This installment covers consumer demand, consensus spanning breastfeeding research, accountability organizations and national and state governments, and the new Joint Commission “Speak Up!”campaign.

What does consumer demand by the numbers look like?

Click on chart to enlarge

These statistics, taken from the CDC 2011 Breastfeeding Report beautifully illustrate the strong consumer demand on the part of women to breastfeed. Oregon has exceeded the Healthy People 2020 goal for 81.9% initiation of breastfeeding. What this tells us is that most women today plan to breastfeed – more than 91% initiate breastfeeding. This is great news. But within six months we see a dramatic drop-off, especially when we consider breastfeeding exclusivity. Why is this?

Behind these declining rates are the potholes and gaps of an inadequate infrastructure entirely incapable of meeting and supporting women and families in their infant feeding decision to breastfeed. Soon after or right along with the first latch, mothers and babies face multiple threats to breastfeeding from several angles that hound, hobble and thwart them all along the way. Behind these numbers lurk the stories of women and families who are forced into a choice they initially rejected – formula feeding. Who among us doesn’t know first or second hand the details of these unanticipated transitions to formula and the associated loss of maternal and child health benefits?

What these numbers also fail to illustrate are the social and ethnic inequities perpetuated via barriers to breastfeeding. Unacceptable disparities in breastfeeding persist by race/ethnicity, socioeconomic characteristics, and geography. Here in Oregon, only 25% of African-American mothers and babies are breastfeeding at six months, compared to the 62% of Oregonians. (ICTC Black Birth Survey)

Important as data collection is, standard metrics do not capture the emotions, frustrations and isolation women and families experience when faced with the unanticipated and multiple barriers that threaten and frequently succeed in separating babies and mothers from breastfeeding.

In sum, our maternity care system falls woefully short of meeting consumer demand for effective breastfeeding services. Fortunately, consumers (mothers) are beginning to connect the contradictory advice they receive from physicians, nurses, lactation consultants, nurses’ aids and housekeeping staff with the poor outcomes they experience. More women are beginning to see how gaps in standard hospital practice undermine them before they ever go home to struggle alone. The actions and activities of innumerable local and national groups sprouting up are giving voice to the dissatisfaction women and families feel with the standard of care.

Consumers are not alone in connecting the dots…..

Click on chart to enlarge

In the big picture, women are no longer alone in their search for meaningful support. The time for big change in maternity care is here.

Research

• Health benefits. We are beyond debating the pros and cons of biologically normative infant feeding. Multiple short- and long-term health benefits of breastfeeding for mothers and babies have been firmly established.
• Hospital practice. Research conclusively demonstrates that evidence-based hospital practices positively influence breastfeeding duration and exclusivity.
• Cost savings. Thanks to Bartick et al’s 2009 cost analysis (The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis), we also have clear documentation of the massive projected savings in dollars and lives that come with exclusive breastfeeding.
• SIDS. 2011 research confirms breastfeeding is associated with reduced rates of SIDS. The effect is stronger when breastfeeding is exclusive. This finding has special significance for my community of Lane County. Between July 2007 and June 2010, 23.5% of 85 fetal-infant mortalities are among post-neonates (babies one month or older). Breastfeeding reduces the risk of SIDS.
• Childhood obesity. Breastfeeding is associated with reduced odds of obesity throughout the life span with greater benefits conferred with exclusive breastfeeding. Breastfeeding promotion and childhood obesity risk reduction go together.

Accountability

Consumer voices and research findings are increasingly making their way to the top of the agenda for major actors in the development and implementation of health care policies. As these bodies move beyond signaling interest to taking action, forward-thinking hospitals will take action to be in position for a time when reimbursement dollars will be tied to breastfeeding outcomes. Action means adopting evidence-based practice for infant feeding.

• CDC mPINC. A national survey of hospitals to measure infant feeding policies and practices. Facilities receive private analyses outlining their strengths and areas that need improvement. Unfortunately, consumers are not permitted access to facility-level reports.
• Joint Commission. The nation’s most important hospital-accrediting body recently included exclusive breast milk feeding in its new perinatal core measure set.
• US Surgeon General Call to Action and Healthy People 2020. Both documents guide national, state and local health policy making. Increasing the number of breastfed infants is a key public health goal.

Nation

• Healthcare reform. is a major national issue. Promoting and protecting the rights of nursing mothers to pump included in legislation.
• Let’s Move. The First Lady’s campaign includes breastfeeding as part of the solution to the childhood obesity epidemic.
• Transforming Maternity Care. Maternity and infant care are the most expensive hospital condition in the United States – $98 billion in 2008. The US spends more than any other industrialized country on maternity and infant care. The outcomes do not support this spending. Any discussion of improving the healthcare delivery service must focus on maternity and infant care.
• Breastfeeding. Discussion of infant feeding reform thus fits within a larger context spanning the entire perinatal period from conception through an infant’s first birthday.

Oregon

• WIC. Oregon WIC is one of only 6 states awarded a Breastfeeding Performance Bonus from USDA, tied for the first time to exclusive breastfeeding rates.
• Oregon Hospitals Partnering for Evidence-based Infant Nutrition. This is a statewide project of the BCO to provide facility-specific technical assistance and encouragement to hospitals adopting evidence-based practices. The May 2011 hospital summit brought hospitals and community groups together to develop plans for next steps. This summit provided my community’s two leading hospitals (McKenzie Willamette Medical Center and Sacred Heart Medical Center) with an opportunity to publicly share their commitment to become Baby Friendly-designated facilities.
• Oregon Health Insurers Partnering for Prevention (OHIPP). This group of health insurers selected breastfeeding as an evidence-based prevention strategy for reducing obesity. Incentives to hospitals that attain the Baby-Friendly designation are being explored.

