. Key findings are discussed in a theme analysis. Conclusions: The Baby-Friendly Hospital Initiative is a path towards providing optimal care for newborns and mothers to support, promote, and protect breastfeeding. BFHI could be expanded in Ohio hospitals to increase lactation rates, increase lactation support, and promote breastfeeding. Keywords: Ohio, Lactation, Breastfeeding, Baby-Friendly Hospital Initiative iii

4 Table of Contents: Part 1: Introduction- Pages 1-12 Part 2: Methods- Pages Part 3: General Observations and Theme Analysis- Pages General Observations- Pages Theme 1: Policy- Pages Theme 2: Hospital Personnel- Pages Theme 3: Patient Education- Pages Part 4: Discussion- Pages Limitations and Recommendations for Future Research- Pages Part 5: Conclusion- Pages Work's Cited- Pages Appendices- Pages iv

5 Part 1: Introduction: Breast milk is the best and most ideal food for human babies. Babies benefit in numerous ways from breast milk and mothers benefit in numerous ways from nursing. Breastfed babies experience lower rates of many illnesses such as: urinary and respiratory infections, diarrhea, and bacterial meningitis. So too, benefits to mothers of nursing and pumping include: reduced risk of breast and ovarian cancer, and nursing helps moms lose weight postpartum ( 101 Reasons to Breastfeed, 2011). The following chart from "the Surgeon General's Call to Action to Support Breastfeeding, 2011" highlights several of the excess health risks faced by mothers and babies that do not nurse (U.S. Department of Health and Human Services, 2011). 1

6 In addition to improving health amongst babies and mothers, breastfeeding also reduces medical costs and is better for the environment. It is estimated that $13 billion a year in health care costs could be saved if all American babies breastfed. Additionally, research demonstrates that mothers who breastfeed are more productive since they miss work less often to care for their sick infants, and employer medical costs are less impacted by the cost of medical care. Breastfeeding is also better for the environment than formula feeding because it produces less waste in the form of formula containers ( Why Breastfeeding is Important, 2011). "The Surgeon General's Call to Action to Support Breastfeeding, 2011" found: Increasing rates of breastfeeding can help reduce the prevalence of various illnesses and health conditions, which in turn results in lower health care costs. A study conducted in 2001 on the economic impact of breastfeeding for three illnesses otitis media, gastroenteritis, and NEC found that increasing the proportion of children who were breastfed in 2000 to the targets established in Healthy People 2010 would have saved an estimated $3.6 billion annually. These savings were based on direct costs (e.g., costs for formula as well as physician, hospital, clinic, laboratory, and procedural fees) and indirect costs (e.g., wages parents lose while caring for an ill child), as well as the estimated cost of premature death. A more recent study that used costs adjusted to 2007 dollars and evaluated costs associated with additional illnesses and diseases (sudden infant death syndrome, hospitalization for lower respiratory tract infection in infancy, atopic dermatitis, childhood leukemia, childhood obesity, childhood asthma, and type 1 diabetes mellitus) found that if 90 percent of U.S. families followed guidelines to breastfeed exclusively for six months, the United States would save $13 billion annually from reduced direct medical and indirect costs and the cost of premature death. If 80 percent of U.S. families complied, $10.5 billion per year would be saved (U.S. Department of Health and Human Services, 2011). With such a prevalence of formula feeding today, it is important to understand how formula came to compete with breastfeeding. Although breastfeeding is the natural way to nourish a human baby, during the late nineteenth century and throughout the twentieth century alternatives to human milk substitutes developed. In the early years of the twentieth century, sanitation and preservation technology developed significantly (the home icebox, preservatives, 2

7 etc.), which improved dairying practices and milk handling. At the turn of the twentieth century, most infant formulas were made at home where they could be stored in the home icebox. The early formulas were not vitamin fortified. In the 1920 s, orange juice and cod liver oil were given to infants along with the formula to combat survey and rickets. The largest decline in breastfeeding occurred from 1930 through the 1960s due to the increased availability of commercially prepared formulas and a concomitant increase in iron deficiency among infants. Iron fortified formulas were introduced during this period. At the same time, cow s milk and beikost were introduced into the diet at earlier ages. Eventually, few infants were breastfed or formula fed after four to six months of age (Fomon, 2001). Increased availability of commercially prepared formulas caused home-prepared formulas to decline as well. From 1970 through the end of the century, there was a resurgence of breastfeeding and a prolongation of formula feeding with the increase in usage of iron-fortified formulas. Beginning at the end of the twentieth century, formula feeding and breastfeeding older infants supplanted the use of fresh cow s milk and the prevalence of iron deficiency of formula fed infants has decreased (Fomon, 2001). In the United States, formula companies heavily market their products to new mothers through formula giveaways at physician offices and birthing hospitals, and through aggressive advertizing. An October 15th, 2012 article in the New York Times entitled, "Hospitals Ditch Formula Samples to Promote Breast-feeding" suggests, "The C.D.C., the World Health Organization, and breast-feeding advocates say samples turn hospitals into formula sales agents and imply that hospitals think formula is as healthy as breast-feeding." The article continues, "They say that while some women face serious breast-feeding challenges, more could nurse longer with greater support, and that formula samples can weaken that support system 3