The Joint Commission’s message to mothers? Speak Up!

Now that consumers are joined by research scientists and health policy makers at the national and state levels, we are beginning to see efforts to encourage women to seek and insist on excellent infant feeding care. Having recently signaled to US hospitals that exclusive breast milk for infant nutrition is increasingly on the agenda by putting it as an optional perinatal performance measure, the Joint Commission is signaling again. This time, the Joint Commission is speaking directly to consumers. The Joint Commission’s new “Speak Up!” campaign tells mothers they must take action by “speaking up,” if they are to be successful in realizing their preference to breastfeed.

The medium for this latest signal is a brochure. There are several things to like about this campaign’s brochures:

• It is intended for distribution during the prenatal period when women have the opportunity to think and plan ahead.
• Breastfeeding, while a biological norm, is presented as a skill to be learned. Learning requires preparation before, during and after birth for mother and baby
• Women and support people are encouraged to speak up and ADVOCATE for themselves to ensure they are receiving proper, evidence-based care. In other words, being a squeaky wheel is a good thing.
• Telling women to speak up implies that they ought not assume their hospital’s care is in line with successful outcomes.
• The information provided is consistent with Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding and, therefore, is evidence based.

Encouraging personal responsibility is laudable. That said, my reservation with this campaign is that it requires a consumer to have a rather deft capacity to read between the lines. The target audience is unlikely to be able to do this, if they are not first informed that the current and common infant feeding support they are likely to encounter is rife with serious deficits. A more straightforward approach would be great.

I suspect, however, the greatest significance of this campaign is the signal it sends to hospitals rather than to consumers. Brochures are a rather passive form of support that may or not be read by consumers. I am confident, however, that the administrators inside hospitals who make decisions about whether or not to pursue the Baby Friendly designation are able to see this campaign in a larger context – one in which an ever-clearer signal is being sent for hospitals to link doing a better job by consumers with accreditation status. Seen in this light, “Speak Up!” is a very positive development.

– End of installment 2, final installment coming soon. Feedback appreciated!

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This installment covers introductory info, background on me and why thinking of women as consumers rather than patients can be productive. The next installment will go into consumer demand, the Baby Friendly Hospital Initiative and the increasing support for Baby Friendly at all levels of government and among accrediting bodies.

The Role of Consumer Advocacy in Increasing Evidence-Based Infant Feeding Practice

“Mothers are acutely aware of and devoted to their responsibilities when it comes to feeding their children, but the responsibilities of others must be identified so that all mothers can obtain the information, help, and support they deserve when they breastfeed their infants.” (Surgeon 2011: v)

Good morning. My name is Katharine Gallagher. I have been invited to speak with you today about the role consumer advocacy plays in increasing evidence-based infant feeding practice. My objective is to outline how responding to consumer demand and encouraging and engaging consumer advocacy encourages hospitals and providers toward practices that effectively support women in making sound infant feeding decisions.

The framework for this year’s annual meeting is the Surgeon General’s 2011 Call to Action to Support Breastfeeding. The fundamental assertion made in this call to action is that a woman’s ability to initiate and sustain breastfeeding is influenced by a host of variables and factors. These include an individual woman, her partner, extended family, healthcare providers and employer. Public health and social service agencies as well as community-based programs also influence breastfeeding decisions as do schools, child care centers, houses of worship, business and industry, and, let’s not forget…the media.

In other words, decisions and outcomes related to infant feeding occur in a multi-layered and dynamic environment. The manner in which these multiple factors support or thwart a woman’s ability to make and follow through on infant-care decisions has a very fast-acting and mostly permanent impact on the trajectory of decisions to breastfeed.

Each of us comes to this meeting with a particular role to play in curbing the discord of the aforementioned factors that influence individual-level decisions. We are here to develop meaningful social supports to ensure women can follow through on the decision to breastfeed their babies. My focus this morning is on the inter-play between women as the consumers of infant feeding services and health care facilities – hospitals – and  providers.

Responding to demand and partnering with consumers fosters improved maternity care. It moves us closer to a model that consistently educates and supports women, families and communities to make choices supported by sound scientific research, good judgment and individual preferences and values. Once engaged, consumers provide an invaluable feedback loop to support and inform policy, practice and outcome analysis. As system users, consumers have a unique perspective. They know from experience how well a particular system is or is not working. Frequently, they know what is needed.  When this information is regularly sought and acted upon, we have a culture of consumer engagement.

About Me

Before getting started, I’d like to share a little about myself and how I came to be involved with maternity care reform as a consumer advocate.

I am the mother of two boys – ages four and six. My professional background is in public policy. My experiences over the past six years with both evidence-based and non-evidence-based maternity care have profoundly influenced me as a person, a mother and a citizen. The result is a deeply-held conviction that we must transform maternity care in this country. This is not solely a women’s issue. We are talking about reforming policies and practices as well as behaviors and decision-making approaches with major physical, emotional, social and financial implications for the economic health and security of this generation and those to come. This is an “everyone” issue.

My first pregnancy was a healthy, low-risk experience that resulted unexpectedly in what I believe to have been an unnecessary and entirely avoidable cesarean section. Hindsight is 20/20. Only in retrospect could I see the signs pointing to and hinting at the impatience and aggressive management my Ob/Gyn employed during my labor and birth. My postpartum trajectory continued south as my son and I had extreme difficulties establishing breastfeeding. However, because he was such a determined latcher, we were considered to be doing fine and encouraged to skip our lactation consultation before discharge from the hospital. This decision was made despite the telltale signs of chewing on my nipples and my too-shyly stated observations that “things didn’t feel right.” At home with a chomper-latch baby and reeling from the shock of an unanticipated surgery, hazy from painkillers, things got worse and worse still.

A long story short, my pleas for help from the medical practice I was using and a willingness to pay out of pocket failed to secure the assistance we needed. In serious need of help, during an appointment for my baby, I asked the pediatrician to look at my breasts to confirm that I had a problem. He would not, and no referral was made. A desperate late-night call to La Leche League and another pediatrician’s gentle support resulted in our finally finding someone to help. We found an independent lactation consultant who works outside the healthcare system.

By this point, all of us were in pretty wretched shape. My nipples were chewed to shreds, my son was far from content and my husband was worried. Getting back on track required weeks of pumping and syringe feeding until my breasts healed. We then slowly re-introduced my baby to the breast. This was a team effort. My husband and I both took unpaid maternity leave and my mother moved in and  took care of all of us. Weeks of perseverance paid off and eventually we were where we needed to be to continue breastfeeding. Clearly this experience is and would be the exception, not the rule for most women and families.

Pregnant again and much better informed the second time, I knew I wanted to have a different birth and postpartum experience – one that would allow me to hold and hug my two-year old and tend to a newborn without the physical and emotional challenges of cesarean recovery. I selected the Baby-Friendly designated PeaceHealth Nurse Midwifery Birth Center for my care. My prenatal experience exhibited the hallmarks of optimal healthcare – individualized care, personal responsibility, shared decision making and informed consent. Attended by a midwife at the hospital, I had an un-medicated VBAC. My second son was born content and alert and eased peacefully into life outside the womb beginning with the glorious and inordinately important but yet to be fully understood skin-to-skin time. My delight and amazement in seeing a baby so alert and present was shared by the many Labor and Delivery nurses who came in to see an “un-medicated baby.”

Consistent with Baby Friendly, I had been counseled and educated prenatally about breastfeeding. I had the knowledge and support to confidently continue nursing my first son through my second pregnancy. Per my wishes, I was also able to tandem nurse until my oldest son weaned at 3 yrs old. Furthermore, along the way I connected with other new mothers using the Nurse Midwifery Birth Center. These women became an invaluable source of support for breastfeeding and just about everything else – pumping, returning to work, not returning to work, how to take a shower, the best places in town to change diapers and the lists goes on.

Tops on our personal lists for breastfeeding success? The weekly drop-in baby clinic and 24-hour phone support for lactation. We had a  lactation safety net and while many of us had not realized it would so critical before birth, we soon discovered how necessary it is to getting breastfeeding started and maintained. We did not yet know this lactation support was the outcome of evidence-based practice or that it had a name –the Baby Friendly Hospital Initiative. What we did know was that it worked. This was a most welcome change from my first breastfeeding experience and I was continually struck by the way in which new mothers were seamlessly supported in learning to breastfeed and to solve problems and overcome challenges that are part of life with a new baby.

Consumer or Patient?

“Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming barriers to safe, effective care.” (Romano, 53) 

Just as communities, healthcare systems, government and employers must re-tool or re-orient themselves to support evidence-based infant feeding decision making, so too must those who consume maternity services – women. Seeing oneself as a consumer rather than as a patient can provoke a radically different set of perspectives and actions that positively influence individual and system-wide care.

Pregnancy is a gateway experience into the health care system for many women. For most, pregnancy is a time of health, discovery and a renewed commitment to well-being. Women’s experience shapes their behaviors and expectations for future interactions with healthcare throughout the life cycle. Add to this that women frequently take the lead in heath care decision making for nuclear and extended family members and their initial experiences via maternity care have multiple ripple effects. Accordingly, the manner in and degree to which they participate in decision making during pregnancy, birth and the postpartum period has significant social, health and economic implications in the lives of women, families and communities that reach well beyond today’s topic of infant feeding.

Re-conceiving of the users of the maternity care system as consumers rather than patients promotes productive ideas and behaviors by providers and users. Consumers are associated with:

• Knowledge
• Choice
• Purchasing Power
• Autonomy
• Responsibility

As a consumer advocate and childbirth educator, I encourage women to take an active role in their care. I encourage them to use their purchasing power and autonomy to shop around and ask questions in order to identify facilities and practices with the best reputations for thorough lactation support with excellent post-birth outcomes. I remind them that it is okay to change hospitals, birth centers and providers, too.

When women are seen as and view themselves as consumers with the attributes of knowledge, choice, purchasing power and autonomy, it is much easier to develop and benefit from the resulting personal responsibility, mutuality, partnership, collaboration and trust when they engage care in a particular setting. This beginning orientation lays the groundwork for developing the expectation for and demand for consistent evidence-based practices. It lays the anticipatory groundwork on the part of the user for share decision making and informed consent across the life cycle.

These assertions have yet to be borne out by research. The majority of current maternal and child health research focuses on interventions fully within the realm of providers with little to no consumer participation. Cesarean surgical techniques or intensive care treatments are examples of “provider realm” interventions. Research into consumer-realm interventions would invert institutional paradigms to elevate women receiving care to the position of  a “positive” and “powerful” actor capable of moving maternal and child health outcomes in a positive direction. In this era of health reform in which we appear to be searching for meaningful ways to move toward a preventive model with the associated reduced costs, increased positive outcomes and great consumer satisfaction, this type of inquiry is much needed.