8 (Belluck)." The United States has not adopted the International Code of Marketing of Breastmilk Substitutes. The Code is a health policy framework used internationally that was adopted by the World Health Organization (WHO) and the World Health Assembly (WHA) in Developed in the early 1980 s, the purpose of this code was to promote a public health strategy that recommends restrictions on the marketing of breastmilk substitutes to ensure that mothers are not discouraged from breastfeeding as a result of aggressive marketing ( International Code of Marketing Breast-Milk Substitutes, 1981). The number of women breastfeeding in the United States has been increasing consistently since the early 1990 s, although recently these gains have begun to level-off. In 2011, 74.6% of US women initiated breastfeeding, 44.3% of US women breastfeeding at six months, and 23.8% of US women breastfed for one year ( Breastfeeding Report Card- 2011", 2011 ). The Healthy People 2020 goals are for 81.9% of women to initiate breastfeeding, 60.6% of women to breastfeed for six months, and 34.1% of women to breastfeed for one year ( Maternal, Infant, and Child Health- Healthy People ). The current rates fall far short of these goals, especially at the six month and one year levels. 4

9 Because of all the benefits to babies, mothers, the environment and society, encouraging breastfeeding is a national public health goal. In 2000, the US Surgeon General said, The nation must address these low breastfeeding rates as a public health challenge and put into place national, culturally appropriate strategies to promote breastfeeding (Grummer-Strawn and Shealy, 2009). This issue continues to be at the forefront of the Surgeon General s agenda. In January 2011, the Surgeon General stated in their Call to Action : One of the most highly effective preventive measures a mother can take to protect the health of her infant and herself is to breastfeed. However, in the U.S., while 75 percent of mothers start out breastfeeding, only 13 percent of babies are exclusively breastfed at the end of six months. Additionally, rates are significantly lower for African-American infants. The decision to breastfeed is a personal one, and a mother should not be made to feel guilty if she cannot or chooses not to breastfeed. The success rate among mothers who want to breastfeed can be greatly improved through active support from their families, friends, communities, clinicians, health care leaders, employers and policymakers. Given the importance of breastfeeding for the health and well-being of mothers and children, it is critical that we take action across the country to support breastfeeding. (U.S. Department of Health and Human Services, 2011) The January 2011 Call to Action was a milestone for breastfeeding advocates in the United States and drew attention to the importance of removing the barriers that prevent women from reaching their breastfeeding goals. It also served as an important voice to encourage all participants in the US health care system to promote breastfeeding (Saadeh, 2012). Certain cross-sections of the population exhibit greater success initiating and sustaining breastfeeding. More specifically, studies show the following demographics are most likely to initiate and sustain breastfeeding: those who are white, older, married, have received some higher education, and are better off financially. Social influences including, support from the infant s father, family, friends, nurses and physicians, can also have a positive effect on 5

10 breastfeeding initiation and duration. Other key factors that affect breastfeeding initiation and sustaining breastfeeding for all races are the need to return to work, beliefs about breastfeeding and knowledge of the benefits of breastfeeding (Lewallen and Street, 2010). The study by Lewallen and Street (2010) suggested that, A less well studied factor that may also affect the breastfeeding practices of African American women is culture. Lewallen and Street argue that there may be cultural norms in place that make it challenging for African American women to initiate and continue nursing such as perceptions that formula feeding is better, discomfort with nursing publicly, and inadequate support from family and peers as to the benefits of nursing. In the United States, there are different geographic norms that also affect breastfeeding initiation and duration. The state of Ohio is one of the lowest performing states, 44th out of 50 for having ever breastfed. According to the CDC's Breastfeeding Report Card-2012, only 62.3% of Ohioans ever breastfed, 39.5% were breastfeeding at six months, and only 25.6% breastfed for at least twelve months. States in the Midwest and South tend to have similar rates to Ohio ("Breastfeeding Report Card United States, 2012", 2012). The Centers for Disease Control and Prevention 2011 Breastfeeding report card suggests, Birth facility policies and practices significantly impact whether a woman chooses to start breastfeeding and how long she continues to breastfeed. Several specific policies and practices, in combination, determine how much overall support for breastfeeding a woman birthing in a given facility is likely to receive and how likely her baby is to receive formula in the first 2 days. There are two initiatives, one national and one global, which provide informative measures of birth facility support. The national initiative is the mpinc Survey initiated by the CDC, in collaboration with the Battelle Centers for Public Health Research and Evaluation in The mpinc survey measures breastfeeding-related maternity care practices at 6

11 intrapartum care facilities across the U.S. and compares the extent to which these practices vary by state. The state mpinc score represents the extent to which each state's birth facilities provide maternity care that supports breastfeeding ( Breastfeeding Report Card- 2011, 2011). The global initiative is called the Baby-Friendly Hospital Initiative (BFHI). BFHI is an international program established in 1991 and revised in It is sponsored by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for lactation based on the WHO/UNICEF Ten Steps to Successful Breastfeeding for Hospitals ( Breastfeeding Report Card- 2011, 2011). The BFHI assists hospitals in giving mothers the information, confidence, and skills needed to successfully initiate and continue breastfeeding their babies or feeding formula safely, and gives special recognition to hospitals that have done so. There are more than 19,000 hospitals around the world that have BFHI designation. However, there are only 143 in the United States as of May, Four of the 143 facilities with Baby-Friendly designation are located in the state of Ohio ("Baby-Friendly Hospital Initiative", 2012). In order to be designated as "Baby-Friendly," facilities undergo external evaluation and must demonstrate that the facility meets all of the Ten Steps requirements. 1. Maintain a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6. Give infants no food or drink other than breastmilk, unless medically indicated. 7. Practice rooming in -- allow mothers and infants to remain together 24 hours a day. 7