We are seeing hints of this forward-thinking inversion here in Oregon. During the last legislative session, a law was passed directing the Oregon Health Authority to investigate how doulas (labor companions) improve birth outcomes for women at disproportionate risk. Doulas provide emotional, non-medical support associated with positive outcomes. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period. Rep. Tina Kotek (D-N and NE Portland) and Rep. Lew Frederick (D-NE Portland) sponsored the bill. Portland-based International Center for Traditional Childbearing played a critical role in the introduction of the bill.

Fortunately, there is one very important “consumer realm” intervention for infant feeding services that has already clearly demonstrated massive maternal and child health benefits.. It is the Baby Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding. From start to finish, consumers are educated, engaged in decision making with the necessary evidence-based information about infant feeding and provided with full-spectrum perinatal support for making breastfeeding work. This intervention can be summarized in two words: “It works!” It works for mothers, families, employers, communities, economies and, well, everyone. Baby Friendly figures greatly into any discussion, including this one, of policy development and implementation for heeding the Surgeon General’s Call to Action to Support Breastfeeding.

End of installment #1…..

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Inadequate prenatal care is linked to increased risk for low birth weight, prematurity and infant and maternal mortality. Lane County fetal-infant mortality data for the period of July 2007 to June 2010 shows than 34% of affected families accessed prenatal care after the first trimester.

In an effort to minimize delays stemming from policy non-compliance, DHS has sent a policy transmittal to case workers and eligibility workers who process OHP applications. The transmittal reiterates and clarifies existing policy that until now has had variable degrees of implementation. Women can verify pregnancy with an informal note from a medical clinic or crisis center. Neither a note from a doctor, nor an ultrasound are required – though an ultrasound may be used for verification purposes.

“Emergent medical needs, and those who are pregnant, have priority when processing applications for medical. They do not need to disclose the basis of their emergent need. The application should be pended, approved or denied by the eligibility worker within one business day whenever possible.” – DHS transmittal

Pregnant women can print and bring this transmittal with them when applying for OHP. Regardless of a woman’s plans for her pregnancy, she is entitled to have her application expedited. If a woman planning to terminate her pregnancy encounters delays, this should be reported to the Network for Reproductive Options (NRO).

Special thanks to Representative Mitch Greenlick for providing legislative intern Jessica Matthews, MPH, the opportunity to work on this issue. Matthews worked with the Oregon Health Authority to clarify and communicate the correct policy. Thanks, too, to Bayla Ostrach for sharing the data from her master’s thesis that found low-income pregnant women in Oregon experience notable delays in the OHP application process.

Wider awareness of this policy can help to further eliminate bureaucratic barriers to pregnant women seeking access to care – spread the word. If you have a website or blog, post the DHS transmittal.

Midwifery Bill

HB 2380 passed the House Ways and Means Committee yesterday and now goes to the Senate floor. This bill creates a majority of licensed direct-entry midwives on the Oregon Board of Direct Entry Midwives, establishes protected peer review for licensed midwives, alters birth statistic collections to accurately record midwife-attended births (including transports), exempts receiving physicians from liability for injuries caused by a transporting midwife and distinguish outcomes between licensed direct-entry midwives and direct-entry midwives who are not licensed. 2380 goes a long way toward improving maternal health and birth outcomes through the provision of accurate statistics.

According to the Oregon Midwifery Council (a bill supporter), the Oregon Medical Association and Oregon Health & Sciences University support 2380.

The current legislative session is drawing to a close. Bill supporters are encouraged to contact their representatives  in the Senate to encourage a “yes” vote.

Increased Awareness for Maternal Mental Health Illness

On June 2^nd, Governor Kitzhaber signed HB 2235 into law, creating the Maternal Mental Health Patient and Provider Education Program within the Oregon Health Authority. This program will produce and provide health-care providers with materials and training about maternal mental health illness during pregnancy and within one year following birth. Rep. Carolyn Tomei (D-Milwaukie) sponsored the bill. Among key supporters and advocates for HB 2235 was Lane County’s Eugene-based WellMama, Inc.’s executive director Amy-Rose White.

24 percent of Oregon’s new mothers self-report depression during and/or after pregnancy. Maternal mental health illness can include depression, anxiety, inability and disinterest in sleeping and eating, and overpowering feelings of failure, despair and inadequacy. While effective screening and treatment exist, the vast majority of affected women are never diagnosed or connected with services.

HB 2235 originally included funding for a provider training program and required that providers make educational material available to pregnant women. The Lund Report reports that medical groups including the Oregon Medical Association and the Oregon Pediatric Society objected to mandatory provision of information. Funding was also stripped and provision of educational materials is now optional. Maternal health advocates envision future legislation to make maternal mental health screening part of the standard of care for pregnant women.

Read coverage in The Statesman Journal and The Lund Report.

Impact of Doulas in Improving Maternal Health

Earlier this month, HB 3311 was signed into law. Under the new law, the Oregon Health Authority will investigate how doulas (birth companions) improve birth outcomes for women at disproportionate risk for poor birth outcomes. Rep. Tina Kotek (D-N and NE Portland) and Rep. Lew Frederick (D-NE Portland) sponsored the bill. Portland-based International Center for Traditional Childbearing played a critical role in the introduction of the bill.