12 8. Encourage unrestricted breastfeeding. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic The "Baby-Friendly" designation can be sought by all types and sizes of birth facilities. In the United States, there is great variety in the institutions that have received "Baby-Friendly" designation. In some states, there are several small "Baby-Friendly" facilities; in other states there are only one or two large ones; yet, still other states have none at all ( Breastfeeding Report Card-2011, 2011). The Centers for Disease Control and Prevention recommends in the 2011 Breastfeeding Report Card, Because facilities vary in size and the number of births, measuring their impact on public health requires more than just counting the number of "Baby-Friendly" facilities per state. The best way to measure their impact is to look at the proportion of births in a given state occurring at facilities that have earned the "Baby-Friendly" distinction. In 2011, only 4.1% of births in the state of Ohio were at "Baby-Friendly" facilities ( Breastfeeding Report Card-2011, 2011). The number of institutions with Baby-Friendly designation in the United States has continued to grow, but is still under ten percent of all US Birthing facilities. With the Call to 8

13 Action and the CDC annual breastfeeding report cards, BFHI is on the radar of politicians, policy analysts, politicians and hospital administrators. In April of 2012, Mayor Bloomberg announced that the New York City (NYC) Health Department would launch an initiative to encourage city hospitals to obtain Baby-Friendly designation. The health department of NYC is asking maternity hospitals to voluntarily limit the promotion of infant formula because it can interfere with breastfeeding. The state of Illinois is also promoting the BFHI. On June 28, 2012, Illinois Governor Pat Quinn signed House Bill The bill calls on every hospital that provides birthing services to adopt an infant feeding policy to promote breastfeeding. The bill asks hospitals to consider guidance from the Baby-Friendly Hospital Initiative in developing their policies (O Mara, 2012). 9

14 In 2011, the US Surgeon General issued a Call to Action concerning the low breastfeeding rates in the United States (U.S. Department of Health and Human Services, 2011). The call to action recognizes the BFHI to be a promising strategy to improve the care provided to new mothers (Joint Commission on Accreditation of Healthcare Organizations, 2006). The Baby-Friendly Hospital Initiative is part of Action 7, which is to ensure that maternity care practices throughout the United States are fully supportive of breastfeeding. The implementation strategies for Action 7 are to accelerate the implementation of the Baby-Friendly Hospital Initiative and to establish transparent, accountable public reporting of maternity care practices in the United States. The 2011 report card based off of the mpinc survey administered by the CDC recommends the State of Ohio to increase adoption of the BFHI in Ohio hospitals and birthing centers ( Maternity Practices in Infant Nutrition and Care in Ohio, 2011). The California WIC association found, Disparities in in-hospital rates of exclusive breastfeeding are not found in hospitals that have implemented the policies and practices of the Baby-Friendly Hospital Initiative, while the opposite is true in hospitals that are in the same geographic region but are not designated as Baby-Friendly (California WIC Association, 2008). Perrine and colleagues found that, Two-thirds of mothers who intend to exclusively breastfeed are not meeting their intended duration. Increased Baby-Friendly hospital practices, particularly giving only breast milk in the hospital, may help more mothers achieve their exclusive breastfeeding intentions. Saadeh (2012) found, The BFHI has led to increased rates of exclusive breastfeeding, which are reflected in improved health and survival 1. The BFHI has had great impact on breastfeeding practices among both healthy and sick infants. 1 The improved health and survival is due to the health benefits of nursing, such as decreased risk of SIDS and diarrhea. 10

15 As of September 12, 2012 there are currently four "Baby-Friendly" Hospitals in Ohio and 143 throughout the United States. The four hospitals in Ohio that have received designation are: Lakewood Hospital (Cleveland, OH), Southview Hospital (Kettering, OH), Mercy Hospital Anderson (Cincinnati, OH), and Mercy Hospital Fairfield (Cincinnati, OH) ( Baby-Friendly ). Several hospitals in Ohio are in the process of becoming "Baby-Friendly", but Baby-Friendly Hospital Initiative USA will not disclose the list of hospitals in the process of receiving the designation 2. The National Institute for Child Health Care Quality has a grant to help 90 hospitals become "Baby-Friendly" with the support of the Centers for Disease Control and Prevention. The aim of this program, known as Best Fed Beginnings, is to improve maternity care and increase the number of "Baby-Friendly" hospitals in the US. Currently five hospitals in Ohio are part of this program including: Atrium Medical Center (Middletown, OH), Doctors Hospital (Columbus, OH), Riverside Methodist Hospital (Columbus, OH), Summa Health System (Akron, OH), UC Health/University Hospital (Cincinnati, OH), and University Hospitals MacDonald Women s Hospital (Cleveland, OH) ( Best Fed Beginnings ). There is a need in Ohio to increase lactation rates for the health of Ohio babies and mothers. The Surgeon General s support of "Baby-Friendly" coupled with the evidence suggesting the benefits of implementing the Ten Steps, leads one to consider why so few hospitals in the United States and specifically Ohio have obtained Baby-Friendly Hospital Initiative designation. Through interviewing the four "Baby-Friendly" hospitals in Ohio, this paper aims to better understand the process, benefits, and challenges the hospitals faced in achieving designation. The information from the interviews combined with the policy analysis will provide information for making generalizable findings about BFHI and its application in 2 In an informal discussion with Baby-Friendly USA, the representative told the researcher that there had been a few sabotage attempts on hospitals once it was disclosed that certain hospitals were undergoing the ten steps. 11

16 Ohio hospitals. The significance of this research is that it will assist policy makers, hospital administrators, and the general public to better understand the BFHI and its application in Ohio hospitals. This research provides generalizable knowledge as to whether BFHI is a possibility for Ohio hospitals to initiate in order to improve breastfeeding rates in Ohio to meet the Surgeon General s 2011 Call to Action and the Healthy People 2020 goals. Part 2: Methods A systematic literature and policy analysis of the Baby-Friendly Hospital Initiative (BFHI) was completed in order to understand the historical context of lactation in the United States, trends in lactation in Ohio, the Baby-Friendly Hospital Initiative and the impact and expansion of the BFHI. Following the literature review and policy analysis, the researcher conducted three semi-structured, hour-long telephone interviews with lactation staff representing all four hospitals in Ohio with BFHI designation. One of the interviewees was involved in aiding two hospitals in obtaining BFHI designation. Prior to contacting the hospitals, the researcher received institutional review board approval by the University of Cincinnati Institutional Review Board 3. Interviewees were recruited through the lactation department of each of the four hospitals: Mercy Hospital Fairfield, Mercy Hospital Anderson, Southview Medical Center, and Lakewood Hospital, which are listed on the "Baby-Friendly" website: Through talking with the department, the researcher found the appropriate contact person to phone interview. Once the researcher 3 See Appendix 1 for IRB approval 12

17 confirmed she had the appropriate contact person, the researcher arranged a one-hour phone interview. The researcher took notes on her computer during the interview. The interviews were not audiotaped. All interviews were conducted using the same semi-structured interview over the period of two months (September and October of 2012). After completing the interviews, the researcher independently identified categories and performed a theme analysis of the qualitative data. The findings from the interviews, combined with the policy analysis, provide data for making generalizable findings about BFHI and its application in Ohio hospitals. The interviews were guided by the following questions: 1. In what year did your institution become "Baby-Friendly" (BF)? 2. To the best of your knowledge, how long did the process take? 3. Who made the decision to become BF? a. (If known), How was the decision expressed to the staff? i. Was it received well among the staff? 1. Why or why not? 4. To the best of your knowledge, what steps were taken at your organization to become BF? a. Were certain steps harder/ longer than others? i. (If yes), Which ones and in which ways were they more challenging? 1. (If yes), Can you tell me more about step x, step y, etc.? b. Were certain steps easier/ quicker than others? i. (If yes), Which ones and in which ways were they simpler to implement? 1. (If yes), can you tell me more about step x, step y, etc.? 5. Were there barriers to becoming BF? a. (If yes), Can you tell me more about barriers 1, 2, 3, etc.? 6. What have been the biggest positive changes that you have seen as a result of becoming BF? a. (If have positives), Can you tell me more about positive 1, 2, 3, etc.? 7. Were there any negatives to becoming BF? a. (If yes), Can you tell me more about negatives 1, 2, 3, etc.? 8. Would you recommend others hospitals go through the ten steps? 9. What are some reasons for a hospital to become BF? a. Can you tell me three positive aspects for a hospital to become BF? 13

18 10. Are there any reasons why a hospital would/should not become BF? These ten main questions and sub-questions helped the researcher to identify certain themes concerning the experience of the BFHI in Ohio hospitals. The researcher arrived at the following theme analysis by analyzing the qualitative findings from the three interviews and categorizing and compiling the content from the interviews. Part 3: General Observations and Theme Analysis: This chapter contains two components: the participants general observations including the costs and benefits of obtaining the Baby-Friendly designation and a theme analysis of issues faced by respondents as they implemented the Ten Steps. General Observations: The Baby-Friendly Hospital Initiative was viewed positively among all research participants. Although, the process and challenges that each hospital faced may have been unique, each interviewee recommended that other hospitals should go through the Ten Steps. All participants believed the time, energy and expense were worthwhile because the results were so profound. As one interviewee proudly exclaimed, "Baby-Friendly" designation does what is best for mothers and babies. Towards the end of the interview, the researcher asked the participants to rate the top three reasons to become "Baby-Friendly" and the following are their responses in order by frequency. 1. Increase initiation of breastfeeding 2. Provides support, promotes breastfeeding, and supports breastfeeding 3. Health and wellness for mom and baby 4. Good marketing to say the hospital is "Baby-Friendly" 5. Babies just do better- far fewer babies in the nursery, less monitoring of babies 14