Doulas are labor companions who provide emotional, non-medical support associated with positive outcomes and all-too-frequently absent from a laboring woman’s side. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period.

According to The Lund Report, Oregon’s infant mortality rate among African Americans is 9.4 per thousand, compared with 5.5 per thousand in the Caucasian population. The Urban League of Portland reports African-American babies are roughly twice as likely as white babies to be born with a low birth weight. Lane County’s  disturbingly high rate of fetal-infant mortality highlights the need to focus on disparities and gaps in care.

Read coverage in The Lund Report.

Last week, representatives from 35 of Oregon’s 52 maternity hospitals participated in a day-long summit devoted to evidence-based infant nutrition. Provided with resources, expertise and mentoring, hospital teams developed action plans for closing the gap between current infant feeding practices and evidence-based mother-baby care. For background on the infant feeding gap, read “Closing the Quality Gap: Promoting Evidence-Based Breastfeeding Care in the Hospital.”

Prevalent non-evidence-based mother-baby practices include routine supplemental feedings of formula, repeat separation of mother and baby beginning with the first minutes of life and pervasive distribution of formula company marketing samples to breastfeeding mothers. Optimal care following birth includes skin-to-skin time, keeping mother and baby together and care from trained and educated staff. Optimal care occurs in a commercial-free environment.

The summit marked the half-way point in the year-long Oregon Hospitals Partnering for Evidence-based Infant Nutrition – a project of the Breastfeeding Coalition of Oregon, one of five community coalitions supported by the Oregon Public Health Institute. (See The Lund Report’s coverage) Amelia Psmythe, director of the Breastfeeding Coalition of Oregon, provided much of the vision, creative energy and sheer determination necessary to make this potentially-transformative opportunity available to Oregon hospitals. Because of her uniquely collaborative approach to the summit, teams returned to their respective hospitals prepared to begin the work of aligning infant feeding care with the high expectations mothers, families, communities, employers and governments at all levels have for them.

With the Breastfeeding Coalition of Oregon as its principal organizer, the project develops collaborative relationships inside and outside hospitals and provides technical support to assist reform efforts. Funders include:

• Oregon Public Health Institute
• Multnomah County Health Department
• Oregon WIC
• Oregon Association of Hospitals and Health Systems
• Legacy Health System
• Kaiser Permanente
• Providence Health & Services
• Oregon Health & Science University
• Tuality Healthcare
• Medela, Inc.

Funders as well as community partners attended the summit. Community partners included MotherBaby Network, Northwest Mother’s Milk Bank, the Nursing Mothers Counsel of Oregon, Multnomah County Health Department, Multnomah WIC, the March of Dimes, the Oregon Health Authority and the United States Breastfeeding Committee.

US Sen. Jeff Merkley’s wife Mary Sorteberg, RN presented awards to the state’s five Baby Friendly facilities and to four with formal commitments to become designated. Visit the Breastfeeding Coalition of Oregon’s Facebook page to see photos. The Baby Friendly Hospital Initiative (BFHI) – a global program sponsored by WHO and UNICEF to promote, protect and support breastfeeding – certifies hospitals practicing the Ten Steps for Successful Breastfeeding. Women receiving lactation services at a Baby Friendly facility can be confident of comprehensive evidence-based care.

The Centers for Disease Control is monitoring the project’s trajectory. Its early success engaging and leveraging the interests and resources of multiple constituencies inside and outside of Oregon hospitals warrants this attention. Depending on how the next several months unfold, an effective model for other states could result. Such a model would have national significance in light of the current CDC focus on encouraging exclusive breastfeeding for the first six months of life as the public health intervention with the greatest potential for addressing the skyrocketing rates of childhood obesity.

Lane County

Lane County had a strong showing at the summit. The county is home to the state’s first facilities to earn Baby Friendly status: the PeaceHealth Nurse Midwifery Birth Center and the Cottage Grove Healthcare Community (since closed), both in 1997. The county’s two largest hospitals, Sacred Heart Medical Center and McKenzie Willamette Medical Center, both sent teams. All four facilities were acknowledged during the morning award’s ceremony. Lane County could be on the path toward evidence-based infant feeding as a community standard.

Lane County’s Desiree Nelson works on behalf of the project. Nelson led Cottage Grove’s hospital to become a designated facility in 1997 and, until recently, worked at the PeaceHealth Nurse Midwifery Birth Center. She is also co-founder, along with Debbie Jenson of Sacred Heart, of Baby Connection, a phenomenally successful grassroots demonstration project of evidence-based, drop-in breastfeeding support groups. The existence of post-discharge groups satisfies Baby Friendly step 10. Baby Connection serves all women and families.

What did hospital teams do?

Throughout the day, hospital teams developed facility-specific action plans. Team members included physicians, labor and delivery managers, family birth center managers, charge nurses, lactation consultants, childbirth educators and quality improvement staff. 

As a condition of participation, hospital teams arrived having reviewed the latest CDC 2009 benchmark data for their facility. This data is captured in the CDC Maternity Practices in Infant Nutrition and Care (mPINC) reports. Teams updated their benchmarks to reflect 2011. These advance team-based activities were intended to ensure familiarity with current practices and policies.

Aggregate state-level mPINC data will soon be available. Facility-specific results are currently anonymous. Anonymity is considered key to participation. Download a Sample Benchmark Report. mPINC reports for other states’ facilities are being printed now. The CDC expedited shipping to support the work of the summit.