19 6. Joint commission has made exclusive breastfeeding as one of their core measures. Upon asking if there were reasons for not becoming "Baby-Friendly", two issues were suggested: the costs associated and the time associated with obtaining designation. Cost was the biggest barrier. It is expensive to apply for designation, to train staff, and to maintain the designation. Nevertheless, it was unanimously deemed worth the expense. One interviewee put it, The results are well worth the time and money. There were several foreseeable costs in becoming "Baby-Friendly" for a hospital. The most significant included: paying for formula, replacing things branded by formula manufacturers, paying for staff and physician education, staffing support groups and extra lactation services, and paying for the application to obtain designation. Formula manufactures usually give hospitals free formula so long as hospitals distribute formula gift bags upon discharge from the hospital. Since "Baby-Friendly" forbids the distribution of formula gift bags, hospitals must pay for formula. One hospital found that paying for formula was budget neutral. In paying for the regular formula they were able to effectively negotiate more expensive formulas needed for babies with special needs (ex. lactose intolerant). The other hospitals did not discuss if paying for formula was a financial burden on the institution. One hospital discussed that it created a take home bag that included coupons for breastfeeding mothers, freezer bags to store frozen breastmilk, and water bottles. This breastfeeding friendly take-home bag replaced the formula gift bags. Replacing branded items was an unanticipated expense for most hospitals. Items like pens, mugs, nametags, crib carts, and measuring tapes provided by formula manufacturers sported their logos. Items bearing logos of formula manufacturers are also prohibited by the Ten Steps. Purging all the logoed items was time consuming. Many of the hospitals discussed their 15

20 disbelief regarding how many displayed advertisements. Replacing the branded items at a clinic that feeds into the hospital is also an expense because the hospitals had to provide material in place of all the items formula companies provided. All of the things provided by formula manufactures had to be replaced and paid for by the institution. Paying for staff education was another cost. The costs involved time (18 hours for nurses and 3 hours for physicians) and money (if a course such as Jones and Bartlett was purchased). Staffing support groups and clinics were additional costs that many non-"baby-friendly" hospitals were already paying. Half of the hospitals had pre-existing support groups prior to becoming "Baby-Friendly". The requirement for the support group does not mandate that a lactation consultant be present. It could be led by volunteers or could be affiliated with another lactation support group such as La Leche League International. Paying for a lactation clinic is an added expense, but it is not required by the Ten Steps. This is an optional step that hospitals can take to further support nursing mothers. Finding creative ways to fund it could potentially make it budget neutral. This includes charging a small fee for use or having a boutique that sells breastfeeding items such as pumps where the profits go towards funding the center. Applying for "Baby-Friendly" designation is not free. The fee for hospitals with more than 500 births a year is $3000 for each of the following phases: development, dissemination and designation. An additional $1000 fee is paid to "Baby-Friendly" annually after designation is received. There are lower fees for hospitals and freestanding birth centers with under 500 births per year. A research study performed by DelliFraine et. al (2011) found, "Becoming baby-friendly" is relatively cost-neutral for a typical acute care hospital. Although the overall expense of 16

21 providing baby-friendly hospital nursery services is greater than nursery service costs of non baby-friendly hospitals, the cost difference was not statistically significant. " Every hospital felt that the benefits of becoming "Baby-Friendly" far outweighed the challenges that each institution faced in obtaining and maintaining designation. One interviewee insisted, This is the right thing to do! Another said, Yes, definitely! It is, because this is how it is meant to be. A third says, It is great, moms and babies will get what they need. It is what is right, and we need to move forward! "Baby-Friendly" even benefits formula feeding mothers by encouraging rooming-in and skin-to-skin. Every hospital saw increases in breastfeeding initiation. The state of Ohio requires all hospitals to chart breastfeeding at discharge. The hospitals are not required to follow-up to see if breastfeeding is sustained. Two of the hospitals experienced around twenty percentage point increases in their breastfeeding rates (from the mid-60 s to the mid-80 s). Two others had been growing slowly (at about 1 percentage point every two years since the institutions began keeping track in 1990). After receiving designation, those hospitals experienced four percentage point increases in one year. The reasons these rates did not go up as much as the other two hospitals is that one third of the Ten Steps were already in place in both institutions. The institutions were already doing rooming-in, classes, support group, etc. The hospitals have all witnessed breastfeeding rates that have gone up. It is hard to determine how much of the increase resulted from people becoming more aware of breastfeeding benefits and how much is from "Baby- Friendly". Still, the fact that each institution saw such large increases immediately following the full implementation of "Baby-Friendly" indicates it had an impact. Although these increases in breastfeeding initiation are promising, it is hard to tell if they will lead to an increase in longer-term rates, such as exclusively breastfeeding at six months. 17

22 One hospital suggested that they saw a huge drop-off after six weeks and three months when many mothers return to work. The hospital that was tracking estimated that, Of the people who start, maybe 15 percent make it the year. This is still not enough! Theme Analysis: Although "Baby-Friendly" was viewed positively among participants, each hospital had unique experiences in the process of obtaining designation. Every hospital is a unique environment defined by a unique set of relationships, a unique administration, and a unique culture. As such, each hospital approached "Baby-Friendly" differently. The following theme analysis serves as the compilation of the findings from the three semi-structured interviews into key themes. Three key themes developed with several sub-themes, which include: policy, education, and hospital personnel. Theme 1: Policy The process of becoming "Baby-Friendly" requires new policies to be developed by hospitals to implement the Ten Steps. The policy changes that need to occur require both a change in written policy and in hospital practice. The changes to hospital policy can be very time consuming and affect the length of time it takes to receive designation. The first of the Ten Steps is to have a written breastfeeding policy that is routinely communicated to all health care staff. Written Lactation Policy Baby Friendly USA Support Timing to Designation 18