At the summit, participants were guided by Carol Melcher, RNC, CLE, MPH – clinical director of San Bernardino’s Perinatal Services Network (PSN). Melcher has led numerous hospitals in San Bernardino county to achieve Baby Friendly designation. PSN instructs hospitals in the SOFT Approach which teaches hospitals to earn designation by building connections that align cultural and procedural priorities with evidence-based care. Needed connections include those between families and staff, between administrators and nurses, between hospitals and between communities and hospitals. These connections place collaboration ahead of competition.

A critical resource for results-oriented learning and facility-level planning was the multiple interactions teams had with small table mentors. Mentors brought expertise in one of three areas: hospital Quality Improvement,  leading a hospital to the Baby-Friendly designation, and large-scale systems change. Hospital teams worked with one of each type of mentor. Mentors volunteered their time at the summit as well as during an advance training session.

To provide an observation-free environment for hospital teams, community partners convened separately following the awards ceremony. They received a briefing on hospital team activities and a presentation by Northwest Mothers Milk Bank.

Why are hospitals ground zero for closing the infant feeding gap?

Hospital-based culture and practices create an environment in which individuals make long-lasting decisions about infant feeding. These first decisions and experiences heavily influence the ultimate role breastfeeding will play in the months to come. Hospital reform is critical for realigning prenatal, birth and postpartum environments to support —rather than thwart— individual feeding decisions that lead to the multiple positive outcomes associated with breastfeeding. Read this consumer survey to learn what women and families have to say about care in a Baby Friendly facility that aligns with their decision to breastfeed.

A well-known recent study reports that 911 deaths, mostly among infants, could be averted and $13 billion per year saved, if 90% of US families breastfeed exclusively for six months. Despite considerable room for improvement, Oregon leads the nation in breastfeeding benchmarks. It starts off with an “A” but quickly plummets to a failing grade by month six. Nine in 10 Oregonian women initiate breastfeeding. At six months, 2 in 10 babies are exclusively breastfed. Even with a failing grade, Oregon is frequently touted as an example for other states.

Like the CDC, the Oregon Health Insurers Partnering for Prevention (OHIPP), another OPHI project, is also monitoring the project. Comprised of health insurers (representing 65% of private insurance and 45% of Medicaid) and public health policy advocates, OHIPP is a collaborative obesity prevention effort. It has selected increasing breastfeeding rates as its first collaborative public health intervention. Imagine the potential for moving Oregon forward were insurers to set a date for implementing different rates of reimbursement depending on a hospital’s Baby Friendly status?

Sorteberg described Sen. Merkley’s state and national legislative efforts to protect and promote the rights of breastfeeding women in the workplace. Her comments highlighted the need to work across barriers so that women will have hospital care that lays the foundation for returning to work with plans to continue breastfeeding intact. Without effective hospital-based support systems, the potential for current legislation is severely undermined.

Effective community connections reach beyond hospitals

Developing opportunities for hospital teams to identify and work with their local community partners is critical to the project’s long-term prospects. The Surgeon General’s 2011 Call to Action to Support Breastfeeding encourages the involvement of multiple groups for the removal of barriers. Families, communities and employers also have an active role in removing barriers. Including these stakeholders in the work of hospital-practice reform is key ingredient for making long-lasting, sustainable change.

Oregon’s strong showing of community partners at the summit points to an inherent and potentially unexamined strength for creating not only a state network of Baby Friendly hospitals but a model of care consistent with current calls to develop patient / consumer engagement in healthcare-decision making models. The SOFT Approach begs to be made Oregonian by actively including the perspectives of local community stakeholders in hospital teams.

What might this look like? Hospital teams can add a healthcare consumer of breastfeeding services to their efforts. Breastfeeding coalitions, La Leche groups, WIC peer counselors and healthy baby coalitions are potential sources for participants with relevant consumer perspectives. As the project moves beyond the summit to develop state-level collaborative frameworks, meaningful inclusion of local community partners should be a priority, too.

Women frequently take the lead in decision making for nuclear and extended family members. The manner and degree in which they participate in healthcare decisions during pregnancy and postpartum have major implications beyond infant feeding. Consumer (or patient) engagement promotes effective partnering for prevention and treatment practices throughout the life cycle. Including consumer perspectives in the discussions and planning that must occur to close the infant feeding gap has the potential to set the even further-reaching example of the kind of collaboration needed to make quality healthcare more affordable and accessible across the life cycle.

Beyond the summit

Urban or rural, rich or poor, large or small, degree and type of diversity among populations served  – these are not the characteristics that determine a hospital’s capacity to become Baby Friendly. Commitment to building the necessary connections for closing the current gap is the single-most important distinguishing characteristic for change. Developing and utilizing internal and external lines of communication within and among hospitals as well as with community stakeholders and setting milestone dates are far more important than specific facility characteristics. Facilities making the needed commitments and seeking opportunities to collaborate are in a position to close the infant feeding gap. Those who succeed will align with their mission by honoring their obligation to the mothers and babies of Oregon. It is possible that Oregon could make evidence-based infant feeding care a statewide community standard.

#1 International Midwives Day Legislative Rally

• Sponsor: The Oregon Midwifery Council
• When: May 5th, 2011 from 2:00 pm – 4:30 pm
• Where: Oregon State Capitol Building Steps (900 Court Street NE, Salem OR 97301)
• Cost: Free
• Flier

#2 Jennifer Block OSU Speaking Engagement

“Everything you need to know about childbirth, but weren’t going to ask until later”

Jennifer Block is the author of “Pushed: The Painful Truth  About Childbirth and Modern Maternity Care.”

• Sponsors: OSU Department of Philosophy, the Hundere Endowment in Religion and Culture, and the Department of Anthropology
• When: May 6th, 2011 at 7:00 pm
• Where: Gilfillan Auditorium, Oregon State University Campus, Corvallis, OR
• Cost: Free
• Flier

#3 Film Showing of Guerrilla Midwife

This powerful film shows the work of midwife Robin Lim in disaster-stricken areas.

• Sponsor: Heart of the Valley Birth Network
• When: May 7th, 2011 at 7:00pm
• Where: Odd Fellows Hall (223 SW 2nd Street, Corvallis, OR 97333)
• Cost: $5 – $20.00 suggested donation (proceeds to benefit Bumi Sehat)
• Flier

  April is Cesarean Awareness Month:

What are the cesarean section rates for local hospitals, Lane County and Oregon?

In 2009, the US cesarean section rate rose from 32.3 percent in 2008 to 32.9 percent. This was the 13^th consecutive year of increase. Since 1996, the rate at which U.S. cesarean sections are performed increased by 60%. Cesarean section is increasing among women of all age and all race and ethnicity groups. For detailed information, consult the National Vital Statistics Report Births: Preliminary Data for 2009.

The following graph from The Unnecesarean illustrates the cesarean section rate from 1970 to 2009. Cesarean section rates in the United States and Lane County are well beyond recommendations that they not exceed 15%. Tables 1 through 8 below provide 2010 cesarean section rates for Oregon hospitals, counties and the state. 

Exceptionally high rates continue despite the evidence that this practice places women and babies at increased risk for morbidity and mortality immediately following birth and in the long term. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, dangerous placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased percentage of maternal death.

As cesarean section rates have risen, access to VBAC (vaginal birth after cesarean) has diminished in spite of the 2010 statements from the National Institutes of Health and the American Congress of Obstetricians and Gynecologists supporting it as a safe option. 

Despite the prevalence of cesarean section being performed, women, particularly “low risk” pregnant women, are frequently un- or under-informed about the risks they face for having a one. Gaining insight into their providers’ and hospitals’ philosophies, practices and outcomes is important information that can help a woman decide where and with whom she will give birth. Yet, this information is hard to come by as it is not made readily available or generally offered upon individual request.

Yesterday, the California Department of Public Health released a much-anticipated report on maternal deaths. In addition to race/ethnicity, poverty, education and access to healthcare, medical problems from cesarean sections were reported to have contributed to an increase in maternal deaths. Regarding cesarean section, California Watch reports that it contributed to 15 of 98 maternal mortalities between 2002 and 2003. While women who do not need cesarean section are getting them, other women, for whom the benefits would actually outweigh the risks, are not. The Los Angeles Times’ coverage of the rise in maternal mortality specifically notes the role of cesarean section: Caesarean sections are a major factor in pregnancy-related deaths, report finds

A closer look at Oregon and Lane County

The Oregon Public Health Authority collects statistics for cesarean section by county and facility in a document titled “Oregon Occurrence Births by Final Method of Delivery by County, 2010.” The following tables and graphs were created by MotherBaby Network using the OPHA document statistics. For each Oregon facility, this document lists three methods of delivery: (1) total, (2) cesarean and (3) “other method or unknown.” MotherBaby Network calculated the percentages communicated in Tables 2 – 8. Cesarean section is only performed in hospitals. Accordingly, a  “O %” statistic appears beside non-hospital facilities.

Lane County residents will be interested to know that:

• Lane County’s 2010 cesarean section rate of 32.33% is slightly below the 2009 national rate of 32.9%. While lower than the national rate, it is more than twice the recommended rate. Table 4 contains statistics for Lane County.

• Among Oregon hospitals with the ten highest total 2010 births, Sacred Heart River Bend has the third highest cesarean rate, 35.18%, (Table 6). This rate is well above the state and national averages.

Oregonians will be interested to see the greater than 20% variation in cesarean section rates among the state’s hospitals with the ten highest total births in 2010. (Table 6) Within the Portland metro area, Legacy Emmanuel Hospital & Health Center has a rate of 42.34 for 1809 births while Kaiser Sunnyside Medical Center has a rate of 21.39% for 1725 births. For an interesting discussion of cesarean section rate variation among “low risk” pregnant women accessing hospitals located just miles apart, read For-profit hospitals performing more C-sections.

Something to ponder

Relative to other states, Oregon has a higher rate of out-of-hospital births. It is also comprised of many rural counties and communities. It would be interesting to explore how these two characteristics may contribute to the state cesarean section rate being considerably lower than the national average as well as the rates of thirty others states in the union. Were Oregon out-of-hospital birth rates similar to most other states, would the statewide cesarean section rate increase?

How does Oregon compare with other states?

Oregon’s 2009 cesarean section rate was 29.4. According to OPHA, the 2010 rate is now 29.45.

Table 1

What are the cesarean section rates for each of Oregon’s counties? (Click on table to enlarge)

Table 2

By descending order of total births (highest to lowest), what are the cesarean section rates for each of Oregon’s counties? (Click on table to enlarge)

Table 3

What are the rates for Lane County and its hospitals? (Click on table to enlarge)

Table 4

What are the rates for Oregon hospitals? (Click on table to enlarge)

Table 5a

Table 5b

What are the rates for Oregon’s hospitals with the top ten total births in 2010? (Click on table to enlarge)

Table 6

How many of Oregon’s hospitals have cesarean section rates consistent with the World Health Organization recommendation of 10 to 15%? (Click on table to enlarge)

Table 7

Which of Oregon’s hospitals have the ten lowest cesarean section rates?(Click on table to enlarge)

Table 8

Where can women and families learn more about cesarean section?