23 Written Lactation Policy: *As part of the theme analysis, the author provides her recommendations to each sub-theme under the italicized sub-theme headings. Hospitals implementing "Baby-Friendly" should seek to: 1. Implement model policies which are available from Baby-Friendly USA. 2. Use Baby-Friendly USA as a resource, when a challenge arises. The written lactation policy for some hospitals was the easiest step and for others was a big hurdle. One hospital shared that the biggest hurdle was trying to figure out everything that needs to go into a policy with a group of people. Working as a group can be a challenge because people have different opinions and it can be hard to come to consensus. One interviewee suggests, Thinking of everything that goes into a policy is an ongoing process. We are constantly making changes. One hospital discussed how helpful Baby-Friendly Hospital Initiative USA was in writing their policy. The interviewee said, "Baby-Friendly" walked us through the steps. The same hospital representative also talked about how helpful the other "Baby-Friendly" Hospitals in the state were with writing the policy, and report that they visited another "Baby-Friendly" Hospital while working on their designation. Two hospitals suggested that the written policy was not a barrier because "Baby-Friendly" has samples that served as the basis for their own policies. Support from Baby-Friendly Hospital Initiative USA: All of the hospitals discussed how helpful Baby-Friendly Hospital Initiative USA was in their process to achieve "Baby-Friendly" designation. Whether it was writing the policy document, or answering a simple question, the organization provided support throughout the process if a hospital asked for it. Timing: Hospitals implementing "Baby-Friendly" should seek to: 19

24 1. Complete an internal audit to gain a better understanding of what already exists and what steps need to be implemented. 2. Have hospital leadership remain cognizant of the impact of size. For example smaller hospitals can typically obtain designation faster. All four hospitals that are currently "Baby-Friendly" in Ohio have received the designation over the last ten years. The time to receive designation depended on many factors including: size of maternity unit, number of lactation consultants, independence of management decision making, management motivation, and number of "Baby-Friendly" steps already in place prior to beginning the process. The fewer steps that needed to be implemented, the more streamlined and fast tracked the process was. For this reason, hospitals that already have some of the Ten Steps implemented will have fewer steps to complete to receive designation, shortening the process. Participants perceived that it was easier and faster for smaller birthing units to receive designation because fewer staff needed to be trained and fewer people needed to buy-into the idea of "Baby-Friendly". The time to designation for the hospitals in Ohio spanned from three years to nearly a decade. The first two hospitals in Ohio to receive the designation, received it one day a part (October 2003) and were part of a larger system that sought to have all birthing centers in the system receive the designation. A third hospital in this system received BFHI designation in 2002, but is no longer operating a maternity unit. The process for the staff at the two hospitals in the system that are still "Baby-Friendly" took nearly a decade from conception of the idea to receiving the designation, with the majority of the efforts towards obtaining the designation in the final year ( ). A third hospital in the state of Ohio received designation in This hospital was able to complete the process in three years. This hospital is relatively small, with less than 2000 births per year and a sufficient number of lactation consultants (nine) to provide lactation services to patients. The fourth hospital received designation in 2012 after 20

25 about five years of work. This probably took a bit longer than it should have because they were working with a consortium of birthing hospitals in a system. This hospital was the first to ask management in the system to obtain BFHI designation and was the first to receive designation. Theme 2: Hospital Personnel The process of becoming "Baby-Friendly" requires the cooperation of lactation consultants, nurses, physicians, maternity unit staff, and hospital administrators. This requires buy-in from all parties. Even with buy-in, there are unique challenges for nurses and physicians that must be addressed in order to implement "Baby-Friendly". Decision Maker Buy-in Physicians Nurses Decision Makers: Hospitals implementing "Baby-Friendly" should seek to: 1. Recognize that there is no one best approach to BF as the decision to achieve BFHI can come from top down or bottom-up. 2. Minimize staff turnover, which can cause disruptions and delay implementation. The decision to become "Baby-Friendly" is one that requires a tremendous amount of time and effort between management, lactation staff, and the staff of the maternity unit including 21

26 physicians and nurses. The person or group that initiated "Baby-Friendly" varied from hospital to hospital. In two of the hospitals, maternity unit managers with system-level management support, made the decision to become "Baby-Friendly". There had been system level attempts prior, but when the visionary leader left, the process halted. Designation was successfully accomplished when management came to the lactation consultants with a time frame. Another hospital staff decided as a group to become "Baby-Friendly". The instigator for this hospital was an education coordinator on the birthing unit, but the process and decision to become "Baby-Friendly" was a group effort. The Chief Executive Officer at the hospital was very excited about "Baby-Friendly" and supportive. A fourth hospital pursued "Baby-Friendly" because the director of the hospital and the manager of the maternity department decided to pursue it. The president of the system and the vice president and administration needed to be behind it. This institution prepared a presentation and spoke with the system level officials. They were not thrilled with the idea, but also did not really care. The manager noted that the men were uncomfortable discussing lactation. The manager attempted to make the men in the room comfortable with the topic by framing it as a health issue. The variety of decision makers demonstrates that each institution has its own culture and runs differently. This also shows that "Baby-Friendly" can come from top level management down, as occurred in hospitals one, two, and four, or it can come from the bottom to the top as occurred in hospital three. The consistent factor was continued determination to become "Baby- Friendly". The most likely hurdle decision makers encountered was staff turnover. Without the 22