MotherBaby Network recommends visiting Childbirth Connection’s cesarean section information page. Childbirth Connection is a respected source for up-to-date, evidence-based information and resources on planning for pregnancy, labor and birth, and the postpartum period. The following questions can be addressed there.

• How can I make sense of what I hear about c-section and vaginal birth?
• Why should I learn about how cesarean section compares with vaginal birth?
• Is cesarean section a special concern for certain women?
• Will c-section protect my pelvic floor from weakness or injury?
• What if I have already had a cesarean section?

HB 2380 creates a majority of licensed direct-entry midwives on the Oregon Board of Direct Entry Midwives. This is accomplished by reducing the total number of board members from eight to seven. The bill also establishes protected peer review for licensed direct entry midwives. Additionally, the bill requires the Board to collect and report birth data. Outcomes between licensed and unlicensed direct entry midwives will be distinguished in Board reporting.

The bill now goes to the Senate Health Care Committee.  The Oregon Midwifery Council intends to meet with each member of this committee in the next two weeks. Supporters are encouraged to send each of the following committee members letters of support. Letters from constituents are particularly desired.

Frank Morse (Corvallis, Albany, Lebanon, Philomath, Adair Village)
District: 008
900 Court Street NE
Suite S-311
Salem, OR 97301-4068
Phone: (503) 986-1708
Fax: (503) 986-1058
WebSite: http://www.leg.state.or.us/morse/
E-Mail: sen.frankmorse@state.or.us

Chip Shields (parts of North and Northeast Portland)
District: 022
900 Court Street NE
Suite S-421
Salem, OR 97301
Phone: (503) 986-1722
Fax: (503) 986-1080
WebSite: http://www.leg.state.or.us/shieldsc/
sen.chipshields@state.or.us

Laurie Monnes-Anderson (Gresham, Wood Village)
District: 025
900 Court Street NE
Suite S-413
Salem, OR 97301
Phone: (503) 986-1725
Fax: (503) 986-1080
WebSite: http://www.leg.state.or.us/monnesanderson/
E-Mail: sen.lauriemonnesanderson@state.or.us

Alan Bates (Medford, Ashland, Central Point)
District: 003
900 Court Street NE
Suite S-205
Salem, OR 97301
Phone: (503) 986-1703
Fax: (503) 986-1080
WebSite: http://www.leg.state.or.us/bates
E-Mail: sen.alanbates@state.or.us

Jeff Kruse (Roseburg, Gold Beach)
District: 001
900 Court Street NE
Suite S-315
Salem, OR 97301
Phone: (503) 986-1701
Fax: (503) 986-1086
WebSite: http://www.leg.state.or.us/kruse/
E-Mail: sen.jeffkruse@state.or.us

Oregon House Bill 2380

Recently amended, HB 2380 creates a majority of licensed direct-entry midwives on the Oregon Board of Direct Entry Midwives. This is accomplished by reducing the total number of board members from eight to seven. The bill also establishes protected peer review for licensed direct entry midwives. Additionally, the bill requires the Board to collect and report birth data. Outcomes between licensed and unlicensed direct entry midwives will be distinguished in Board reporting.

Before amendment, HB 2380 would have required Oregon’s direct-entry midwives to become state licensed providers. This would have replaced the current voluntary licensure system. MotherBaby Network blogged about this proposed requirement shortly after the bill was  introduced in February. The Lund Report just reported on amending of this bill.

The Oregon Midwifery Council supports HB 2380 and encourages its supporters to contact their state representative in the House to encourage a “yes” vote.

Oregon House Bill 3311

HB 3311 has been amended to require that the “Oregon Health Authority, including the Office of Multicultural Health and Services, shall explore options for providing or utilizing doulas and other community health workers in the state medical assistance program to improve birth outcomes for women who face a disproportionately greater risk of poor birth outcomes.” If passed, OHA would report outcomes to the Health Care Committee in February 2012.

The original bill language focused on improving outcomes for women of color. The amended language is improved by expanding 3311’s focus to include all women who are at a disproportionate risk for poor outcomes. This bill is of particular interest for Lane County, where MotherBaby Network originates, given its disturbingly high rate of fetal-infant mortality. Our overall rate is higher than the nation; higher than the state; and higher than comparable counties and metropolitan areas.

HB 3311 has the potential to address gaps in maternity services by better-integrating doulas and community health workers into the model of care. Doulas are labor companions who provide the emotional and non-medical support all to frequently absent from a laboring woman’s side. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period.

HB 3311 follows Amnesty International’s 2010 release of Deadly Delivery: The Maternal Health Care Crisis in the USA.  Amnesty International reports that despite spending more than any other country on earth on maternal health, US women are at greater risk of dying of pregnancy-related complications than their counterparts in 49 other countries including Kuwait and Bulgaria. Among US women, African-American women are nearly four times as likely to die of pregnancy complications than white American women.

HB 3311 enjoys support from bill sponsor Rep. Tina Kotek as well as from the following organizations:

Coalition of Local Health Officials

International Center for Traditional Childbearing

The Urban League of Portland