27 visionary behind "Baby-Friendly" keeping the ball moving, it can get lost in the day to day demands of a busy maternity unit. Buy-in: Hospitals implementing "Baby-Friendly" should seek to: 1. Keep staff informed of changes and steps being taken. 2. Foster organizationally relevant approaches (multi-pronged and direct approaches). 3. Inform the staff about "Baby-Friendly" early and often throughout the process. Becoming "Baby-Friendly" requires changes in the way the maternity unit of a hospital functions in fundamental ways, whether it is getting a baby skin-to-skin to initiate breastfeeding within one hour of birth or having the newborn room-in with mother. These changes require changes in the way the staff of the unit function, and require buy-in to be successful. The four hospitals used many strategies to get staff to buy-into "Baby-Friendly". All four hospitals acknowledged that there is going to be resistance with change. The consistent factor that led to successful buy-in was keeping the staff on the unit informed about becoming "Baby-Friendly". One hospital achieved buy-in by taking a multi-pronged approach. This included: educating the staff about "Baby-Friendly" at staff meetings, having lactation consultants hold discussions with different staff members, bringing staff into the room when a lactation consultant was working with a mother, putting information about it in staff newsletters, placing little information sheets and teaching tools on bathroom doors in staff bathrooms, and by making sure "Baby-Friendly" information was widely available. This hospital made sure to include the general staff in each step and continued to keep the staff informed as the process continued. The other hospitals took the approach of advising/informing the staff that this is the direction that the hospital is going at a staff/unit meeting or several staff/unit meetings. 23

28 Regardless of if a multi-pronged approach or a direct approach was taken, the key to success was informing the staff about "Baby-Friendly" early and often throughout the process. Nurses: Hospitals implementing "Baby-Friendly" should seek to: 1. Provide continuing education to respond to the needs of the staff 2. Provide continuing education with flexible times. 3. Insure that lactation consultants are available to answer questions 4. Assist nurses during the process of adapting to new workflows. Getting nurses on board with "Baby-Friendly" was a consistent challenge among the four hospitals. The longest tenured nurses were the hardest to get on-board with "Baby-Friendly", since there were fundamental changes that had to occur in nurse workflow. One lactation consultant explained, One of the difficulties that we encountered was that so many nurses did not breastfeed. We had to show the nurses breastfeeding is best. It is hard to admit that what I did (not breastfeeding) was not best. You do not want to make nurses and staff feel guilty, yet, you need to tell mothers what is best. The following five challenges were the most frequently brought-up among the hospitals: 1. The nurses had to get the baby skin-to-skin within one hour. This is a challenge because it requires a change in workflow. 2. The nurse had to bathe the newborn in the room with the mother so that the baby would room-in at least 23 h-ours of a day. This is a change in workflow. 3. Nurses could no longer offer formula or a pacifier to a newborn, unless it was medically indicated. This is a change in practice and often workflow. It is a change in practice because formula is not offered unless medically indicated. It is a change in workflow because nurses may need to provide education about pacifiers and supplementation. 4. Nurses needed to discourage mothers from using the nursery if a nursery was available. This is a change in practice because it requires nurses to serve as educators about the benefits of rooming-in. 5. All nurses had to obtain 18 hours of continuing education in lactation. 24

29 These challenges were addressed by the hospitals in different ways. Nurses have many requirements when it comes to achieving "Baby-Friendly". For full-time nurses, it is hard to find time for anything additional beyond the day to day demands of the job, and becoming "Baby- Friendly" requires several fundamental changes in the way that a nurse works with mother and newborn. For the first four issues, the hospitals mainly addressed them through staff meetings, discussions, and through education. To overcome the first four challenge, some of the hospitals developed targeted strategies. One hospital, to prevent supplementation, especially at night, practiced scripting with nurses. This scripting served to be both supportive and educational for the nurses. This is an ongoing process for all the hospitals. Two hospitals either eliminated or minimized the nursery in order to handle rooming-in. One hospital was in a research study on skin-to-skin with another hospital. The nurses bought into skin-to-skin right away because the babies were so much more stable and breastfed easier. Two hospitals focused on hand expression to deal with challenge three. The nurses at these hospitals were all taught how to teach mothers how to use hand expression, which was either done directly into a baby s mouth or with the use of a spoon or cup directly into mouth. There is a booklet called Enjoy, which explains hand expression, and was given to all breastfeeding mothers. The fifth issue required creativity among the different hospitals to address. Two hospitals' lactation departments obtained continuing education hours for the staff by offering a variety of courses during different shifts and days. They were very flexible with the schedules of the nurses. The lactation staff made luncheon specials where they would sit down with the nurses during the lunch hour. The lactation staff made themselves very available to the nurses. This included having the nurses round with the lactation staff and the lactation staff observed the 25

30 nurses. The lactation staff made sure the nurses were comfortable with assisting in lactation. The lactation consultants had check off lists for the nurses. One of the hospitals provided independent study packets that the nurses could bring home. A second hospital adopted the independent study packets as another way for the nurses to obtain their 18 hours. A third hospital used a Jones and Bartlett 10-step education program, which cost the institution $90 per person to fulfill the 18 hours of required continuing education. The Jones and Bartlett program is specifically created to assist hospitals in getting their staff trained for "Baby-Friendly". A fourth hospital had an educator put the entire education piece together for the institution. The support of the educator streamlined this step for this particular hospital. One of the hospitals took the approach of trying to hire nurses who are already lactation consultants. These nurses prove to be versatile as they can cover for a lactation consultant or another nurse. This also minimizes the amount of extra training that is needed when a new nurse is hired. Physicians: Hospitals implementing "Baby-Friendly" should seek to: 1. Provide continuing education at flexible times. 2. Provide continuing education in a variety of delivery modalities (e.g. on-line)and with multiple options. 3. Award and reward physicians for adopting desired "Baby-Friendly" behaviors. 4. Provide literature on lactation at physician offices in place of literature distributed by formula manufacturers. Just as there are many obstacles to obtaining buy-in for a nurse, there are also challenges with training physicians and getting them to adhere to "Baby-Friendly" practices with regards to skin-to-skin, exclusively nursing, rooming-in, and not handing out formula gift bags. The four 26

31 hospitals have created many successful strategies to overcome the hurdles associated with physicians hour CME Requirement: For physicians, three hours of continuing medical education (CME) are required. Getting the physicians to find time for training was a problem. One hospital had a house doctor who was supportive of "Baby-Friendly" and created a website for physicians with articles. Another hospital sent mass s to doctors offices when a famous physician who specializes in lactation, Dr. Ruth Lawrence, came and lead grand rounds at a local hospital. The advertized the grand rounds as a great way to get started on CMEs and the grand rounds was recorded and made available on the Internet. The hospital also offered a two hour-long class that counted for two credit hours of CMEs that was led by a pediatrician and an obstetrician and that was recorded. The topics were applied to pediatrics and obstetrics. The video was sent to every physician s office with a letter about the grand rounds. 2. Skin-to-skin For one hospital, which is smaller (roughly births a year), all of the physicians bought in immediately. A new group of anesthesiologists joined the hospital, and had no problem doing skin-to-skin right after a Cesarean section. This group was very flexible. They did not have any tough, good, old boys to contend with. Since this hospital was part of a research study with another institution, that was studying skin-to-skin, this process was already underway. The other hospitals struggled with skin-to-skin. It was through staff training and educating the nurses that this was accomplished. 27

32 3. Rooming-in This was a challenge for pediatricians because the exam has to be done in the new mother's room. This causes a change in workflow, since all of the babies have to be observed in different rooms and cannot be observed at once in the nursery. In order to encourage pediatricians to do this, one hospital had an education coordinator that gave gold medals and rewards to the pediatricians for doing it. The hospitals that had eliminated or minimized their nurseries did not have to overcome this barrier. 4. Giving lactation a chance All the hospitals had to seek strategies to work with physicians trying to pre-maturely supplement. Physicians often argue that formula is medically indicated, when it really is not the right thing to do. The key to handling this was continuing to educate physicians about best practices in lactation. 5. Physicians offices A barrier, that is a continuous hurdle, is trying to eliminate formula bags from physicians offices. If a physician s office is part of the hospital, then it can be influenced by the hospital. It is more of a challenge for an independent physician, who has an office out of the control of the hospital. The pre-natal piece is a problem because patients need to be educated in physician offices. Clinics that feed into a hospital are simpler. One hospital created material for the physician s waiting rooms to educate expectant mothers about lactation. Another hospital also created material for the waiting rooms for expectant mothers as well as had games available that were about lactation for expectant mothers and gave little prizes to mothers who completed the games. In a clinic that feeds directly into a "Baby-Friendly" Hospital, all formula advertisements must be eliminated. Since most parenting magazines are covered in formula advertizing, it is 28

33 critical to have something to replace this material with that can be flipped through while waiting for a physician or nurse midwife. Theme 3: Patient Education Patient education is a key aspect of "Baby-Friendly" and represents two of the Ten Steps. Patient education is divided into pre-natal education and post-natal education and support. The Ohio "Baby-Friendly" hospitals had innovative ways of educating expectant and new mothers about the benefits of lactation. Pre-natal Education Post-natal Education & Support Culture Success Breastfeeding Pre-natal Education: Hospitals implementing "Baby-Friendly" should seek to: 1. Provide material on lactation at physician offices in place of literature distributed by formula manufacturers. One of the biggest challenges a hospital in Ohio faces is that most women who come to the hospital for delivery have already made their decision on how they will feed their newborn. For this reason, pre-natal education is crucial. All of the hospitals offer pre-natal education courses, including one on lactation. Although this is in place, it is not necessarily sufficient when it is combined with excess formula advertising outside of this course. Advertizing is prevalent in mothering magazines, physicians offices, mailings, and giveaways. Since independent physician practices are not regulated by the hospital, physicians must buy-in to "Baby-Friendly" in order to change their own practices with regards to educating their patients 29